Abdominal Wall Hernias

Abdominal Wall Hernias
Springer Science+Business Media, LLC

Robert Bendavid, MD
Jack Abrahamson, MD
Maurice E. Arregui, MD
Jean Bernard Flament, MD
Edward H. Phillips, MD
Editors
Abdominal
Wall Hernias
Principles and
ManagelIlent
Foreword by Raymond c. Read, MD
Preface by Rene Stoppa, MD
With 738 Figures, 46 in Full Color
Springer
Robert Bendavid, MD
Toronto, Canada
Jaek Abrahamson, MD
Haifa, Israel
Mauriee E. Arregui, MD
Indianapolis, IN, USA
Jean Bernard Flament, MD

Reims, Franee
Edward H. Phillips, MD
Los Angeles, CA, USA
Library of Congress Cataloging-in-Publication Data

Abdominal wall hernias : principles and management / editors, Robert Bendavid... [et all.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4612-6440-8 ISBN 978-1-4419-8574-3 (eBook)
DOI 10.1007/978-1-4419-8574-3
1. Hernias-Surgery. 2. Hernias-Pathophysiology. I. Bendavid, Robert.
[DNLM: 1. Hernia, Ventral. 2. Abdomen-pathology. 3. Abdomen-surgery. 4. Surgical
Procedures, Operative. WI 955 A135 2000]
RD621 .A193 2000
617.5'59----dc21
00-020620
Printed on acid-free paper.
© 2001 Springer Science+Business Media New York

Originally published by Springer-Verlag New York, Inc. in 2001
Softcover reprint of the hardcover 1st edition 2001
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ISBN 978-1-4612-6440-8 SPIN 10750916

This book is dedicated, with love,
to the memory of my first and most important teacher,
my father.
He was always there.
R.B.
A powerful idea communicates some of its power to the man who contradicts it.
MARCEL PROUST, 1919-In Search of Lost Time
Who shall decide, when doctors disagree?

ALEXANDER POPE, 1732-Epistle III: Of the Use of Riches
We are usually convinced more easily by reasons we have found ourselves

than by those which have occurred to others.
BLAISE PASCAL, 1670-Pensees
He that will not apply new remedies must expect new evils;
for time is the great innovator.
SIR FRANCIS BACON, 1625-Essays 1597-1625; "On Innovation"
The certainties of one age are the problems of the next.

R.H. TAWNEY, 1926
Don't limit a child to your own learning, for he was born in another time.
Rabbinic saying
Foreword
Herniology, during the latter part of the twentieth century, had become transformed by the
realization that most abdominal defects in the adult are not predetermined by anatomic
anomalies. Rather, they relate to connective tissue damage brought about by abnormal col-
lagen metabolism, secondary to extended longevity, cigarette smoking, or impaired genetic
expression. Surgeons now recognize that sutured repairs under tension are liable to give
way sooner or later. Fortunately, bridging with prosthetic mesh has repeatedly been shown
to be well tolerated and successful when the interposition is firmly anchored. The intro-
duction of laparoscopic placement has led to the competitive development of minimally in-
vasive open techniques which, by reducing postoperative pain, hasten recovery.
The herniologist has emerged as a specialist, supported by a dedicated staff and clinic fa-
cilities, with a professional society and journal. Two of the heroes who, with their gold stan-
dard, led the way were the Shouldices, father and son. Therefore, it is fitting that this, the
first new text of the third millenium, is edited by one of their colleagues. Robert Bendavid
took a sabbatical year to write this book, with the help of his peers from around the world.
Although educated in Canada, he was born overseas, and is multilingual. This skill has helped
him edit the many foreign contributions in the light of his own enormous clinical experi-
ence. Robert, despite his promotion of the "Modern Bassini," has already put together an
internationally recognized text on prostheses and abdominal wall hernias. He is well known
for other original contributions-fletching and umbrella prostheses for groin defects, para-
pubic herniation, dysejaculation after hernia surgery, nomenclature, and a new under-
standing of the transversalis fascia. He has been a mainstay at international conferences on
herniae during the past 15 years and has contributed 25 chapters to the textbooks of other
editors.
The text itself, as is expected from such a leading scholar in the field, encompasses all
the new information that has so recently become available. It begins with history, anatomy,
epidemiology, and pathology. Extensive documentation of new biomaterials is followed by
adjuncts to surgery, techniques of repair, plastic surgery, emergencies, and pediatrics. The
female hernia patient is followed by the elderly, incidental pathology, sports injuries, and
ventral defects. Finally, complications are dealt with, along with unusual herniae and
medicolegal aspects.
It is a wonderfully fresh product that will serve as a point of reference for years to come.
Dr. Bendavid and his co-editors have taken much time and trouble to provide us with a state-
ment of what is known around the world today regarding herniology. Hopefully, this gift will
enable us to better serve humanity.
RAYMOND C. READ
Little Rock, Arkansas, USA
ix
Preface
It gives me particular pleasure to present the compilation Abdominal Wall Hernias: Principles
and Management. One would not expect anything of less substance and quality from a text-
book edited by Robert Bendavid, at the fateful start of the third millennium. Since Ephraim
Chambers's and Denis Diderot's encyclopedic works, compilations such as this call for the
collaboration of many experts, whose participation is obtained by virtue of the editor's own
noteworthiness, unremitting work, and expertise in the subject. Is not every editor com-
pelled to do better than his rivals in a strongly competitive field? This has been done-in
the opinion of the most exacting among them.
The coauthors have reconsidered all the accepted classics in the light of more recent ad-
ditions, in accordance with the editor's plan. The necessary chapters on fundamentals be-
gin with the historical evolution of some of the main themes of surgery, as seen by surgeons
themselves. Then, by way of update, comes the discussion of the many techniques commonly
used in surgery of the abdominal wall, some already established, others-more recent-still
in the process of being evaluated. Prostheses have a significant legitimate place, for they
have experienced a remarkable upsurge and are used not only in recurrent hernias and
burst abdomens, but also very considerably in primary treatment. Laparoscopic surgery of
hernias-a seductive product of high technology-was another item to be tackled with par-
ticular attention among the methods being currently evaluated.
Thus, should readers wish to review a standard technique or one of its details, they will
find it, more often than not, described by its inventor in this book. Should they be con-
fronted by particular cases of rare hernias or exceptional circumstances, surgeons will be
able to find exhaustive and up-twate information on these less familiar problems.
Certain matters rarely approached in detail have also been notably considered, such as
abdominal wall surgery for patients with ascites, for athletes, the obese, women, the elderly,
even for the futuristic surgeon-the intellectual disciple of Jules Verne-technologies yet
to be invented, in which robots will perhaps make their appearance, technologies to be
welcomed cautiously and on the condition that they bring true benefit to the patient and
to society.
This book is a successful achievement, a tribute to the vitality of the surgeon of the ab-
dominal wall. Remarkably illustrated, and with unvarying precision throughout, the work
serves well its double purpose: to help readers to acquire fundamental, indispensable prin-
ciples for up-twate understanding of abdominal wall pathology and to enhance their abil-
ity to make good choices of tactics or techniques, whatever the situation. This is the best
one can ask for. Everyone knows that a consensus is unlikely, at present or in the near fu-
ture, on the problem of the treatment of hernias. This question cannot be resolved solely
by the contribution of scientific proofs, because it has "sociological" elements derived from
the diversity of the many people concerned (the surgeons and their patients) and from the
polymorphism of the lesions.
One can promise that Abdominal Wall Hernias: Principles and Management will fulfill the eth-
ical obligation to further the teaching of abdominal wall surgery and the control of its qual-
ity. This remains essential to this day. The 1998 Inquiry of the National Union of the Medical
Press and Health Professionals in France revealed that written documents are the primary
source of information in continued medical education, ahead of conferences and meetings.
xi
xii Preface
A book like this one must therefore have the support of many readers, as indeed one must
hope it shall. But then, a simple glance at the table of contents is enough to disclose the
difference between this and other comparable books, a difference in favor of the present
work, which must take its place within reach of every surgeon's hand.
These few words are thus no more than a deliberately brief preface to the feasts prepared
for the satisfaction of the reader.
RENE STOPPA
Amiens, France
Introduction
As we begin a new millennium, it seems fitting that a publication on hernias should meld
the acquired knowledge and wisdom on the subject to constitute a state-of-the-science
address-a century-ending statement before starting a new surgical period. This much has
been attempted.
The versatility and speed of today's communications have brought more than 120 sur-
geons from 16 countries into a futuristic "surgical village" dotted with satellite dishes and
antennas. The abundance of scientific information has been difficult to contain, but an ef-
fort has been made to include all current concepts, theories, practices, operations, pros-
theses, and even gadgets: so much so that inclusion should not be construed as a
recommendation, which brings to mind a quote from Sir Maximillian Beerbohm, "It dis-
tresses me, this failure to keep pace with the leaders of thought, as they pass into oblivion!"
Foremost in my thoughts was an attempt to remain above controversy, to avoid bias, and
to allow a generous exposure to all participants. To that end, I have to apologize for the
elimination of certain chapters when authors were too opinionated too early, but also un-
shakeable in their attitude and presentation. The existence of an European Hernia Society
and now the American Hernia Society has made it imperative that both sides of the Atlantic
be given an even role in the elucidation of the hernia diathesis. This I feel was fairly
accomplished.
This book was made possible thanks to the generosity of each contributor who shared his
time and knowledge. I know also that for some it meant a sacrifice. For that, I am grateful,
and many readers will express the same feeling. My hope is that the result will meet with
their warm approval.
ROBERT BENDAVID
Toronto, Ontario, Canada
xiii
Contents
Foreword by Raymond C. Read ................................... ix

Preface by Rene Stoppa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Introduction ................................................ xiii
Contributors ................................................ xxv
Part I History
1 Evolution and Present State of Groin Hernia Repair . . . . . . . . . . . . . . . . 3

RENE STOPPA, GEORGE E. WANTZ, GABRIELE MUNEGATO, AND
ALFONSO PLUCHINOTTA
2 Use of the Preperitoneal Space in Inguinofemoral Herniorrhaphy:

Historical Considerations ................................... 11
RAYMOND C. READ
3 Prostheses in Hernia Surgery: A Century of Evolution .............. 16

JAMES R. DEBoRD
4 Evolution of Laparoscopic Hernia Repair ....................... 33

KARL LEBLANC AND RALPH GER
Part II Anatomy
5 Anatomy of the Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

JEAN BERNARD FLAMENT, CLAUDE AVISSE, AND
JEAN FRANQOIS DELATTRE
6 Aponeurotic Hernias: Epigastric, Umbilical, Paraumbilical, Hypogastric . . . 64

OMAR M. ASKAR
Tribute to Omar M. Askar by John E. Skandalakis 71
7 Surgical Anatomy of the Inguinal Region

from a Laparoscopic Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
RICCARDO ANNIBALI, ROBERT J. FITZGIBBONS, JR., AND THOMAS QUINN
8 Fascial Anatomy of the Inguinal Region ........................ 86
JONATHAN D. SPITZ AND MAURICE E. ARREGUI
xv
xvi Contents
9 The Ligaments of Cooper and Thomson ....................... 92

J.P. RICHER, J.P. FAURE, M. CARRETIER, AND JACQUES BARBIER
10 The Transversalis Fascia: New Observations ..................... 97

ROBERT BENDAVID
11 The Space of Bogros and the Interparietoperitoneal Spaces ........ 101

J. HUREAU
Part III Epidemiology

12 Epidemiology of Inguinal Hernia: A Useful Aid for Adequate
Surgical Decisions ....................................... 109
ALEJANDRO WEBER, DENZIL GARTEIZ, AND SALVADOR VALENCIA
13 Occult Hernias in the Male Patient ........................... 116

SAM G.G. SMEDBERG AND LEIF SPANGEN
14 Quality Control and Scientific Rigor .......................... 122

ERIK NILSSON AND STAFFAN HAAPANIEMI
15 Classification of Inguinal Hernias ............................ 128

V. SCHUMPELICK AND K- H. TREUTNER
Commentary: An IDF Classification? IYy Robert Bendavid 130
Part W Pathology
16 Mechanisms of Hernia Formation ............................ 133
JACK ABRAHAMSON
17 Metabolic Aspects of Hernia Disease . . . . . . . . . . . . . . . . . . . . . . . . .. 139

RAYMOND C. READ
18 Pathological Tissue Changes and Hernia Formation .............. 143

ALAIN PANS
19 The Role of Collagen in Hernia Genesis ....................... 150

LARS NANNESTAD JORGENSEN AND FINN GoTTRUP
20 Recurrent Herniation: Etiology and Mechanisms 156

JACK ABRAHAMSON
21 Respiratory Pathophysiology and Giant Incisional Hernias ......... 166

GIOVANNI TRIVELLINI AND PIERGIORGIO DANELLI
Commentary IYy Robert Bendavid 172
22 Undescended and Cryptorchid Testes ......................... 173

JOHNM. HUTSON AND SUZANNE HASTHORPE
Commentary by Robert Bendavid 178
23 Testicular Atrophy ............................. :......... 179

ROBERT M. ZOLLINGER, JR.
Commentary IYy Robert Bendavid 182
Contents xvii
24 Unexpected Findings in Inguinal Hernia Surgery 184

ENRICO NICOLO
25 Soft Tissue Infection and Loss of Abdominal Wall Substance ....... 192
RONALD T. LEWIS
Part V Biomaterials
26 Biochemistry, Immunology, and Tissue Response to

Prosthetic Material ....................................... 201
SUSANNE K. WOLOSON AND HOWARD P. GREISLER
27 Biomaterials: Structural and Mechanical Aspects

of Prosthetic Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
RJ. MINNS AND M.I.A. SELMIA
28 Biomaterials Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
NIR KOSSOVSKY, CHARLES J. FREIMAN, AND DAVID HOWARTH
29 Carcinogenicity of Implantable Biomaterials .................... 235

B. KLOSTERHALFEN, U. KLINGE, AND V. SCHUMPELICK
30 Suture Selection for Hernia Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

PHILIP B. DOBRIN
31 Use of Fibrin Glues in the Surgical Treatment

of Incisional Hernias ..................................... 246
J.P. CHEVREL AND A.M. RATH
32 Collagen-Based Prostheses for Hernia Repair ................... 250

P.B. VAN WACHEM, T.M. VAN GULIK, MJ.A. VAN LUYN, AND
ROBERT P. BLEICHRODT
33 Clinical Applications of Stainless Steel Mesh .................... 258

JEAN JACQUES DURON
Commentary by Rnbert Bendavid 260
34 Repair of Abdominal Wall Defects by Intraperitoneal Implantation

of Polytetrafluoroethylene (Teflon®) Mesh ..................... 262
M.L. DRUART, R. CHAMLOU, A. MEHDI, AND J.M. LIMBOSCH
Commentary by Rnbert Bendavid 265
35 Polyester (Dacron®) Mesh ................................. 266

MARC SOLER, PIERRE J. VERHAEGHE, AND RENE STOPPA
36 Polypropylene Prostheses 272

PARVIZ K. AMID
37 Expanded Polytetrafluoroethylene ........................... 279

NICHOLAS LAw
38 Vypro®: A New Generation of Polypropylene Mesh ............... 286

U. KLINGE, B. KLOSTERHALFEN, AND V. SCHUMPELICK
xviii Contents
39 Combined Absorbable and Nonabsorbable Prostheses in the

Treatment of Major Defects of the Abdominal Wall .............. 292
GIOVANNI TRIVELLINI
40 Prosthetic Materials and Adhesion Formation ................... 294

RICCARDO ANNIBALI
41 Intraperitoneal Prostheses ................................. 299

R.KJ. SIMMERMACHER
42 Use of Absorbable Mesh in the Staged Repair of Contaminated

Abdominal Wall Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
MERRIL T. DAYTON
Part VI Adjuncts to Surgery
43 Local Anesthesia ........................................ 317

ORESTE TERRANOVA, LUIGI DE SANTIS, AND FRANCESCO BATTOCCHIO
44 Antibiotics in Hernia Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324

JOHN M.A. BOHNEN
45 Imaging Hernias of the Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . 335

]. ANDREW HAMLIN
46 Techniques of Pneumoperitoneum . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

LE6N HERSZAGE
47 Relaxing Incisions ....................................... 343

ROBERT BENDAVID
48 Drains in Hernia Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

PAOLO BOCCHI
Part VII Techniques of Open Groin Hernia Repair

Introduction to Pure Tissue Repairs 353
ROBERT BENDAVID
49 The Bassini Operation .................................... 354

ORESTE TERRANOVA, LUIGI DE SANTIS, AND LUIGI CIARDO
50 The Dam Repair ........................................ 361

JACK ABRAHAMSON
51 The McVay Operation .................................... 365

JOHN]' RYAN
52 The Shouldice Repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370

ROBERT BENDAVID
Contents xix
Introduction to Tension-Free Repairs 376

ROBERT BENDAVID
53 Gilbert's Repair of Inguinal Hernias .......................... 377

ARTHUR I. GILBERT, MICHAEL F. GRAHAM, AND WALTER]. VOIGT
54 The Mesh Plug Repair .................................... 382

IRA M. RUTKOW AND ALAN ROBBINS
55 Moran's Preperitoneal Mesh Repair for Inguinal Hernias .......... 388

ROBERT M. MORAN
Commentary by Rnhert Bendavid 389
56 The Nyhus Preperitoneal Repair of Groin Hernias ............... 391

JOSE F. PATINO
57 Unilateral Giant Prosthetic Reinforcement of the Visceral Sac:

Preperitoneal Hernioplasties with Dacron® ..................... 396
GEORGE E. WANTZ AND EVA FISCHER
58 The Rives Technique: Treatment of Groin Hernias with Mersilene

Mesh by an Inguinal Approach .............................. 401
JEAN BERNARD FLAMENT, CLAUDE AVISSE,JEAN-PIERRE PALOT,
AND]. RIVES
59 The Gridiron Hernioplasty 407

FRANZ UGAHARY
60 Dynamic Self-Regulating Prosthesis (Protesi Autoregolantesi

Dinamica) (PAD) ........................................ 412
G. VALENTI, A. TESTA, AND N. BARLETTA
61 Ventral Hernias: Use of the Kugel Patch ....................... 416

ROBERT D. KUGEL
62 Use ofVicryl Pads in Inguinal Hernia Repairs ................... 419

H.R WILLMEN
63 Lichtenstein Tension-Free Hernioplasty for the Repair of Primary

and Recurrent Inguinal Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
PARVIZ K. AMID
64 Reinforcement of the Visceral Sac by a Preperitoneal Bilateral

Mesh Prosthesis in Groin Hernia Repair . . . . . . . . . . . . . . . . . . . . . . . 428
RENE STOPPA
65 A Combined Abdominoinguinal Approach to Stoppa's Giant

Prosthetic Reinforcement of the Visceral Sac Procedure ........... 437
VINCENZO MANDALA
66 Open Techniques of Femoral Hernia Repair .................... 439

JEAN-PIERRE PALOT AND CLAUDE AVISSE
xx Contents
Part VIII Laparoscopic Techniques of Groin Hernia Repair

67 Laparoscopic Intraperitoneal Onlay Mesh Repair ................ 451
MORRIS E. FRANKLIN,JR., AND JOSE ANTONIO DfAZ-ELIZONDO
68 Laparoscopic Transabdominal Preperitoneal Hernia Repair (TAPP) . . . 454

MICHAEL S. KAvlc AND SERGIO ROLL
69 Laparoscopic Totally Extraperitoneal Hernioplasty (TEP): Part I . . . . . 464

EDWARD L. FELIX
70 Laparoscopic Totally Extraperitoneal Repair for Inguinal Hernias

(TEP): Part II ........................................... 472
JONATHAN D. SPITZ AND MAURICE E. ARREGUI
Part IX Open Techniques of Incisional Hernia Repair

71 The Shoelace Repair ..................................... 483
JACK ABRAHAMSON
72 Closure of Chronic Abdominal Wall Defects: The Components

Separation Technique .................................... 487
OSCAR M. RAMIREZ AND JOHN A. GIROTTO
73 The Components Separation Technique Modified for Use

with Enterostomies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
SYLVESTER M. MAAs, TAMMO S. DE VRIES REILINGH, AND
ROBERT P. BLEICHRODT
74 Treatment of Incisional Hernias by an Overlapping Herniorrhaphy

and Onlay Prosthetic Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
J.P. CHEVREL
75 The Kugel Repair for Groin Hernias ......................... 504

ROBERT D. KUGEL
76 Treatment of Major Incisional Hernias ........................ 508

JEAN BERNARD FLAMENT,JEAN-PIERRE PALOT, A. BURDE,
JEAN FRANc,;;OIS DELATTRE, AND CLAUDE AVISSE
Part X Laparoscopic Techniques of Incisional Hernia Repair

77 Repair ofIncisional Hernias and Midline Defects .. . . . . . . . . . . . . . . 519
GUY R. VOELLER
Part XI Loss of Abdominal Wall Substance

78 Loss of Abdominal Wall Substance ........................... 527
J.P. CHEVREL
79 Acute Loss of Abdominal Wall Substance and Abdominal

Compartment Syndrome 538
H. HARLAN STONE
Contents xxi
Part XII Plastic and Reconstructive Surgery
80 Plastic Surgery of Abdominal Wall Reconstruction . . . . . . . . . . . . . . . . 547

A. BERGER AND J. LIEBAU
Commentary by Rnlph Ger 553
Part XIII Emergency Surgery
81 Should Prostheses Be Used in Emergency Hernia Surgery? ........ 557

XAVIER HENRY AND N. BOURAS-KARA TERKI
82 Groin Hernias in the Adult Presenting as Emergencies ... . . . . . . . . . 560

DAVID WATKIN
83 Abdominal Wound Dehiscence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569

DIRK VAN GELDERE
84 Treatment of Strangulated Inguinal Hernias with

Nonabsorbable Prostheses .................................. 577
ALAIN PANS, C. DESAIVE, AND N. JACQUET
85 Use of Prosthetic Materials in Incisional Hernias with a Septic Risk ... 580
VINCENZO MANDALA
86 Incisional Hernias as Emergencies ........................... 582

DAVID V. FELICIANO
Part XIV Pediatrics
87 Pediatric Hernias ........................................ 591

BRADLEY M. RODGERS, EUGENE D. MCGAHREN, III, AND
ROBERT C. BURNS
Part XV The Female Hernia Patient
88 Epidemology of Hernias in the Female ........................ 613

ALEJANDRO WEBER, SALVADOR VALENCIA, DENZIL GARTEIZ,
AND ALFREDO BURGUESS
89 Anesthesia for Hernia Repair in Pregnancy and Lactation ......... 620

STEPHEN HALPERN AND MARGARET SREBRNJAK
90 Nonpalpable Inguinal Hernia in Women 625

LEIF SPANGEN AND SAM G.G. SMEDBERG
91 Hernia and Chronic Pelvic Pain in Women ..................... 630

IBRAHIM M. DAOUD
92 Chronic Pelvic Pain in Women .............................. 632

MICHAEL S. KAVIC
xxii Contents
93 Femoral Hernias in Females: Facts, Figures, and Fallacies ......... 639

ROBERT BENDAVID
Part XVI Special Problems

94 Hernias in the Elderly .................................... 643
PIERRE J. VERHAEGHE, TSIRY B. ANDRIAMIHAMISOA,
AND FIDY M. RALAIMIARAMANANA
95 Elective Herniorrhaphy in an Aging Population ................. 646

STANLEY D. BERLINER AND NATHANIEL SPIER
96 Management of Genitourinary Tract Pathology Encountered

During Inguinal Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653
W. SCOTT McDOUGAL
97 Sports Injuries and Groin Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657

OJ.A. GILMORE
98 Hernias and Patients with Ascites ............................ 662

J. BELGHITI AND M. HAKIM
99 Paraostomy Hernias: Prevention and Prosthetic Mesh Repair ....... 666
PAUL H. SUGARBAKER
100 Hernia and Obesity ...................................... 672

HARVEYj.SUGERMAN
101 Pneumoperitoneum in the Treatment of Giant Hernias, with

Special Reference to Obesity ............................... 675
EDWARD E. MASON
102 Umbilical Hernias ....................................... 680

MAXIMO DEYSINE
103 Epigastric Hernias 685

MAXIMO DEYSINE
104 Acquired Lumbar Hernias ................................. 688

PARVIZ K. AMID AND ROBERT BENDAVID
Part XVII Complications of Hernia Repairs
105 Complications of Groin Hernia Surgery ....................... 693

ROBERT BENDAVID
106 Complications of Laparoscopic Inguinal Hernioplasty . . . . . . . . . . . . . 700

STEVEN M. FASS AND EDWARD H. PHILLIPS
107 Complications of the Use of Prostheses: Part I .................. 707

PARVIZ K. AMID
Contents xxiii
108 Complications of the Use of Prostheses: Part II .................. 714

GIANFRANCO FRANCIONI, PRO SPERO MAGISTRELLI,
AND MARIO PRANDI
109 Infected Abdominal Wall Prosthesis .......................... 721

DONALD E. FRY
110 Chronic Pain Following Repair of a Groin Hernia ................ 726

PJ. O'DWYER AND M.G. SERPELL
111 Neuralgia Following Hernia Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . 730

C. TONS, J. HOER, AND V. SCHUMPELICK
112 Mesh Inguinodynia Mter Inguinal Herniorrhaphy . . . . . . . . . . . . . . . . 734

JAMES R. STARLING
113 Ilioinguinal/Iliohypogastric Neuropathy ....................... 737

R. GRAHAM VANDERLINDEN, RAJIV MIDHA, AND LOREN VANDERLINDEN
114 Sexual Dysfunction Following Inguinal Hernia Repair ............. 740

JERALD BAIN
115 Vascular Injuries from Hernia Surgery ........................ 743

JAMES R. DEBORD
116 Seromas............................................... 753

ROBERT BENDAVID AND MATTHIAS Kux
117 Dysejaculation .......................................... 757

ROBERT BENDAVID
Part XVIII Other Considerations
118 Medicolegal Issues Relating to Herniorrhaphy ................... 761

ERLE E. PEACOCK
119 Ambulatory Hernia Surgery ................................ 767

MARTIN KURZER, PHILIP A. BELSHAM, AND ALLAN E. KARK
120 Telemedicine and Robotics in Surgery 772

PETER M.N.Y.H. Go
Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776
GEORGE E. WANTZ
Index ..................................................... 777

Contributors
JACK ABRAHAMSON, MD
31 Kadimah Street, Haifa 34383, Israel
PARVIZ K AMID, MD
Lichtenstein Hernia Institute, Los Angeles, CA 90069, USA
TSIRY B. ANDRIAMIHAMISOA
Service de Chirurgie Viscerale et Digestive, Hopital Nord, Amiens 80054, France
RICCARDO ANNIBALI, MD
Department of Surgery, Section of Coloproctology, San Pio 10th Hospital,
Milan 20159, Italy
MAURICE E. ARREGUI, MD
Department of General Surgery, St. Vincent Hospital and Healthcare Center,
Indianapolis, IN 46260, USA
OMAR M. AsKAR, MDt

Department of General Surgery and Anatomy, University of Cairo, Cairo, Egypt
CLAUDE AVISSE, MD
Department of Surgery, Hopital Robert Debre, Reims 51100, France
JERALD BAIN, MD
Department of Endocrinology, University of Toronto/Mount Sinai Hospital,
Toronto, Ontario M5G 1X5, Canada
JACQUES BARBIER, MD
Service de Chirurgie Viscerale, Jean Bernard University Hospital, Poitiers 86021,
France
N. BARLETIA, MD
Department of General Surgery, Ospedale G.B. Grassi, Rome 00189, Italy
FRANCESCO BATIOCCHIO, MD
Division of Surgery, Hospital of Este, Este 35056, Italy
J. BELGHITI, MD
Hopital Beaujon, Clichy 92210, France
xxv
xxvi Contributors
PHILIP A. BELSHAM, MD
The British Hernia Center, Hendon, London NW4 4RS, UK
ROBERT BENDAVID, MD
18 Cedarcroft Boulevard, Toronto, Ontario M2R 2Z2, Canada
A. BERGER, MD
Department of Plastic, Hand, and Reconstructive Surgery, Medical School of
Hannover, D-30659 Hannover, Germany
STANLEY D. BERLINER, MD
75-967 Hiona Street, Holualoa, HI 96725-9601, USA
ROBERT P. BLEICHRODT, MD
Department of Surgery, Nijmegen University Medical Center, Nijmegen 6500HB,
The Netherlands
PAOLO BOCCHI, MD
Divisione Chirurgica, Ospedale Magiore di Parma, Parma 43100, Italy
JOHN M.A. BOHNEN, MD

160 Wellesley Street East, Toronto, Ontario M4Y IJ3, Canada
A. BURDE, MD
ALFREDO BURGUESS, MD
Department of General Surgery, Hospital Angeles de las Lomas, Huixquilucan
52763, Mexico
ROBERT C. BURNS, MD
Department of Surgery, University of Virginia Health Sciences, Charlottesville,
VA 22906, USA
M. CARRETIER, MD
Jean Bernard University Hospital, Poitiers 86021, France
R. CHAMLOU, MD
Centre Hospitalier Etterbeck-Ixelles, Brussels 1050, Belgium
J.P. CHEVREL, MD
Service de Chirurgie Generale et Digestive Hopital Avicenne,
Bobigny 93009, France
LUIGI CIARDO, MD
Department of Surgical and Gastroenterological Sciences, University of Padua,
Padua 35128, Italy
PIERGIORGIO DANELLI, MD
Department of General Surgery, State University of Milan-"L. Sacco"-
University Hospital, Milan 20157, Italy
IBRAHIM M. DAOUD, MD
Department of Surgery, University of Connecticut and St. Francis Hospital and
Medical Center, Hartford, CT 06105, USA
Contributors xxvii
MERRIL T. DAYTON, MD
Department of Surgery, University of Utah, Salt Lake City, UT 84131, USA
JAMES R. DEBORD, MD
Department of Surgery, University of Illinois College of Medicine at Peoria,
Peoria, IL 61603, USA
JEAN FRANCOIS DELATTRE, MD

C.DESAIVE,MD
Department of Abdominal Surgery, Clinique A. Renard, Herstal 4040, Belgium
LUIGI DE SANTIS, MD
Department of Surgical and Gastroenterological Sciences, University of Padua,
Padua 35128, Italy
MAxIMO DEYSINE, MD
Department of Surgery, State University of New York at Stony Brook and
Mercy Medical Center, Rockville Center, NY 11570, USA
JOSE ANTONIO DiAl-ELIZONDO, MD

Department of Surgery, University of Texas Health Sciences Center,
San Antonio, TX 78222, USA
PHILIP B. DOBRIN, MD, PHD

Department of Surgery, University of Missouri-Columbia, Harry S Truman
Memorial Veterans' Hospital, Columbia, MO 65211, USA
M.L. DRUART, MD
Centre Hospitalier Etterbeek-Ixelles, Brussels 1050, Belgium
JEAN JACQUES DURON, MD

Department of Digestive Surgery, Pitie-Salpetriare, Paris 75013, France
STEVEN M. FASS, MD
Department of Surgery, Cedars-Sinai Medical Center, University of California at
Los Angeles, School of Medicine, Los Angeles, CA 90048, USA
J.P. FAURE, MD
Jean Bernard University Hospital, Poitiers 86021, France
DAVID V. FELICIANO, MD
Department of Surgery, Emory University School of Medicine, Grady Memorial
Hospital, Atlanta, GA 30303, USA
EDWARD L. FELIX, MD
Department of Surgery, University of California, San Francisco, Fresno,
CA 93710, USA
EVA FISCHER, MD
Department of Surgery, The New York Hospital Cornell Medical Center,
New York, NY 10021, USA
ROBERT J. FITZGIBBONS, JR., MD

Department of Surgery, Creighton University School of Medicine, Omaha, NE
68131, USA
JEAN BERNARD FLAMENT, MD

xxviii Contributors
GIANFRANCO FRANCIONI, MD
Department of General Surgery, S. Andrea Hospital, La Spezia 19100, Italy
MORRIS E. FRANKLIN,JR., MD
Department of Surgery, University of Texas Health Sciences Center,
San An~?nio, TX 78222, USA
CHARLES J. FREIMAN, MD
Department of Surgery, University of California at Los Angeles, School of
Medicine, Los Angeles, CA 90095, USA
DONALD E. FRy, MD
Department of Surgery, University of New Mexico School of Medicine,
Albuquerque, NM 87131, USA
DENZIL GARTEIZ, MD
52763, Mexico
RALPH GER, MD
Department of Anatomy, Albert Einstein College of Medicine, Bronx, NY
10461-1975, USA
ARTHUR I. GILBERT, MD
Hernia Institute of Florida, Miami, FL 33143, USA
OJA. GILMORE, MS, FRCS, FRCS (ED)

The Groin and Hernia Clinic, London WIN 2ET, UK
JOHN A. GIROTTO, MD
Department of Surgery, The Johns Hopkins University School of Medicine,
Baltimore, MD 21205, USA
PETER M.N.YH. Go, MD

St. Antonius Ziekenhuis, Nieuwegein 3430, The Netherlands
FINN GoTTRUP, MD
Bispebjerg Hospital, University of Copenhagen, Copenhagen Wound Healing
Center, Copenhagen NY, DK-2400 Denmark
MICHAEL F. GRAHAM, MD
HOWARD P. GREISLER, MD
Department of Surgery, Loyola University Medical Center, Maywood,
IL 60153, USA
STAFFAN liAAPANIEMI, MD
Department of Surgery, Vrinnevi Hospital, Norroping 60182, Sweden
M. HAKIM, MD
Department of Surgery, University of Paris, Paris 75343, France
STEPHEN HALPERN, MD
Department Anesthesia, Sunnybrook and Women's College Health Sciences
Centre, University of Toronto, Ontario M5S 1B2, Canada
Contributors xxix
J. ANDREW HAMLIN, MD
Department of Radiology, St. John's Hospital, Santa Monica, CA 90404, and
Department of Radiology, Century City Hospital, Los Angeles, CA 90065, USA
STAFFAN HAPPANIEMI, MD
Department of Surgery, Vrinnevi Hospital, Norroping 60182, Sweden
SUZANNE HAsTHORPE, PH.D.

Surgical Research, Royal Children's Hospital Research Institute,
University of Melbourne, Parkville, Victoria 3052, Australia
XAVIER HENRY, MD
Service de Chirurgie Viscerale et Disgestive, Hopital Nord, Amiens 80054, France
LEON HERSZAGE, MD
Department of General Surgery, I. Pirovano Hospital, Buenos Aires, Argentina 1055
J. HOER, MD
Department of Surgery, University of Aachen, Aachen 52076, Germany
DAVID HOWARTH, MD
Department of Pathology, Mount Sinai Hospital, Toronto, Ontario M5G 1X4,
Canada
J. HUREAU, MD
85 Avenue Emile Thibault, Paris 10362, France
JOHN M. HUTSON, MD, FRACS

Department of General Pediatric Surgery, Royal Children's Hospital Research
Institute, University of Melbourne, Parkville, Victoria 3052, Australia
N. JACQUET, MD
Department of Abdominal Surgery, CHU Saet Tilman, Liege 4000, Belgium
LARs NANNESTAD JORGENSEN, MD

Department of Surgical Gastroenterology, Bispebjerg Hospital,
University of Copenhagen, Copenhagen NY, DK-2400 Denmark
ALLAN E. KARK, MD
MICHAEL S. KAVIC, MD
Department of Education and General Surgery, St. Elizabeth Health Center,
Youngstown, OH 44501-1790, USA
U. KLINGE, MD
B. KLOSTERHALFEN, MD
Institute for Pathology, University of Aachen, Aachen 52076, Germany
NIRKossovsKY, MD
Department of Surgery, University of California at Los Angeles, School of
Medicine, Los Angeles, CA 90095, USA
xxx Contributors
ROBERT D. KUGEL, MD
Hernia Treatment Center, Olympia, WA 98506, USA
MARTIN KURZER, MD
MATTHIAS Kux, MD
Department of Surgery, St. Joseph Hospital, Vienna 11130, Austria
NICHOLAS LAw, MD
Case Far Hospital, The Ridgeway, Enfield, Middlesex EN2 8JL, UK
KARL LEBLANc, MD
Department of Surgery, Louisiana State University, New Orleans, LA, and
Surgical Specialty Group, Inc., Baton Rouge, LA 70808, USA
RONALD T. LEWIS, MD
Department of Surgery, McGill University, Montreal, Quebec H3A 1A1, Canada
LIEBAu, MD
J.
Department of Plastic, Hand, and Reconstructive Surgery, Medical School of
Hannover, Hannover 30659, Germany
J.M. UMBOSCH, MD
Department of Surgery, Centre Hospitalier Etterbeck-Ixelles, Brussels 1050,
Belgium
SYLVESTER M. MAAs, MD
Department of Plastic and Reconstructive Surgery, Academic Hospital
Maastricht, Maastricht 6202 AZ, The Netherlands
PROSPERO MAGISTRELLI, MD
VINCENZO MANDAIA, MD
Department of General and Emergency Surgery, Villa Sofia-CTO Hospital,
Palermo 90015, Italy
EDWARD E. MAsON, MD
University of Iowa College of Medicine, Iowa City, IA 52242, USA
W. SCOTT McDOUGAL, MD
Department of Urology, Harvard Medical School, Massachusetts General
Hospital, Boston, MA 02114, USA
EUGENE D. MCGAHREN, III, MD

Department of Surgery, University of Virginia Health Sciences,
Charlottesville, VA 22906, USA
A. MEHDI, MD
Department of Surgery, Centre Hospitalier Etterbeck-Ixelles, Brussels 1050,
Belgium
RAJIV MIDHA, MD
Department of Neurosurgery, Sunnybrook and Womens College Health Sciences
Centre, University of Toronto, Toronto, Ontario M4N 3M5, Canada
RJ. MINNS, PH.D., DSCTECH

Department of Medical Physics, Dryburn Hospital, Durham DH1 5TW, UK
Contributors xxxi
ROBERT M. MORAN, MD
National Ambulatory Hernia Institute, La Puente, CA 91744, USA
GABRIELE MUNEGATO, MD
Department of Surgery, Clinique Chirurgicale de l'Universite, Centre Hospitalier
Universitaire, Amiens 80054, France
ENRICO NICOLO, MD, FACS

Department of Surgery, University of Pittsburgh Medical Center,
McKeesport, PA 15132, USA
ERIK NILSSON, MD, PH.D., FRCS

Department of Surgery, Motala Hospital, Linkoping University, Motala 5-591 85,
Sweden
PJ. O'DWYER, MH, FRCS
Department of Surgery, Western Infirmary, Glasgow G11 6NT, UK
JEAN-PIERRE PALOT, MD
Service de Chirurgie Generale et Digestive, Universitaire de Reims, Reims 51687,
France
ALAIN PANS, PH.D.
Department of Abdominal Surgery, Clinique A. Renard, Herstal 4040, Belgium
JosEF. PATINO, MD
Department of Surgery, Fundacion Santa Fe de Bogota, Bogota, Distrito Especial,
Columbia
ERLE E. PEACOCK, MD
Department of Surgery, University of North Carolina School of Medicine,
Chapel Hill, NC 27514, USA
EDWARD H. PHILLIPS, MD
Department of Surgery, Cedars-Sinai Medical Center, University of California at
Los Angeles, Los Angeles, CA 90048, USA
ALFONSO PLUCHINOTTA, MD
Department of Surgery, Clinique Chirurgicale de l'Universite Centre Hospitalier
Universitaire, Amiens 85004, France
MARIo PRANDI, MD
THOMAS QUINN, MD
Department of Biomedical Sciences, Creighton University, Omaha, NE 68178, USA
FIDY M. RALAIMIARAMANANA, MD
Service de Chirurgie Visceral et Digestive, Hopital Nord, Amiens 80054, France
OSCAR M. RAMIREZ, MD
Department of Plastic Surgery, The Johns Hopkins University,
Lutherville, MD 21093, USA
A.M. RATH, MD
Serivce de Chirurgie Generale et Digestive, Hopital de Bobigny, Bobigny 93009,
France
RAYMOND C. READ, MD
Department of Thoracic Surgery, Central Arkansas Veterans Healthcare Center,
Department of Surgery, University of Arkansas for Medical Sciences,
Little Rock, AR 72205, USA
xxxii Contributors
TAMMO S. DE VRIES REIUNGH, MD

Department of Surgery, University Hospital "Vrije Universeiteit," 1081 HV
Amsterdam, The Netherlands
JP. RICHER, MD
jean Bernard University Hospital, Poitiers 86021, France
JRIvEs, MD
Universitaire de Reims, Reims 51687, France
ALAN ROBBINS, MD
The Hernia Center, Freehold, Nj 07728, USA
BRADLEY M. RODGERS, MD
Department of Surgery, University of Virginia Health Sciences,
Charlottesville, VA 22906, USA
SERGIO ROLL, MD
Department of Surgery, University of Sao Paulo, Sao Paulo 04012-002, Brazil
IRA M. RUTKOW, MD
Department of Surgery, University of Medicine and Dentistry of New jersey,
New jersey Medical School, Newark, Nj 08903, USA
JOHN J RYAN, MA, MB, BCH, FRCSI

Department of Surgery, University of South Dakota School of Medicine, Sioux
Falls, SD 57105, USA
V. SCHUMPEUCK, MD
Medizinische Fakultat RWTH, Chirurgischen Klinik, Aachen 52074, Germany
M.I.A. SELMIA, MD
Department of General Surgery, South Cleveland Hospital-Middlesborough,
Wickham, Newcastle-upon-Tyne NEll 9PW, UK
M.G. SERPELL, MD
Department of Surgery, Western Infirmary, Glasgow GIl 6NT, UK
R.KJ. SIMMERMACHER, MD
Department of Surgery, University Hospital, Utrecht 3508 GA, The Netherlands
JOHN E. SKANDALAKIS, MD, PH.D.

Center for Surgical Anatomy, Emory University School of Medicine,
Atlanta, GA 30322, USA
SAM G.G. SMEDBERG, MD, PH.D.

Department of Surgery, Helsingborg Hospital, Helsingborg S-251 87, Sweden
MARc SOLER, MD
Chirurgie Generale, Clinique Saint jean, Cagnes sur Mer 06800, France
LEIF SPANGEN, MD
Surgical Clinic, Central Hospital, S-651 85 Karlstad, Sweden
NATHANIEL SPIER, MD
Department of Surgery, North Shore University Hospital,
Manhasset, NY 11030, USA
Contributors xxxiii
JONATHAN D. SPITZ, MD
Department of General Surgery, St. Vincent Hospital and Healthcare Center,
Indianapolis, IN 46260, USA
MARGARET SREBIU-{JAK, MD, FRCPC

Department of Anaestesia, Sunnybrook and Women's College Health Sciences
Centre, University of Toronto, Toronto, Ontario M5S IB2, Canada
JAMESR. STARLING, MD
Department of Surgery, University of Wisconsin, Madison, WI 53792, USA
H. HARLAN STONE, MD
Department of Surgery, University of Arizona College of Medicine,
Phoenix, AZ 85032, USA
RENE STOPPA, MD
Clinique Chirurgicale de l'Universite, Centre Hospitalier Universitaire, Amiens
80054, France
PAUL H. SUGARBAKER, MD
Department of Surgery, Washington Hospital Center, Washington, DC 20010,
USA
HARVEYJ. SUGERMAN,MD
Department of Surgery, Medical College of Virginia of Virginia Commonwealth
University, Richmond, VA 23298, USA
N. BOURAS-KARA TERKI, MD
ORESTE TERRANOVA, MD
Department of Surgical and Gastroenterological Sciences, Geriatric Surgical
Clinic, University of Padua, Padua 35128, Italy
A. TESTA, MD
Department of General Surgery, Ospedale S. Pietro, Rome 00189, Italy
C. TONS, MD
K-H. TREUTNER, MD
GIOVANNI TRIVELLINI, MD
University of Milan, Milan 20142, Italy
FRANZU GAHARY, MD
Department of Surgery, Rivierenland Ziekenhuis Tiel, Tiel 4002,
The Netherlands
SALVADOR VALENCIA, MD
52763, Mexico
G. VALENTI, MD
Lungotevere Sanzeio 1, Rome 00153, Italy
xxxiv Contributors
LOREN VANDERLINDEN, MD
Department of Neurosurgery, Trillium Health Centre, Mississauga,
Ontario L5B 2V2, Canada
R. GRAHAM VANDERLINDEN, MD
Department of Neurosurgery, Trillium Health Centre, Mississauga, Ontario
L5B 2V2, Canada
DIRK VAN GELDERE, MD

Department of Surgery, Ziekenhuis Amstelveen 1180 AH, The Netherlands
T.M. VAN GUUK, MD, PH.D.

Department of Surgery, Academic Medical Center, 1100 DD, Amsterdam,
The Netherlands
MJ.A. VAN LUYN, PH.D.

Department of Pathology, Laboratory Medicine, Medical Biology, University of
Groningen, Groningen 9713 GZ, The Netherlands
P.B. VAN WACHEM, PH.D.

Department of Pathology, Laboratory Medicine, Medical Biology, University of
Groningen, Groningen 9713 GZ, The Netherlands
PIERRE]' VERHAEGHE, MD
GUY R. VOELLER, MD
Department of Surgery, University of Tennessee-Memphis, Memphis, TN
38163, USA
WALTER]. VOIGT, MD
GEORGE E. WANTZ, MD
Department of Surgery, The New York Hospital Cornell Medical Center,
New York, NY 10021, USA
DAVID WATKIN, MD, FRCS

Department of General Surgery, Leicester Royal Infirmary, Leicester LEI 5WW, UK
ALEJANDRO WEBER, MD
Department of General Surgery, Hospital Angeles de las Lomas,
Huixquilucan 52763, Mexico
H.R. WILLMEN, MD
Arzt fUr Chirurgie und Unfallchirurgie, Chirurgische Klinik, Kreiskrankenhaus
Grevenbroich, 41515 Grevenbroich, Germany
SUSANNE K WOLOSON, MD
Department of Surgery, Loyola University Medical Center, Maywood IL 60153, USA
ROBERT M. ZOLUNGER, JR., MD

Department of Surgery, Case Western Reserve University School of Medicine,
University Hospitals of Cleveland, Cleveland, OH 44106. USA
Part I
History
1
Evolution and Present State
of Groin Hernia Repair
Rene Stoppa, George E. Wantz, Gabriele Munegato, and Alfonso Pluchinotta
Known since the beginning of the history of medicine, 1hernias have of patients and the community at large. On behalf of patients, there
required help from the surgeon, mostly on the dramatic occurrence is a sort of ethical obligation, including patient information, safety,
of strangulation (Figs 1.1-1.7). But when evaluating elective hernia and the benign nature of the operation, postoperative comfort,
surgery a little more than a century ago, Paul Segond and William high degree of patient satisfaction, and long-term efficacy. On the
Bull expressed the same sad opinion about the ill-named "hernia part of the community, there is an expectation of low postopera-
cure" of their time. In 1883, Segond said, "There is no operation tive disability, low direct and indirect costs, and permanent cure.
in the past or present time which deserves the name of radical cure: Thus, surgical tactics have reached currently accepted policies
this remains a chimera. Would radical cure be the unique aim of inspired by "minimum" as well as "maximum" rules of quality con-
the surgeon, his duty should be never to operate."2 Later, in 1890, trol. These rules of quality are minimum anesthesia, surgical
Bull remarked, "The use of the word cure for speaking of the op- trauma, postoperative disability, complications, and cost; maxi-
erative treatment should be abandoned, and the results measured mum rapid learning, easy training, quick performance of the pro-
by the period of relief before recurrence took place."3 cedure, and reproducibility of satisfactory results.
The modem surgical era, facilitated by the advent of anesthe- There are pertinent issues raised from past discussions and more
sia and asepsis, began with Bassini4 who, in 1887, developed the recent assessments in classic hernia surgery. Attention given to the
first modem, anatomically based hernia treatment. This procedure repair of the posterior inguinal wall, including the transversalis
spread worldwide, but was often executed poorly, and hernia re- fascia, is vital for an effective cure. This is credited to Cooper
pair fell into a state of second class surgery. (Fig. 1.8),9 Thomson,10 Bassini (Fig. 1.9 and 1.10),4 Shouldice,6
Forty years ago, in 1958, the meticulous work of American sur- Fruchaud,7 McVay,ll and Condon.l 2 Toward this goal, surgeons use
geon Chester McVay and anatomist Barry Anson5 clarified the diverse techniques adapted to the various types of defects (Fig. 1.11).
anatomy of the groin and popularized the Cooper's ligament in- The posterior approach has gained great popularity. First de-
guinal hernioplasty. In the late 1940s, Canadian surgeon E. scribed by Annandale,13 supported by Cheatle 14 and Henry,15 it
Shouldice6 developed a hernioplasty similar to the Bassini opera- was promoted by Nyhus 16 and enthusiastically followed by Rives 17
tion. This procedure became extremely popular as well as the stan- and Stoppa. 18 The retroparietal cleavable spaces are excellent
dard of the classic pure tissue hernioplasties. In France in 1956, approaches to the wall defect, and also perfect sites for the place-
Henri Fruchaud7,8 published his wonderful anatomic study of the ment of synthetic meshes held in place by the positive intra-
groin, which became the bible for the European Hernia Society abdominal pressure, according to Pascal's hydrostatic principle.
(GREPA) members. At the same time, convenient modem pros- We agree with Griffith, who said, "Equal familiarity with these two
thetic materials appeared after World War II, and the innovations approaches allows one to suit the operation to the patient rather
progressively became part of the surgical arsenal. Despite advances than the patient to the operation.... "19 Recently, laparoscopic
in understanding about hernias, and with more than 200 tech- video-assisted hernia surgery, taking up the posterior approach, is
niques described, a 5 to 10% recurrence rate continued to plague rediscovering the regional anatomy of the groin from inside the
patients. This is where hernia surgery was when, in the early 1990s, abdomen.
laparoscopic video-assisted surgery (a seductive product of high Compared to "pure tissue repairs" limited by tissue resistance
technology) entered the field of hernia surgery. Today, hernia re- and suture tension, the prosthetic repair is logically more able to
pair is still changing, discussions continue about important aspects reinforce or replace the weak layer of the groin as extensively as
of open operations, while laparoscopic surgery, currently being necessary, and can provide tensionless repair for the largest de-
evaluated, struggles to gain popularity. fects and the most difficult procedures. The replacement or rein-
Key data on the evolution of the principles of hernia surgery forcement of the deep inguinal floor by using synthetic mesh
are founded partly on the anthropologic nature of hernia, partly answers one of the questions of the day: mending the biologic as-
on a humanistic concern, and partly on its social appropriation. pect of the multifactorial mechanism of herniation, Peacock's
Because hernias are a well-known common pathology, hernia re- "metabolic defect,"20 and Read's "metastatic emphysema."21 There
pair is also a community problem. Demands have been recently is no scientific evidence of any late adverse effects after using pros-
expressed by the media and accepted by the surgeons on behalf thetic materials in young patients.
R. Bendavid et al. (eds.), Abdominal Wall Hernias 3

© Springer Science+Business Media New York 2001
FIGURE 1.1. Phoenician terracotta figurine showing an umbilical hernia FIGURE 1.3. Ancient "upside-down" treatment of a strangulated hernia.
(5th-4th century BC). (From Museo Arqueologico, Barcelona, Spain.) (From the Book ofCyrugia, Hieronymus Brunschwig, 1497.)
FIGURE 1.4. Trusses for inguinal hernia. From Ambroise Pare, Of Tumours
FIGURE 1.2. Surgical treatment of a scrotal hernia. From Rolandus Chirur- Against Nature in Genera~ 1649. This English translation and the multiple
gia, by Roger of Salerno (1l40-?). Twelfth century manuscript. (From editions in French were the standard textbooks of surgery for a hundred
Casanatense Library, Rome, Italy.) years.
4
1. Evolution of Groin Hernia Repair 5
FIGURE 1.5. Woman with a femoral hernia. In Die Handschrift des Schnitt
und Augenarteztes. Caspar Stromayr (l6th century). By Walter Brunn, 1925, FIGURE 1.6. Prolapsed fecal fistula after a strangulated hernia. In Wund
Idra-Verlagsanstalt, Berlin. Artzney by Fabricius Hildanus, 1652.
After World War II, synthetic meshes were introduced in France tients, delay can increase the risk of incarceration and emergency
by Aquaviva who used nylon,22 and in the United States, Usher23 operation: elective herniorraphy can be safely performed after
and Koontz24 using polypropylene. Experience with polyester careful management of significant other ailments, and, whenever
mesh was reported in France by Rives 25 and Stoppa. 26 In clean her- possible, under local anesthesia.
nia procedures, all modem fabrics have a similar good tolerance. There are still two tendencies in current hernia surgery. One is
Macroporosity is the most essential physical property to ensure the routine use of a single operative technique for all types of her-
rapid integration and resistance to infection. Microporous mater- nias. This has contributed to perfection of the details of the pro-
ial is encysted, rather than integrated, and is not recommended. cedures, but it also leads to a number of recurrences. We agree
Synthetic meshes are used in various ways (plugs, patches, or large with many surgeons who prefer an individual approach, person-
wrapping of the peritoneal sac), and can be placed in diverse alizing the operation to suit the patient as taught by Nyhus 28 and
anatomic sites. The underlay position between peritoneum and Devlin. 29 This takes into account the type and size of the defect,
endoabdominal fascia seems to be the best one to fulfill Fruchaud's the status of groin anatomic structures, and the condition of the
exhortation to "close the window, not the curtain," and give fa- patient. Just as there is no panacea to cure all sicknesses, there is
vorable working conditions to the hydrostatic principle of Pascal. no gold standard operation to cure all hernias.
Finally, prosthetic material must not be used in patients at risk for Selective indications of diverse techniques rely on a nonuniver-
sepsis. This includes emergent operations for strangulated hernias. sally adopted classification of groin hernias, based on the evalua-
The diagnosis of hernia can be missed in some patients, as in tion of the risk for recurrence. Several classifications have been
the example of groin pain in obese or athletic patients. The ul- published by, among others, McVay,I1 Harkins,30 Casten,31 Gil-
trasonographic examination in supine and upright positions with bert,32 Nyhus,28 and Bendavid.33 Many surgeons trust the Nyhus
a Valsalva maneuver has a diagnosis sensitivity and specificity of scheme 28 based on the state of the posterior wall, allowing recur-
90%. Computed tomography is rarely indicated. Herniography ap- rences to be related specifically to the type. In 1993, Stoppa34
pears no longer justified in adults. adopted Nyhus's four hernia types, with some modifications to al-
Indications for hernia repair are diverse also, and the proce- low for aggravating factors. These include the characteristics of
dures are aimed at relieving symptoms and preventing the still the hernia (size, multiplicity, sliding), patient condition (age, ac-
deadly menace of strangulation. Only an asymptomatic direct her- tivity, associated diseases), and special surgical circumstances (in-
nia in the elderly can be observed under regular control, follow- fection risk, foreseen technical difficulties).
ing the 1994 guidelines of the Royal College of Surgeons of Short hospital stay and ambulatory surgery, as well as early re-
England. 27 A femoral hernia, statistically more likely to strangu- turn to activity, have been demonstrated by comparative studies to
late, must be operated on as soon as diagnosed. In geriatric pa- provide long-term results for outpatient procedures that are the
6 R. Stoppa et al.
same as those for inpatient procedures, and with fewer complica-

tions. Initiated in Scotland by Nicoll,35 this is a currently accepted
practice in North America. In spite of its economic advantages and
the absence of disadvantages for the patient, ambulatory surgery
has not gained popularity in Europe. The reasons for this include
the lack of political and individual motivation and the fact that ap-
propriate ambulatory surgical units are not readily available. The
legal and professional responsibility of the surgeon is the same for
an outpatient as it is for an inpatient setting.
About anesthesia: a well-informed patient may participate in the
choice between local, spinal, or general anesthesia. Local anesthe-
sia can be widely used for primary, uncomplicated hernia repair if
it is performed by experienced teams, in psychologically well-pre-
pared, nonobese, nonallergic adults. Laparoscopic hernia repair has
complicated anesthetic techniques because the pneumoperitoneum
reduces cardiac output and produces hypercapnia. Epidural anes-
thesia, often used in open procedures, is of limited use in laparo-
scopic repair, mostly for rapid procedures in young patients because
its hemodynamic effects add to those of the pneumoperitoneum.
The current panorama of groin hernia classic repairs is as fol-
lows: current classic suture repairs are the popular Marcy (Figs.
1.11 and 1.12),36 Bassini,4 Shouldice,6 and McVayll operations.
Current open prosthetic repairs include anterior onlays: Lichten-
stein's tension free repair,37 Gilbert's sutureless hernioplasty,38 and
their variations. Among preperitoneal underlays are Rives's oper-
ation (by inguinal approach),25 Stoppa's operation (by midline
subumbilical approach),26 and Wantz's GPRVS39-42 (by the supra-
inguinal route). The success of their introduction on a large scale
has been supported by their feasibility and efficiency.
The controversy between open and laparoscopic hernia surgery
FIGURE 1.7. Technique of division of the deep inguinal ring for a stran- supporters continues. Laparoscopic hernia surgery is not only
gulated hernia. Manual of Operative Surgery and Surgical Anatomy, Belliere:
New York, 1855.
A B
FIGURE 1.8. (A) Posterior view of the groin showing the neck of a femoral neck of a femoral hernia sac. This anatomic dissection, made by Cooper,
hernia sac. From Astley Paston Cooper's famous book The Anatomy and may have served as the model for the artist's rendition of the same. Cour-
Surgical Treatment of Inguinal and Congenital Hernia. Parts I and II. T Cox: tesy of the UMDS Gordon Museum, London.
London, England, 1804. (B) Posterior of a dissected groin showing the
FIGURE 1.10. The Bassini inguinal hernioplasty as illustrated by his pupil

A. Catterina. Catterina, upset because so many surgeons were doing the
Bassini hernioplasty incorrectly, set out to educate surgeons in the correct
technique. He stressed the fact that Bassini divided the cremaster muscle
and also the floor of the inguinal canal, steps that most surgeons omitted.
(From G.E. Wantz, The operation of Bassini as described by Attilio Catte-
rina, Surg Gynecol Obstet 1989;168:67-80.)
fort level, the complication rate and severity, the length of hospi-
tal stay, lost work time, and the cost of the procedure.
Randomized clinical trials propose a quasi-metaphysical prob-
FIGURE 1.9. Bassini's illustration of the surgical dissection for his inguinal lem to the surgeon, who as a craftsman is naturally inclined to do
hernioplasty. Note that the floor of the inguinal canal has been divided, ex- the best possible work and is reluctant to proceed at random. Ran-
posing preperitoneal fat. This essential step of the hernioplasty was not men- domized studies are inconsistent with the principle of personal-
tioned in his written description and may explain why so many surgeons ization of hernia cure. Comparison in hernia surgery is more
doing the Bassini hernioplasty never opened the posterior wall of the in- difficult than in evaluations of medical treatments. Even the meta-
guinal canal. From E. Bassini, Uber die Behandlung des Leistenlmtches, 1890. analysis method, which is considered a statistical technique that
limits personal and/ or institutional bias, should require organi-
zation to compare equivalent techniques applied to the same her-
merely a different approach but a new method, using different nia types and to the same patient groups.
tools, bringing a different type of physical contact with the patient,
having different potential risks, and even a different philosophy.
Its feasibility has been assessed by expert laparoscopic surgeons,
but laparoscopic hernia surgery is more difficult than other la-
paroscopic procedures. It is more difficult than open hernia
surgery to teach, to learn, and to perform. 4o
The safety of laparoscopic repair, even when satisfactory in ex-
pert hands, is not universally acceptable. Rare but unacceptably se-
vere complications are reported,41 mostly during the learning
period. Some of these complications may be unrecognized intra-
operatively (for example, a bowel injury), leading to catastrophic
consequences related to delayed diagnosis. 42 Because every method
has its limits, criteria for laparoscopic repair should be established.
Laparoscopy's real benefit in terms of patient satisfaction has
been investigated in several recent controlled studies. The princi-
pal criterion for the evaluation of a hernia cure is consensually the
recurrence rate, after a follow-up of at least five years, preferably
by a surgeon, on at least 90% of the total number of patients. Be-
cause this long-term follow-up is difficult to realize in active patient
series, a logical exacting "maximum bias method" has been recently FIGURE 1.11. Halsted's illustration showing his first hernioplasty. All layers
proposed. It consists of treating as recurrences all patients who have of the abdominal wall are cut through down to the peritoneum. The cord
not changed addresses and who refuse to answer the surveys. Other is withdrawn to the subcutaneous tissues. The repair is done with mattress
criteria used in comparative evaluations are the postoperative com- sutures that encompass all aponeurotic-muscular layers of the abdomen.
8 R. Stoppa et a\.
FIGURE 1.12. Illustration from Marcy's famous book showing simple ring
closure. There is no doubt as to the nature of the repair. The transverse FIGURE 1.14. Fruchaud's myopectineal orifice (10) delineated by the rec-
aponeurotic arch is sutured to the iIiopubic tract. From The Anatomy and tus muscle medially (11), the iliopsoas muscle laterally (6), the internal
Surgical Treatment of Hernia. New York: D. Appleton & Co, 1892. oblique muscle superiorly (1), and the pecten of the pubis inferiorly (12).
The spermatic cord (9) and iliac vessels (7,14) cross the myopectineal ori-
fice. Drawing by A. Moreaux in H.M. Fruchaud, Anatomie Chirurgicale des
However that may be, some controlled studies have compared Hernie de [,Aine, Doin: Paris, 1956.
laparoscopic techniques to nonlaparoscopic repairs (Brooks,43
Payne,44 Stoker,45 Barkun,46 Lawrence,47 Wilson,48 Filipi,49 Horey-
seck, 50 Zieren,51 Champault,52 Heikkinen,53 Liem 54 ). Most of them laparoscopic techniques do not provide better results than those
are open to criticism on a statistical level, and most provide con- of classic surgery.
troversial conclusions, but they have merit and take some steps in Studies comparing the two main laparoscopic procedures (TAPP
the search for evidence. Compared to some current open repairs, vs TEP) are few: Khoury,55 Schrenk,56 Tschuydi.57 They have a low
laparoscopic hernia surgery does not reduce hospital stay. Post- follow-up, but these reports indicate that the TAPP procedure is
operative pain is not less than it is after the Lichtenstein or Gilbert the easiest to learn and to perform. But the intra-abdominal ma-
procedures. The return to normal activity occurs after nearly the nipulation, with incision of the peritoneum and extraperitoneal
same amount of time after each procedure in comparable groups insertion of mesh (TAPP; transabdominal preperitoneal), much
of patients (same age, type of work). In long-term recurrence rate, like the IPOM; intraperitoneal onlay patch repair which leaves
mesh in the peritoneal cavity, exposes the patient to the risk of
postoperative obstruction and may have a higher recurrence rate
than the TEP technique. As far as individualization of the repair
is concerned, laparoscopic procedures, which systematically use
prosthetic material, are overtreatrnent for types I and II hernias.
Because of the paucity of convincing studies favoring laparo-
scopic procedures and the need for a minimum of five years of
follow-up, we must wait several years for reports of rigorous com-
parative results before we will know the most efficient procedures
in terms of postoperative comfort, recurrence rate, and cost.
Laparoscopic repair has not replaced open hernia operations,
currently the most commonly performed. It is necessary and wise
to continue to teach the classic procedures. Taking into account
laparoscopic surgery's technical difficulty, highly technologic de-
pendence, and its uncertain safety, it seems advisable not to in-
troduce this hernia surgery on a large scale. Surgeons with
experience and skill in laparoscopic repair can continue to oper-
ate this way, but they must think twice about pressuring the sur-
gical community and influencing public opinion in exclusive favor
FIGURE 1.13. From an 1899 Ferguson paper showing the undissected sper- of laparoscopic hernia repair (Wantz58 ).
matic cord and the repair that consisted of the approximation of the in- There remains the unresolved question of whether hernia
ternal oblique abdominal muscle to the inguinal ligament. surgery should be a surgical specialty. Indeed, it has an undeni-
able identity, composed of its anatomic and physiologic bases, its 19. Griffith CA. Indirect inguinal hernia. With special reference to the
requirement for benignity and success, and its humanistic and Marcy operation. In: Nyhus LM, Harkins HN, eds. Hernia. 1st ed.
social implications. There is a community of specially interested Philadelphia: Lippincott; 1964.
surgeons and great demands for these services. There are large 20. Peacock EE, Jr, Madden JW. Studies on the biology and treatment of
recurrent inguinal hernia: II. Morphological changes. Ann Surg. 1974;
differences in the results between experts and nonexperts.
179:567.
But hernia surgery, a very good example of a well-regulated
21. Read RC. Attenuation of rectus sheath in inguinal herniation. Am J
surgery with rather simple basic procedures, is really a part of gen- Surg. 1970;120:610.
eral surgery. Performing good hernia surgery has proved benefi- 22. Aquaviva DE, Bourret P, Corti F. Considerations sur l'emploi des plaques
cial to the practices of young surgeons. Progress has not been made de nylon dites crinoplaques comme materiel de plastie pamtale. Cong Fr de
only by those surgeons devoted exclusively to inguinal hernio- Chirugie, Paris: Masson; 1949:453.
plasty. We believe that unnecessary specialization could impover- 23. Usher FC, Ochsner JL, Tuttle LL,Jr. Use of Marlex mesh in the repair
ish hernia surgery, when maintaining it within general surgery of incisional hernias. Ann Surg. 1958;24:969.
would result in more creative exchanges. On condition that resi- 24. Koontz AR, Kimberley RC. Tantalum and Marlex mesh (with a note
dents in general surgery be excellently taught the details of on Marlex thread). An experimental and clinical comparison-pre-
liminary report. Ann Surg. 1960;151:796.
anatomy of the groin and thoroughly trained in hernia repair, her-
25. RivesJ, Lardennois B, FlamentjV, et al. La piece en tulle de Dacron,
nia surgery is "a quintessential operation, which epitomizes
traitement de choix des hernies de l'aine de l'adulte. A propos de 183
surgery" (Wantz59 ). cas. Chirurgie. 1973;99:564.
It falls to surgeons to continue to push hernia repair toward ex- 26. Stoppa RE, Rives JL, Warlaumont CR, et al. The use of Dacron in the
cellence, a duty assumed with close application by Chevrel and the repair of hernias of the groin. Surg Clin North Am. 1984;64:269.
GREPA members for more than 20 years,60 and by the American 27. Royal College of Surgeons of England. Guidelines on the Manage-
Hernia Society members, among others. This is an ethical service ment of Groin Hernia in Adults. Report of a Working Party Convened
and, at the same time, a source of professional pride. by the Royal College of Surgeons of England. London, 22 April
1993.
28. Nyhus LM, Klein MS, Rogers FB. Inguinal hernia in current surgical
problems. Surgery XXXVIIII, St. Louis: Mosby Year Book, Inc., 1991;
References 6:403.
29. Devlin HB. Management of Abdominal Hernias. London: Butterworth,
1. Stoppa R, Wantz G, Munegato G, et al. Hernia Healers. An IUustrated 1988.
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2. Segond P. Cure radicale des hernies. In: These du Concours d'Agregation, Commentary on preperitoneal herniorraphy. Preliminary report on
Paris: Masson; 1883. fifty patients. West J Surg. 1959;6:48.
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operations or radical cure. NY MedJ 1891;53:615. cation and treatment of groin hernias. Am J Surg. 1967;114:894.
4. Bassini E. Sulla cura radicale dell'ernia inguinale. Arch Soc ltal Chir. 32. Gilbert AI. An anatomic and functional classification for the diagno-
1887;4-30. sis and treatment of inguinal hernia. Ann Surg. 1989;157:331.
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6. Shouldice EE. Surgical treatment of hernia. Ontario Med Rev. 1945; graphie GREPA. 1993;15:12-14.
12:43. 34. Stoppa RE, Warlaumont CR The midline preperitoneal approach and
7. Fruchaud H. Anatomie chirurgicale des hernies de l'aine. Paris: Doin; 1956. the prosthetic repair of groin hernia. In: Nyhus LM, Baker RJ, eds.
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Paris: Doin; 1956. 35. NicollJH. The surgery of infancy. Br MedJ 1909;ii:753-756.
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don: Longman; 1804, 1807. Trans lnt Med Congo 1891;2:446.
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11. McVay CB, Chapp JD. Inguinal and femoral hernioplasty. Evaluation 38. Gilbert AI. Inguinal hernia repair: biomaterials and sutureless repair.
of a basic concept. Ann Surg. 1958;148:499. Perspec Gen Surg. 1991;2/1:113.
12. Condon RE. Surgical anatomy of the transversus abdominis and trans- 39. Wantz GE. Giant prosthetic reinforcement of the visceral sac. Surg Gy-
versalis fascia. Ann Surg. 1971; 173: 1. necol Obstet. 1989; 169:408.
13. Annandale T. Case in which a reducible oblique and direct inguinal 40. Wantz GE. Atlas of Hernia Surgery. New York: Raven Press; 1991.
and femoral hernia existed on the same side and were successfully 41. Wantz GE. The technique of giant prosthetic reinforcement of the vis-
treated by operation. Edinb MedJ 1876;21:1087. ceral sac performed through an anterior groin incision. Surg Gynecol
14. Cheatle GL. An operation for the radical cure of inguinal and femoral Obstet. 1993; 176:497.
hernia. Br Med J 1920;2:68. 42. Wantz GE. Properitoneal hernioplastywith Mersilene,® giant prosthetic
15. Henry'AK. Operation for femoral hernia by a midline extraperitoneal reinforcement of the visceral sac (GPRVS). In: Bendavid R, ed. Pros-
approach: with a preliminary note on the use of this route for reducible theses and Abdominal Wall Hernias. Austin: RG. Landes Company; 1994.
inguinal hernia. Lancet. 1936;1:531. 43. Brooks DC. A prospective comparison oflaparoscopic and tension-free
16. Nyhus LM, Stevenson JK, Listerud MB, et al. Preperitoneal hernior- open herniorrhaphy. Arch Surg. 1994;129:361-366.
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18. Stoppa R, Petit J, Abourachid H. Procede original de plastie des 45. Stoker DL, Spiegelhalter DJ, Singh R, et al. Laparoscopic versus open
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de Dacron par voie mediane sous-peritoneale. Chirurgie. 1973;99:119. 1243-1245.
10 R. Stoppa et al.
46. BarkunJ, Wexler~, Hinchey EJ, et al. Laparoscopic versus open in- 53. Heikkinen T, Haukipuro K, LeppalaJ, et al. Total costs oflaparoscopic
guinal herniorrhaphy: preliminary results of a randomized controlled and Lichtenstein inguinal repairs: a randomized prospective study.
trial. Surgery. 1995;118:703-710. Surg Laparosc Endosc. 1997;7:1-5.
47. Lawrence K, McWhinnie D, Goodwin A Randomised controlled trial 54. Liem MSL, van der GraafY, van Steensel Cj, et al. Comparison of con-
of laparoscopic versus open repair of inguinal hernia; early results. Br ventional anterior surgery and laparoscopic surgery for inguinal her-
MedJ 1995;311:981-985. nia repair. N EnglJ Med. 1997;336:1541-1547.
48. Wilson MS, Dean GT, Brough A Prospective trial comparing Licht- 55. Khoury N. A comparative study of laparoscopic extraperitoneal and
enstein with laparoscopic tension-free mesh repair of inguinal hernia. transabdominal preperitoneal herniorrhaphy. ] Laparoendosc Surg.
BrJ Surg. 1995;82:274-277. 1995;5:349-355.
49. Filipi Cj, Gaston:Johansson F, McBride PJ. An assessment of pain and 56. Schrenk P, WoisetschHiger R, Rieger R, et al. Prospective randomized
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free Lichtenstein repair. Surg Endosc. 1996;10:983-986. ter transabdominal preperitoneal, total preperitoneal or Shouldice
50. Horeyseck G, Roland F, Rolfes N. "Tension-free" repair of inguinal her- technique for inguinal hernia repair. BrJ Surg. 1996;83:1563-1566.
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1996;67:1036-1040. paroscopic transabdominal preperitoneal hernioplasty vs Shouldice
51. Zieren J, Zieren HU, Wenger FA, et al. Laparoskopische oder Kon- herniorrhaphy, early results. Surg Endosc. 1996;10:845-847.
ventionelle Leistenhernienreparation mit oder ohne Implantat. Eine 58. Wantz GE: Editorial: The American Hernia Society. Hernia. 1997;1:3.
prospektiv-randomisierte Studie. Langebecks Arch ChiT. 1996;38:289-294. 59. Wantz GE. Abdominal wall hernias. In: Schwartz S, Shires GT, Spencer
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Randomized trial of 100 cases. Surg Laparosc Endosc. 1997;7:445-450. Berlin Heidelburg: Springer-Verlag; 1998.
2
Use of the Preperitoneal Space
in Inguinofemoral Herniorrhaphy:
Historical Considerations
Raymond C. Read
In ancient Egypt, groin hernias were treated only by external ma- ing Poupart's, Gimbernat's and Cooper's ligaments. The suture
nipulation and bandaging, but celiotomy was used in India by the was then passed down the femoral canal through the saphenous
Hindus in the Brahmanic era (800-500 BC) and Praxagoras in foramen and affixed to the skin of the thigh.lO
Greece (350 BC) for the relief of obstructed and strangulated One of the enthusiasts of "abdominal section for displaced her-
bowel resistant to taxis. Reduction of intestine, with or without nia," Lawson Tait,n was a gynecologist who noticed the ease of in-
incision of the hernial ring (kelotomy) or resection was accom- cidental herniorrhaphy while operating in the pelvis in 1883. His
plished through a small incision in the linea alba near the pro- patient had an ovarian cyst in association with an undiagnosed in-
trusion. During the Dark Ages, this procedure continued to be carcerated femoral hernia. Mter resecting the tumor from the
performed in the East. Most of the Greeks and all the Romans cut pelvis, he was able to reduce the herniated omentum and adher-
from below. I This dichotomy between the transabdominal (pos- ent intestine. He closed the femoral ring with a silk purse-string
terior) and the inguinal (anterior) routes continued. In the Mid- suture. This experience led him to recommend that the treatment
dle Ages, the incisor Stromayr, in his manuscript of 1559,2 of herniation by median abdominal section should be extended
illustrated transfixion of the spermatic cord at the external in- to nonstrangulated, reducible chronic hernias. He spelled out the
guinal ring. Cantemir reported on transperitoneal taxis and re- advantages of the intraperitoneal approach to the elective "radi-
pair in his history of the Ottoman Empire. This was translated into cal" cure of reducible hernias through a suprapubic linea alba in-
French by Joncquieres3 in 1743, and Marcy published it in English cision in an extensive presentation to the section of surgery at the
in 1892.4 1891 meeting of the British Medical Association. The benefits in-
According to Chavasse,5 Crompton of Birmingham, England, cluded: (a) ease of pulling out rather than pushing back herni-
used the transperitoneal posterior approach to the groin in a ated intestine or omentum; (b) rare need to dilate the hernial
patient with strangulated umbilical herniation in 1860. Finding ring; (c) less hemorrhage; (d) laparotomy easily extended for in-
the gut gangrenous, he desisted and laid the sac open. Niven,6 the testinal resection; (e) no risk of reductio en masse; (f) quick re-
following year, suggested that femoral hernias could be similarly pair; (g) no risk of injury to the intestine; (h) incision bloodless
managed. The great Scottish surgeon, Annandale, repeated and easy to close; and (i) no damage to the inguinal canal, infe-
Crompton's procedure in 1873. Bowel obstruction relented, but rior epigastric vessels or the parietes. 12 A number of British sur-
the patient died two days later. He commented, "The ease with geons enthusiastically supported him. Keetley (1886) summarized
which a strangulated portion of the gut is relieved when gentle their case reports. Celiotomy was recommended for adults with
traction is made upon it, is remarkable."7 In the United States, large umbilical, inguinal or femoral protrusions and any others
Hutchinson (1878) reported on a case of inguinal herniation which presented difficulties. 13
which, after multiple unsuccessful attempts at taxis under anes- In the United States, Kelly (1898), the first gynecologist-in-chief
thesia, was operated upon in this manner. Bowel displaced through at Johns Hopkins Hospital, followed Tait's lead. He sometimes
a tear in the peritoneum was found, and the reductio en masse plugged the femoral canal from within, using a marble. 14 Later,
was relieved, but gangrene supervened, resulting in the death of Gillion (1891) published an article in Belgium,15 and Robins
the patient. s A similar case treated successfully was described by (1909) of Richmond, Virginia, another gynecologist, described a
Ward eight years later. 9 patient with recent strangulation of an inguinal protrusion. Find-
In the 1880s and 90s, a number of case reports appeared in ing the hernia irreducible from a groin incision, he extended it
British medical journals attesting to the value of this approach in superiorly, split the rectus muscle, entered the abdominal cavity
the management of strangulated hernias. Maunsell, from New and reduced the bowel. Mter ligating the sac, he returned below
Zealand, published in support of this operation in 1887, and par- and performed a repair. His patient made an uneventful recov-
ticipated in a spirited discussion at the 1891 annual meeting of ery.l6 In 1919, LaRoque, also from Richmond, Virginia, published
the British Medical Association. He propounded the importance his intraperitoneal approach to all inguinal hernias. He used a
of complementary closure of the femoral ring, which he achieved muscle-splitting transverse incision in the internal oblique and
with transperitoneal placement of a silver wire mattress suture join- transversus layers immediately above the internal inguinal ring to
11
R. Bendavid et al. (eds.), Abdominal Wall Hernias
12 R.e. Read
perform celiotomy, closing the neck of the sac from within. A con- marcates with a dihedral angle formed by the fascia transversalis
ventional herniorrhaphy followed. 17 In 1922, his technique was ap- and the fascia iliaca inferiorly, a triangular prismatic interval filled
plied to femoral herniation. I8 with preperitoneal adipose tissue called the space of Bogros. "30
In 1907, Moschcowitz recommended transperitoneal repair of Further, Bogros described the inferior epigastric vessels as "first
femoral defects through a suprainguinal incision.l 9 In 1913, Bates passing inferiorly, overlying the parent external iliac vessels, then
applied Moschcowitz's operation to the elective intraperitoneal returning anteriorly to enter the abdominal wall." Thus, their plexes
pair of indirect herniation. 20 LaRoque's operation was later rec- run between Cooper's two laminae of transversalis fascia, not
ommended, particularly for sliding hernias, incarcerated or within the extraperitoneal space, as suggested by Condon and Ben-
strangulated intestine, and cryptorchidism by Williams 2I until the david. 31 That Bogros's space is avascular was demonstrated in 1972
end of World War II. It was revived by Dennis and Varco in 1947 by Tyson and Reichle, who used it for extraperitoneal femoro-
for strangulated femoral herniation. 22 McEvedy (1966)23 and femoral arterial bypass. Nevertheless, illey reported that in a pa-
Wilkinson (1967) were the last to publish on the intraperitoneal tient with iliac thrombophlebitis undergoing saphenofemoral
technique. 24 The introduction of laparoscopic techniques (pio- venous bypass, vesical venous collaterals can be torn. 32 It would be
neered again by gynecologists) to groin herniorrhaphy in 1982 by 53 years before Annandale, and 62 years before Bassini, docu-
Ger,25 resurrected the intraperitoneal posterior approach. mented division of the external oblique aponeurosis and the trans-
Pari passu with the interest detailed above in the transabdomi- versalis fascial floor of the inguinal canal, for the repair of
nal (intraperitoneal) route to the groin, the anterior approach herniation.
from below continued. In the early 19th century, repair was little The topography of the midline pubovesical preperitoneal space
different from that provided by the Romans, except that efforts of Retzius33 (1852) is well known. Amazingly, this Swedish an-
were made not to include the spermatic cord in the ligature of atomist was unaware of the space of Bogros since its description
the processus vaginalis. Later on, attempts were made to also oblit- was documented only in a thesis, Bogros dying of pulmonary tu-
erate the inguinal canal by external compression (trusses), some- berculosis in 182~three years after his monumental contribu-
times supplemented by injected escharotics. The culmination of tion. However, as indicated above, Rouviere and other French
these efforts by, among others, Gerdy (1797-1856), a French sur- anatomists at the beginning of the twentieth century pointed out
geon who plugged the external inguinal ring with inverted scro- that the lateral spaces of Bogros and the midline space of Retzius
tal skin held by sutures, and Wutzer (1789-1858), who secured it communicate.
with a wooden plug, was Wood's operation (1863)26 and that of The first surgeon to use the preperitoneal space in the repair
MacEwen (1886).27 They dissected up the hernial sac blindly from of groin herniation was Annandale, in 1876. He reported an op-
the external ring, and used it to plug the internal abdominal ring, eration he had performed on a 46-year-old man with unilateral,
being fixed, transcutaneously, by suture to the postero-Iateral triple herniation, indirect, direct inguinal and femoral defects.
abdominal wall using a Reverdin needle. Bassini employed this The protrusions were so large that no truss could be fitted. The
procedure which, he showed at autopsy, failed from eventual ab- patient suffered from a dragging pain, and since the protrusions
sorption of the sac. It was this experience which prompted him to came down when he stood, walked, or coughed, he was unable to
develop his own operation (anterior approach), thus laying the work. Annandale made an incision an inch above the inguinallig-
foundation for modern herniology.28 ament and cut through the roof and floor of the inguinal canal,
severing the epigastric vessels. The necks of the inguinal sacs were
isolated close to the general peritoneum. Mter opening, they were
ligated, all content being reduced. The femoral sac reduced spon-
The Use of the Preperitoneal Space taneously, and he plugged the femoral canal with the inguinal sac
stitched below to the skin of the thigh, overlying the saphenous
The Anterior Preperitoneal opening. The patient was seen three months later when he was
Approach to the Groin doing well except for a femoral bulge, which was treated with a
truss. 34 Annandale was thus the first to use the anterior preperi-
Remarkably, the first surgical use of the preperitoneal space was toneal approach for femoral and inguinal herniorrhaphy. He pre-
not for herniorrhaphy, but proximal ligation (Hunterian) of the ceded Bassini (1884) in dividing the roof of the inguinal canal in
epigastric or external iliac artery for aneurysm. An extraperitoneal the management of groin herniation. His operation was further
approach was designed to avoid the risk of peritonitis (before an- developed by Ruggi (1892),35 in Italy, and Lotheissen (1898), a
tisepsis) from dividing the closely applied peritoneal layer with pupil of Billroth. 36
higher abdominal incisions. This procedure was undertaken from Bassini's operation (1887), which revolutionized the surgery of
below, using the anterior approach to the groin, the roof and floor groin herniation, also made use of the preperitoneal space as
of the inguinal canal being divided. The operation, performed be- reached from below through the anterior approach. Like Annan-
fore the development of anesthesia, was described in an MD the- dale, he not only divided the external oblique aponeurosis-the
sis to the University of Paris in 1823 by Bogros.29 This Professor roof of the canal-but also transected the transversalis fascial floor
of Surgical Anatomy at that institution had observed, "The exter- as well, while preserving the epigastric vessels. He was followed
nal iliac artery terminates without a serosal cover ... The peri- closely by Halsted (1889).37 Unfortunately, numerous modifica-
toneum extending from the anterior abdominal wall to the iliac tions soon replaced these preperitoneal procedures with suturing
fossa leaves in front a space 13.5 to 15.5 mm wide." Rouviere of the internal oblique muscle to the inguinal ligament. It took
(1912), the great French anatomist, added, "... the outer layer of more than 60 years before the Shouldice Clinic reinstituted the
the peritoneum, in the shape of a gutter, concave above and be- modern Bassini and returned the operation to the preperitoneal
hind, is in contact with the soft tissues of the iliac fossa from 1 to position. Concern about tension and suture failure, especially with
1.5 cm above the inguinal ligaments. The peritoneum thus de- direct and recurrent herniation, led to the introduction of pros-
2. History of the Preperitoneal Space 13
theses by Acquaviva and Bourret (1948).38 Usher (1958) put an- muscle. The repair was performed internal to them in the avas-
terior prosthetic repair on the map, using the preperitoneal ap- cular lateral preperitoneal space of Bogros. He commented upon
proach. 39 Mahorner and Goss (1962), in two patients with finding "unsuspected and potential sacs" on the contralateral side,
recurrent herniation who had lost both inguinal and Cooper's lig- "dimples" of peritoneum and obliterated cords of processi vagi-
aments, inserted a preperitoneal dermal graft from below. 4o Rives nales. Occasionally, the urachus or a partially obliterated hypo-
(1965), in France, used Mersilene® in the same way and stimu- gastric artery (lateral umbilical fold) were seen. Ifhe encountered
lated his students, Stoppa and Flament, to further develop properi- an incarcerated hernia, he opened the peritoneum and converted
toneal prosthetic placement from both above and below. 41 More his operation to the intraperitoneal posterior procedure.
recently, Schumpelick42 and 143 have reported our experiences Thus, Cheatle's particular contribution was entering the lateral
with anterior preperitoneal prosthetic repair. suprainguinal parietoperitoneal space of Bogros via the space of
Retzius, thereby providing access to bilateral groin herniation. In-
cidentally, he described concomitant appendectomy. He lived for
30 more years without publishing further on this procedure. It is
The Posterior Preperitoneal remarkable that his landmark publication made so little impact
Approach to the Groin that it was not even mentioned in his obituary ("No surgical in-
novations are associated with his name.") .48 His operation was re-
The first procedure from above the pubis using the posterior discovered by Henry in 1936, who described bilateral closure of
preperitoneal space in the repair of inguinofemoral herniation indirect inguinal sacs at their true neck next to the general peri-
was that of Cheatle in 1920. 44 George Lenthal Cheatle received his toneal envelope. 49 Nevertheless, little interest was shown in this
medical education at King's College in London, graduating in procedure until after World War II. It was not even mentioned in
1887. He obtained his surgical training at the hospital under Edwards's authoritative review of herniology in 1943,50 or that of
Joseph Lister, Chairman of Surgery (1877-1893), assisting the lat- Harkins in 1949. 51
ter in the last operation he performed. Cheatle, who was blessed The procedure was revived in the United States by Jennings and
with an original mind and a passion for research, particularly in Anson (1942), who touted its advantages, exposure of the defect,
regard to inflammation and cancer of the breast, loved the un- access to the deep transverse layer, importance of preperitoneal
orthodox. He became a devoted disciple of Lister, from whom he fatty protrusion, high ligation of peritoneal sacs, less infection, and
learned the virtues of enthusiasm, hard work, and attention to de- absence of injury to the spermatic cord and the accompanying
tail. He spent his whole surgical career at King's College Hospital, nerves. 52 In 1949, Musgrove and McCready, at the Mayo Clinic,
becoming senior surgeon in 1923, retiring in 1930. He is best recommended the Cheatle-Henry operation for femoral and
known for his discovery of the association between Paget's disease obturator hernias. 53 Riba and Mehn (1952) described its associa-
of the nipple and underlying breast cancer, as well as his widely tion with retropubic prostatectomy.54 Hull and Ganey (1953),55
used dressing forceps. Mikkelsen and Berne (1954),56 Shandling and Thomson (1960),57
Herniology flourished at this institution. In 1863, Professor and Lipton (1961)58 then reported extensively on the procedure.
Wood had published his book on hernia, which described subcu- The latter three contributors worked with children, emphasizing
taneous fascial invagination and obliteration of the inguinal sac its use in cryptorchidism and incarcerated or recurrent hernia-
within the canal, a procedure which was derived from the earlier tion. McVeigh and Barker (1954) pointed out disadvantages-
Gerdy (1820)45 and Wutzer (1838)46 inverted skin procedures. It local anesthesia could not be used, there was no easy way to per-
became widely used. Lister and his pupils from Britain and around form a relaxing incision, scrotal sacs could not be removed, good
the world, including Annandale, Marcy, Bassini and Lucas-Cham- fascia was not always available in direct herniation, the external
pionniere, searched for the radical cure. They had an advantage oblique layer could not be used in the repair, and its ring remained
over many of their colleagues because they had not resisted, for a open. 59 The Cheatle-Henry approach was enthusiastically en-
decade or two, the application of antisepsis. They were thus able dorsed by Stoppa, who over the last quarter of a century has used
to open up tissue planes, dissect, and use buried sutures. his giant prosthesis reinforcement of the visceral sac (GPRVS) to
Cheatle's first description of his operation was brief, little more repair bilateral groin herniation. He has concentrated on difficult
than haifa page. His first use ofa paramedian incision was adopted cases, many with recurrent disease. It is remarkable that he has
because it was less liable to break down than the midline. It also been able to obtain a recurrence rate similar to most surgeons op-
did not require as much retraction to work within the lateral erating on primary herniation. 60 Wantz has popularized this im-
preperitoneal suprainguinal space of Bogros. Like Henry later, he portant advance in the United States and developed his own
pointed out that there is an intra-abdominal preperitoneal sper- unilateral variant. 61 Most laparoscopic repairs today use the pos-
matic cord which may contain an indirect sac between the inter- terior preperitoneal approach and attempt to reproduce Stoppa's
nal ring and the general peritoneal cavity. prosthetic repair, avoiding any slit for the spermatic cord.
The following year, in his second publication,47 Cheatle pointed Perhaps the most important post-World War II contribution to
out that he was "led to devise a new method," the transabdominal posterior preperitoneal herniorrhaphy was made by P.G. McEvedy
preperitoneal abdominal approach, because he had encountered in 1950. 62 He introduced the unilateral approach from above for
a succession of cases which, from below, "presented difficulties in femoral herniation. His incision through the rectus sheath was
the efficient excision of the sac." He had now reverted to median originally vertical, extending into the thigh where necessary to re-
section, conducted with a Pfannenstiel incision recommended by lieve incarceration. At the suggestion of Ogilvie and McNaught
the gynecologist Victor Bonney, emphasizing again the influence (1956),63 the incision was made oblique with medial, rather than
of this specialty and (later with Henry) urology on the develop- lateral, retraction of the rectus muscle. The same year, Reay'-
ment of herniology. Cheatle described retraction, within the space Young64 changed the approach to half a Pfannenstiel incision.
of Retzius, of the inferior epigastric vasculature with the rectus The prime mover in posterior preperitoneal herniorrhaphy of
14 RC. Read
the groin has been Nyhus (1960).65 He and his associates (1959)66 8. Hutchinson E. Case of strangulated hernia operated on by abdominal
were stimulated by Mikkelsen and Berne to use the Cheatle-Henry section. Laparotomy. Ohio Med SurgJ 1878;3:499-502.
approach. Visiting Professor John Bruce of Edinburgh, in discus- 9. Ward E. Abdominal section for displaced hernia. Lancet. 1886;2:201-
sion of their paper, recommended using the unilateral McEvedy 203.
approach. Taking his advice, Nyhus's group reported the follow- 10. Maunsell HW. Radical cure of strangulated femoral hernia by supra-
pubic laparotomy. N Z MedJ 1887;1:23-25.
ing year on a large series using a modified McEvedy procedure,
11. Tait L. On the radical cure of exomphalos. Br Med J 1883;2:1118.
extended across the midline in bilateral defects. 12. Tait L. A discussion on treatment of hernia by median abdominal sec-
Nyhus's contribution sparked an explosion of interest in the tion. Br MedJ 1891(2):685-691.
approach from above and led to a better understanding of the 13. Keetley CB. Thirteen cases of herniotomy for strangulated hernia. Br
anatomy of the preperitoneal suprainguinal space. Fowler MedJ 1883;2:1093-1095.
(1975) ,67 an Australian pediatric surgeon, made an important con- 14. Kelly HA. Femoral hernia. operative Gynecology. New York: D. Appleton
tribution when he brought together previous observations of Co.; 1898;Vol. 2:490-491.
Bassini regarding peritoneal ligation in the iliac fossa (1890); 15. Gillion L. Un nouveau procede de herniotomie, laparotomie pour
Henry, true and false necks of the processes vaginalis (1936); and hernie ombilicale. Clinique (Brux). 1891;5:758-760.
Lytle, the internal inguinal ring (1945).68 These were extended by 16. Robins CR Rectus incision for reduction of strangulated hernia with
a report of a case of strangulated hernia in the sac of an undescended
Lampe for the preperitoneal fascia (1989)69 and Read, Cooper's
testicle. Old Dom J Med Surg. 1909;8:324-326.
posterior lamina of transversalis fascia (1992).70 The result was an 17. LaRoque GP. The permanent cure of inguinal and femoral hernia: a
understanding that the internal spermatic fascia was not derived modification of standard operative procedures. Surg Gynec Obstet. 1919;
from the internal inguinal ring and the anterior lamina of the 29(5):507-511.
transversalis fascia, but more internally from preperitoneal fascia 18. LaRoque GP. The intra-abdominal operation for femoral hernia. Ann
and the posterior lamina of the transversalis fascia at the secondary Surg. 1922;75:110-112.
internal ring close to the general peritoneal cavity. A preperitoneal 19. Moschcowitz AV. Femoral hernia: a new operation for the radical cure.
spermatic cord, with or without a processus vaginalis, runs through JAMA. 1907;48:896-900.
the fatty avascular space of Bogros. High ligation of the sac de- 20. Bates UC. New operation for the cure of indirect inguinal hernia.
mands dissection internal to the internal inguinal ring. Preperi- JAMA.1913;60:2032-2033.
21. Williams C. Repair of sliding inguinal hernia through the abdominal
toneal fat in the space of Bogros may therefore be a source of
(LaRoque) approach. Ann Surg. 1947;126(4):612-623.
sliding herniation, with or without a processus vaginalis, and must 22. Dennis C, Varco RL. Femoral hernia with gangrenous bowel. Surgery.
be distinguished from cord lipomata. The inferior epigastric vas- 1947;22:312-323.
culature courses between the two laminae of transversalis fascia. 23. McEvedy BV. The internal approach for inguinal herniae. Postgrad Med
Dissatisfaction with the results of sutured repairs through this J 1966;42:548-550.
approach prompted the application of prosthetics. This had been 24. Wilkinson BW. LaRoque intra-abdominal approach for removal of
successfully performed in a large series from the anterior preperi- hernia sac of inguinal and femoral hernia. W Va Med J 1967;63:
toneal approach by Usher, et al. in 1958. Nyhus used a polyvinyl 142-146.
alcohol sponge in a patient (1959). Estrin and associates,71 in a se- 25. Ger R The management of certain intra-abdominal hernias by intra-
ries employing Usher's Marlex® (polypropylene) mesh (1963), pi- abdominal closure of the sac. Ann R Coll Surg Engl. 1982;64:342-344.
26. Wood J. On Rupture, Inguinal, Crural and Umbilical; the Anatomy,
oneered their application from the posterior preperitoneal
Pathology, Diagnosis, Cause and Prevention with New Methods of Ef-
approach. I followed in 196772 and 1976. 73 Calne (1967)74 com- fecting a Radical and Permanent Cure, Embodying the Jacksonian
bined the anterior and posterior preperitoneal approaches, laying Prize Essay of the Royal College of Surgeons of London. London:
a large piece of Mersilene® mesh behind both rectus muscles af- Davies; 1863.
ter opening both groins for bilateral groin herniation. These many 27. MacEwen W. On the radical cure of oblique inguinal hernia by inter-
contributions have allowed the profusion of preperitoneal tech- nal abdominal peritoneal pad and the restoration of the valved form
niques available to the surgeon today for the management of pa- of the inguinal canal. Ann Surg. 1886;4:89-119.
tients presenting with herniation through the groin. 28. Bassini E. Nuovo metodo per la cura radicale dell'ernia inguinale. Atti
Congre Assoc Med leal. 1887;2:179-182.
29. Bogros AJ. Essai sur l'anatomie chirurgicale de la region iliaque et de-
scription d'un nouveau procede pour faire la ligature des arteres epi-
gastrique et iliaque externe. Th. Paris 1823, no. 153. A Paris, de
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Am. 1984;64:185-196. Masson Edit, Paris, 1912.
2. Read RC. Properitoneal herniorrhaphy: a historical review. WorldJ Surg. 31. Bendavid R The space of Bogros and the deep inguinal venous cir-
1989; 13:532-540. culation. Surg Gynecol Obstet. 1992;174:355-358.
3. de Cantemir D. Histoire de l'agrandissement de l'empire Ottoman. Trans- 32. Tyson RR, Reichle FA. Retropubic femorofemoral bypass: a new route
lated by M. De Joncquieres. 1743;2:397-401. through the space of Retzius. Surgery. 1972;72(3):401-403.
4. Marcy HO. The Anatomy and Surgical Treatment of Hernia. New York: D. 33. Retzius AA. Some remarks on the proper design of the semilunar lines
Appleton Co.; 1892. of Douglas. Edinb Med J 1858;3:865-867.
5. Chavasse TF. On a method of operating in strangulated umbilical her- 34. Annandale T. Case in which a reducible oblique and direct inguinal
nia. Lancet. 1882;1:865. and femoral hernia existed on the same side and were successfully
6. Niven J. A new operation for the relief of hernia. Lancet 1861;1:276. treated by operation. Edinb MedJ 1876;21:1087-1091.
7. Annandale T. On a method of operating in certain cases of strangu- 35. Ruggi G. Metodo operativo nuovo per la cura radicale dell'ernia cru-
lated hernia. Edinb MedJ 1873-4;19:209-211. rale. Bull Sci Med Bologna 1892;7(3):223.
2. History of the Preperitoneal Space 15
36. Lotheissen G. Zur Radikaloperation des Schenkelhernien. Centralbl 56. Mikkelsen WP, Berne CJ. Femoral hernioplasty: suprapubic extraperi-
ChiT. 1898;25:548-550. toneal (Cheade-Henry) approach. Surgery. 1954;35:743-748.
37. Halsted WS. The radical cure ofhernia.]ohns Hopkins HospBull. 1889; 57. Shandling B, Thompson S. The Cheade-Henry approach for inguinal
1:12-13. herniotomy in infants and children: The Hospital for Sick Children,
38. Acquaviva DE, Bourret P. Cure des eventrations par plaques de nylon. Toronto. Can] Surg. 1963;6:484-488.
Presse Med. 1948;56:892. 58. Lipton S. Use of the Cheade-Henry approach in the treatment of crypt-
39. Read RC. Francis C. Usher: the herniologist of the twentieth century. orchidism. Surgery. 1961;50(5):846--848.
Hernia. 1999;3:57-61. 59. McVeigh HJ, Barker WF. The midline extraperitoneal approach for
40. Mahorner H, Goss CM. Herniation following destruction of Poupart's the repair of inguinal and femoral hernias. West] Surg Obstet Cynec.
and Cooper's ligaments: a method of repair. Ann Surg. 1962;155(5): 1954;62:534-538.
741-748. 60. Stoppa RE, RivesJL, Warlaumont CR, PalotjP, Verhaeghe PJ, Delattre
41. Rives J. Surgical treatment of the inguinal hernia with Dacron® patch. Prin- JF. The use of Dacron in the repair of hernias of the groin. Surg Clin
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42. Schumpelick V. Atlas of Hernia Surgery. Philadelphia: B.C. Decker Inc; 61. Wantz GE. Giant prosthetic reinforcement of the visceral sac. Surg Gy-
1990. necoIObstet.1989;169:408-417.
43. Read RC, Barone GW, Hauer:Jensen M, Yoder G. Properitoneal pros- 62. McEvedy PG. Femoral hernia. Ann R Coll Surg Engl. 1950;7:484-496.
thetic placement through the groin: the anterior (Mahorner-Goss, 63. McNaught GHD. Femoral hernia: the rectus sheath operation of
Rives-Stoppa) approach. Surg Clin Narth Amer. 1993;73(3):545-555. McEvedy. ] R Coll Surg Edinb. 1956; 1:309-311.
44. Cheade GL. An operation for the radical cure of inguinal and femoral 64. Reay-Young PS. Repair offemoral hernia. Lancet. 1956;2:1217-1218.
hernia. Br MedJ 1920;2:68-69. 65. Nyhus LM, Condon RE, Harkins HN. Clinical experiences with
45. Gerdy PN. Nouvelles operations pour guerir radicalement les hernies preperitoneal hernial repair for all types of hernia of the groin. Am]
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48. Obituary. GL Cheade. Lancet. 1951;1:115-116. groin and the "secondary" internal inguinal ring. Aust N Z] Surg.
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Surg Clin North Am. 1949;29:1457-1482. 70. Read RC. Cooper's posterior lamina of transversalis fascia. Surg Cynecol
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Cynec Obst. 1942;74:697-707. femoral hernias. Surg Cynecol Obstet. 1963;116:547-550.
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55. Hull HC, Ganey JB. The Henry approach to femoral hernia. Ann Surg. 74. Calne RY. Repair of bilateral hernia: a technique using Mersilene®
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3
Prostheses in Hernia Surgery:
A Century of Evolution
James R. DeBord
Introduction Preserved fascial homografts and xenografts were the next log-
ical step in the development of tissue patches for hernia repair.
"A serious consideration of prophylactic and remedial measures in Over the years these have included "freeze-dried" human fascia
large hernia, of whatever nature, is surely justified by the knowledge lata,18.19 lyophilized homologous aorta,20 preserved human dura
that the individual thus afflicted can be nothing but a miserable in- mater,21.22 heterologous bovine (ox) fascia,23 and porcine dermal
valid. Not even the best fitting supporter can render life more than collagen. 24.25 While these biomaterials have had anecdotal success
bearable, nor is it possible for such a person to make any severe ex-
in hernia repair and appear to provide an adequate matrix for au-
ertion, whether it be in the pursuance of an occupation or in the en-
tologous fibroblastic ingrowth, there remain problems related to
joyment of an athletic sport." (Willard Bartlett, M.D., Washington
University, St. Louis, Mo., 19031) the host local inflammatory reaction to these nonautologous tis-
sues as well as the modern concerns about occult viral disease
From the beginning of modern anatomical hernia surgery, ush- (HIV) transmission, however remote, that might possibly occur
ered in by Bassini in 1887,2 recurrences have plagued and frus- whenever "preserved" tissues are transplanted. There remains,
trated surgeons of all ages, experience, skill, and nationality. Over however, a role for careful autologous closure of large abdominal
the past century, it has become clear even to the most recalcitrant wall defects using local tissue transfer techniques such as the bi-
devotee of autologous tissue repairs that prosthetic biomaterials lateral advancement flap technique of Lucas and Ledgerwood,
will sometimes be required to bridge or reinforce natural and un- which mobilizes the external oblique and recti muscles medially
natural defects in the integrity of the abdominal wall, inguinal via a lateral relaxing incision. 26
canal, and chest wall.
Metal Prostheses
Autologous Repair
Silver Filigrees
Techniques for the use of free pedicle-based autografts of exter-
nal oblique aponeurosis and fascia lata were developed and uti- The earliest use of man-made prosthetic reinforcements for her-
lized for the repair of hernias from 1901 to the present-day use of nia repair was the placement of silver wire coils on the floor of
the tensor fasciae latae myocutaneous flap, which provides both the inguinal canal by Phelps in 1894.27 This concept was expanded
vascularized fascia and viable soft tissue and skin coverage.3-11 by the German surgeons Witzel 28 and Goepel,29 who utilized for
While the advantages of autogenous fascia are apparent, and each hernia repair hand-made silver wire filigrees. Filigree is a term orig-
patient can provide his own perfectly biocompatible tissue with inally referring to fine, lace-like ornamental work of intertwined
good tensile strength and long-term viability, the disadvantages of wire of gold or silver; in surgery, it describes an open arrangement
these techniques have prevented the use of autologous fascial of fine silver wire into a prosthesis for hernia repair. The filigree
transplants from becoming more popular. The disadvantages cen- became the first prosthetic "mesh" to be routinely incorporated
ter primarily on the negative aspects of a second operation to har- into the surgical armamentarium for repair of difficult or recur-
vest the autologous graft, which involves the added operating room rent hernias, and many variations of the silver wire filigree were
time and expense, the discomfort and scar associated with the developed (Fig. 3.1). Seemingly crude by today's standards, the
donor wound, and the potential for surgical complications at the use of filigrees in the repair of hernias nevertheless persisted, with
donor site. These same objections apply to the use of autologous refinements, over a longer period than any other prosthetic ma-
skin and dermal grafts, which have been used with some success, terial, including the most popular meshes in use today. Meyer in
but also have been associated with added local complications such 1902,30 and Bartlett1 in 1903, utilizing different styles of filigrees
as sinus tracts, cyst formation, and epidermoid carcinoma related (wire netting versus a wire loop filigree), reported small series of
to retained epidermal elements which cannot be completely re- successful repairs of difficult hernias, the first reports in the North
moved from these grafts.I 2- 17 American literature on this technique. Lawrie McGavin ofthe Sea-

3. Prostheses in H ernia Surgery 17
spite these results, the use of silver filigrees gradually faded from
the surgical scene primarily because of the discomfort reported by
some patients due to silver wire's lack of pliability and its tendency
to become work-hardened, as well as its lack of inertness in hu-
man tissues which, while stimulating a fibrous reaction, also led to
fluid accumulation, sinus tract formation with occasional persis-
tent drainage, and an increased potential for infection. The emerg-
ing development of newer prosthetic biomaterials at the time of
Ball's report ended the long experience of surgeons with silver
wire filigrees for hernia repair.
Tantalum Gauze
Tantalum approaches glass in resistance to acid and alkalis, mak-
A
ing it inert in the physiochemical environment ofliving tissue. This
element possesses high tensile strength, ductility, and malleability,
allowing it to be drawn into fine wire and woven into a gauze (Fig.
3.2). In 1940, Burke introduced tantalum for general use in
surgery and described its reaction and tolerance to human tis-
sues. 34 Tantalum gauze became popular in hernia surgery after the
reports of Throckmorton,35 Koontz,36 Douglas,37 and Lam and col-
leagues. 38 All were published in 1948.
The clinical success reported in these four initial papers
prompted an increase in the popularity of this procedure, as did
the favorable report of Dunlop in 1950. 39 In 1951, Koontz reported
on 77 patients with large direct inguinal hernias and poor tissues
using tantalum gauze to buttress a McVay-Cooper's ligament repair,
with one recurrence over a 25-month follow-up.4o Also in 1951 ,
Flynn et al. reported on 45 ventral incisional hernia repairs with
tantalum mesh, with only one recurrence in a follow-up of four and
one-half years. 41 A few years later, Burton42 and Adler43 reported
several disadvantages to the use of tantalum gauze. These problems
B with the tantalum gauze became apparent only after a period of ad-
equate follow-up and evaluation, and related primarily to fatigue
FIGURE 3.1. Examples of early silver wire filigrees for hernia repair. 30.32 fractures of the gauze mesh with resultant patient discomfort,
man's Hospital in England, reported on his technique of the dou-

ble filigree method of hernia repair in 1907. 31 In this technique
one filigree was placed deep to the transversalis aponeurotic arch,
which was sutured over the filigree to the shelving edge of
Poupart's ligament, and the superficial filigree was placed above
the cord and beneath the external oblique apopneurosis. Percival
Cole reviewed the extensive experience of the Seaman's Hospital
with the double filigree technique of McGavin in 1941 and noted
that from 1920-1940, 23% of the inguinal hernia operations per-
formed at that institution were done with silver wire filigree im-
plants. 32 Ball, in 1958, reported from Melbourne on his use of a
larger silver wire filigree placed in the preperitoneal space and
covering the entire posterior floor of the groin.33 Ball stated, "Sil-
ver wire filigrees appear to be the best method of repair if prop-
erly used, and I believe that the method has fallen into some
disrepute because of technical faults in the placing of the filigree.
It must be placed in a properly prepared bed and kept perfectly
flat. The silver wire does slowly disintegrate and therefore is a mild
tissue irritant and stimulates the production of fibrous tissue." In
this series of 500 patients, Ball reported only two known recur-
rences, and this probably reflects the known benefits of the FIGURE 3.2. Tantalum gauze fabric in two mesh sizes (below) compared
preperitoneal placement of any prosthesis in hernia surgery. De- with older silver wire prosthesis (above).34
18 J.R. DeBord
irregularities in the abdominal wall contour, and even to recurrent Annealed fine stainless steel mesh appears to have features that
herniation through the area of mesh fracture despite the associ- make it a useful surgical prosthesis, especially in the presence of
ated fibrous ingrowth surrounding the tantalum gauze. Seroma infection. It should be noted, however, that metallic implants con-
formation was also frequently noted postoperatively, as was the prob- traindicate the use of magnetic resonance imaging.
lem of the dense adhesions to any underlying bowel or the diffi-
culty in removing the prosthesis if it should ever be necessary.
Nonmetallic Synthetic Prostheses
Stainless Steel In 1959, Koontz and Kimberly stated, "We believe that one of the
great needs in surgery is some nonmetallic, nonabsorbable mate-
Annealed stainless steel wire surgical sutures have been used since rial which can be used both for sutures and for prostheses and
the 1920s, and screens or mesh made from fine stainless steel wire which will not cause trouble in the presence of infection."52 In
were readily available for many industrial uses when Babcock be- their experiments, they tested in dogs numerous fabrics both in
gan to apply this material to the surgical problems of hernia, tho- aseptic and septic conditions. They examined Dacron® fabric,
racic wall defects, orthopedic problems, and cosmetic surgery Dacron and nylon cloth, fiberglass, mylar, nylon mesh, Orlon®
problems in 1952.44 Earlier studies in dogs found no evidence of cloth, polyethylene, polyvinyl sponge, Teflon® mesh, Teflon and
foreign body reaction to the stainless steel mesh, and tissue in- nylon cloth, and vinyon-N cloth. In the absence of infection, Or-
corporation with reperitonealization had occurred without adhe- Ion cloth showed the most promise with better infiltration by fi-
sion formation within two weeks. 45 To improve on the flexibility broblasts and a stronger end result than any of the other materials.
and conformability of steel mesh, Haas and Ritter developed a There was also good fibroblast infiltration into the Dacron fabric,
stainless steel ring chain net made up of larger lO to 11 mm flat fiberglass, and nylon mesh, but this did not produce the strength
rings connected by smaller round rings of 3 to 4 mm diameter. 46 of the Orlon cloth. None of these materials withstood infection,
This net was based on the original design of Goepel, who described however, and as a rule the infected implanted material was found
a ring chain net made of silver wire in 1928 (Fig. 3.3).47 floating in an abscess cavity in the weeks following implantation.
Preston and Richards in 1973 reviewed more than 2,000 cases They did point out, however, that occasionally good healing with-
over a 24-year period using annealed stainless steel mesh in the out infection occurred when most of these materials were used,
treatment of hernia. 48 They found this prosthesis to demonstrate even in the presence of contamination.
excellent strength and durability, resistance to and tolerance of in-
fection, freedom from the problem of "work hardening" and metal
fatigue, and good acceptance by their patients. While they re- Fortisan Fabric
ported an infection rate of only 0.1 %, they did not report a re-
currence rate or provide any clinical barometer of the effectiveness Narat and Khedroo described their efforts in 1952 to overcome
of their techniques. the shortcomings of tantalum and stainless steel meshes with the
Mathieson and James, Bapat and Patel reported on the suc- biologically inert, regenerated cellulose fabric fortisan. 53 However,
cessful use of stainless steel mesh in inguinal hernia repair in in the presence of infection the fortisan fabric became a rolled-
1975. 49.50 As recently as 1986, Validire 51 et al. reported on 150 large up foreign body in an abscess cavity or caused persistent sinus tract
abdominal incisional hernias repaired by fascial approximation formation. Fortisan fabric never became clinically useful for her-
and stainless steel mesh reinforcement. They achieved a primary nia repair. 54
success rate of 90% and a secondary success rate of more than
95% in these difficult cases over an average follow-up of four years.
Polyvinyl Sponge
Polyvinyl sponge (Ivalon®) is a polymer of polyvinyl alcohol with
formaldehyde in which air is blown through the liquid plastic to
form a solid, white, odorless, tasteless "sponge" which, when al-
lowed to dry, becomes firm and rigid and can then be cut into
sheets for surgical use that have an appearance on cross-section
of a "slice of bread" (Fig. 3.4). Ivalon was first introduced in 1949
as a plombage following pneumonectomy in dogs. 55 In the decade
or so following its initial use, Ivalon was used for nearly every fea-
sible surgical application. 56 Shilling et al. described very little for-
eign body reaction in tissues to Ivalon sponge and showed
complete fibroblastic invasion into the mesh, forming a framework
of fibrous tissue providing strength to the repaired wound. 57
Schofield and colleagues reported that polyvinyl sponge met all
of the requirements of a foreign material for use in hernia repair
and recommended its clinical use. 58 In 1957, Abrahams and
Jonassen published their clinical experience with Ivalon sponge
FIGURE 3.3. Goepel's original silver wire ring chain net, later fabricated in in the repair of 16 recurrent hernias. 59 They used 2 mm-thick slices
stainless steel. 47 of polyvinyl sponge and sutured the prosthesis well beyond the
3. Prostheses in Hernia Surgery 19
FIGURE 3.5. Thin, medium, and thick nylon netting (left to right).68
FIGURE 3.4. Polyvinyl sponge (Ivalon®).55

in those patients followed for two years of 4.7%. All six patients
with medium net repairs who developed infection had to have the
margins of the defect under moderate tension. There were two nylon net removed.
cases of wound infection which healed completely, and in follow- Kron, in 1984, reported on the use of the French nylon mesh
up to 30 months there were no recurrences. Schofield as well as crinoplaque in the preperitoneal repair of bilateral inguinal her-
Koontz and Kimberly, however, reported experimental data clearly nias. 69 He reported no recurrences and no serious septic compli-
indicating that, in the presence of infection, polyvinyl sponge cations in 200 cases.
would not be a satisfactory prosthesis in hernia repair.52,60 Adler Koontz's experiments with nylon mesh demonstrated that in the
and Darby thoroughly studied the tissue responses to Ivalon absence of infection the mesh may undergo excellent infiltration
sponge and also the tensile strength of this prosthesis after im- by fibrous tissue, but be entirely unreliable in the presence of in-
plantation. 56 ,61 They concluded that most of the desirable features fection .52 Adler and Firme pointed out that nylon tended to lose
of Ivalon sponge were altered in vivo, that the material was poorly its tensile strength and deteriorate when implanted into tissues,
tolerated by the body in the presence of infection, and that the and Ludington and Woodward demonstrated that nylon loses
sponge may fragment and dissolve with time. 80% of its strength due to hydrolysis and chemical denaturing
in vivo. 70, 71
Nylon
Silastic
Nylon as a suture material is well accepted by surgeons as a strong
and reliable material that initiates minimal tissue reaction and re- Silicones are polymers of alternate silicon and oxygen atoms with
mains in common use in modern surgery. A technique utilizing branching alkyl groups. The longer chain polymers form a rub-
nylon sutures to weave or darn the groin floor to repair hernias bery solid called silastic. Prostheses for abdominal wall repair are
with a tension-free lattice was reported by Maloney in 1948, and made by combining the silastic with Dacron or nylon mesh, with
10 years later he reviewed his experience with this technique. 62 ,63 the mesh sandwiched between two layers of the silicone. This re-
He reported a recurrence rate of less than 1 % in 253 hernia reinforced silicone elastomer is a relatively thick material that initi-
pairs followed for more than five years. 64 ates only a minimal inflammatory reaction.
Callum et al. reported their results with the nylon darn tech- This material was introduced and utilized primarily by pediatric
nique in 1974 with a recurrence rate of 7.5% in 186 repairs with surgeons for the correction of large omphalocele and gastroschi-
a follow-up of five to 12 years. 65 Abrahamson and Eldar performed sis defects in neonates. 72- 76 While apparently successful in a small
this repair on 780 patients over a 10-year period and reported in number of hernia patients, silastic sheeting continues to be used
1988 a recurrence rate of 1.8% with a minimum follow-up of three clinically with regularity only in pediatric surgery in the tempo-
years.66 rary silo closure of neonatal congenital abdominal wall defects.
Cumberland, in 1952, issued a preliminary report on the use of
a prefabricated nylon mesh for the repair of ventral hernia. 67 He
used the nylon weave to repair ventral hernias in seven patients Teflon
in which there were no recurrences during the brief follow-up that
averaged less than eight months. Teflon (polytetrafluoroethylene or PTFE) was developed by E.I.
The large experience of Doran, Gibbins, and Whitehead with DuPont & Co. of Wilmington, Delaware. Teflon became most fa-
various forms of nylon net in hernia repair was published in 1961 mous for its use as a nonstick surface in cookware and its unique
(Fig. 3.5).68 They found that a thin net in 86 patients had a sep- physical property that it cannot be wet with water. Nothing will
sis rate of 1.2%, but a two-year recurrence rate of over 20%. A adhere to it, and this singular physical property of this chemically
thick net was used in only 15 cases and abandoned due to a sep- inert plastic prompted its study as a biomaterial for surgical use.
sis rate of 53%. A medium thickness net was employed in 212 re- LeVeen and Barberia, in 1949, studied the tissue reaction to
pairs with an acceptable sepsis incidence of 2.8% and a failure rate Teflon in dogs. They noted, after varying intervals, that Teflon
20 J.R. DeBord
with 58 recurrent inguinal hernias by Van Ooijen and Kalsbeek in

1989.85 With a mean follow-up of 5.2 years, there were five recur-
rences (9%) and one deep wound infection that led to removal
of the Teflon patch. At the time of final follow-up, there were no
signs of infection or sinus tracts. They attributed the low re-
recurrence rates as much to the tension-free technique they em-
ployed as to the Teflon mesh prosthesis. They felt the disadvan-
tages of Teflon mesh for hernia repair were minimal.
In 1992, Mozingo et al. reported on 100 recurrent inguinal her-
nias in 84 men repaired by a preperitoneal approach using a
Teflon prosthesis. 86 In follow-up of six months to five years, there
were three recurrences, all in cases where the mesh slipped. No
postoperative infections or testicular complications occurred.
Despite some success, especially with the intraperitoneal or
preperitoneal implantation, original Teflon mesh is not incorpo-
rated into body tissues, is not tolerant of infection, and has too
FIGURE 3.6. Close-up view of Teflon®mesh. high a rate of wound complications to be recommended for rou-
tine use in hernia repair.
chips implanted in the peritoneal cavity were lying free with

no acute inflammatory changes and no gross evidence of tissue Carbon Fiber
reaction. 77
Ten years later, Ludington and Woodward used PTFE mesh in Flexible filamentous carbon fiber, which can be produced in var-
the repair of abdominal wall defects in 26 patients. 71 Based on a ious shapes for surgical implantation, is well tolerated in living
six- to 12-month follow-up of their patients with no recurrences, tissue and attracts a significant fibroblastic ingrowth producing
they felt their results warranted further clinical trials of Teflon a dense fibrous tissue response that can mimic tendon and fas-
mesh in hernia repair (Fig. 3.6). In 1964, Gibson and Stafford re- cia. This material's usefulness in orthopedic surgery has been
ported on 25 patients with large or recurrent ventral incisional documen ted. 87 ,88
hernias with Teflon mesh repair.78 They reported a 50% wound In 1980, Johnson-Nurse and Jenkins produced large experi-
complication rate, and five of the 25 patients had to have the mesh mental abdominal hernias in sheep and repaired them, compar-
removed to achieve healing. They suggested that the enthusiasm ing Dacron mesh with a reefing suture repair using continuous
for the use of prosthetic materials be reappraised and tempered braided carbon fiber.89 They noted that the braided carbon fiber
because of the excessive morbidity in their experience. material was well tolerated in the tissues, with a strong stimulus to
In 1968, Copello reported from Argentina on the use of Teflon collagen formation and fibrosis even within the matrix of the
mesh in the repair of complicated recurrent groin hernia. 79 In 35 braided carbon.
cases followed for two years or more, there was no infection or si- Concern about the possibility of carbon being a carcinogenic
nus tract formation and no rejection or removal of the mesh. agent was raised because of the association of coal dust to lung
There were no recurrences. Snijders's 1969 paper on the use of cancer. To date there are no data to support this contention. Tay-
Teflon gauze in the treatment of medial and recurrent inguinal ton et al. in 1982 studied the long-term effects of carbon fiber on
hernias reviewed 150 hernia repairs with two to six years' fOllow- soft tissues in a rat model and found no signs of malignant change
up, and found a 2.7% recurrence rate. 80 No wound infections or after an average period of over 17 months. 9o
fistulas occurred. In 1982, Minns et al. fabricated a carbon fiber mesh and im-
In 1974, Kalsbeek reported his series of 34 patients with ventral planted it in the dorsal lumbar fascia in rabbits and compared this
incisional hernias with an intraperitoneal implant of Teflon to Dacron mesh. 91 The carbon fiber mesh tensile strength was ini-
mesh. 81 There were 12 failures in 34 patients in this group, with tially very weak, but the force to rupture increased as the postim-
an average follow-up of 4.6 years. Ten of the cases developed plantation time increased.
fistulas. Greenstein et aI., in 1984, presented an experimental study in
Blondiau et aI., in 1979, described 56 cases of recurrent or bi- rats using an absorbable polylactic acid polymer-coated filamen-
lateral inguinal hernia treated by a preperitoneal approach with tous carbon mesh for ventral herniorrhaphy.92 Polylactic acid is a
a Teflon mesh implantation. 82 Forty-eight of these patients were biodegradable polyester of lactic acid. They concluded that the
available for follow-up six to 42 months postoperatively, and there carbon-polylactic acid mesh was a more appropriate synthetic bio-
were no recurrences or infectious sequelae. Similar results using material for a large ventral herniorrhaphy.
the same preperitoneal approach with Teflon mesh was reported In 1985, Cameron and Taylor confirmed Greenstein's findings,
by Azagra et al. in 1987.83 again using rats to compare a carbon fiber darn repair with
Repair of ventral incisional hernias with an intraperitoneal im- polypropylene mesh repair of ventral hernias. 93 Tensiometry of the
plant of PTFE prosthesis was performed in 23 cases by Druart and excised abdominal wall showed no difference in the strength of
Limbosch in 1988.84 With a mean follow-up of 18 months, only the two repairs. Morris et aI., in 1990, studied tissue ingrowth oc-
one recurrence (4.3%) was noted. They noted also that Teflon curring in carbon fibers implanted in rats for up to 12 months in
mesh was remarkably well tolerated by the body when implanted induced abdominal wall defects. 94 Compared to polypropylene
intraperitoneally. mesh, carbon fibers induced significantly more tissue ingrowth at
The effectiveness of Teflon mesh was evaluated in 54 patients six to 12 months postoperatively.
In an October 20, 1990 editorial, Lancet reviewed in general

terms the literature established regarding carbon fibers and her-
nia repair. 95 It was concluded that carbon fiber implants may be
useful for reinforcing abdominal wall defects in man. They noted
carbon fibers are very biocompatible and induce the formation of
new connective tissue that is similar in appearance and strength
to normal ligaments.
Morris et aI., in 1998, studied a carbon fiber mesh in the repair
of facial defects created in dogs. 96 The authors felt a randomized
clinical trial in patients undergoing hernia repair was justified.
Nevertheless, despite the appealing characteristics of composite
carbon fiber mesh and its apparent advantages over polypropylene
mesh in experimental studies, there has not yet been a significant
clinical experience reported in humans to assess the long-term re-
sults of carbon fiber prostheses in the repair of hernias.
FIGURE 3.7. High-power view of the interlocking polyester fibers of Mersi-
lene® mesh.
Polyester Dacron Mesh
A polyester polymer from ethylene glycol and terephthalic acid bilateral recurrence, and one infection requiring removal of the
was developed in 1939 and introduced to the United States in mesh. Caine felt that this technique utilizing Mersilene mesh was
1946.97 By the late 1950s, this material, known as Dacron, was especially useful for difficult large or recurrent bilateral groin her-
machine-knitted into a fabric mesh and marketed by Ethicon Inc. nias, but did not recommend it in patients with small bilateral her-
of Somerville, NJ, under the trade name Mersilene.® All products nias who have good tissues.
described as polyester mesh or Dacron mesh or Mersilene mesh Casebolt, in 1975, reported on the use of fabric mesh repair in
are referring essentially to the same product. 35 cases of abdominal wall defects. 103 He used polyester and
Wolstenholme, in 1956, became reluctant to implant the stiff polypropylene meshes in equal amounts in a variety of hernia
metal prostheses available then and utilized a commercial Dacron problems with two recurrences after a mean follow-up of 36
fabric in the repair of 15 inguinal and four ventral hernias. 98 He months. There was a 14% incidence of minor wound complica-
was encouraged by his initial results, as all patients healed from tions and an 8% incidence of deep infections involving the mesh.
their wounds without complications, but no long-term follow-up In 1975, Haskey and Bigler repaired 20 ventral incisional her-
was reported. nias with Mersilene mesh without major complications. 97 They
A large series of over 3,000 patients was reported by Bellis in used an inlay technique successfully with no recurrences reported.
1969 using Mersilene mesh in a tension-free technique under lo- Stoppa et al. described their use of a very large, unsutured
cal anesthesia. 99 He reported only 19 failures, 14 of which were Dacron prosthesis for repair of difficult groin hernia using a
due to "rejection" of the mesh. preperitoneal approach through a low midline incision in 1975.104
Durden and Pemberton, in 1974, emphasized that successful The easy bloodless dissection in the subperitoneal spaces of Retz-
hernia repair with Dacron mesh requires careful and meticulous ius and Bogros, the excellent exposure of the myopectineal ori-
surgical technique. IOO They repaired 96 large direct inguinal her- fice to be repaired, and the opportunity to repair several inguinal
nias with Mersilene mesh with one seroma, one recurrence, and floor defects by a single approach appealed to the authors. Stoppa
no infections. In a group of 13 patients undergoing ventral and Warlaumont reviewed a more recent assessment of this unsu-
herniorrhaphy with Dacron mesh as a bridge across the defect, tured pre peritoneal Dacron prosthetic repair of groin hernia in
complications included five seromas, no recurrences, and one pa- 1989 and reported a long-term recurrence rate of 1.4% in 604 re-
tient with infection. The follow-up period for all patients was two pairs. 105
to five years. No patient with Dacron mesh had difficulty with frag- Cerise et aI., in both an experimental and clinical study, evalu-
mentation of the implant, extrusion of the mesh, or pain from the ated Mersilene mesh in 100 consecutive hernia repairs in humans
presence of the prosthesis. They felt that Dacron mesh met many (87 groin, 13 ventral), noting only one recurrence with follow-up
of the criteria for an ideal prosthesis for hernia repair. of one to 4.5 years, and only one significant complication con-
Polyester mesh was used by Abul-Husn in 1974 to repair 23 her- sisting of recurrent abscesses and sinus formation at 20 months
nias. 101 He noted that the mesh is fine and light, yet strong and postsurgery.106
pliable, durable, moderately elastic, can be autoclaved, and, be- Using a scanning electron microscope, Minns and Tinckler, in
cause of its interlocking polyester fibers (Fig. 3.7), can be cut with 1976, studied transversalis fascia and Mersilene mesh to analyze
scissors to any shape desired by the surgeon without its edges fray- their structural features. 107 These studies, not surprisingly, showed
ing. He reported the recurrence in 16 inguinal hernia repairs, but hernia fascia to be weaker than normal fascia and mesh to be
no recurrences in the two umbilical hernias and five ventral inci- stronger than either fascia.
sional hernias repaired with polyester mesh. In 1985, van Damme reported a series of 100 consecutive pa-
Also in 1974, Caine reported on the use of Mersilene mesh to tients who underwent prosthetic repair of inguinal hernia through
repair bilateral inguinal hernias from the preperitoneal approach a preperitoneal approach.l 08 In 49%, the hernia was recurrent.
through a single suprapubic incision and passing the mesh behind Using a technique similar to Stoppa's, which has now become
the rectus abdominus.102 Twenty-six patients were followed for known as "giant prosthetic reinforcement of the visceral sac" or
more than one year, and there were six unilateral recurrences, one GPRVS,109 he used mostly Dacron mesh to achieve a lOO% success
22 J.R. DeBord
rate with one chronic draining sinus tract, one hematoma, and found it uniformly successful in replacing segments of abdominal
two hydroceles as complications. Van Damme emphasized that if wall without infection and with little microscopic evidence of for-
there were no technical errors with this technique, there was no eign-body reaction. 120
recurrence. In classical herniorrhaphy, however, even after a per- In 1960 and 1962, Usher reported a collected review of 541 cases
fect operation recurrence is always possible, even many years later, of hernia repair with Marlex mesh. 121 ,122 The mesh was used only
because the result does not only depend upon the surgeon but for large and more difficult hernias with a high risk for recurrence,
also to a large extent on the tissues and the strain to which they and 240 cases had minimum follow-up of one year. There was a
are subjected. recurrence rate of 10.2% for incisional hernias and 5.9% for in-
In 1987, Adloff and Arnaud described their technique for the guinal hernias, with complication rates of 15% and 4.3% respec-
surgical repair of large incisional hernias utilizing an intraperi- tively. In six of 358 incisional hernias, the mesh had to be removed
toneal Mersilene mesh in conjunction with a plasty of the anterior because of infection. This was not necessary in any of the 183 in-
rectus sheath. 110 In 130 repairs with a follow-up of one to eight guinal hernia repairs.
years, there were six recurrences (4.5%), which were all a result Adler found, in a survey of general surgeons throughout the
of lateral detachment of the mesh. Overall, more than 90% of the United States in 1962, that 20% were using it for complicated her-
patients who underwent surgical treatment of their large incisional nia repair. 43 In 1963, an improved version of Marlex was intro-
hernia fully recovered. duced by Usher, based on a new knitted mesh of polypropylene
In 1989, Wantz reviewed his results using the procedure of monofilament fiber, used initially as a suture material. This pros-
GPRVS with 237 hernias of the groin in patients at high risk for thesis remains in use today, marketed by C.R. Bard, Inc. of Biel-
recurrence. 11l- 114 He used primarily Mersilene prostheses, and his Ie rica, MA, as Marlex, though the name was later changed to Bard®
data emphasized that Dacron is the mesh of choice for GPRVS be- Mesh (Fig. 3.8) .123,124
cause it does not become rolled up or folded upon itself in the Jacobs and colleagues, in 1965, found knitted Marlex mesh to
preperitoneal space. There were nine recurrences, most of which be useful in the repair of difficult incisional hernias as have many
were noted within six months of surgery, and all successfully rere- published authors since. 125-139
paired. Five of the recurrences were due to nonfixation of the In 1987, Bendavid devised a clever umbrella-shaped Marlex pros-
mesh (four Marlex,® one Gore-Tex®) and four recurrences with thesis for insertion from below into the preperitoneal space through
Mersilene mesh were due to inadequate positioning of the mesh the femoral defect for treatment of femoral hernia.1 40 This "um-
by the surgeon. Complications were very few, and the overall re- brella" consisted of an 8 cm disk of Marlex with a stem to facilitate
currence rate for these problem hernias of 3.7% was extremely handling and ease of insertion. The stem is eventually resected when
good. Wantz stated, "Herniation after GPRVS is inconceivable, pro- the disk portion has been properly inserted and sutured. In 30 pa-
viding the mesh suitably adheres, does not disintegrate, and is cor- tients operated on for femoral hernia, there have been no recur-
rectly sized, shaped, and placed." rences after insertion of the Marlex umbrella, although two patients
Thill and Hopkins confirmed the utility of Mersilene mesh in developed postoperative seroma. The number of umbrella repairs
the repair of adult groin hernias compared with a standard Bassini without recurrence reached 81 in a later report. 141
repair in their 1994 report involving 303 patients with 364 groin Nyhus and colleagues reported in 1988 on the evolution of their
hernias.1l5 The complication rates were similar between the two preperitoneal approach to the problem of recurrent groin her-
repairs, but the recurrence rate at an average follow-up of five nia.1 42 Over a 100year period they came to believe that the proce-
years was 11.5% for the Bassini repair and 3.3% for the polyester dure of choice for recurrent groin hernia was a preperitoneal
mesh repair. primary tissue repair of the defect with application of a Marlex
A unique polyester mesh was introduced for laparoscopic repair mesh buttress also placed posteriorly. They reported a 1. 7% re-
of abdominal wall hernias by Helfrich and Gianturco in 1995.1 16 recurrence rate with this technique with follow-up from six months
The mesh incorporated a removable internal wire to maintain its to 10 years.
circular shape of either 7 em or 10 cm diameter. Bendavid described, in 1989, a complete mesh reconstruction
Dacron mesh was the first popular nonmetallic mesh to stand of the groin floor and inguinal ligament using polypropylene mesh
the test of time, and it remains in active clinical use today, although prepared as a three-leafed "fletching."141 This complicated pros-
its use has decreased as polypropylene mesh has become popular. thetic repair is well illustrated in the text and is indicated in the
repair of the multirecurrent groin hernia, where total destruction
of the inguinal ligament may have occurred and the defect ex-
Polypropylene Mesh tends to the anterior superior iliac spine. He reported 26 such
cases with no infection, no testicular atrophy, and two seromas.
Usher introduced a new polyethylene plastic mesh called Marlex- There was one recurrence 10 months after surgery due to de-
50 in a series of experimental and early clinical papers in 1958 to tachment of the fletching from the remnant of the inguinalliga-
1959. 117- 1l9 Usher and Wallace placed various plastics into the peri- ment near the iliac spine. This was successfully rerepaired by
toneal cavities of dogs and found Teflon and Marlex caused less resuturing the mesh.
foreign-body reaction than did nylon, Orlon, or Dacron. They de- In an editorial in the February 1989 American Journal of
scribed this new material as possessing high tensile strength Surgery, Peacock concluded that the continued effort to repair di-
(50,000-150,000 lb/sq-in) and pliability; being impervious to wa- rect inguinal hernias by tissue approximation with sutures should
ter and resistant to most chemicals; with a softening temperature be abandoned. 143 "The modem biologically based concept for re-
of 260 F, so sterilization by boiling was no problem; and as an im-
0 pair of groin hernia acquired during adult life is application of a
plant it became infiltrated by connective tissue. patch, avoidance of tension, and use of local anesthesia so that the
Ponka, in 1959, tested this new polyethylene mesh in dogs and result can be tested intraoperatively."
~ ~IH
..
,
~.
'V4.
\l! r..~ ~ l"'Jo
it ~~1 ~
~
...,
~ ~~
~~
t-: ~~ W
'), ~!(~ ~ ~~~

A B
FIGURE 3.8. Marlex® mesh: (A) gross appearance, (B) close-up

view, (C) scanning electron microscope view of monofilament
knitted interstices.
c
In this same journal issue, Lichtenstein and associates reported david reported successful repairs in all of the patients with this
on 1,000 consecutive patients with primary repair of inguinal her- technique.
nia using a "tension-free" repair employing a Marlex mesh pros- Many additional reports confirm the good results of polypropyl-
thesis to bridge the direct floor of the groin without approximation ene as a prosthesis or prosthetic device. 147- 164 However, not being
of the tissue defect. 144 complacent or easily satisfied, surgeons will continue to spear-
Jones and Jurkovich, in 1989, reviewed their own experience head, along with bioengineers, the development of improved
and that of others with polypropylene mesh in closure of infected biomaterials for surgical reconstruction of the human body.
abdominal wounds. 145 They described five patients of their own in
whom polypropylene mesh was used to close the abdomen fol-
lowing celiotomy for intra-abdominal sepsis. Complications di- Expanded Polytetrafluoroethylene
rectly related to the mesh placement occurred in four patients
(80%) : a small bowel fistula developed in all four patients, and a PTFE is a fully fluorinated polymer with the chemical formula
wound dehiscence also occurred in one. All eventually had the (CF2-CF2)n. It was discovered accidentally in 1938 by RJ. Plun-
mesh removed. kett of E.I. DuPont & Co., Inc.I 65 Its unique chemical and physi-
Using a preperitoneal approach, Bendavid, described in 1990 cal properties are well documented. 166 Its use as a biomaterial for
the use of Marlex mesh to repair a series of seven incisional para- hernia repair has been reviewed earlier in this chapter.
pubic hernias. 146 This unusual hernia is the result of previous In 1963, Shinsaburo Oshige of Sumitoma Electric Industries,
surgery that has disrupted the insertion of the musculotendinous Osaka, Japan, discovered a process for expanding PTFE to pro-
elements of the abdominal wall on the pubis. The defect, usu- duce a highly uniform, continuous fibrous, porous structure
ally round and 5 to 8 cm in diameter, emerges just above the pu- which, after sintering, retained its microstructure with vastly im-
bis and requires a prosthetic repair. The Marlex is sutured to proved mechanical strength. 167 The technique for expanding
both Cooper's ligaments and the arcu ate pubic ligament below PTFE was ultimately refined by Robert W. Gore l68 and initially ap-
and to the full thickness abdominal wall structures above. Ben- plied clinically to the development of a functional vascular pros-
24 J.R. DeBord
FIGURE 3.9. Gore-Tex® soft tissue patch.
thesis that was introduced to the market in 1975 by both Impra, 25 J-L, and this unique porous microstructure provides a flexible,
Inc. of Tempe, Arizona, and W.L. Gore and Associates, Inc. of soft, nonfraying, conformable biomaterial that allows cellular in-
Flagstaff, Arizona. Subsequent to the development of the ex- filtration and tissue incorporation into the patch (Fig. 3.10). Ex-
panded PTFE (ePTFE) vascular graft, ePTFE was radially expanded PTFE has been documented to have adequate material
panded to provide a sheet material that would meet the demands tensile strength for safe clinical use, and, using industrial testing
of a prosthesis used in the repair of hernias and other soft tissue methods, the Gore-Tex® soft tissue patch (STP) has been shown
deficiencies. This new biomaterial was first used clinically in 1983. to be stronger than Marlex, Prolene,® or Mersilene mesh and
The ePTFE patch is composed of pillar-shaped nodes of PTFE that equivalent to these materials in terms of suture retention strength
are connected by fine fibrils of PTFE with a multidirectional (Table 3.1).169-170
arrangement of the fibrils in the surface view which imparts bal- From the late 1970s to the mid 1990s, numerous experimental
anced strength properties to the patch in all directions (Fig. 3.9). and clinical papers described the utilization of e-PTFE in many
The average internodal fibril length (that is, pore size) is 20 to different arenas from orthopedic to dental to plastic surgery to
A B
FIGURE 3.10. Tissue incorporation into Gore-Tex® soft tissue patch 27 etration of the patch interstices; (B) Hand E stain, 50X magnification of
months after hernia repair: (A) Milligan's Trichrome stain, 25X magnifi- fibroblasts and a few macrophages with collagen fibers within the patch
cation of fibrous tissue adherent to both patch surfaces with collagen pen- spaces.
TABLE 3.1. High rate strength comparison l related to the intraperitoneal placement of the ePTFE prosthesis
in either series.
Prosthetic material Material strength 2 Suture retention 3
Since its first clinical use in 1983, the e-PTFE patch has been
Gore-Tex® soft tissue patch 30.0 kg/cm 3.4 kg/pin found to be an effective biomaterial for a wide array of clinical
(2 mm) problems. The ultimate role of this biomaterial in modern surgery
Gore-Tx soft tissue patch 14.8 kg/cm 1.92 kg/pin is still being evolved, and it is now just under two decades since
(1 mm) its first clinical applications, so long-term follow-up data will now
Marlex® mesh 3.5 kg/cm 1.46 kg/pin become available.
Prolene® mesh 6.4 kg/cm 2.06 kg/pin
Mersilene® mesh 1.0 kg/cm 0.46 kg/pin
lFifteen samples were tested in each case. Data reported are mean values. Absorbable Mesh
2All materials were tested by rupturing a notched rectangular sample at a
strain rate of 9000%/sec and measuring the maximum force sustained by Polyglycolic acid (Dexon®-Davis and Geck, Inc. Manati, PRJ
the sample. and polyglactin 910 (Vicryl®-Ethicon, Inc. Somerville, NJ)
3All materials were tested by pulling five small diameter pins (spaced 4 mm meshes have been developed as outgrowths of the successful uti-
in from an edge and 2 mm apart) out of a sample at a rate of approxi- lization of these slowly absorbable synthetic fibers as suture ma-
mately lOO cm/sec. The pins were of approximately the same diameter as terial. Dexon mesh is a wide weave of polyglycolic acid braided
suture materials used in prosthetic hernia repairs. fibers which produces a soft, pliable, and stretchable prosthetic
Data from W.L. Gore and Associates, Inc., Patch Project Work Plan #215.
netting which is biodegradable and is gradually absorbed over a
(170) .
period of about 90 days.226 Vicryl mesh, on the other hand, is a
tightly woven broadcloth, which is flexible although not elastic,
and shares similar physical and biodegradable properties as
Dexon mesh. 227 Both of these biomaterials are absorbed and
chest wall reconstruction and, of course, to inguinal and ventral should not be used as the sole prosthesis for repair of abdomi-
incisional hernia repair. These reports are reviewed in more de- nal hernia.
tail in the earlier edition of this book and in a recent review by In experimental studies, Delany et aI., in 1982, showed that
this author.171-217 Dexon mesh could be used to wrap the injured spleen of dogs and
The repair oflarge primary and recurrent ventral incisional her- successfully tamponade the parenchymal hemorrhage. 226
nias is the most demanding of all hernia repairs and is accompa- Lamb and colleagues, in 1983, repaired clean rabbit abdominal
nied by high recurrence rates if a prosthetic biomaterial is not wall defects using Vicryl mesh and found, at three weeks, there
used. Techniques for the laparoscopic repair of these difficult her- was no weakness when compared with nonabsorbable meshes. 228
nias have been described, and early results appear promising and However, at 12 weeks, the bursting strength of the polyglactin 910
offer relief from many of the wound complications associated with repair was significantly less than that of nonabsorbable meshes. In
open repair.218-221 Standard to all of these reports is the use of addition, 40% of the animals repaired with Vicryl mesh developed
ePTFE prostheses and transabdominal fixation sutures augmented a hernia due to inadequate fibrous tissue incorporation into the
by staples. Low rates of hernia recurrence and complications, mesh before hydrolysis of the prosthesis occurred. They concluded
along with short hospital stays and earlier return to normal activ- that Vicryl mesh was not a suitable biomaterial for permanent re-
ities, continue to be the outcome advantage promoted by surgical pair of abdominal wall defects.
laparoscopists. Jenkins et ai., in 1983, compared prosthetic materials in rats for
Despite its appeal to many, the technical challenge and learn- abdominal wall repair and found no difference in bursting
ing curve of laparoscopic ventral hernia repair leave a majority strength, up to eight weeks, when Vicryl mesh was compared with
of surgeons currently utilizing open prosthetic repair as their pre- Marlex and Gore-Tex prosthesesP4 In this study, the best long-
ferred approach and the technique with which they are most com- term protection against adhesions was provided by the absorbable
fortable and confident. Gillion et al. published a 1997 review of mesh. Their eight-week follow-up may not have been long enough
158 patients with incisional hernias repaired with an open tech- to detect hernia recurrence following absorption of the Vicryl
nique using ePTFE patches. 222 Their infection rate (4%) and re- mesh.
currence rate (4%) were low, with a mean follow-up of 37 months. In 1985, the first clinical application of absorbable mesh for re-
Similar results were reported by Balen et al. in 1998, with one repair of the spleen was reported in six patients by Delany et ai. 229
currence in 45 operations with a mean follow-up of 39 months. 223 The repairs were performed using the Dexon mesh in several ways
In 1999, Gonzalez et al. of Spain and Bauer et al. of New York with good results and with no complications directly related to the
published their results on 84 and 98 complex repairs with ePTFE presence of the mesh. Similar results with the successful Dexon
respectively.224,225 Gonzalez's data with 1-3 years' follow-up mesh repair of the injured spleen and kidney have been reported
showed an infection rate of only 1.7% and a recurrence rate of by others. 230 ,231
2.4%. Twenty-five percent of his cases were recurrent hernia op- Reconstruction of the pelvic peritoneum is an additional appli-
erations. Bauer, with one-half of his patients presenting with re- cation for absorbable mesh material as described by Delany et al.
current hernias, had an overall 19% recurrence rate, but nine of in 1985. 232 This sling-type peritoneal substitution procedure sus-
these were due to removal of infected patches. Recurrence oc- pended the small intestine out of the pelvis and out of the field
curred with an intact patch in 10 patients (10.2%), with a mean used for postoperative radiation following resection for rectal
implant duration of 6.2 years. There were no bowel complications cancer.
26 J.R. DeBord
The use of Dexon mesh to repair contaminated abdominal wall 7. Should be capable of being fabricated in the form required;
defects in patients was reported by Dayton and colleagues in 8. Should be capable of being sterilized.
1986. 233 As an alternative to placing polypropylene mesh in a con-
taminated field, they used polyglycolic acid mesh to repair infected It has become apparent that there is no single ideal operation
abdominal wall defects in eight patients. In follow-up studies up that exists for the permanent cure of hernia, and it is unlikely that
to 18 months, six of the eight patients (75%) developed hernias a single ideal prosthesis to augment hernia repair will be devel-
at the site of the absorbable mesh repair. They concluded that oped that is universally adaptable. Three biomaterials in hernia
postoperative hernia development was probable in patients whose repair currently in widespread use throughout the world are well
defects were repaired with absorbable mesh. However, this com- tolerated by the body: polyester mesh, polypropylene mesh, and
plication has to be balanced against the serious complications of expanded polytetrafluoroethylene patch. None of these materials
sepsis, fistula, bleeding, skin erosion, and drainage, which require has been shown to be carcinogenic or to elicit an allergic reaction
removal of nonabsorbable prostheses in a large percen tage of cases in tissues. While ePTFE material strength and suture retention
when the latter are used in contaminated areas. The authors felt strength exceed those of polyester and polypropylene mesh, no
placement of absorbable mesh for temporary abdominal wall sup- clinical failures of any of these biomaterials has ever been reported
port until wound contamination resolved might enhance the like- due to mechanical prosthesis failure.
lihood of subsequent successful placement of a permanent These three biomaterials have all been shown, both macro-
prosthesis. scopically and microscopically, to allow tissue ingrowth into the
When compared with Marlex mesh in a dog model over a 16- prosthesis. The more coarse macro porous meshes clearly differ
week period, Dexon mesh was shown by Delany et al., in 1992,234 from the smooth microporous ePTFE patch in this regard. The
to produce fewer intraperitoneal adhesions and, unlike Marlex, polyester and polypropylene meshes incite a more proliferative,
these adhesions and acute tissue reaction diminished over time as although disorganized, fibrous collagenous response that many
the prosthesis was absorbed. feel creates a more secure bond with the surrounding fascia. The
While absorbable mesh, as common sense would predict, does only prosthetic material that seems to elicit a strong, orderly, and
not provide adequate support for hernia repair, Pans et al. studied organized collagen response, aligned in the direction of the stress
its role in hernia prevention in morbidity obese patients undergo- applied, is carbon fiber-based material that has had little clinical
ing bariatric surgery.235 A total of 288 patients were randomized to use reported.
primary closure with polyglactin sutures alone or with the same su- The micro porous ePTFE patch does support tissue ingrowth
tures plus a polyglactin mesh placed above the omentum but not into its internodal spaces, and this has been histologically well con-
fixed with any sutures. Not surprisingly, there was no significant firmed. When implanted as a replacement for the abdominal wall,
benefit of the mesh in reducing the incidence of incisional hernia without peritoneal coverage, the ePTFE patch supports the rapid
during the follow-up period. The two main predictive factors in the development of a mesothelial-like cellular monolayer, which acts
overall 26% incidence of incisional hernia in these patients were to "reperitonealize" the visceral surface of the patch. The result-
patient age and preoperative weight. ing decrease in adhesion formation and bowel complications in
this setting has been reported in numerous experimental and clin-
ical papers reviewed earlier.
The rationale for the selection of a prosthetic biomaterial in
The Ideal Prosthesis hernia repair must be based on a sound knowledge of the prop-
erties of the various available prostheses as reviewed by DeBord238
Zimmerman said in 1968, "The use of artificial materials in the re- and Goldstein. 239
pair of hernia has created an interest and evoked a literature which Future biomaterials must meet three additional criteria to more
probably exceeds the importance of this innovation. From this nearly match the Cumberland and Scales requirements for the
chaotic volume, numerous materials and various techniques have ideal prosthetic material:
been, and continue to be, promulgated, but few factual conclu-
sions can be drawn. "236 In the 32 years since that statement was 1. They must be resistant to infection;
made, some would say that its sentiments are still applicable. It 2. They must provide a barrier to adhesions on the visceral side;
seems, however, that some conclusions can be drawn from the cur- 3. They must respond in vivo more like autologous tissue-allow-
rent accumulation of data, but it is doubtful that we have yet seen, ing tissue incorporation for good fixation and a strong, lasting
in any currently available form the "ideal" prosthetic biomaterial. repair, without encouraging the scarring and encapsulation
Cumberland67 and Scales,237 in the 1950s, developed eight still problems seen with many of today's prostheses.
pertinent criteria for the ideal implantable biomaterial. These
have been more recently enumerated by Hamer-Hodges and Amid and associates combined biomaterials in an effort to find
Scott. I78 The material: a combination that might promote the desirable incorporation of
the mesh with the abdominal wall while preventing the undesir-
1. Should not be physically modified by tissue fluids; able adherence of the biomaterial to the intestine. 240 Of all the
2. Should be chemically inert; combinations of prosthetic material used in this rabbit model, only
3. Should not excite an inflammatory or foreign-body reaction; the polypropylene mesh/polypropylene sheeting combination
4. Should be noncarcinogenic; met these dual criteria. No clinical experience has been reported.
5. Should not produce a state of allergy or hypersensitivity; In 1996, Velitchkav et al. described an extensive experience with
6. Should be capable of resisting mechanical strains; a new biomaterial developed in Bulgaria. 241 Ampoxen, a multifil-
amen ted polycaproamide impregnated with 5-nitro-8-hydroxy- pears to prevent bacterial colonization and subsequent infection.
quinolinum (Medica, SA, Sandanski, Bulgaria) was developed in DeBord et al. have recently studied both laboratory and clinical
1975 and is widely available and inexpensive in Bulgaria. This mesh findings after implantation of this antimicrobial agent-impregnated
is nonabsorbable and impregnated with the broad-spectrum anti- ePTFE patch in patients and found no untoward effects from this
septic nitroxoline to which bacterial resistance has not been seen. biomaterial (Dual Mesh Plus,® W.L. Gore and Associates, Inc.,
This mesh has a rapid fibrinous fixation in the tissues and avoids Flagstaff, Arizona).249 Clinical data should develop now that this
seroma formation. Within seven days of implantation, it is difficult modified ePTFE patch is commercially available to determine
to separate Arnpoxen mesh from host tissues. The mesh is elastic, whether or not this silver-chlorhexidine impregnation reduces the
which facilitates its handling characteristics. These authors re- risk of clinical infection when implanting this patch for hernia
ported 846 inguinal hernia repairs using Arnpoxen mesh and a repair.
Lichtenstein technique, with no recurrences and very low general Thus, it appears that an antimicrobial-impregnated prosthesis
complications. Unfortunately, outside Bulgaria there has been lit- that allows well-organized fibrous ingrowth on one side and has
tle reported experience with this biomaterial. anti-adhesion properties on the other side would approach the
A new prototype mesh consisting of a knitted polyester struc- brass ring of an ideal prosthetic biomaterial for abdominal wall
ture treated with a fluoropolymer and impregnated with gelatin reconstruction.
was described in 1996 by Soares et al. 242 The FluoropassiV® mesh "Prostheses, whatever their value, cannot replace a full knowl-
(Vascutek Ltd., Inchinnan, Scotland) has a polyester wrap-knitted edge of the underlying anatomy and pathology of hernia, or sub-
structure made by knitting texturized multifilament polyester stitute for the exercise of time-honored principles of surgical
yams into a two-bar reverse lockknit fabric. It is then coated with technique."236
a fluoropolymer solution using proprietary technology and im-
pregnated with gelatin that has been cross-linked with formalde-
hyde and softened with glycerol. In this study, Fluoropassiv mesh
was compared with polypropylene and ePTFE in experimentally
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4
Evolution of Laparoscopic Hernia Repair
Karl LeBlanc and Ralph Ger
The concept of a posterior approach to the repair of abdominal the hernia sac using a prototype instrument called the "hernio-
wall hernias had its earliest beginnings in North America in 1878 stat" in beagle dogs.!1 The results in these models seemed promis-
in Utica, New York, when E. Hutchinson reported a case of in- ing. In that same article, he reported the potential benefits of the
guinal hernia that was strangulated at the internal ring. Hutchin- laparoscopic approach to groin hernia repair as: (1) creation of
son made a midline incision between the umbilicus and the pubis. puncture wounds rather than formal incisions; (2) minimal dis-
Entering the peritoneal cavity, he released the gangrenous bowel, section; (3) less risk of spermatic cord injury and ischemic orchi-
but the patient died the following day.1 tis; (4) minimal risk of bladder injury; (5) decreased incidence of
Annandale was the first (1876) to enter the preperitoneal space neuralgias; (6) possibility of an outpatient procedure; (7) ability
through an incision parallel to Poupart's ligament for the purpose to achieve the highest possible ligation of the hernial sac; (8) min-
of treating an indirect and femoral hernia. 2 But it was 50 years ear- imal postoperative discomfort; (9) a faster recovery time; and (10)
lier still, in 1823, that the first surgeon entered the preperitoneal ability to perform simultaneous diagnostic laparoscopy and to di-
space: searching for a safer approach to the ligation of the exter- agnose and treat bilateral inguinal hernias. These potential ad-
nal iliac artery, A. J. Bogros investigated and described the space vantages and advances in the laparoscopic repair of hernias
now known by his name. s continue to be the recognized goals of each method. Since the
Tait (1891), Cheatle (1920), Henry (1936) and McEvedy (1966) publication of Ger's article, most inguinal hernia repairs have been
described this "newer" approach to hernia repair through the carried out on an outpatient basis.
preperitoneal space. 4 This approach was rediscovered and estab-
lished by Nyhus (1959) as an effective method of herniorraphy.5
The benefits of using a prosthetic mesh placed in the preperi- Techniques Developed
toneal space were shown by Rignault,6 NyhUS,' Stoppa,8 and
Wantz. 9 These surgeons did not have access to laparoscopic Bogojavalensky initially presented the use of a prosthetic bioma-
methodology at that time to investigate this method of access to terial with laparoscopy in 1989. 12 He placed a roll of polypropyl-
the abdominal or preperitoneal spaces. ene mesh into indirect hernias offemale patients. POpplS repaired
a coincidental direct hernia that was found at the time of a uter-
ine myomectomy. He recognized the need to provide coverage of
First Use a wider area than that of the defect itself. To accomplish this, he
placed a 4 cm by 5 cm patch of dehydrated dura mater over the
The first report of the use of the laparoscope in the repair of an defect. This was secured to the peritoneum with catgut sutures
abdominal hernia was made by Ger in 1982. 10 He reported a se- that were tied extracorporeally. Popp expressed concerns that the
ries of 13 patients treated in the 1970s in which he closed the peri- intra-abdominal repair of inguinal hernia could lead to adhesive
toneal opening of the sac using Michel clips. All but the last patient complications and suggested that a preperitoneal approach might
in this series was repaired through an open incision. The thir- be preferable.
teenth patient was repaired in 1979 under laparoscopic guidance Schultz reported the first patient series of laparoscopic hernior-
with a special stapling device. The first report of the use of the la- raphy14 in 1990. He used a combination of rolls of polypropylene
paroscope in the repair of abdominal hernias was made by Ger in that were packed into the hernial orifice and the placement of two
1982. 10 He reported a series of 12 patients treated in the 1970s in or three flat sheets of polypropylene mesh (2.5 cm by 5 cm) over
which he closed the peritoneal opening of the sac through an the defect. The rolls of mesh were not secured to either the fas-
open abdominal incision using Michel clips. In a thirteenth pa- cia or the peritoneum, which was closed using clips. This was prob-
tient the repair was carried out in 1979 under laparoscopic guid- ably the earliest attempt at a type of transabdominal preperitoneal
ance with a special stapling device. The patient was lost to follow (TAPP) repair that is commonly used today. Corbitt15 modified
up after a short period. Ger continued his efforts to repair these this technique by inverting the hernia sac and performing a high
hernias laparoscopically. He reported the closure of the neck of ligation with sutures or with an endoscopic stapling device. The
33
34 K. LeBlanc and R. Ger
initial reports were promising, but longer follow-up revealed re- under direct visualization in that space. The completed totally ex-
currence rates of 15 to 20%.1 6 Because of this, both of these meth- traperitoneal (TEP) repair was identical to that of the TAPP but
ods were abandoned. decreased the risk of injury to intra-abdominal organs.
Nevertheless, the avoidance of extensive dissection by these
methods was appealing. A similar concept was applied in the in-
traperitoneal onlay patch (IPOM) technique. This repair was Results
investigated by Salerno, Fitzgibbons, and Filipi,17 using a poly-
propylene patch in a porcine model. They placed rectangular pros- These publications proved that the repair of inguinal hernias
theses against the abdominal wall, covering the internal inguinal could be accomplished with the laparoscopic technique. Contro-
ring and secured it with a stapling device. The success of these re- versy persisted,37 then as well as now, as to whether or not these
pairs led them to apply the method in clinical trials. operations should be done. Part of the controversy concerns the
At about the same time, Toy and Smoot18 reported upon their variety of new complications, such as bowel and bladder injury,19
first 10 patients repaired with the IPOM technique. They secured inferior epigastric and iliac artery laceration,38 trocar herniation,36
an expanded polytetrafluoroethylene (PTFE) patch to the in- genitofemoral neuralgia,38,39 and lateral femoral cutaneous neu-
guinal floor with staples, using a prototype stapling device of their ralgia. 16,38 Additionally, the laparoscopic repair was more difficult
own design. A subsequent report of their first 75 patients was pub- to master, operating times were longer, and the instrumentation
lished in 1992. 19 In this later series, the same prosthetic biomate- was more costly.35 A multicenter analysis40 of the procedure, using
rial (7.5 cm by 10 cm) was attached with the Endopath EMS® most of the methods noted above, verified that the repair had a
stapler. Mter a follow-up of up to 20 months, the recurrence rate recurrence rate of 0.4-3% and a low incidence of complications
was 2.4%. They noted a significant decrease in postoperative pain in experienced hands.
and earlier return to normal activity, as compared to the open re- Currently, the majority of laparoscopic inguinal hernia repairs
pair of inguinal hernia. Others reported similar results. 20-22 are approached by either the TAPP or TEP method and utilize a
Fitzgibbons 23 later abandoned the IPOM repair except for sim- polypropylene prosthesis. Most of the surgeons who perform the
ple indirect inguinal hernias. He found that the patch material TEP repair use the commercially available dissection balloons to
could be displaced into the hernial defect because it was anchored prepare the preperitoneal space.
to the peritoneum alone rather than the fascia. He used the TAPP In a recent report,41 the recurrence rate of these repairs was
approach, which had also been reported by Arregui24 for the other 0.4% in 10,053 repairs with a median follow-up of 36 months. The
types of groin hernias. In this repair, the peritoneum is incised and surgeons that continue to perform laparoscopic herniorrhaphy be-
dissected away from the transversalis fascia to expose the posterior lieve that the goals anticipated by Cerll have been realized.
inguinal wall. The mesh material is then secured to that fascia, The improvement in recovery in the laparoscopic cholecystec-
which was believed to ensure superior fixation and tissue ingrowth. tomy and herniorrhaphy patients led us to attempt the repair of
Popp25 described a method of dissecting the peritoneum away ventral and incisional hernias in 1992.42 This initial report involved
from the abdominal wall prior to the incision of the peritoneum only five patients, but the quick recovery and the safety of the pro-
in the TAPP repair. This technique used saline injected by a cedure were encouraging. These patients are free of recurrence
transcutaneous syringe. This "aquadissection" probably led to the after more than seven years. The fixation was that of the "box type"
idea that the entire dissection could be accomplished from within of hernia stapler without the use of sutures. With more patients
the preperitoneal space, eliminating the need to enter the ab- and follow-up, no recurrences were noted. 43 ,44 The use of ePTFE
dominal cavity. prostheses is preferred by us given its in-growth characteristics and
Other operations that were attempted at that time included the relative freedom from the development of intra-abdominal adhe-
"ring-plasty" and a preperitoneal iliopubic tract repair. Ring-plasty sions. 45 In 1995, Barie46 proposed the use of a polyester material
is a sutured repair that approximates the deep structures of the covered on the visceral side with a mesh of absorbable polyglactin.
lateral iliopubic tract to the proximal arching musculotendinous However, Stoppa and Soler demonstrated that transmigration
fibers of the transversus abdominis muscle. 20 ,26 The preperitoneal through the bowel was still a threat when the polyglactin was ab-
iliopubic tract repair sutures the iliopubic tract to the transversus sorbed. They abandoned the idea as early as 1991. 47
abdominis muscle. 27,28 While this repair incorporated the use of Park48 modified our technique for the repair of large ventral
a prosthetic material, it had the disadvantage of tension. hernias by utilizing the transfixion of the ePTFE patch or Pro-
As techniques of laparoscopic inguinal herniorrhaphy matured, lene® mesh with transabdominally placed Prolene sutures passed
the predominant method was the TAPP repair using either a through a Keith needle. In their series of 30 cases, one recurrence
polypropylene mesh 16,29 or an expanded polytetrafluoroethylene was noted. This repair used a fascial overlap of 2 cm. Holzman49
material (ePTFE).30 Arregui31 and Phillips32 introduced a tech- placed Marlex® prostheses with a 4 cm overlap onto normal fas-
nique that did not involve a peritoneal incision in the repair of cial edges and secured them with an endoscopic stapler. He found
the posterior inguinal wall. The dissection of the preperitoneal this technique to be safe and effective. In separate investigations,
space was accomplished instead under direct visualization of the Holzman49 and Park50 found that the laparoscopic repair took
area through a laparoscope placed in the peritoneal cavity. The longer to accomplish but was associated with fewer postoperative
laparoscope was then moved into the newly dissected preperi- complications and a shorter hospital stay.
toneal space to complete the repair. Dulucq33,34 was the first sur- Currently, it is felt that a minimum of a 3 cm overlap is required
geon to perform the laparoscopic repair of an inguinal hernia for an adequate repair. The prosthesis is preferably fixed to the
without entering the peritoneal cavity. Ferzli35 and McKernan36 abdominal wall with both transabdominal sutures and the use of
later popularized this technique. Using the "open" entry into the the helical tacking device. The size of the mesh and the method
preperitoneal space, the dissection of the space was carried out of fixation determine the success of a hernia repair. The recur-
4. Evolution of Laparoscopic Hernia Repair 35
rence rate declines with better fixation methods, as shown by com- 21. LeBlanc KA, Booth WV. Avoiding complications with laparoscopic
paring the results of using staples alone (15%), helical tacks alone herniorrhaphy. Surg Laparosc Endosc. 1993;3 (5) :420-424.
(8%), or tacks with transabdominal sutures (0%).51 22. LeBlanc KA, Spaw AT, Booth WV. Inguinal herniorrhaphy using in-
The history of open inguinal hernia repair spans many cen- traperitoneal placement of an expanded polytetrafluoroethylene
turies. The use of the laparoscope in the repair of inguinal and patch. In: Arregui ME, Nagan RF, eds. Inguinal hernia: advances or con-
troversies? Oxford: Radcliffe Medical Press; 1994:437-439.
ventral hernias is still in its infancy by comparison. In experi-
23. Fitzgibbons RP. Laparoscopic inguinal hernia repair. In: Zucker KA,
enced hands, the recurrence rate is comparable to the open
ed. Surgical laparoscopy update, St. Louis: Quality Medical Publishing;
tension-free repair, the complication rate is low, and recovery is 1993:373-934.
rapid. Operating times have diminished, but many believe that 24. Arregui ME. Preperitoneal repair of direct inguinal hernia with mesh.
laparoscopic herniorrhaphy does not achieve an appropriate Advanced Laparoscopic Surgery: The International Experience. Indi-
cost-benefit profile. Improved technology, continued innovation anapolis, Ind.: May 20--22; 1991.
and refinement of techniques, and long-term results will ulti- 25. Popp LW. Improvement in endoscopic hernioplasty: transcutaneous
mately determine whether it will become a generally accepted, aquadissection of the musculofascial defect and preperitoneal endo-
standard procedure. scopic patch repair.] Laparoendosc Surg. 1991; 1 (2) :83-90.
26. Dion YM, Morin J. Laparoscopic inguinal herniorrhaphy. Can] Surg.
1992;35:209-212.
27. Gazayerli MM. Anatomic laparoscopic repair of direct or indirect her-
References nias using the transversalis fascia and iliopubic tract. Surg Laparosc En-
dosc. 1992;2:49-52.
1. Hutchinson E. Case of strangulated hernia operated by abdominal sec- 28. Gazayerli MM, Arregui ME, Helmy HS. Alternative technique: laparo-
tion laparotomy. Ohio M & SJ 1878;3:499. scopic iliopubic tract (IPTR) inguinal hernia repair with inlay buttress
2. Annandale T. A case in which a reducible oblique and direct inguinal of polypropylene mesh. In: Ballantyne GH, Leahy PF, Modlin IR, eds.
and femoral existed on the same side and were successfully treated by Laparoscopic surgery. Philadelphia: WB Saunders; 1993.
operation. Edinb MedJ 1876;21:1087-1091. 29. Kavic MS. Laparoscopic hernia repair. Surg Endosc. 1993;7:163-167.
3. Bendavid R. The space of Bogros. Postgrad Gen Surg. 1995;6(1):1. 30. Campos L, Sipes E. Laparoscopic hernia repair: use of a fenestrated
4. Read RC. Preperitoneal herniorrhaphy: a historical review. World] Surg. PTFE graft with endo-clips. Surg Laparosc Endosc. 1993;3(1);35-38.
1989; 13:532-540. 31. Arregui ME, Navarrette j, Davis Cj, et al. Laparoscopic inguinal hernior-
5. Nyhus LM. Preperitoneal herniorrhaphy. West] Surg, Obstet Gynecol. rhaphy: techniques and controversies. Surg Clin North Am. 1993;73(3):
1959;7:48-54. 513-527.
6. Rignault DP. Preperitoneal prosthetic inguinal herniorrhaphy through 32. Phillips EH, Carroll Bj, Fallas MJ. Laparoscopic preperitoneal inguinal
a Pfannenstiel approach. Surg Gynecol Obstet. 1986;162:465. hernia repair without peritoneal incision: technique and early clinical
7. Nyhus LM, Pollak R, Bombeck TC, et al. The preperitoneal approach results. Surg Endosc. 1993;7:159-162.
and prosthetic buttress repair of recurrent hernia. Ann Surg. 1988; 33. Dulucq jL. Treatment of inguinal hernia by insertion of a subperi-
208:722-727. toneal patch under preperitoneoscopy. Chirurgie. 1992;118(1-2):
8. Stoppa RE, Warlaumont CR. The preperitoneal approach and pros- 83-85.
thetic repair of groin hernia. In: Nyhus LM, Condon RE, eds. Hernia. 34. Dulucq JL. Treatment of inguinal hernias by insertion of mesh
Philadelphia: Lippincott; 1989: 199-225. through retroperitoneoscopy. Post Grad Surg. 1992;4(2):173-174.
9. Wantz GE. Prosthetic repair groin hernioplasties. In: Atlas of Hernia 35. Ferzli GS, Massad A, Albert P. Extraperitoneal endoscopic inguinal her-
Surgery. New York: Raven Press; 1991;101-151. nia repair.] Laparoendosc Surg. 1992;2(6):281-286.
10. Ger R. The management of certain abdominal herniae by intra- 36. McKernan jB, Laws HL. Laparoscopic repair of inguinal hernias us-
abdominal closure of the neck of the sac. Ann R Coll Surg Engl. 1982; ing a totally extraperitoneal prosthetic approach. Surg Endosc. 1993;
64:342-344. 7:26-28.
11. Ger R, Monro K, Duvivier R, et al. Management of inguinal hernias 37. Rutkow IJ. Laparoscopic hernia repair. The socioeconomic tyranny of
by laparoscopic closure of the neck of the sac. Am] Surg. 1990;159: surgical technology. Arch Surg. 1992;127(11):1271.
370-373. 38. Felix EL, Michas C. Double-buttress laparoscopic herniorrhaphy.] La-
12. Bogojavalensky S. Laparoscopic treatment of inguinal and femoral her- paroendosc Surg. 1993;3(1):1-8.
nia (video presentation). 18th Annual Meeting of the American As- 39. Geis WP, Crafton WB, Novak Mj, et al. Laparoscopic herniorrhaphy:
sociation of Gynecological Laparoscopists. Washington, DC; 1989. results and technical aspects in 450 consecutive procedures. Surgery.
13. Popp LW. Endoscopic patch repair of inguinal hernia in a female pa- 1993;114:765-774.
ltient. Surg Endosc. 1990;5:10-12. 40. Tetik C, Arregui ME, DulucqjL, et al. Complications and recurrences
14.' Schultz L, Graber j, Pietrafittaj, et al. Laser laparoscopic herniorrha- associated with laparoscopic repair of groin hernias: a multi-institu-
phy: a clinical trial, preliminary results.]Laparoendosc Surg. 1990;1:41-45. tional retrospective analysis. Surg Endosc. 1994;8:1316-1323.
15. Corbitt J. Laparoscopic heniorrhaphy. Surg Laparosc Endosc. 1991;1: 41. Felix E, Scott S, Crafton B, et al. Causes of recurrence after laparo-
23-25. scopic hernioplasty. Surg Endosc. 1998;12:226-231.
16. Corbitt J. Laparoscopic herniorrhaphy: a preperitoneal tension-free 42. LeBlanc KA, Booth wv. Laparoscopic repair of incisional abdominal
approach. Surg Endosc. 1993;7:550-555. hernias using expanded polytetrafluoroethylene: preliminary findings.
17. Salerno GM, Fitzgibbons Rj, Filipi C. Laparoscopic inguinal hernia re- Surg Laparosc Endosc. 1993;3(1):39-41.
pair. In: Zucker KA, ed. Surgicallaparoscopy. St. Louis: Quality Medical 43. LeBlanc KA, Booth WV, Spaw AT. Laparoscopic ventral herniorrhaphy
Publishing; 1991:281-293. using an intraperitoneal onlay patch of expanded polytetrafluoroeth-
18. Toy FK, Smoot RT. Toy-Smoot laparoscopic hernioplasty. Surg Laparosc ylene. In: Arregui ME, Nagan RF, eds. Inguinal hernia: advances or con-
Endosc. 1991;1:151-155. troversies? Oxford: Radcliffe Medical Press; 1994:501-510.
19. Toy FK, Smoot RT. Laparoscopic hernioplasty update. 1992;2(5): 44. LeBlanc KA, Booth WV, Whitaker jM. Laparoscopic repair of ventral
197-205. hernias using an intraperitoneal onlay patch: report of current results.
20. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatom- Contemp Surg. 1994;45(4):211-214.
ical basis.] Laparoendosc Surg. 1991;1:269-277. 45. LeBlanc KA. Two-phase in vivo comparison studies of the tissue re-
36 K. LeBlanc and R. Ger
sponse to polypropylene, polyester, and expanded polytetrafluonr 48. Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional
ethylene grafts used in the repair of abdominal wall defects. In: Treuter hernias. Surg Laparosc Endosc. 1996;6(2):123-128.
KH, SchumpeJick, eds. Peritoneal adhesions. Berlin: Springer-Verlag; 49. Holzman MD, Parut CM, Reintgen K, et al. Laparoscopic ventral and
1997:352-362. incisional hernioplasty. 1997;11:32-35.
46. Barie PS, Mack CA, Thompson WA. A technique for laparoscopic re- 50. Park A, Birch DW, Lovrics P, et al. Laparoscopic and open incisional
pair of herniation of the anterior abdominal wall using a composite hernia repair: a comparison study. Surgery. 1998;124:816-822.
mesh prosthesis. Am] Surg. 1995; 170:62-63. 51. LeBlanc KA. Current considerations in laparoscopic incisional and
47. Soler M. Eventrations post operatoires, etude de deux nouveaux pro- ventral herniorrhaphy. Submitted.
cedes. Doctoral thesis. University of Picardie: 1991.
Part II
Anatomy
5
Anatomy of the Abdominal Wall
Jean Bernard Flament, Claude Avisse, and Jean Fran~ois Delattre
The Anterolateral Abdominal Wall These muscles are myoaponeurotic systems comprising a mus-
cle body extended by a wide aponeurosis. The transversus abdo-
The anterolateral abdominal wall occupies a hexagonal area lim- minis displays two systems of aponeuroses, one anterior and the
ited cranially by the angle of the xiphoid process and the costo- other posterior. These different aponeuroses form the sheath of
chondral margins; laterally, the limit is the midaxillary line and the rectus muscle and are arranged differently in the upper two-
caudally the anterior part of the pelvic skeleton and pubic sym- thirds and lower one-third of the abdominal wall.
physis.
We will describe successively the different aspects of the an- External Oblique The muscular fIbers of this flat muscle arise from
terolateral abdominal wall which the surgeon must know when the lateral part of the thoracic wall (the lateral surface of the low-
performing a laparotomy, closing a laparotomy, or managing de est seven or eight ribs) by slips that interdigitate with those of the
novo or incisional hernias of the abdominal wall. anterior serratus. The fibers of the muscle take an oblique course
downward and toward the midline. The posterior and superior
part of the external oblique is composed of fleshy muscular fIbers
Muscles of the Anterolateral Abdominal Wall inserting on the anterior end of the iliac crest and the anterior
superior iliac spine. Its anterior aponeurosis spreads out in front
Rectus Abdominis of the rectus. Along the line extending from the xiphoid process
to the pubic symphysis, the fibers of the external oblique on one
The rectus muscles of the abdomen run vertically, like two pillars, side interdigitate with those of the other side to form a chevron
from the anteroinferior thoracic skeleton to the pubic region. pattern. This pattern shows progressive accentuation in the lower
Each rectus is attached on the thorax by three digitations to the part of the abdominal wall.
anterior part of the fIfth rib, the sixth rib and its cartilage, and The lower fIbers of the aponeurosis of the external oblique split
the seventh costal cartilage and xiphoid process. The body of the from each other inferiorly and medially to form the opening of
rectus is wide in its upper half (10-12 cm at the level of the costal the superfIcial inguinal ring. The aponeurotic fIbers form the su-
ridge and 5-8 cm near the umbilicus). The muscle ends in a fi- perior (medial) and inferior (lateral) crura of the superficial in-
brous tendon measuring 2-3 cm in width at the level of the pubis guinal ring. Arcuate fibers arch over the superior rim of this
(Fig.5.1A). slit-like opening in the aponeurosis of the external oblique. They
Three to five tendinous intersections cross the rectus muscle. are known as intercrural fibers (Fig. 5.2).
This polygastric arrangement is a reminder of the primitive The inferior crus (lateral crus) inserts into the pubic tubercle
metameric segmentation of the abdominal musculature, and the and pecten; the superior or medial crus inserts anterior to the pu-
fibrous intersections may be considered the equivalent of ab- bic bone and symphysis. The insertion of the inferior crus is, in
dominal ribs. These interesting fibrous bands are usually incom- part, by way of the lacunar ligament. Fibers from the superior crus
plete in both the anteroposterior and the transverse direction (Fig. cross the midline to insert on the opposite pubic tubercle.
5.1B). The innominate fascia of Gallaudet, or fascia of the external
oblique muscle, is a tissue-thin membrane that covers the exter-
nal oblique muscle and aponeurosis. It forms the intercrural fibers
Flat Muscles in the superfIcial ring and follows the spermatic cord to form the
external spermatic fascia.
The triple layer of the flat abdominal muscles lies on each side of The external oblique lowers the ribs (expiratory muscle), bring-
the two central paramedian pillars formed by the rectus muscles. ing the thorax closer to the pelvis.
The fibers of these three large muscles run obliquely in different
directions: the external oblique has its fibers oriented downward InternalOblique The internal oblique muscle lies deep to the ex-
and forward, the internal oblique fibers run upward and forward, ternal oblique with its fibers running in an opposite direction to
while the transversus abdominis fibers run horizontally. those of the external oblique. The muscle is inserted on the pelvic
39
40 J.B. Flament et al.
FIGURE 5.1. Rectus muscle and its sheath.

(A) Anterior view; (B) sagittal section.
A 8
skeleton and stretches upward, forward, and medially to the tho- fibers over the entire length, and they insert on the cartilage of
racic border and linea alba. The aponeurotic fibers of the inter- the lowest three ribs. The main part of the muscle continues into
nal oblique are classically considered to be the major constituent its aponeurosis, which blends into its homologues from the other
of the sheath of the rectus. side in the region of the linea alba, splits into two laminae (up-
The insertions of the internal oblique are the following: the an- per two-thirds of the aponeurosis) which pass around the anterior
terior two-thirds of the intermediate line of the iliac crest; the and posterior surfaces of the rectus.
aponeurosis of the lumbosacral muscles; the anterior superior il- At the level of the lower third of the rectus, the anterior pas-
iac spine; the lateral third of the inguinal ligament; and the il- sage of all the aponeurotic fibers causes a rupture in the posterior
iopsoas fascia. The fibers of the muscle are oriented in an upward wall of the fibrous rectus sheath referred to as the semicircular
direction. The posterior fascicles are composed only of fleshy line of Douglas (arcuate line).
The fibers of the internal oblique, originating from the ante-
rior superior iliac spine and lateral third of the inguinal ligament,
run medially and slightly downward to fan out over the anterior
surface of the rectus. These muscle fibers form the anterior part
of the conjoined tendon (falx inguinalis).
The lower part of the internal oblique continues on to the sper-
matic cord as the cremaster muscle (Fig. 5.3).
The action of this muscle is comparable to that of the external
oblique, although its unilateral contraction leads to rotation and
lowering of the thorax on the side of the contraction.
Transversus Abdominis Muscle The transversus, from its cranial to

caudal parts, is inserted posteriorly on the six lower ribs, lum-
bodorsal fascia, iliac crest, and iliopsoas fascia. The thoracic inser-
tions of this muscle are on the medial surface of the cartilage of
the lowest seven or eight ribs and interdigitate with the insertions
of the diaphragm. The transversus may be considered as a verita-
ble antagonist of the diaphragm and the main expiratory muscle.
In the lumbar region, the muscle is inserted on the tips of the
costal processes of the lumbar vertebrae and, by its aponeurotic
sheet, on the thoracolumbar fascia.
In the pelvic region, the transversus abdominis inserts on the
anterior half of the medial edge (labium internum) of the iliac
crest, the anterior superior iliac spine, and classically, the lateral
third of the inguinal ligament medial to the insertions of the in-
FIGURE 5.2. Aponeurosis of the external oblique: 3 = lateral crus; 4 = me- ternal oblique. In reality, these fibers of the transversus abdominis
dial crus; 5 = intercrural fibers. (Reprinted from H. Fruchaud, Anatomie are attached to the iliac fascia behind the inguinal ligament and
chirurgicale des hernies de l'aine. G. Doin; 1956, Fig. 43, p. 77, with permission.) then run forward and inward and come to lie almost parallel to
5. Anatomy of the Abdominal Wall 41
FIGURE 5.3. Disposition of the internal oblique muscle: 1 = internal

oblique fibers; 2 = internal oblique fibers; 3 = cremasteric muscle; 4 =
rectus muscle. (Reprinted from H. Fruchaud, Anatomie chirurgicale des
hernies de l'aine. C. Doin; 1956, Fig. 51, p. 87, with permission.)
FIGURE 5.4. Transversus abdominis muscle in a classical textbook of
anatomy. (From Bourgery, Atlas of Anatomy, 1832.)
the deep surface of the internal oblique. These fibers form the
"conjoined tendon," and contribute to the formation of the cre- Cooper, in the 1827 edition of his work, described the trans-
master (Fig. 5.4). versalis fascia as follows:
The fleshy body of the transversus abdominis, except for its low-
"When the lower portions of the internal oblique and transversalis
ermost part, blends into the anterior aponeurosis of the muscle.
muscles [sic] are raised from the subjacent attachments, a layer of
The boundary between its muscular and fibrous parts is rather sin-
fascia is found to be interposed between them and the peritoneum,
uous and will be described later as the semilunar line of Spiegel. through which the spermatic vessels emerge from the abdomen. This
The aponeurotic fibers of the transversus abdominis above the fascia, which I have ventured to name fascia transversalis, varies in
arcuate line (semicircular line, or fold of Douglas) pass posterior density, being strong and unyielding towards the ilium, but weak and
to the rectus abdominis muscle, while those below this level gen- more cellular towards the pubis." [Editor's Note: "Transversalis mus-
erally pass anteriorly and thus contribute to the anterior portion cle" was a term used for the transversus abdominis muscle.]
of the rectus sheath.
The transversus is the main muscle in the retention of the ab- The fascia propria, an areolar adipose layer of variable thick-
dominal viscera. This muscle is very important in respiration, since ness in different individuals, is often referred to as the subperi-
it displaces or blocks the visceral mass under the diaphragm at the toneal fat. It separates the transversalis fascia from the peritoneum,
end of the initial stage of diaphragmatic inspiration. The power- except at the level of the umbilicus, where it is practically absent.
ful traction of this muscle on the linea alba tends to separate the It penetrates between the bladder and the pubis into the space of
margins of a laparotomy incision. This accounts for the high fre- Retzius (retropubic space) and laterally (in contact with the iliac
quency of wound dehiscence subsequent to vertical midline inci- fascia) into the space of Bogros (retroinguinal space). The fascia
sion of the abdominal wall. Furthermore, the rapid retraction of propria is a loosely organized and largely intercommunicating
the transversus explains the persistence of the dehiscence and the layer.
difficulties encountered in its treatment, even in the absence of
loss of abdominal wall tissue .
The Rectus Sheath
Transversalis Fascia This fibrous layer lines the deep surface of
the transversus abdominis and can be easily separated from the The rectus muscle is enclosed in a stout sheath formed by the bi-
muscle over most of its surface. Its mechanical resistance is very laminar aponeuroses of the three flat muscles, which split and pass
weak above the umbilicus. However, below the umbilicus, it gains anteriorly and posteriorly around the muscle, starting at the lat-
a certain structural consistency, which is more pronounced in the eral border of the rectus abdominis, forming the linea alba me-
inguinal region. At this level, the transversalis fascia displays the dially, and continuing in a complicated way to the opposite side.
properties of a true aponeurosis, as pointed out by Cooper in 1827, The crossing of these fibers, at the midline, is the real insertion
tightly adhering to the posterior surface of the transversus abdo- of the fleshy bodies of the flat muscles of the anterior abdominal
minis, even seeming to extend the muscle downward (Fig. 5.5) . wall.
FIGURE 5.6. Structure of rectus sheath: 1 and 8 = internal oblique; 2 =

external oblique; 3 = transversus abdominis; 4 and 11 = transversalis fas-
cia; 5 = inguinal ligament; 6 = rectus sheath; 7 = aponeurotic fiber of the
external oblique ending on the rectus sheath; 10 = rectus muscle; 9 =
public tubercle. (Reprinted from H. Fruchaud, Anatomie chirurgicale des
hernies de l'aine. G. Doin; 1956, Fig. 146, p. 244, with permission.)
muscle. The transversalis fascia forms the only fascial layer poste-
FIGURE 5.5. Transversus abdominis muscle and transversalis fascia: 1 = rior to the rectus abdominis muscles below the level of the arcu-
external oblique; 2 = internal oblique; 3 = transversus abdominis muscle; ate line, midway between the umbilicus and the symphysis pubis.
4 = inguinal ligament (schematic); 5 = iliopubic tract; 6 = epigastric
As previously noted, the posterior rectus sheath in this area is com-
artery; 7 = Gimbernat's ligament; 8 = Cooper's ligament. (Reprinted from
posed of peritoneum, areolar tissue, and transversalis fascia as
H. Fruchaud, Anatomie chirurgicale des hernies de l'aine. G. Doin; 1956, Fig.
clearly shown in Figure 5.9.
65, p. 103, with permission.)
The Arcuate Line (Semicircular Line ofDouglas) The arcuate line lies
roughly along the line joining the right and left anterior superior
Below a limit formed by the semicircular line, the posterior lam- iliac spines. It is usually a clearly defined, rather sharp structure.
ina of the rectus sheath is no longer present and is replaced by Sometimes, it is marked by a progressive zone of transition where
the transversalis fascia. the resistant posterior lamina of the rectus sheath continues into
the much weaker transversalis fascia. This zone of transition is a
The Anterior Lamina of the Rectus Sheath (Fig. 5.6) This is formed weak area, lined posteriorly by the umbilico-prevesical aponeuro-
by the fibers of the oblique muscles, forming an overlapping sis, which narrows upward. So the zone of weakness lies usually at
chevron pattern facing upward or downward at an angle of
90-110°. This arrangement of the fibers of the sheath flattens out
in the umbilical region, which probably accounts for the relative
weakness of transverse sutures in this zone.
The Posterior Lamina of the Sheath This is derived mainly from the
aponeurosis of the transversus abdominis. Neurovascular trunks
penetrate the rectus sheath through small openings in the poste-
rior lamina.
Midway between the xiphoid and the umbilicus, the arrange-
ment of the aponeurotic layers is such that the external oblique
aponeurosis passes in front of the rectus abdominis muscle. The
internal oblique aponeurosis divides into two laminae at the lat-
eral margin of the rectus abdominis muscle. One layer passes in
front of the rectus to form a portion of its anterior sheath, while
the other layer contributes to the formation of the posterior rec-
tus sheath (Figs. 5.7 and 5.8).
Below the arcuate line, (linea semicircularis of Douglas), layers
forming the rectus sheath have another arrangement: the aponeu- FIGURE 5.7. Posterior view of the rectus sheath. On the left side, the mus-
rosis of the external oblique, the internal oblique, and the trans- cle has been resected to show the anterior lamina of the rectus sheath.
versus abdominis muscles all pass anterior to the rectus abdominis (From Bougery, Atlas oj Anatomy, 1832.)
is very weak. Thus, the muscle can be freed very easily. This dis-
section is totally bloodless. It provides a retromuscular, prefascial
plane that we have widely used for the placement of a prosthesis
in the treatment of incisional hernias.
Linea Alba
The linea alba is formed by decussating aponeurotic fibers of the
rectus sheath. It is a solid median raphe running vertically down
the abdominal wall.
The linea alba represents the site of insertion of the flat mus-
cles of the abdominal wall, and the most frequently used approach
to the abdominal cavity. It is therefore the most common site for
incisional hernias.
Midline incisions at this level can and should allow the surgeon
to dissect between the rectus muscles without opening their
FIGURE 5.8. Posterior view of the abdominal wall after section of urachus
sheath. Below the umbilicus, and especially below the arcuate line,
and the umbilical arteries: 1 = arcuate ligament; 2 = probe placed be-
the fibrous separation of the rectus muscles is less obvious. Indeed,
tween transversalis fascia and transversus abdominis muscle; 3 = transver-
salis fascia; 4 = inferior epigastric artery with an anastomosis to obturator
the medial borders of the two rectus muscles are often in contact
artery; 5 = suprapubic artery; 6 = external iliac vein; 7 = umbilico- with each other and may even overlap slightly. Identification of
prevesical aponeurosis; 8 = umbilical artery; 9 = ductus deferens; 10 = 51 the interstitium between the two muscles is further complicated
and 52 roots; 11 = superior gluteal artery; 12 = urachus. (Reprinted from inferiorly by the presence of the small pyramidal muscles (in 90%
A. Hovelacque etJ. Turchini, Anatomie et histologie de l'appareil urinaire et de of subjects), extending from the pubis to the center of the sub-
l'appareil genital de l'homme. G. Doin; 1938, with permission.) umbilical midline.
In a recent anatomico-radiological study, A.M. Rath and J.P.
the most lateral part of the arcuate line. In this region, herniation Chevrel 2 have shown that the average length of the linea alba (in
(so-called Spigelian hernia) may occur. 40 cadaveric dissections) was 29.11 cm (20-40 em). It is wider at
the level of the umbilicus (2.24 cm) than above it (1.72 cm) or
Adherence of the Rectus Abdominis to the Laminae of Its Sheath The below (0.66 cm). They compared the cadaveric data with the re-
rectus can be easily mobilized within its sheath, except at the level sults obtained from 40 tomodensitometric slices. The values they
of the fibrous intersections, which adhere to the anterior lamina. found in vivo were somewhat different: the average width of the
The adherence of the rectus to the posterior lamina of the sheath linea alba being 8.3 ± 5.63 cm above, 21.2 ± 8.07 cm at, and 9.3 ±
6.74 em below, umbilical level. There is thus a considerable dif-
ference between the two studies at the supraumbilical level.
Semilunar (Spigelian) Line

A. van der Spiegel (1578-1625) described the semilunar line as
the boundary between the muscle body and the anterior aponeu-
rosis of the transversus abdominis. Indeed, in most subjects, the
semilunar line describes a medially concave line, since the upper
and lower parts of the body of the transverse approach the ab-
dominal midline, whereas the middle part of the muscle lies in a
more lateral position, especially in the region of the anterior su-
perior iliac spine.
Owing to the fact that the myoaponeurotic boundary between
the internal and external oblique does not correspond to the
boundary of the transversus abdominis, the use of the term "lat-
erallinea alba" to designate the semilunar line is not appropriate.
This zone resembles a lateroreetus band rather than a true line.
It is traversed by vessels arranged stepwise and thus offers a lim-
ited route of approach if one is to avoid destructive incisions. The
intersection between the semilunar line and the arcuate line is a
point of weakness.
FIGURE 5.9. Posterior view of the transversalis fascia: 1and 7 = transversalis
fascia; 2 = fascia iliaca; 3 = inferior epigastric trunk; 4 = spermatic artery; The passage in this area of the inferior epigastric vessels run-
5 = vas deferens; 6 = obturator artery. (Reprinted from H. Fruchaud, ning along the posterior surface of the rectus abdominis con-
Anatomie chirurgicale des hernies de l'aine. G. Doin; 1956; Fig. 185, p. 328, with tributes also to the weakness of this region where the rare Spigelian
permission. ) hernia may arise. This type of hernia is found in the triangle
bounded laterally by the semilunar line, superiorly by the lateral Venous Drainage
part of the arcuate line, and inferiorly and medially by the oblique
course of the inferior epigastric vessels. The system of venous drainage has a pattern similar to that of the
arteries. The inferior epigastric veins (two per artery), join to-
gether to form a short common terminal trunk drained by the ex-
ternal iliac vein. The inferior epigastric veins run along the medial
Vascularization of the Anterolateral border of the artery for about 1 cm and then leave it to join the
Abdominal Wall external iliac vein. The terminal trunk of these veins measures usu-
ally 3 cm in length. This venous trunk can be reached by the clas-
Arterial Vascularization sic inguinal approach or by a vertical pararectus route exposing
the origin of the venous trunk. The latter route allows catheteri-
The general pattern of the arterial vascularization of the an- zation of the vein if required at a safe distance from structures
terolateral abdominal wall is formed by a vertical axis, reinforced which might be injured.
by metameric arrangement of the lateral vessels. The vertical ar-
terial axis, lying along the posterior surface of the rectus mus-
cle, is formed by the inferior and superior epigastric arteries. Lymphatic Drainage
This vertical axis is reinforced by the metameric arrangement of
the lateral vessels originating from the intercostal and lumbar The upper part of the muscular abdominal wall is drained by the
arteries. internal thoracic lymph nodes, while in the lower part drainage is
The inferior epigastric artery, which is the predominant artery, provided by the external iliac nodes. Finally, lateral lymphatic
arises from the external iliac artery just behind the inguinal liga- drainage is provided by the lumbar nodes.
ment. It runs cranially and medially, pierces the transversalis fas-
cia and then lies anterior to it. It is accompanied by Hesselbach's
(interfoveolar) ligament, which is a thickening of this fascia. The Innervation of the Anterolateral
artery then has a variable course toward the lateral border of the Abdominal Wall
rectus, crossed at a point situated 4 to 8 cm above the pubis.
Posterior to the rectus, the artery divides into a descending A precise knowledge of the nerve distribution to the abdominal
branch running toward the pubis, and an ascending branch, the wall is very important to the surgeon who performs abdominal op-
larger of the two. The ascending branch may persist as a single, erations. Section of a single nerve results in little harm, even for
dominant axis, which splits into parallel ascending branches, or the sensory functions, since adjacent nerves overlap the area. Di-
divide into two main branches running about 1 cm from the lat- vision of two nerve trunks is not advisable, but the harm is not yet
eral and medial margins of the rectus. serious. If a third nerve trunk is divided, a particular type of
Direct anastomosis between the inferior and superior epigastric pseudohernia, or diffuse weakness, will result. Hence, the distri-
arteries is relatively rare. bution of the intercostal nerves should be known to all who may
The superior epigastric artery is an abdominal branch of the in- incise the abdominal wall.
ternal thoracic artery, descending through Larey's cleft (the ster-
nocostal triangle). Regardless of the anastomotic pattern,
communication between the two arteries is well developed, since Skin Innervation
the opacification of one of them immediately leads to massive re-
flux of contrast material into the other. The segmental distribution of the intercostal nerves is well known.
The lateral arterial system is a reminder of the initial metameric The anterior rami are found between the internal oblique and the
arrangement of the trunk arteries. These transverse arteries are transversus abdominis muscles. These nerves run medially and
supplied by the diaphragmatic branch of the internal thoracic penetrate the internal oblique muscle as they approach the rec-
artery, which is anastomosed to the termination of the intercostal tus sheath. At the lateral margin of the rectus abdominis muscle,
arteries and the lumbar arteries. The latter show many commu- the nerves supply the muscle and its sheath. The 6th or 7th tho-
nications with the deep circumflex iliac artery, a branch of the ex- racic nerve applies the epigastric area; the 10th innervates the area
ternal iliac artery. There are significant vertical anastomoses to the level of the umbilicus, while the 12th thoracic nerve reaches
joining these metameric arteries to form a ladder-like system. the area just above the groin. The anterior rami of the first lum-
Accordingly, in the flanks, there is a parietal arterial plexus sup- bar nerve complete the nerve supply to the inguinal area through
plying the perforating branches, which, along with nerve fila- the iliohypogastric and ilioinguinal nerves.
ments, enter the rectus sheath and anastomose to the vertical The iliohypogastric and ilioinguinal nerves supply sensory in-
arterial axis. nervation to an oblique band of the abdominal wall comprising
The superficial perforating arteries arise from the horizontal ar- the lower part of the iliac fossa, the inguinal region, and part of
terial system. Nevertheless, these perforating arteries are also sup- the external genital organs.
plied by the vertical epigastric arterial axis. As previously pointed The genitofemoral nerve arises from the first and second lum-
out, the subcutaneous abdominal (superficial epigastric) and su- bar nerves and contributes to the sensory innervation of the root
perficial circumflex iliac arteries form a remarkable inferior cu- of the external genital organs. It is also the motor nerve of the
taneous arterial system. cremaster (Fig. 5.10).
At the level of the flat abdominal muscles, the arterial branches The lateral cutaneous nerve of the thigh, originating from the
are found mainly in two layers, one on each side of the internal second lumbar nerve, is not involved in the superficial innerva-
oblique. tion of the abdominal wall.
The Skin and Its vessels

Cutaneous and Subcutaneous Layer
The structure and organization of the cutaneous and subcuta-
neous layers have considerable influence on the planning of ab-
dominal wall incisions. Vascularization is a determining factor in
the mobilization of surgical flaps. Finally, knowledge of the in-
nervation of this layer is of importance from the point of view of
symptomatology, since referred visceral pain often projects to the
cutaneous layer of the abdominal wall.
The skin is relatively mobile over the myofasciallayers of the an-
terolateral abdominal wall, although its medial area is stabilized
by the umbilicus which acts like a central "thumbtack."
The loosely organized subcutaneous tissue forms a pad, which
may be very thick, containing within it the superficial fascia. The
major feature of this layer is the elastic traction lines or Langer's
lines. These lines run transversely across the anterolateral ab-
dominal area. Their direction is practically horizontal in the
supraumbilical region, but below they slant downward to outline
an arc of increasing superior concavity as they progress toward the
pubic region.
The surgeon should be aware of the direction of Langer's lines
if, after abdominal section, the incision is to heal with minimal
scarring (Fig. 5.11). In 1941 Cox4 studied the cleavage lines of the
skin with precision and presented his findings clearly. Vertical in-
cisions across these lines produce widely gaping wounds, and al-
though they do heal, with the passage of time the scar tends to
widen. Generally speaking, there is far less spreading of the wound
FIGURE 5.10. Innervation of the anterolateral abdominal wall: 1 = seventh edges when transverse or oblique incisions are made.
intercostal nerve; 2 = external oblique; 3 = eighth intercostal nerve; 4 =
internal oblique muscle; 5 = anterior lamina of the rectus sheath; 6 = ex-
ternal oblique aponeurosis; 7 = internal oblique aponeurosis; 8 = ninth
intercostal nerve; 9 = 10th intercostal nerve with nerves to internal
oblique; 10 = 11th intercostal nerve; 11 = 12th intercostal nerve; 12 =
nerve to the internal oblique; 13 = cutaneous branch; 14 = iliohypogas-
tric nerve. (Reprinted from A. Hovelacque, Anatomie des nerfs craniens et
rachidiens. G. Doin; 1927, with permission.)
Parietal Muscle Innervation

The 7th through 12th intercostal nerves, along with the iliohy-
pogastric and ilioinguinal nerves, supply the motor innervation of
the anterolateral abdominal wall. The classic pattern of this mo-
tor innervation has been described by Hovelacque in 1927.3 The
7th, 8th, and 9th intercostal nerves distribute to the supraumbili-
cal part of the rectus. The 10th intercostal nerve runs toward the
umbilicus along an imaginary line extending across the midline
to the anterior superior iliac spine on the opposite side. The 11 th
intercostal nerve passes below the umbilicus in the direction of
the contralateral inguinal ligament. Finally, the 12th intercostal
nerve runs in a very inferior position in the direction of the pu-
bic tubercle on the opposite side.
The motor branch of the iliohypogastric nerve reaches the in-
ferior part of the rectus and the pyramidalis muscle, while that of
the ilioinguinal nerve terminates in the flat abdominal muscles.
The nerve trunks run first between the internal oblique and the FIGURE 5.11. Langer's lines, usual disposition. (Reprinted from H.
transversus abdominis to reach the rectus at a point slightly me- Fruchaud, Anatomie chirurgicale des hernies de l'aine. G. Doin; 1956, Fig. 156,
dial to its lateral margin (Fig. 5.10). p. 265, with permission.)
Arterial Vascularization of Cutaneous

Layers of the Abdomen
The arterial vascularization of the cutaneous layers of the ab-
dominal wall is rich. Many vessels emerge from the anterior sur-
face of the rectus sheath and then ramify extensively under the
skin. Some of these vessels perforate the aponeurosis of the ex-
ternal oblique in the mid-axillary line, while others emerge from
the anterior lamina of the sheath of the rectus abdominis. There
are usually four supraumbilical and three subumbilical vessels on
each side. The umbilicus is surrounded by four highly anasto-
mosed perforating arteries (periumbilical arterial circle).
The perforating arteries, arising deep in the cutaneous layers,
are supplied by the lateral vessels of the abdominal wall, that is, by
the lower intercostal and the lumbar arteries. These lateral vessels
show many anastomoses with the deep circumflex iliac network.
There are also specific cutaneous arterial systems running up-
ward from the inguinal region. The superficial epigastric and su-
perficial circumflex iliac arteries arise from the femoral artery.
These two superficial arteries are highly anastomosed to one an-
other and to the deep arterial network. The territory supplied by FIGURE 5.12. The myopectineal orifice: 1 = iliacus muscle; 2 = fascia ili-
them extends a few centimeters lateral to the midline and ends aca; 3 = external oblique muscle; 4 = internal oblique muscle; 5 = supe-
about halfway between the umbilicus and the xiphoid process. rior iliac spine; 6 = femoral nerve; 7 = iliopsoas muscle; 8 = pectineus
muscle; 9 = rectus muscle; 10 = internal oblique muscle; 11 =
iliopectineal tract; 12 = fascia iliaca; 13 = Cooper's ligament; 14 = pubic
Venous Drainage tubercle (Reprinted from H. Fruchaud, Anatomie chirurgicale des hernies de
l'aine. G. Doin; 1956, Fig. 193, p. 338, with permission.)
The system of venous drainage runs parallel to the arterial system.
In the region of the umbilicus, the venous system of the abdomi- dominis muscles which form the falx inguinalis or conjoined ten-
nal wall may communicate above with a patent ligamentum teres don. Laterally, the myopectineal orifice is bounded by the iliop-
hepatis (Cruveilhier-Baumgarten syndrome) and below with the soas muscle, with its thick aponeurosis, the fascia iliaca, covering
pelvic veins running along the allantoic sheath. the femoral nerve, while the medial border is formed by the rec-
tus muscle with the ligament of Henle (Fig. 5.13).
Lymphatic Drainage
The system oflymphatic drainage is extremely diffuse, fanning out
from the umbilicus. This system communicates with the deep he-
patic and pelvic lymphatic networks. The lymphatic ducts of the
abdominal wall run downward to the inguinal region, join the
deep lymphatic trunks of the lumbar region laterally, and connect
above with the intercostal and internal mammary systems. These
different lymph vessels form a channel on each side and along the
mammillary line. Primary cancer of the breast or of a supernu-
merary nipple may seed neoplastic nodes along this line.
6 _____ _
Groin Anatomy
General Concept of the Inguinofemoral Area
Henri Rene Fruchaud5 emphasized the fact that all hernias of the
groin originate within a single weak area which he named the myo-
pectineal orifice (Fig. 5.12). According to Fruchaud, the myo-
pectineal orifice forms a single orifice bounded below by the bony
margin of the pelvis, which here forms part of the anterior bor-
FIGURE 5.13. Myopectineal orifice with femoral vessels: 1 = internal
der of the ilium, covered by the pectineal ligament, and the oblique; 2 = iliopsoas muscle; 3 = fascia iliaca; 4 = iliopectineal tract; 5 =
pectineus muscle, and above by the flat (broad) muscles of the an- Cooper's ligament; 6 = pubic tubercle; 7 = rectus muscle; 8 = inguinallig-
terolateral abdominal wall. These are arranged in two layers, a su- ament; 9 = femoral vein; 10 = femoral canal. (Reprinted from H.
perficial layer constituted by the external oblique muscle, and a Fruchaud, Anatomie chirurgicale des hernies de l'aine. G. Doin; 1956, Fig. 195,
deep layer constituted by the internal oblique and transversus ab- p. 341, with permission.)
--r1~m~~----------e
If!!f'->L-- f
~--~t---- g
H-~H"--- h
A B
FIGURE 5.14. Sagittal section of the myopectineal orifice. (A) Inguinal and
femoral canals according to Testut: 1 = spermatic cord; 2 = femoral vein;
13 = Cooper's ligament; 14 = iliopubic ramus of the pelvic bone. (From
L. Testut, Traiti d 'anatomie humaine. G. Doin; 1923.) (B) Inguinal and femoral
canals according to Fruchaud; a = inguinal canal; b = transversus abdominis
muscle; c = external oblique muscle; d = external oblique aponeurosis; e =
transversalis fascia; f = iliac artery; g = transversalis fascia; h = spermatic
cord; i = inguinal ligament; j = Cooper's ligament; k = femoral artery.
(Reprinted from H. Fruchaud, Anatomie chirurgicale des hernies de l'aine. G.
Doin; 1956, Fig. 30, p. 54, with permission.). (C) Frozen cadaveric sagittal
section. (From the collection of the Department of Anatomy, Reims Uni-
versity.) c
The Myopectineal Orifice The pectineal ligament (Cooper's ligament) is a very resistant,
composite structure reinforcing the periosteum of the pubic
Superficially, the myopectineal orifice is divided into two levels by pectin between the pubic tubercle and the iliopectineal eminence.
an aponeurotic structure, the inguinal ligament (or crural arch), This ligament joins the inguinal ligament medially where it forms
which represents the termination of the aponeurosis of the ex- the lacunar ligament of Gimbernat but diverges laterally from it
ternal oblique muscle. Figure 5.12 represents the original con- when it runs in a much deeper position.
ception of Fruchaud's myopectineal orifice, as it was reproduced The pectineal ligament is a heterogeneous structure compris-
by Wantz in his Atlas of Hernia Surgery.6 The superior, inguinal level ing three layers. The deep layer is in continuity with the perios-
provides a passage for the spermatic cord (or round ligament), teum of the superior pubic ramus. The middle, muscular layer is
while the inferior, femoral (or crural) level provides a passage for formed by fibers of the pectineus muscle. This muscle, which be-
the femoral vessels (Fig. 5.14A,B) as schematically described in the longs mainly to the muscular floor of the femoral triangle, arises
sagittal theoretical cross section. from the pectineal surface and pecten of the pubis. The muscle
Roughly quadrangular, the myopectineal orifice has four mar- belly, oblique downward, terminates at the pectineal line on the
gins, inferior, superior, medial, and lateral, as they were described posterior aspect of the superior epiphysis of the femur. The su-
by Fruchaud. perficial (aponeurotic) layer is very resistant, being formed by the
overlapping of the vertical fibers of the aponeurosis of the
pectineal muscle and transverse fibers running along the innom-
Inferior Margin of the Myopectineal Orifice inate line of the pelvis (arcuate line). Some of these fibers seem
to emanate from the psoas minor.
The inguinofemoral region is constructed at the anterior border The pectineal ligament displays an extreme degree of mechan-
of the iliac bone (Fig. 5.15), which presents from above downward ical resistance. Although it is only a few millimeters thick, wires
and from without inward the anterior superior iliac spine, an un- passed under the ligament in contact with the bone can be used
named notch, the anterior inferior iliac spine, the iliopubic emi- to virtually lift up the whole body (Fig. 5.16).
nence (a bony prominence over the acetabulum), and last the
pectineal surface of the superior ramus of the pubic bone,
bounded behind by the pecten of the pubis and medially by the Medial Margin of the Myopectineal Orifice
pubic tubercle. The pubic bone is lined in its upper part by the
pectineal ligament of Cooper, l to which the sutures can be firmly The terminal part of the rectus and the overlying pyramidalis form
anchored. the medial boundary of the fibromuscular frame. The rectus ter-
izontally. It is formed by the fusion of the lower fibers of the in-

ternal oblique and transversus abdominis muscles. The muscle
fibers of the conjoined tendon arise laterally, not from the inguinal
but rather from the iliac fascia of the psoas major and iliac mus-
cles and from the anterior superior iliac spine. These fibers ini-
tially run parallel to the inguinal ligament and are connected to
it by fibrous bands. The fibers of the conjoint tendon then run
upward and horizontally above the inguinal ligament, to termi-
nate as a reinforcement of the prerectus aponeurotic layer.
Lateral Margin
The lateral margin of the myopectineal orifice is formed by the il-
iopsoas muscle and the iliopectineal arch (Figs. 5.17, 5.18).
The iliopsoas muscle, arising from its origins at the lumbar ver-
tebrae and internal iliac fossa, goes from the abdomen to the thigh
in front of the iliopubic eminence to terminate at the posterior
aspect of the lesser trochanter of the femur. It is surrounded by
its sheath, the iliac fascia, beneath which the femoral nerve is sit-
FIGURE 5.15. Anterior border of the iliac bone: 1 = iliopectineal tract; 2 =
Cooper's ligament; 3 = iliopubic tract; 4 = Gimbernat's ligament; 5 = pu- uated in the space separating the two muscle heads.
bic tubercle. (Reprinted from H. Fruchaud, Anatomie chirurgicale cles hernies The iliopectineal arch is the medial thickening of the iliac fas-
de l'aine. G. Doin; 1956, Fig. 131, p. 213, with permission.) cia covering the iliacus muscle where the muscle leaves the pelvis.
This arch attaches laterally to the anterosuperior iliac spine and
medially to the iliopectineal eminence. It is never used directly by
minates inferiorly on the surface extending from the pubic sym- the surgeon, but it is important as a common junction site of the
physis to the pubic tubercle. The anterior surface of the muscle is following structures of the lateral groin: the insertion of fibers of
covered by a thick aponeurosis, while its posterior surface is lined the external oblique aponeurosis (fibers of the inguinal ligament) ,
by the transversalis fascia only. The margin of the rectus sometimes the origin of some fibers of the internal oblique muscle; the trans-
presents a lateral expansion which goes to the pubic tubercle and versus abdominis muscle; and the lateral attachment of the ilio-
is referred to as Henle's ligament (this ligament is present in 30 to pubic tract. The iliopectineal arch also contributes to the lateral
50% of patients and is fused with the transversalis fascia). wall of the femoral sheath.
Superior Margin of the Myopectineal Orifice Closure of the Myopectineal Orifice

The superior boundary is formed by the so-called conjoined ten- Superficially, the myopectineal orifice is divided into two levels by
don (falx inguinalis), a twin muscular layer running roughly horan aponeurotic structure, the inguinal ligament, which represents
____ 9
_ ___10
A B
FIGURE 5.16. Pectineal (Cooper's) ligament. (A) Sagittal cross section of 10 = external oblique aponeurosis; 11 = spermatic cord; 12 = Cooper's
the inguinal canal showing precisely the structure of the Cooper ligament: ligament; 13 = urinary bladder; 14 = endopelvic fascia. (Reprinted from
1 = inferior epigastric trunk; 2 = iliopubic tract; 3 = inguinal ligament; H. Fruchaud, Anatomie chirurgicale cles hernies cle l'aine. G. Doin; 1956, Fig.
4 = Gimbernat ligament; 5 = pectineus muscle; 6 = pubic bone; 7 = trans- 53, p. 89, with permission.) (B) Dissection (left side). (From the collec-
versus abdominis muscle; 8 = internal oblique muscle; 9 = peritoneum; tion of the Department of Anatomy, Reims University.)
FIGURE 5.17. Inguinal and femoral canals: 1 = inguinal ligament; 2 = il-

iopsoas muscle; 3 = femoral artery; 4 = iliopectineal tract; 5 = Cooper's FIGURE 5.18. Inguinal ligament, inguinal canal, and femoral canal: 1 = in-
ligament; 6 = Gimbernat's ligament; 7 = pubic tubercle. (Reprinted from guinal ligament, extended by iliopubic tract; 2 = iliopsoas muscle; 3 = il-
H. Fruchaud, Anatomie chirurgicale dRs hernies de l'aine. G. Doin; 1956, Fig. iopectineal tract; 4 = femoral canal; 5 = Cooper's ligament; 6 =
38, p. 68, with permission.) Gimbernat's ligament; 7 = pubic tubercle; 8= external oblique aponeu-
rosis; 9 = spermatic cord. (Reprinted from H. Fruchaud, Anatomie chirur-
gicale des hernies de l'aine. G. Doin; 1956, Fig. 36, p. 62, with permission.
the termination of the aponeurosis of the external oblique mus- [Editor's note: In his comment on this drawing, Fruchaud states that,
cle. The superior, inguinal, level provides a passage for the sper- though it is conventional, it is wrong.])
matic cord (or round ligament), while the inferior, femoral (or
crural), level provides a passage for the femoral vessels. Deeply,
the myopectineal orifice is closed by the transversalis fascia, which In this area, the transversalis fascia presents arcuate reinforce-
becomes evaginated around the spermatic or femoral structures ments. Henle's ligament has already been described. Hesselbach's
passing through the region. ligament (ligamentum interfoveolare) is a fibrous reinforcement
of the sheath of the inferior epigastric vessels at the medial side
of the inguinal ring. Laterally, the transversalis fascia adheres
The Inguinal Ligament rather tightly to the iliac fascia, and inferiorly, to the inguinallig-
ament and the pectineal ligament in the medial part of this re-
The inguinal ligament forms the reinforced inferior edge of the gion. According to McVay and Anson 7 (1940), the pectineal
external oblique aponeurosis. Opening this aponeurosis to ap- ligament is the true inferior insertion of the medial part of the
proach an inguinal hernia exposes this ligament as a whitish, transversalis fascia, whereas the areolar layer lying anterior to the
ribbon-like structure which spreads out when the aponeurosis is fascia and adhering to the inguinal ligament should not be con-
pulled downward and laterally. The inferior margin of the inguinal sidered mechanically significant. At a more lateral site, the trans-
ligament is not completely free, since it is in continuity with the versalis fascia separates from the pectineal ligament to blend with
fibrous structures blending above with the transversalis fascia and the femoral sheath anterior to the femoral vessels, thus delimiting
below with the femoral sheath (Fig. 5.19A and B). a prevascular funnel about 3 cm long (the funnel of Anson and
The question may be asked whether there is truly a discrete fi- McVay).
brous structure (Poupart's ligament) stretched between the ante-
rior superior iliac spine and pubic tubercle. The existence of the
inguinal ligament was questioned by many authors, especially by Reinforcement of the Transversalis Fascia
Winckler, who demonstrated that the so-called inguinal ligament (Fig. 5.21B)
was only the inferior edge of the external oblique aponeurosis
(Fig. 5.20A and B). The interfoveolar ligament (of Hesselbach) is an apparent thick-
ening of the transversalis fascia at the medial side of the internal
inguinal ring. Like a spider web, it lies in front of the inferior epi-
Transversalis Fascia (Fig. 5.21A) gastric vessels. When well developed, it gives the impression that
it is only a lateral condensation of the ligament of Henle. How-
The frame of the myopectineal orifice is closed by the lower part ever, it is not a true ligament.
of the transversalis fascia. This fascia, which is rather weak else- The iliopubic tract, posterior to the lower margin of the exter-
where, constitutes a veritable aponeurosis in this region, where it nal oblique aponeurosis, is a fibrous structure sometimes called
extends under the inferior margin of the transversus abdominis. the bandelette of Thomson. Attached medially near the pubic tu-
A B
FIGURE 5.19. The inguinal ligament. (A) True position of the inguinallig- (Reprinted from H. Fruchaud, Anatomie chirurgicale des hernies de l'aine.
ament, of the ligament of Gimbernat, and of the myopectineal orifice: 1 = Doin; 1956, Fig. 90, p. 137, with permission.) (8) Personal dissection show-
external oblique resected; 2 = internal oblique muscle; 3 = inguinal liga- ing the termination of flat muscles and the rectus sheath. Dissection can
ment; 4 = iliopsoas muscle; 5 = iliopsoas muscle; 6 = internal oblique create an artificial "inguinal ligament." Compare with (A). (From the col-
muscle; 7 = external oblique resected; 8 = rectus sheath; 9 = fascia iliaca; lection of the Department of Anatomy, Reims University.)
10 = Cooper's ligament; 11 = Gimbernat's ligament; 12 = pubic tubercle.
berc1e and running laterally to the iliac fascia, the tract continues ent in 98% of Condon's dissections. This author notes that it is of-
more laterally to the anterior superior spine of the ilium. Medi- ten confused with the inguinal ligament. 7 Although nearby, this
ally, it forms the lower border of the internal ring, crossing the ligament belongs to the anterior lamina (superficial myoaponeu-
femoral vessels to form the anterior margin of the femoral sheath. rotic layer), while the iliopubic tract is part of the deeper layer
The tract curves around the medial surface of the femoral sheath (postlaminar structures).
to attach to the pectineal ligament. The iliopubic tract was pres- Every surgeon who repairs groin hernias must understand the
A B
FIGURE 5.20. (A) Anterior view of external oblique muscle and its aponeu- muscle aponeurosis. (Reprinted from H. Fruchaud, Anatomie chirurgicale des
rosis, forming the inguinal ligament, according to Winckler (in Fruchaud); hernies de l'aine. G. Doin; 1956, Fig. 41, p . 75, with permission.) (8) Inguinal
1 = muscular fibers of the external oblique; 2 = external oblique fibers ligament and myopectineal orifice: 1 = external oblique; 2 = internal
going to anterior superior iliac spine; 3 = external oblique fibers going to oblique; 3 = inferior edge of the external oblique aponeurosis forming the
fascia iliaca; 4 = lateral cutaneous femoral nerve; 5 = fascia iliaca; 6 = su- inguinal ligament. (Reprinted from H. Fruchaud, Anatomie chirurgicale des
perficial inguinal ring; 7 = lateral crus; 8 = medial crus; 9 = pectineus hernies de l'aine. G. Doin; 1956, Fig. 128, p. 205, with permission.)
A B
FIGURE 5.21. Transversalis fascia and its reinforcement. (A) Hesselbach's deferens; 4 = Hesselbach's triangle; 5 = anastomosis between inferior
ligament. (From H. Fruchaud, Anatomie chirurgicale des hernies de l'aine. G. epigastric and obturator trunks. (Reprinted from H. Fruchaud, Anatomie
Doin; 1956, Fig. 85, p. 131. With permission.) (8) Fascia transversalis and chirurgicale des hernies de l'aine. G. Doin; 1956, Fig. 86, p. 132, with permis-
internal ring; 1 = semicircular line; 2 = inferior epigastric artery; 3 = vas sion.)
boundaries of Hesselbach's triangle. This knowledge is basic to un- just before it passes under the inguinal ligament. The spermatic
derstanding and successful repair of direct and indirect inguinal cord lies anterior to the floor of this triangle after it emerges from
hernias. the abdomen just lateral to the inferior epigastric artery.
The medial margin is made up of the lateral border of the rec- Indirect inguinal hernias arise lateral to the inferior epigastric
tus abdominis muscle and its sheath; at the inferior margin lies artery, then continue on an oblique path along the cord from the
the inguinal ligament. [Editor's Note: When originally described internal abdominal ring, through the inguinal canal and the ex-
by Hesselbach, the lower margin was the ligament of Cooper.] The ternal ring, into the scrotum. Direct hernias take an anterior path
lateral border of the triangle is marked by the inferior epigastric directly through the abdominal wall medial to the inferior epi-
artery (Fig. 5.22). This artery arises from the external iliac artery gastric artery.
Peritoneum
The peritoneum is the innermost layer of the abdominal wall and,
therefore, of the inguinal area. It is loosely connected with the
transversalis fascia in most areas, with the exception of the inter-
nal ring, where the connection is stronger. The processes vaginalis,
a peritoneal diverticulum, is embryologically related to the deep
inguinal ring (Fig. 5.23).
The ascending fibrous and vascular structures interposed be-
tween the transversalis fascia and peritoneum push up against the
latter to form three inguinal depressions. From medial to lateral,
these depressions are: the internal inguinal fossa, lying between
the obliterated urachus (median umbilical ligament) and umbili-
cal artery (medial umbilical ligament) ; the middle inguinal fossa,
lying between the umbilical artery and the inferior epigastric ves-
sels; and the external inguinal fossa, located lateral to the umbil-
ical vessels and corresponding to the deep inguinal ring.
The external inguinal fossa is a peritoneal infundibulum cor-
FIGURE 5.22. Fascia transversalis and Hesselbach's triangle. 1 = external
responding to the mouth of the embryonic vaginoperitoneal canal.
oblique aponeurosis; 2 = conjoined tendon; 3 = spermatic cord; 4 = in- This fossa is the natural course of sliding indirect hernia, whereas
ferior epigastric trunk; 5 = Hesselbach's triangle; 6 = inguinal ligament; direct hernia results from the progressive distension of the mid-
7 = iliopubic tract. (Reprinted from H. Fruchaud, Anatomie chirurgicale des dle inguinal fossa. Sliding direct hernia via the supravesical fossa
hernies de l'aine. G. Doin; 1956, Fig. 70, p. 109, with permission.) is an exceptional finding.
space is considered to be the lower prolongation of the great pos-

terior paravesical space.
The space of Bogros, according to Bendavid,9 is a lateral ex-
tension of the retropubic space of Retzius and may be explored
by incising the transversalis fascia, or better, the floor of the canal
from the internal ring to the pubic crest. He also reported that a
venous network is located at the lower and anterior part of the
space of Bogros. The Bendavid "venous circle," located at the sub-
inguinal space of Bogros, is composed of the inferior epigastric
vein, the iliopubic vein, the rectusial vein, the retropubic vein, and
the communicating rectusio-epigastric vein. Attached to the ante-
rior wall, this venous circular network is variable (Fig. 5.24A and
B). Familiarity with this venous circle is advised, particularly for
those surgeons using prosthetic material, and for laparoscopic
surgeons.
Inguinal Canal
FIGURE 5.23. Posterior view of the peritoneal fossae: 1 = urachus; 2 = blad-
der; 3 = umbilical artery; 4 = spermatic trunk; 5 = vas deferens; a = ex- The inguinal canal is an oblique rift measuring approximately 4
ternal inguinal fossa; b = middle inguinal fossa; c= internal inguinal fossa.
cm in length. It is located 2 to 4 cm above the inguinal ligament
(Reprinted from H. Fruchaud, Anatomie chirurgicale des hernies de l'aine. G.
between the internal (deep inguinal) ring and the external (su-
Doin; 1956, Fig. 201, p. 351, with permission.)
perficial inguinal) ring opening. The inguinal canal contains ei-
ther the spermatic cord or the round ligament of the uterus.
Preperitoneal Space
Fat and other connective tissue lie within a space between the peri- The Limits of the Inguinal Canal (Fig. 5.25)
toneum and the transversalis fascia. Fibrous bands, and occasion-
ally lipomas similar to those in the spermatic cord, also are present. The anterior wall is formed by the aponeurosis of the external
The preperitoneal space is exposed by the reflection of the pari- oblique muscle, together with the internal oblique muscle laterally.
etal peritoneum toward the iliac fossa before it reaches the pubic The posterior wall, or floor, is the most important wall of the in-
bone. guinal canal. It is formed primarily by fusion of the aponeurosis of
The surgical anatomy of the iliac region was discussed by French the transversus abdominis muscle and the transversalis fascia in
anatomist and surgeon Bogros in 1823. 8 He described a triangu- 75% of subjects, and in the remaining 25% by the transversalis
lar space with the following boundaries: laterally, it is limited by fascia only.
the iliac fascia, anteriorly by the transversalis fascia, and medially The deep inguinal ring is an opening in the upper lateral part
by the parietal peritoneum. This cleavable interparieto-peritoneal of the transversalis fascia, an evagination like the lining of a jacket,
rT,T7J~.Ktelllal ring
•......-......... .••...
.......••••
.1'.-
.-
••••••
A ..., ............ _.......... ..................... B
FIGURE 5.24. (A) The deep inguinal venous vasculature within the space tern. (Reprinted from Surg Gynecol Obstet; 1992;174:335-338, with permis-
of Bogros. (B) Variations in the pattern of the deep inguinal venous sys- sion.)
1
2
3_~
4------7,
FIGURE 5.25. The limits of the inguinal canal. Fruchaud's conception: 3 =

external oblique aponeurosis; 6 = transversalis fascia; 11 = inguinal liga-
ment; 12 = iliopubic tract. (Reprinted from H. Fruchaud, Anatomie chirur-
gicale des hernies de l'aine. G. Doin; 1956, Fig. 67, p. 105, with permission.)
FIGURE 5.26. Anterior wall of the inguinal canal and superficial inguinal
ring. (Reprinted from H. Fruchaud, Anatomie chirurgicale des hernies de l'aine.
where the transversalis fascia joins the fibrous coat of the sper- G. Doin; 1956, Fig. 32, p. 56, with permission.)
matic cord. This fibrous spermatic cord envelope is embryologi-
cally equivalent to the fascia, although it does not display similar
mechanical properties. The deep inguinal ring is strengthened take it for the aponeurosis of the external oblique muscle, which
from below and medially by the passage of the inferior epigastric may lead to treating a superficial ectopic testicle as an inguinal
vessels and the reinforcement of Hesselbach's ligament (ligamen- cryptorchidism. There may be a layer of fat between the fascia and
tum interfoveolare), an apparent thickening of the transversalis the aponeurosis.
fascia at the medial side of the internal inguinal ring. Hesselbach's
ligament has been considered a mechanically important structure.
Tension on this ligament elevates and closes the deep inguinal Arteries of the Spermatic Cord
ring, thus acting in opposition to the forces acting on the exter-
nal inguinal fossa. The arteries of the testis and epididymis are shown in Fig. 5.27.
The superficial inguinal ring (annulus inguinal is superficialis) The internal spermatic, or testicular, artery is a branch of the aorta.
is located above the pubic tubercle in the medial part of this fas- The artery of the ductus deferens originates from the inferior vesi-
cial layer. In this region the spermatic cord lies in the highly vas- cal artery. The external spermatic, or cremasteric, artery arises
cular areolar subcutaneous tissue. Accordingly, care must be taken from the inferior epigastric artery.
when dissection is done in this area. Subsequent to incision made Anastomoses are present between the gonadal and deferential
parallel to the fibers of the aponeurosis of the external oblique, arteries in all patients. There are also some anastomoses between
the first step in the approach to this region is the debridement of these and the cremasteric arteries in approximately two-thirds of
the superficial inguinal ring (Fig. 5.26). patients. Upon division of the cord, collateral circulation is suffi-
In children, the inguinal canal is short (1 to l.5 cm), and the cient to prevent gangrene of the testis in 98% of patients. Testic-
internal and external rings are nearly superimposed upon one ular atrophy will nevertheless occur in 80%. If the surgeon
another. accidentally divides the cord, it is advisable to leave the testicle in
the scrotum and not bring it into the surgical field, to preserve
the collateral circulation from the scrotal artery, the prostatic
The Spermatic Cord artery, and the inferior vesical artery, which may save the testicle.
Between the upper and middle third of the testicle, the testic-
The spermatic cord is a matrix of connective tissue continuous ular artery bifurcates into the main testicular and epididymal
proximally with the preperitoneal collective tissue. It holds the branches. During epididymectomy, dissection of the epididymis
ductus deferens, three arteries, three veins plus the pampiniform should start at the lower pole of the testicle and proceed upward
plexus, and two nerves concentrically invested by three layers of (approximately 2.5 cm) . From there, the surgeon should find the
tissue. One other nerve, the ilioinguinal, lies just lateral to the bifurcation and ligate only the epididymal branch.
components of the cord. The most anterior of the elements of the
spermatic cord is the pampiniform plexus; posterior are the duc-
tus and the remnant of the processus vaginalis, or hernial sac. Veins of the Spermatic Cord
These entities, as well as others, are covered by the spermatic fas-
cia. Medial to the superficial inguinal ring, the spermatic cord lies In the spermatic cord, the pampiniform venous plexus is com-
deep to the fascia of Scarpa and Colles. posed of 10 to 12 veins (Fig. 5.28). These are separated into an-
Scarpa's fascia is so well developed that the surgeon may mis- terior and posterior groups which are drained by three or four
Nerves of the Spermatic Cord

The genital branch of the genitofemoral nerve (Ll, L2) enters the
inguinal canal through the internal inguinal ring. The cremaster
muscle is innervated by the genital branch. The ilioinguinal nerve
(Ll) emerges between the external and internal oblique muscle
near the anterior superior iliac spine. It then enters the canal and
emerges from the external inguinal ring. There, the ilioinguinal
nerve supplies the skin of the penile root and the upper part of
the scrotum.
The arteries of the cord and the ductus deferens are innervated
by sympathetic fibers which come from the prostatic portion of
the pelvic plexus.
Fasciae of the Spermatic Cord

The ductus deferens and the accompanying blood vessels of the
spermatic cord are surrounded by three layers of fascia: the ex-
ternal spermatic fascia, a continuation of the fascia of the exter-
nal oblique muscle (Gallaudet's); the cremasteric fascia, which is
continuous with the musculature and fascia of the internal oblique
and possibly the transversus abdominis muscles; and the internal
spermatic fascia, an extension of the transversalis fascia.
The subcutaneous superficial fascia in the scrotum contains lit-
FIGURE 5.27. Arteries, veins and nerves of the testicles. External view. 1 = tle adipose tissue. This is replaced by smooth muscle, which forms
artery of the ductus deferens; 7 = testicular artery; 8 = spermatic veins. the tunica dartos scroti. The rugal folds of the scrotal skin are
(Reprinted from A. Hovelacque, Anatomie des ncrfs craniens et rachidiens. G. formed by the attachment of these muscle fibers to the skin.
Doin; 1927, Fig. 113, p. 753, with permission.)
The Round Ligament

veins which join to become two veins proximal to the deep in-
guinal ring. These veins run in the extraperitoneal space on ei- In the female, the round ligament of the uterus lies in the inguinal
ther side of the testicular artery. The vein on the right opens canal. It is the homologue of the gubernaculum testis, not of the
directly into the inferior vena cava, that on the left enters the left spermatic cord of the descended testis. The gubernaculum in the
renal vein. The cremasteric vein flows into the inferior epigastric female also becomes the ligament of the ovary. Both round and
veins, while the deferential vein drains into the pelvic plexus. ovarian ligaments are attached laterally to the side of the uterine
wall just under the fallopian tubes. If necessary, the round liga-
ment may be resected without adverse effects.
Scrotum and Labia Majora

The skin of the scrotum is elastic and corrugated. It is thinner and
more pigmented than the inguinal skin. Mter puberty, the scro-
tum has less hair than inguinal skin but possibly has more seba-
ceous and sweat glands. The raphe between the right and left
halves of the scrotum is a median ridge continuous with the raphe
of the penis and perineum.
The dartos is the superficial fascia of the scrotum. The superfi-
cial portion is contributed by Camper's fascia, which covers the
abdominal wall, penis, perineum, thigh, and buttocks. The deep
portion derives from Scarpa's fascia and is continuous over the ab-
dominal wall to the penis (Buck's fascia) and to the perineum
(Colles' fascia). The dartos is composed of connective tissue and
smooth muscle fibers and is attached to the skin. Colles' fascia is
attached laterally to the periosteum of the pubic arch of the lower
abdominal wall. The space deep to the dartos may allow ex-
FIGURE 5.28. Fascia of the spermatic cord: 1 and 2 = external spermatic travasated urine to collect.
fascia; 10 = testicular artery. (Reprinted from H. Fruchaud, Anatomie chirur- The skin of the labia majora is composed of elongated bilateral
gicale des hcrnies de l'aine. G. Doin; 1956, Fig. 163, p . 285, with permission.) folds with lateral and medial surfaces. The lateral surface starts at
the mons pubis, a rounded eminence formed by an accumulation fibers from cutaneous nerves of the region supply the scrotum.
of fat in front of and above the symphysis pubis and ends with the These include the ilioinguinal nerve, genital branch of the gen-
skin of the thigh. The lateral surface is more pigmented but some- itofemoral nerve, which supplies the labia majora, perineal
what less hairy than the inguinal skin. The medial surface is branches of the pudendal nerve, and the perineal branch of the
smooth and hairless, studded with large sebaceous follicles. Start- posterior femoral cutaneous nerve. Any incision in this area should
ing from the anterior commissure, which is the union of the in- be located parallel to, and at least one or two fingers above, the
ner surfaces of the right and left labia majora anteriorly, it ends inguinal ligament.
at the posterior commissure, which is an ill-defined union of both
inner surfaces posteriorly. (In the majority of individuals, such a
union does not occur.) Sebaceous and sweat glands are present Superficial Fascia
on the lateral surface. Smooth muscle fibers, arranged irregularly,
form a counterpart for the tunica dartos of the male. The round This fascia consists of two portions: a superficial layer (Camper's
ligament ends in the subcutaneous tissue of the labium majus. fascia) and a deep layer (Scarpa's fascia). The superficial fascia
consists of subcutaneous fat. The deep layer is thin and membra-
nous. These two layers are well developed in the inguinal area and
Skin and Subcutaneous Layer are clearly defined in most cases.
The hairy skin of the inguinal region is marked by the flexion fold
of the thigh, which runs parallel to the inguinal ligament 2 or 3
cm below it. The bony landmarks of the inguinal ligament, that
The Femoral Canal and the Femoral Sheath
is, the anterior superior iliac spine and pubic tubercle, are easy to
Between the inguinal ligament anteriorly and the linea terminalis
find, even in obese patients.
(iliopectineal line) posteriorly, the femoral level of the myo-
The areolar subcutaneous tissue of the inguinal region is richly
pectineal orifice is a space organized into three compartments
vascularized, sometimes referred to as Thomson's "vascular layer."
(Fig. 5.30).
In addition to the veins and arteries, this tissue contains lymph
The most lateral of these compartments is the neuromuscular
vessels which are invisible to the naked eye.
compartment, which contains the iliopsoas muscle, the femoral
The genital branch of the genitofemoral nerve lies within the
nerve, and the lateral femoral cutaneous nerve. Medially, the vas-
inguinal canal. It arises from the first and second lumbar nerves
cular compartment contains the femoral artery and vein. Still more
and gives branches to the cremaster muscle. The ilioinguinal nerve
medial is the compartment of the femoral canal. The femoral
arises from the first lumbar spinal nerve, passes down the canal,
sheath , an extension of the transversalis fascia of the abdomen,
and emerges from the external inguinal ring. It supplies the skin
envelops the femoral artery, vein, and femoral canal (Fig. 5.31) .
of the penile root and the upper part of the scrotum (Fig. 5.29).
Sympathetic fibers from the prostatic portion of the pelvic
plexus serve the ductus deferens. Similar fibers from the pelvic
plexus supply the arteries of the cord. Sympathetic and sensory
3
4-
5 ______ _
FIGURE 5.29. Nerves of the spermatic cord: 1 = iliohypogastric nerve; 2 = FIGURE 5.30. Iliofemoral trunks in the femoral canal: 2 = transversus ab-
internal oblique; 3 = ilioinguinal nerve; 4 = cremasteric; 5 = spermatic dominis and transversalis fascia; 6 = inferior epigastric artery; 7 = femoral
cord; 6 = external oblique aponeurosis. (Reprinted from H. Fruchaud, artery and vein; 8 = iliopsoas muscle; 9 = pectineus muscle. (Reprinted
Anatomie chirurgicale des hernies de l'aine. G. Doin; 1956, Fig. 31, p. 55, with from H. Fruchaud, Anatomie chirurgicale des hernies de l'aine. G. Doin; 1956,
permission.) Fig. 150, p. 255, with permission.)
FIGURE 5.31. The femoral sheath. Jean Rives's personal interpretation of Fruchaud's conception. (Reprinted from H. Fruchaud, Anatomie chirurgicale
rks hernies rk l'aine. G. Doin; 1956, Fig. 127, p. 204, with permission.)
The femoral canal is conical, approximately 1.25 to 2 cm in are associated with the superficial epigastric and the external pu-
length. The fossa ovalis, the opening for the great saphenous vein, dendal vessels as far as 1 cm above the inguinal ligament. In zone
is at its apex inferiorly. Thus, a femoral hernia may present as a 3, inferomedial nodes were absent in 29% of specimens examined
bulge of the skin over the fossa ovalis. by Daseler and colleagues, and only a single node was present in
The femoral ring is inflexible. Its transverse diameter ranges 37% . In zone 4, the inferolateral quarter, a chain of nodes lies lat-
from 8 to 27 mm, and the anteroposterior diameter ranges from eral to the great saphenous vein; a node is always present at the
9 to 19 mm. However, in 70% of patients these diameters are 10 junction of the great and accessory saphenous veins. In zone 5,
to 14 mm and 12 to 16 mm respectively.I o The lateral boundary is the central zone, 84% of specimens had no nodes and 15% had
the femoral vein and connective tissue. The posterior boundary is only a single node.
Cooper's ligament. The iliopubic tract or the inguinal ligament,
or both, form the anterior boundary. The transversalis fascia,
aponeurotic insertion of the transversus abdominis muscle, and
the lacunar ligament form the medial boundary (Fig. 5.32).
Lymphatics of the Inguinal Area

Inguinal lymph nodes may be categorized into the following: su-
perficial nodes (between the superficial fascia and the fascia lata),
deep inguinal nodes (beneath the fascia lata), and aberrant in-
guinal nodes (within the inguinal canal).
Superficial Inguinal Nodes

These nodes have been divided into five arbitrary groups called
"zones" for nearly 100 years. These groups, centered on the ter-
mination of the great saphenous vein, are shown in Fig. 5.33.
The number of nodes, varying from 4 to 25, is inversely pro-
portional to the size of the individual nodes. Despite the small
number of superficial nodes (Daseler et al. II found an average of
only 8.25 nodes per limb dissected), they form possibly the largest
single group of lymph nodes in the body.
The nodes lie along the blood vessels of the region within the
zones. In zone 1, the superolateral nodes extend along the su- FIGURE 5.32. The medial angle of the inguinal area: 5 = iIiopubic tract;
perficial circumflex iliac vein below the inguinal ligament. Haag- 6 = transversalis fascia; 7 = Cooper's ligament; 8 = inguinal ligament.
ensen et al. found a few above the ligament on the aponeurosis (Reprinted from H. Fruchaud, Anatomie chirurgicale rks hernies de l'aine. G.
of the external oblique muscle. In zone 2, the superomedial nodes Doin; 1956, Fig. 64, p. 101, with permission.)
anterior layers. The posterior and middle layers are around the
sacrospinalis muscle. The middle layer envelops the quadratus
lumborum and continues laterally to the transversus abdominis
aponeurosis by fusion of all three layers.
A middle muscular layer is formed of sacrospinalis, internal
oblique, and serratus posterior inferior muscles.
A deep muscular layer, composed of the quadratus lumborum
and psoas muscles, is covered by the transversalis fascia, the
preperitoneal fat, and the peritoneum.
This posterior abdominal wall, less a "surgical" structure than the
anterior abdominal wall, shows significant direct relations to the
three main retroperitoneal sheaths. The posterior abdominal wall
is in contact with the lumbar neural ganglia, and contains within
its muscles the lumbar plexus and an entire vascular network.
The classical zones of posterior weakness are Grynfeltt's lumbar
quadrangle (tetragonum lumbale) and Petit's lumbar triangle
(trigonum lumbale). Lumbar hernia rarely occurs at these sites;
parietal weakness of the posterior abdominal wall is most often of
postoperative or traumatic origin.
The deep layer of the posterior abdominal wall comprises, in
the midline, the lumbosacral spine flanked laterally by the ilio-
FIGURE 5.33. Superficial inguinal nodes and vessels: 4 = superficial cir- psoas and quadratus lumborum which mask the lumbar inter-
cumflex iliac vessels; 7 = superior external pudendal vessels. (Reprinted transverse muscles.
from H. Fruchaud, Anatomie chirurgicale des hernies d el'aine. G. Doin, 1956,
Fig. 159, p. 269, with permission.)
Median Spinal Axis
The lumbar spine, markedly convex anteriorly, is entirely covered
Deep Inguinal Nodes by a fibrous coat consisting of the anterior longitudinal ligament,
which terminates at the level of the second sacral vertebra, and
Two or three small nodes lie below the fascia lata along the femoral
the diaphragmatic crura. The right crus, the larger, lies over the
vein. The largest, the node of Cloquet, is located at the femoral
bodies of L-2 and L-3 and the neighboring intervertebral disks.
ring between the vein and the lacunar ligament and is almost al-
The left crus is usually smaller, lying over the body of L-2 and the
ways present.
neighboring intervertebral disks. From their insertions on the
spine, the diaphragmatic crura run forward to form the aortic hia-
tus. Fleshy fibers arise from the upper margin of the fibrous arch
Aberrant Nodes of the hiatus. In this way, the diaphragmatic crura constitute the
classic "afibrous bed" of the aorta in front of the lumbar spine.
Aberrant nodes include some small nodes in the inguinal canal,
The flared part of the right crus penetrates between the aorta and
over the symphysis pubis, and at the base of the penis. Drainage
the inferior vena cava. The first two intercostal arteries on the right
from the glans penis or glans clitoris is believed to be to the deep
and left sides pierce the fleshy part of the diaphragmatic crura as
inguinal nodes. Efferent lymphatics from the superficial nodes, es-
they run tangential to the bodies of the vertebrae (Fig. 5.34) .
pecially lower ones, pass to the deep nodes. Those from the infe-
rior groups (zones 3, 4, and 5) pass to superior nodes (zones 1
and 2) and then upward to the lowest iliac nodes along the ex-
ternal iliac vessels. Lymph from the testes passes to aortic and re-
nal nodes, along the arterial supply of the gonads.
Surgical Anatomy of the Posterior

(Lumbar) Body Wall
This lumbar area of the posterior body wall is limited superiorly
by the 12th rib, inferiorly by the crest of the ilium, posteriorly by
the erector spinae (sacrospinalis) muscles, and anteriorly by the
posterior border of the external oblique muscle. This posterior
wall is composed superficially of a thick, tough skin and two lay-
ers of fibrous tissue with fat between them (superficial fascia) .
A superficial muscle layer is formed posterolaterally by the latis-
simus dorsi muscle and anterolaterally by the external oblique FIGURE 5.34. Median spinal axis, lumbar spine and crus of the diaphragm.
muscle. The thoracolumbar fascia contains posterior, middle, and (From M.:J. Bourgery, Atlas of Anatomy, 1832.)
The promontory of the sacrum protrudes into the space be- dominal region via the muscular lacuna beneath the inguinal lig-
tween the common iliac vessels like a bracket above the pelvis. The ament, in the inferior part of the myopectineal orifice.
pelvic viscera are suspended from the promontory, through the The psoas major is a muscle comprising two layers. The ante-
thick fibrous coat covering it and the L5-S1 intervertebral space. rior layer (corporeal) and the posterior layer (costiform) are
The middle sacral vessels run anteriorly over the promontory. The joined together laterally. The space between them contains the
danger point formed by the left common iliac vein, running lumbar plexus, the ramifications of the lumbar arteries, the lum-
obliquely across this region, should be kept in mind. bar veins and their longitudinal anastomosis, and the ascending
The sacrum, forming the posterior wall of the pelvis, contains lumbar vein.
the cavum durale down to the level of S-2. The vegetative nerves The anterior corporeal layer of the muscle is attached to the
distributing to the sphincters and genital organs emerge through spine from the 12th thoracic to the fourth lumbar vertebrae. The
the third and fourth anterior sacral foramina. The position of insertions are mainly on the intervertebral disks rather than on
these nerves should be borne in mind when using the transsacral the vertebral bodies themselves and are joined to one another by
approach to the rectum. Resection through the fourth sacral fibrous arches. These fibrous arches, arranged in opposition to
foramina can be done, whereas in the course of a more superior the concavity of the lateral surfaces of the bodies of the vertebrae,
route it is imperative to preserve at least one of the third sacral form small openings for the passage of the lumbar vascular trunks
foramina. The boundary between the sigmoid colon and rectum and sympathetic communicating branches. On the right, these ar-
classically lies at the level of the anterior part of S2-S3. cuate fibers are most often covered anteriorly by the right margin
The. median osteofibrous spinal axis extends laterally in cruci- of the inferior vena cava. Because of this arrangement, surgical
form fashion by the posterior part of the iliac crests. This crest identification of the sympathetic ganglia may be dangerous.
seems to divide the muscles into two step-like layers. The upper The posterior (costiform) layer of the greater psoas inserts on
layer is formed by the greater psoas lying medially and the quad- the anterior surface of the transverse processes of all five lumbar
ratus lumborum laterally. The lower layer consists of the greater vertebrae.
psoas flanked by the iliacus. The iliac crest thus resembles a very The greater psoas is thus well formed in the upper lumbar re-
thick intersection reinforced by the iliolumbar ligament, which gion. It leaves the diaphragm by passing under the medial arcu-
runs behind the greater psoas and spreads out on the anterome- ate ligament, sometimes referred to as the arch of the psoas. The
dial lip of the bony crest. iliac fascia is attached to the inferior margin of this ligament and
lines the psoas major. An abscess originating from the 12th tho-
racic vertebra can thus travel downward along the fascia.
Lateral Spinal Muscles The psoas minor arises from vertical fascicles inserted on the
12th thoracic and first lumbar vertebrae. This muscle runs along
Iliopsoas Muscles (Fig. 5.35) the medial boundary of the psoas major to attach to the innomi-
nate line and iliopectineal eminence. The psoas minor is not a
The psoas major is a voluminous muscle extending from the 12th constant muscle (present in less than 50% of subjects) . Its lower-
thoracic vertebra to the lesser trochanter. It runs from the lumbar most fibers may be seen to extend down to the pectineal ligament.
spine along the innominate line of the iliac bone, to leave the ab- Finally, it is also attached to the deep surface of the iliac fascia and
thus acts to stretch this fascia.
The iliacus muscle originates from the greater part of the inter-
nal iliac fossa and stretches downward to the level of the anterior
inferior iliac spine. The muscle fibers, grouped together along the
lateral margin of the psoas major, form, along with the latter, a
groove for the femoral nerve. The iliacus fibers then wind around
the terminal tendon of the psoas major and finally pass anterior to
the latter to insert on the lesser trochanter and below; that is, these
fibers extend below the femoral insertion of the psoas major.
The iliacus fascia is a fibrous sheath common to the psoas ma-
jor and iliac muscles. It is relatively thin in its upper part, but be-
comes very thick at the level of the iliac crest. Deep to the inguinal
ligament, the iliacus fascia is reinforced, forming the iliopectineal
arch, which separates the vascular and muscular lacunae. The il-
iac fascia can be stretched only slightly. This finding accounts for
the rapidly compressive complications of hematomas originating
from the rich vascular network within the psoas major. This type
of hematoma occurs frequently in patients taking anticoagulants,
and it may lead to severe damage of the lumbar plexus, especially
to the femoral nerve.
FIGURE 5.35. Iliopsoas muscle, schematic view: 1 = promontory; 2 = recti;

3 and 6 = psoas major; 4 = iliacus; 5 = psoas minor; 7 = Cooper's liga- Quadratus Lumborum Muscle
ment; 8 = pectineus muscle; 9 = pubic tubercle. (Reprinted from H.
Fruchaud, Anatomie chirurgicale des hernies de l'aine. G. Doin; 1956, Fig. 142, This muscle extends behind and lateral to the psoas major in the
p. 235, with permission.) space bounded by the 12th rib, the tips of the transverse processes
matic lymphatic channels form a direct communication between

the retroperitoneal region and the subpleural space. This accounts
for the rapid thoracic and mediastinal extension of certain patho-
logical processes involving the retroperitoneal region, such as
pancreatitis.
Innervation
The posterior abdominal wall is innervated by the lumbar plexus.
The psoas m,yor receives branches at different levels from the first
through fourth lumbar nerves, and the psoas minor receives
branches from the first and second lumbar nerves. Filaments aris-
ing from the femoral nerve supply the iliacus. The motor innerva-
tion of the quadratus lumborum is from the 12th intercostal nerve
and branches from the first three lumbar spinal roots (Fig. 5.36).
The iliohypogastric and ilioinguinal nerves emerge from the lat-
eral margin of the greater psoas at the level of the L-I-L-2 inter-
vertebral disk and then run along the anterior surface of the
quadratus lumborum posterior to the kidney. These nerves follow
the iliac crest to finally enter the inguinal region.
The lateral femoral cutaneous nerve exits from the anterior sur-
face of the psoas m,yor at the level of the lower end of the third
FIGURE 5.36. Posterior abdominal wall and its innervation: 1 = twelfth in- lumbar vertebra or the L-3-L-4 intervertebral disk. It runs
tercostal nerve; 2 = iliohypogastric nerve; 4 = ilioinguinal nerve; 12 = obliquely outward and downward to cross over the lateral margin
genitofemoral nerve; obturator nerve. (Reprinted from A. Hovelacque, of the psoas major at the level of the L-4-L-5 intervertebral disk
Anatomie des nerfs craniens et rachidiens. G. Doin; 1927, with permission.) and then runs along the surface of the iliac bone to finally enter
the muscular lacuna medial to the anterior superior iliac spine.
of the lumbar vertebrae, and the posterior part of the iliac crest. The genitofemoral nerve appears on the anterior surface of the
The muscle body, resembling a rectangle rather than a square, is psoas major at a point slightly medial and inferior to the lateral
composed of interlacing multidirectional fibers originating from femoral cutaneous nerve (L-4-L-5 intervertebral disk). It then de-
the different bony margins listed above (Fig. 5.36). scends parallel to the fibers of the psoas major just behind the in-
The anterior part of the quadratus lumborum muscle is essen- guinal ligament where it divides into terminal branches.
tially composed of fibers extending from the iliolumbar ligament The femoral nerve leaves the lateral margin of the psoas major,
and the deep part of the iliac crest to the inferior margin of the becoming visible in the groove between the latter and the iliacus
12th rib and the tip of the transverse processes of the lumbar ver- at the level of the sacral promontory. This nerve divides just be-
tebrae. The thinner posterior layer of the muscle extends down low the inguinal ligament.
the 12th rib to the lumbar transverse processes. The obturator nerve emerges from the medial border of the
psoas major at about the same level as the preceding nerve, that
is, at the site where the medial margin of this muscle crosses over
Arterial Vascularization and Venous Drainage the ala of the sacrum (the fossette of Cuneo and Marcille). In this
region, it is accompanied by the fifth lumbar nerve root, which re-
The arterial supply to the posterior abdominal wall comes from ceives the first sacral nerve root to form the lumbosacral trunk.
the lumbar arteries, which form a complex anastomotic network
between the 12th intercostal (subcostal) artery above and the deep
circumflex iliac artery below. Action of the Deep Muscles of the
The venous drainage of the posterior abdominal wall is partic- Posterior Abdominal Wall
ularly well developed, especially within the psoas major, where the
veins communicate with the intraspinal venous plexuses by way of The iliopsoas, inserted on the pelvis and spine, acts mainly to flex
conjugate vessels and the arches of the psoas with the inferior vena and laterally rotate the thigh, and thus is very important for walk-
cava. The ascending lumbar vein is one of the roots of the azygos ing. Acting on the axial skeleton, the psoas major resembles a poly-
system. The venous network of the posterior abdominal wall (ilio- articular muscle, leading to lateral flexion and slight rotation of
lumbar, lumbar, and ascending lumbar veins) is able to shunt most the spine on the side opposite the muscle. When both psoas ma-
of the caval blood after a subrenal ligation of the inferior vena jor act simultaneously with the subject supine, they elevate the up-
cava. per and lower parts of the trunk.
The psoas minor, which flexes the lumbar spine with respect to
the pelvis, is a tensor muscle of the iliac fascia. The quadratus lum-
Lymphatic Network borum acts as a lateral brace of the lumbar spine by pulling the
iliac crest and the 11 th rib closer to one another. This muscle can
The upper part of the posterior abdominal wall is drained by the also be considered to depress the 11 th rib, and thus acts as an ac-
lateral caval and lateral aortic lymph nodes. The transdiaphrag- cessory respiratory muscle.
Superficial Layer of the the superficial lamina of the latter. Its floor is the internal oblique
muscle, with contributions from the transversus abdominis mus-
Posterior Abdominal Wall cle and posterior lamina of the thoracolumbar fascia and the
internal oblique muscle. Superficial fascia and skin cover the
Two layers of flat muscles and aponeuroses lie posterior to the
triangle.
deep muscle layer and extend laterally to continue into the an-
A lumbar hernia in the area of the lumbar quadrangle (usually
terolateral abdominal wall. From anterior to posterior, the first of
the upper part), which may enter into Petit's lumbar triangle, is a
these layers is that of the posterior aponeurosis of the transversus
rare finding. In such cases, the neck of the hernial sac is narrow,
abdominis. This aponeurosis, lying posterior to the quadratus lum-
and treatment can thus be achieved with relative ease. Conversely,
borum, is attached to the tips of the transverse processes of the
postoperative incisional hernia in this region is far more prob-
lumbar vertebrae.
lematic. Hernias also sometimes occur following closed trauma,
which causes destruction or detachment of the muscles in this
region.
Deep Weak Area Significant tissue loss, often accompanied by paralysis of the ab-
dominal strap resulting from motor nerve injury, requires the use
Framed by muscle bodies, this aponeurotic layer constitutes a zone of foreign or autoplastic material to achieve repair, that is, large
of weakness, the classic Grynfeltt's lumbar quadrangle. flaps of fascia lata cut in the external iliac fossa and reflected up-
The medial or posterior boundary of this area is formed by the ward onto the iliac crest, as in Koontz's operation.
erector muscles of the spine inserted on the posterior part of the
iliac crest, the posterior iliac spines, and the posterior surface of
the sacrum. These muscles spread out from their origin toward Surgical Anatomy of the Pelvic Wall
the ribs. This muscular mass is invested with a very resistant
aponeurosis, which, along with the arches of the lumbar vertebrae The pelvis, like a box, lies open below the abdominal cavity, lim-
and posterior surface of the transverse processes, forms a verita- ited laterally by an anterior (obturator) area and a posterior (sci-
ble osteofibrous canal (thoracolumbar fascia) through which the atic) area. It is closed, inferiorly, by the perineal diaphragm.
muscles pass.
The inferior lateral boundary of the lumbar quadrangle is
formed by the internal oblique, which runs upward and forward Obturator Area
to make an acute angle with the mass of spinal muscles. Moreover,
the internal oblique is inserted on the thoracolumbar fascia and The obturator region is bound superiorly by the horizontal ramus
the posterior part of the iliac crest, extending up to the inferior of the pubic bone, laterally by the hip joint and the shaft of the
margin of the 12th rib. femur, medially by the pubic arch, the perineum, and the gracilis
The superior medial boundary of the lumbar quadrangle is muscle, and inferiorly by the insertion of the adductor magnus on
formed by the serratus posterior inferior. This muscle, extending the adductor tubercle of the femur (Fig. 5.37).
over the mass of the spinal muscles, is attached by its inferior dig- The obturator foramen is formed by the rami of the ischium
itation to the inferior edge of the 12th rib. and pubis. It lies inferior to the acetabulum on the anterolateral
Finally, a short part of the inferior margin of the 12th rib forms
the superior lateral boundary of Grynfeltt's lumbar quadrangle.
The floor of the triangle is the aponeurosis of the transversus
abdominis muscle arising by fusion of the layers of the thora-
columbar fascia. The roof is the external oblique and latissimus
dorsi muscles.
Superficial Weak Area

This muscular layer is lined posteriorly by a layer containing the
superficial weak area of the region, that is, Petit's lumbar triangle.
The lumbar triangle is bounded by the following structures: be-
low, the base of the triangle is formed by the posterior part of the
iliac crest; laterally and anteriorly, the side of the triangle is formed
by the posterior margin of the external oblique running down-
ward and forward, the anterior part of this muscle being entirely
composed of fleshy fibers from the 12th rib to the iliac crest; and
medially, the posterior (lumbar) side is formed by the lateral mar-
gin of the latissimus dorsi, which runs upward and laterally. This
muscle originates from a large aponeurotic sheet attached to the
spinous processes of the thoracic and lumbar vertebrae, the sacral FIGURE 5.37. Pelvic bone and the limits of the pelvic wall. (Reprinted from
crest, and the posterior iliac spine. This fibrous sheet continues H. Fruchaud, Anatomie chirurgicale des hernies de l'aine. G. Doin; 1956, Fig.
medially with the thoracolumbar fascia and is often described as 134, p . 215, with permission.)
tor membrane and the internal and obturator externus muscles.

Through this canal pass the obturator artery, vein, and nerve.
The obturator nerve is usually superior to the artery and vein.
The nerve separates into anterior and posterior divisions as it
leaves the canal. A hernial sac may follow either division of the
nerve. The obturator artery divides to form an arterial ring around
the foramen.
An obturator hernia is an abnormal protrusion of preperitoneal
fat or an intestinal loop through the obturator foramen. It char-
acteristically affects the right side of middle-aged women.
The herniated fat or ileal loop or, rarely, the urinary bladder,
compresses the obturator nerve, affecting either or both divisions
to produce the characteristic hip-knee pain (Howship-Romberg
sign) present in about one-half of the patients with obturator
hernia.
The formation of an obturator hernia begins with a "pilot tag"
ofretroperitoneal fat in the first stage, followed by the appearance
FIGURE 5.38. The obturator region, coronal schematic cross section: 3 = of a peritoneal dimple in the second stage into which a knuckle
rectum; 9 = levator and internal obturator muscle; 10 = obturator exter- of viscus may be partially incarcerated (Richter's hernia) in the
nus muscle; 11 = ischiopubic ramus of the pelvic bone. (Reprinted from third stage. Eventually, the incarceration of an ileal loop produces
A. Hovelacque etJ. Turchini, Anatomie et histologie de l'appareil urinaire et de complete obstruction. The frequency of pilot tags in cadavers and
l'appareil genital de l'homme. G. Doin; 1936, Fig. 55, p. 105, with permission.) the rarity of actual obturator hernias in patients suggest that most
obturator hernias do not progress beyond the first and second
stages of development (Fig. 5.39A and B) .
wall of the pelvis. Except for a small area, the obturator canal,
the foramen is closed by the obturator membrane. Fibers of the
membrane are continuous with the periosteum of the surround- Surgical Anatomy of the Sciatic Region
ing bones and with the tendons of the internal and obturator ex-
ternus muscles. [Editor's Note: Embryologically, the foramen and A sciatic hernia is a protrusion of a peritoneal sac and its contents
its membrane represent an area of potential bone formation that through the greater or lesser sciatic foramen. It also has been
never proceeds to completion. In this sense, the obturator fora- called a "sacrosciatic," "gluteal," or "ischiatic" hernia.
men is a lacuna, and the obturator canal is the true foramen] There are three potential apertures through which a sciatic her-
(Fig. 5.38). nia may occur. Two are through the greater sciatic foramen above
The obturator canal is a tunnel 2 to 3 cm long beginning in the (suprapiriformic) or below (infrapiriformic) the piriformis mus-
pelvis at the defect in the obturator membrane. It passes obliquely cle, which also passes through the foramen. A third potential her-
downward to end outside the pelvis in the obturator region of the nia (subspinous) may pass through the lesser sciatic foramen below
thigh. the sacrospinous ligament. All three hernial sites are covered by
The canal is bound cranially and laterally by the obturator the gluteus maximus muscle (Fig. 5.40) .
groove of the pubis and caudally by the free edge of the obtura- The suprapiriformic foramen is formed by the anterior sacroil-
FIGURE 5.39. Obturator hernia. (A) Obtu-

rator vessels and nerve emerging from ob-
turator canal. (B) hernia through the ob-
turator externus muscle; hernia and nerve
exit above the obturator external muscle;
the nerve exits above and the hernia below
the obturator externus muscle. (Reprinted
from V. Schumpelick, Atlas ofHernia Surgery;
1990, B.C. Decker, Inc., with permission.) A B
Perineal Area
The Pelvic Diaphragm
The pelvic diaphragm is composed of two paired muscles, the le-
vator ani and coccygeus. They form the floor of the pelvis and the
roof of the perineum (Fig. 5.41A).
The levator ani is itself formed by the iliococcygeus and pubo-
coccygeus muscles. A subdivision of the pubococcygeus, the pubo-
rectalis muscle, is important to rectal continence.
The puborectalis muscle originates from the body of the pubic
bone and the superior layer of the deep perineal pouch (uro-
genital diaphragm). Fibers from the two puborectalis muscles pass
posteriorly and join posterior to the rectum, forming a well-
defined sling. The puborectalis, with the superficial and deep parts
of the external sphincter and the proximal part of the internal
sphincter, form the so-called anorectal ring. This ring can be pal-
pated, and, because cutting through it will produce incontinence,
FIGURE 5.40. Sciatic hernias: I = suprapiriformis; 2 = infrapiriformis; 3 =
it must be identified and protected during surgical procedures. It
spinotuberous. (Reprinted from V. Schumpelick, Atlas of Hernia Surgery; is at the approximation of these divisions of levator ani that weak
1990, B.C. Decker, Inc., with permission.) areas may permit a posterior perineal hernia to bulge.
The peritoneum envelops the front and sides of the upper third
of the rectum. As the rectum passes deeper into the pelvis, how-
iac ligament anteriorly, the upper border of the piriformis muscle ever, progressively more fat is interposed between the peritoneum
inferiorly, the ilium laterally, and the sacrotuberous ligament and and the rectal musculature.
the upper part of the sacrum medially. Finally, the peritoneum separates completely from the rectum
The infrapiriformic foramen is bound above by the lower bor- and passes anteriorly and superiorly over the uterus or, in males,
der of the piriformis muscle, below by the sacrospinous ligament, over the bladder. This creates a depression called either the
posteriorly by the sacrotuberous ligament, and anteriorly by the rectouterine or rectovesical pouch.
ilium. There are three areas of weakness in the wall of the ischiorec-
A subspinous hernia, through the lesser foramen, has a ring tal fossa through which an abscess of the fossa may pass. Of these
composed of the ischial tuberosity anteriorly, the sacrospinous lig- three areas, the weakest is medial, through the anal wall. Slightly
ament and ischial spine superiorly, and the sacrotuberous ligament stronger is the inferior boundary of skin, and strongest is a me-
posteriorly. Through the lesser foramen pass the tendon and the dial pathway through the levator ani muscle or between its com-
nerve of the internal obturator muscle, the pudendal nerve, and ponents. This last pathway can be taken in the opposite direction
the internal pudendal vessels. by a perineal hernia of the ischiorectal type.
A B c
FIGURE 5.41. (A) Anatomy of the pelvic floor: I = pubic symphysis; 2 = IS = spinotuberous hernia; 16 = infrapiriformis hernia; 17 = suprapiri-
deep transverse perineal muscle; 3, 4 = obturator canal and muscle; 5 = form is hernia. (8) Anterior and posterior pelvic floor hernias in the fe-
anal canal; 6 = levator ani muscle; 7 = coccygeus muscle; 8 = piriformis male (labial, pudendal, vaginolabia.) (C) Posterior perineal hernia in the
muscle; 9 = sacrum; 10 = fIfth lumbar vertebra; II = paravesical hernia; male. (Reprinted from V. Schumpelick, Atlas of Hernia Surgery; 1990, B.C.
12 = retrovesical hernia; 13 = obturator hernia; 14 = ischiorectal hernia; Decker Inc., with permission.)
Sites of Perineal Hernia References

A primary perineal hernia may occur anterior or posterior to the 1. Cooper A. The anatomy and surgical treatment of abdominal hernia.
superficial transverse perineal muscle. London: Longman and Co.; 1804.
2. Rath, AM, Chevrel]p. The abdominal linea alba. Surg Rt.u1iol Anat.
An anterior perineal hernia passes through the pelvic and uro-
1996;18:281-288.
genital diaphragms, lateral to the urinary bladder and vagina, and
3. Hovelacque A. Anatomie des ncrfs craniens et rachidiens. Paris: G. Doin;
anterior to the urethra. It has been variously called pudendal, labial, 1956.
lateral, or vaginolabial. It is found only in women (Fig. 5.4IB). 4. Cox, 1941.
A posterior perineal hernia passes between components of the 5. Fruchaud H. Anatomie chirurgicale des hernies de l'aine. Paris: G. Doin;
pelvic diaphragm or through the hiatus of Schwalbe, when pres- 1956.
ent, lateral to the urethra, vagina, and rectum. The hiatus is 6. Wantz GE. Atlas of hernia surgery. New York: Raven Press; 1991.
formed by the nonunion of the obturator internus and levator ani 7. Nyhus LM, Condon RE, eds. Hernia. Philadelphia:JB Lippincott Com-
muscles. There are two possible locations: (1) an upper posterior pany; 1995.
hernia between the pubococcygeus and iliococcygeus muscles; and 8. Bogros, AJ. Essais sur l'anatomie chirurgicale de la region iliaque et
(2) a lower posterior hernia between the iliococcygeus and coc- description d'un nouveau procede pour faire la ligature des arteres
epigastriques et iliaque externe. These Mid, Paris. No. 153, 29 Aout
cygeus muscles, below the lower margin of the gluteus maximus
1823. Paris: Didot Ie Jeune Edit.; 1823.
muscle (Fig. 5.41C). 9. Bendavid R. The space of Bogros and the deep inguinal venous cir-
In males, the perineal hernia enters the ischiorectal fossa. In fe- culation. Surg Gynecol Obstet. 1992;174:355-358.
males, it may enter the fossa or the labium majus, or it may lie 10. Skandalakis LJ, Colborn GL. Surgical anatomy of the abdominal wall.
close to the vaginal wall or below the lower margin of the gluteus In: Bendavid R, ed. Prostheses and abdominal waU hernias. Austin: R.G.
maximus muscle. Landes Company; 1994.
6
Aponeurotic Hernias: Epigastric, Umbilical,
Paraumbilical, Hypogastric
Omar M. Askar
Aponeurotic Hernias (Fig. 6.3A,B, and C). The digastric pattern ensures the perfectly
harmonized function of the anterior abdominal wall musculature.
The term aponeurotic hernia distinguishes epigastric, paraumbil- In fact, the function of any single muscle in the anterior abdom-
ical, umbilical, and hypogastric hernias from other types of ab- inal wall cannot be worked out independently of the others.
dominal hernias because of the very special characteristics of the
central abdominal wall aponeuroses through which these hernias
make their appearance. Appreciation of the structural and func- The Midline Aponeurotic Zone-
tional significance of these aponeuroses is essential to the plan-
ning of surgically and physiologically sound repairs of hernial
The Linea Alba
defects in the aponeurotic area of the anterior abdominal wall. A
Between the two rectus sheaths lies an aponeurotic sheet (Fig. 6.4).
reasonable explanation for the high rate of recurrence following
The term linea alba does not serve to explain the real nature of
a certain type of repair or the use of a specific technique may be
this midline aponeurotic zone. It is a zone of an aponeurotic fab-
given.
ric, the threads of which are fine tendinous strands interwoven to-
gether. They are the tendinous fibers of the abdominal muscles
crossing the midline on their way to join their counterpart from
Surgical Anatomy the opposite side. In their course across the midline aponeurotic
zone, the fibers of one side decussate with their analogues com-
The Aponeurotic Sheets of the ing from the opposite side. In some 30% of individuals, the de-
Anterior Abdominal Wall cussation of the tendinous fibers coming from the two sides occurs
only once at the midline "single decussation" (Fig.6.5). In the
The abdominal wall aponeuroses were long looked upon as inert other 70%, two additional lines of decussation are seen, one on
sheets of fascia into which the flat muscles of the anterior ab- either side of the midline "triple decussation" (Fig. 6.6). In addi-
dominal wall are inserted. Recent studies 1,2 have shown these tion to reinforcing the aponeurotic texture, the two additional
aponeurotic sheets to be an intricately interwoven fabric, the lines of decussation seem to protect the midline decussation. In a
threads of which are fine, glistening tendons invested with loose single decussation, a hernial defect will be seen at the midline (Fig.
areolar tissues to ensure their free mobility over each other (Fig. 6.7), while in a triple decussation the hernial defect lies on one
6.1). Each of these fine tendons belongs to a small fleshy muscu- side of the midline. The force that produced the hernia acted out-
lar belly in one of the three strata of abdominal muscles. Six strata side the triple decussation (Fig. 6.8). This may explain why some
of fine, tendinous aponeurotic slips emerge from the three layers patients appear more prone to develop herniation through the
of abdominal muscles. They flow medially to form two aponeu- abdominal aponeuroses than others. More hernia repair failures
rotic sheets which invest the rectus abdominis muscle, forming the may be expected on the weaker lineae albae with single line de-
rectus sheath. Three strata of aponeurotic tendinous fibers can be cussations, which will be more susceptible to fraying and allowing
seen in both anterior and posterior rectus sheaths disposed in a sutures to slip off.
crisscross triple-ply pattern. At the medial borders of the two recti, Extra lines of decussation were also seen in some individuals,
the aponeurotic fibers from the anterior and the posterior rectus denoting a firmer aponeurotic fabric. 3,4 The firmness given to the
sheaths blend together to form one narrow sheet of aponeurosis: abdominal wall aponeurosis by the additional lines of decussation
the midline aponeurotic zone, or linea alba (Fig. 6.2). The tendi- may be appreciated when the midline aponeurotic zone of man
nous fibers of one side cross the median by passing through the is compared to that of quadrupeds. In quadrupeds, the linea alba
midline aponeurotic linea alba. There they join their counterparts is much wider and thinner, but because of the tightly interwoven
from the other side to form, in effect, one digastric muscle from texture produced by many more lines of decussation4-6 the
the mirror-image muscle of the two sides of the abdominal wall aponeurotic fabric, though wide and thin, almost membranous,
64
6. Aponeurotic Hernias 65
FIGURE 6.1. Anterior rectus sheath (above the umbilicus) as seen under
the dissecting microscope, showing the glistening fine tendinous fibers in
the aponeurotic sheath bound together by loose areolar tissue and dis-
posed in a crisscross pattern.
attains greater strength; it has to stand the weight of all the ab-
FIGURE6.2. Right paramedian incision. The rectus muscle is retracted to
dominal viscera in addition to a pregnant uterus that often con- show anterior and posterior rectus sheath blending together to form the
tains twins. Aponeurotic hernias are not as common in quadrupeds midaponeurotic zone or linea alba.
as in man.
Three distinct functional zones can be identified in the midline
aponeurotic zone: an upper, mobile respiratory or "epigastric
zone," a middle "umbilical zone," and a lower, fairly fixed hy- The Epigastric Zone
pogastric or "belly support zone" (Fig. 6.4) .1,7
Each of the three zones has its own aponeurotic pattern which In the epigastric zone, the aponeurotic fibers take an oblique up-
bears direct relation to its function as well as to the mechanism ward medial and downward medial direction (Fig. 6.5, 6.6). This
by which a hernial defect may be produced. This fact should be obliqueness allows the linea alba and the whole aponeurosis in the
taken into consideration when planning the type of repair needed epigastric zone to shorten and lengthen to adapt to the move-
for a hernial defect in each zone and when looking for a cause of ments of the trunk (Fig. 6.9 and 6.10) and to stretch in response
recurrence following such a repair. to respiration.1.3 As a result of the oblique direction of the aponeu-
A B c
FIGURE 6.3. Diagrams showing the digastric pattern of the muscles of the (posterior lamina) and the (right) transversus; (C) between the two trans-
abdominal wall: (A) between the (right) external oblique and (left) in- versus abdominis muscles.
ternaloblique (anterior lamina); (B) between the (left) internal oblique
66 O .M. Askar
FIGURE 6.4. Transilluminated silhouette of anterior abdominal wall in nor-

mal adult (postmortem specimen) showing the midline aponeurotic zone
(linea alba) between the two rectus abdominis muscles: (A) epigastric, ex-
pansile, respiratory zone; (8) tendinous intersection; (C) lower, strong sub-
umbilical portion of rectus muscle.
FIGURE 6.6. Diagram of single line of decussation between the aponeurotic
fibers of the two external oblique aponeuroses.
rotic fibers, lengthening is accompanied by narrowing of the

fabric (Fig. 6.11). Thus, in abdominal distension, the midline The Relation of the Epigastric Zone
aponeurotic zone increases in length but not in breadth, result- to the Diaphragm
ing in downward displacement of the umbilicus, a physical sign
noted in cases of chronic abdominal distension. Stretching of the On the posterior aspect, the linea alba in the epigastric zone re-
aponeurosis in its transverse dimension would result in divarica- ceives aponeurotic fibers descending from the sternocostal por-
tion of the two recti, and possibly contribute to widening of the tion of the diaphragm. These fibers terminate about midway be-
subcostal angle. tween the xyphoid and the umbilicus by intermingling with the
tendinous fibers coming from the posterior rectus sheaths, as well
as those derived from the middle tendinous intersection (Fig.
6.12). These fibers appear to synchronize the movements of the
epigastric zone with those of the diaphragm.
Herniation through the epigastric zone often occurs as a com-
plication of its main function, respiration. A sudden severe stretch
of the aponeurosis, such as that produced by vigorous coughing
FIGURE 6.5. Linea alba above the umbilicus (at operation), single line of
decussation. FIGURE 6.7. Midline hernias in patient with a single line of decussation.
FIGURE 6.10. The effects of stretching obliquely oriented woven fabrics.
A midline epigastric incision can cause herniation in the epi-

gastric zone, especially when done in a weak midline aponeurosis
with a single line of decussation. Lacking interwoven texture, the
weak aponeurotic fabric allows the sutures to slip along the slip-
pery aponeurotic fibers. Other types of epigastric hernial defects
such as congenital defect (Fig. 6.14) are much less frequent.
FIGURE6.8. Diagram showing triple decussation on the anterior surface of
the midline aponeurosis
The Umbilical Zone
or straining, may create a force strong enough to tear open an
In the umbilical zone, the linea alba widens (Fig. 6.4). In addition
epigastric aponeurosis with a weak single line of decussation. The
to their obliqueness, the aponeurotic fibers take an S-shaped
point receiving the maximal load of this fo:ce wo~ld be w~ere. t~e
course (Fig. 6.9). This allows even more stretch in the midregion;
aponeurotic fibers from the middle tendmous mtersectIon Jom
pregnancy converts this curvature to a straight line. Abdominal
those from the anterior and posterior rectus sheaths as well as
distension exceeding the physiologically permissible limits would
those descending from the diaphragm. This point lies about mid-
load this area around the umbilicus; paraumbilical hernias are of-
way between the xyphoid and umbilicus, where an epigastric her-
ten seen in women who have borne children. Abdominal disten-
nia would develop.
sion pressing on the midaponeurotic "umbilical zone" tends to
Such a hernia is often seen in robust, adult males (Fig. 6.13) .
stretch the aponeurosis in both the longitudinal and the trans-
The old theory that epigastric hernias are caused by protuding ex-
verse axes. Unlike the epigastric zone, the umbilical zone stretches
traperitoneal fat finding its way through the aponeurosis, enter-
ing and enlarging a fascial foramen created by the passage of a
blood vessel that pierces the linea alba,1.6 was not supported by
many investigators. 7- JO
·'
Im
·.....
'
·· .
, ,
,
IIi
" ,
,
Y~A.~
', ' ~ ..
..:
,
y&"S: ~ . ~
· fK.x.:< "
~
Jr;':''X
B
A
C
FIGURE 6.9. Hernia to one side of the midline, in patient with triple FIGURE 6.11. Diagram of effects of stretching obliquely oriented woven
decussation. fabrics.
68 O.M. Askar
FIGURE 6.12. Tendinous aponeurotic slips descending from the ster-

nocostal portion of the diaphragm to join the midline aponeurosis about
halfWay between xiphoid process and umbilicus.
FIGURE 6.14. Congenital epigastric and paraumbilical hernias in a male

patient.
more transversely than longitudinally. This fact seems to have
caught the attention of Mayo,n who suggested a transverse over-
lap for the repair of hernial defects in the midaponeurotic um-
terior rectus sheath escape forward to join those of the anterior
bilical zone. The upper flap is provided by the elongated epigastric
rectus sheath in forming a fairly strong cover to a well-developed
zone.
lower part of the rectus muscle. The relatively few remaining pos-
terior aponeurotic fibers pass behind the rectus muscle to end in
the arcuate line. Very few fibers pass along the fascia transversalis
The Hypogastric "Belly Support" Zone in the region of the inguinal canal. Most of the aponeurotic fibers
in the hypogastric region are directed downward and medially.
In the lower hypogastric zone,I,12 the linea alba tapers at its lower
The linea alba is thin and is formed by a single line of decussa-
end on the os pubis. Most of the aponeurotic fibers on the pos-
tion only.I3 The strong lower subumbilical segment of the rectus
muscles thus forms the main constituent of the belly support mech-
anism. The medial edges of the two recti often overlap or may
even blend together to make one strong sheet of muscle. The sur-
geon must reconstitute the two recti in the closure of a midline
subumbilical incision, for these muscles form the main barrier in
the repair of a subumbiIical hernial defect.
The Tendinous Intersections

The tendinous intersections are three to five pairs of horizontal
tendinous septa along the course of the flat rectus muscle. They
are formed by fine tendinous slips which emerge from the mus-
cular bellies of the rectus muscle (Fig. 6.15). Some of them pass
straight up from one segment of the intersected rectus muscle to
the next, acting as intermediate tendons (Fig. 6.16A). The others
curve forward to join the anterior rectus sheath, some of them ac-
quiring an upward medial direction, then join the aponeurotic
fibers of the anterior rectus sheath lying in the same orientation,
namely, those of the anterior lamina of the internal oblique
aponeurosis. Other tendinous slips run downward and medially
(Fig. 6.16B). In this very short course between the rectus muscle
and its sheath, the upward tendinous fibers decussate with their
downward counterparts, forming a transverse line of decussation
FIGURE 6.13. Epigastric hernia in a robust male. along which the rectus muscle gains attachment to its anterior
...
.- tt I itt ---t
FIGURE
tt 1
"
6.17. Diagram of mechanism of transformation, through the tendi-
nous intersections, of the vertical force of longitudinal contraction of the
rectus abdominis muscle into a lateral pull of the midline aponeurosis
(linea alba).
midline aponeurotic zone (Fig. 6.17) . A forcible lateral pull at a

FIGURE 6.15. Right paramedian incision (intraoperative photograph) .
critical spot in the weak midline aponeurosis of a single decussa-
Tendinous aponeurotic fibers of a tendinous intersection emerging from
tion pattern may be strong enough to tear open the aponeurosis
the rectus muscle (left) to join the anterior rectus sheath (right).
and produce a hernial defect.
It can be seen (Fig. 6.4) that all the tendinous intersections are
situated in relation to the mobile areas of the anterior abdominal
sheath. A fairly strong band of aponeurotic tendinous slips wall, namely, the upper expansile respiratory and umbilical zones.
emerges from the medial border of the rectus muscle and passes The lower tendinous intersection joins the linea alba at a point
directly medially to join the midline aponeurotic zone, sharing in just above the umbilicus. Its functional importance is that it de-
the formation of its aponeurotic fabric (Fig. 6.16C). These fibers marcates the fairly fixed lower belly support zone from the upper
may be of special importance as they transmit the longitudinal respiratory and umbilical zones. The point at which this lower
contracting force of the rectus muscle into a lateral pull on the tendinous intersection joins the midline aponeurotic zone is a crit-
ical spot for the development of paraumbilical hernial defects (Fig.
6.18) . In a few instances, one or both lower tendinous intersec-
tions may gain attachment to the linea alba at a point just below
the umbilicus. These can give rise to an infraumbilical paraum-
bilical hernial defect.
The middle tendinous intersection joins the linea alba at a point
about midway between the xyphoid process and the umbilicus,
where the aponeurotic slips descending from the sternocostal por-
8 tion of the diaphragm join the posterior aspect of the midline
aponeurosis. This constitutes another critical spot for the devel-
opment of an epigastric hernial defect, especially in a weak alba
with a single line of decussation (Fig. 6.19).
The Relation of the Skin to

the Midline Aponeurosis
Above the umbilicus, at the midline, the skin of the anterior ab-
dominal wall has a form of attachment to the midline aponeuro-
sis. This was found to be due to the presence of fine tendinous
slips that emerge from the anterior surface of the midline aponeu-
rosis: they pass forward through the subcutaneous tissues to gain
FIGURE 6.16. Diagram of aponeurotic fibers of three types of tendinous in-
tersections: (A) fibers acting as intermediate tendons between the rectus attachment to the dermis at the midline. In their path from the
muscle bellies; (B) fibers passing forward to join the rectus sheath (as in aponeurosis to the skin they describe an x-shaped pattern. These
Fig. 6.10); (C) fibers emerging from the medial edge of the rectus mus- tendinous bands must be cut to allow reflection of the skin of the
cle to join the midline aponeurosis. anterior abdominal wall at the midline. Lateral to their attach-
70 O.M. Askar
SK1N~
"NT~ :_-----::::---__=;-----
-
SHtATH .:_?±~~~;.~~
pOST. R£Q .::::------------- - .-
-----i2
~---------------:::
SHEATHl
FIGURE6.20. Diagram of x-shaped aponeurotic slips attaching the skin in

the umbilical area to the midline aponeurosis.
ment, the skin may be peeled offwith blunt dissection (Fig. 6.20).
These x-shaped aponeurotic bands are responsible for the locu-
lations seen in paraumbilical and epigastric hernias, but rarely in
other hernias.
The presence of these bands above the umbilicus but not be-
low may have a significance in the formation of a pendulous belly
below rather than above the umbilicus. In obesity, the deposition
of fat above the umbilicus occurs away from the midline over the
hypochondria. It is through these aponeurotic bands that the
heavy weight of a pendulous belly can be transmitted to the
aponeurosis above the umbilicus. Resection of an obese pendu-
lous belly would help to relieve the harmful downward traction on
the aponeurosis, quite apart from its cosmetic effect (Fig. 6.21).2,14
Also, the umbilical scar, being a fixed point on the anterior wall
aponeurosis, provides another means whereby the pendulous
obese belly can exert harmful downward traction on the linea alba;
it should, for this reason, be disconnected from the skin. Attempts
FIGURE 6.18. Diagram of mechanism of paraumbilical hernia creation in at refashioning an artificial umbilicus by joining the skin to the
pregnancy and labor: RM = rectus muscle; ARS = anterior rectus sheath; aponeurosis with a suture, are often followed by recurrence of the
PRS = posterior rectus sheath; U = umbilicus. hernial defect at the site of the suture.
The Umbilical Orifice

The umbilical orifice is a natural defect in the midline aponeu-
rosis to allow the passage of the umbilical cord structures dur-
ing fetal life. During development, the aponeurotic fibers of the
FIGURE 6.19. Diagram of the mechanism of epigastric hernia defect cre-

ation: arrows indicate directions of force in spasmodic effort. Diaphrag-
matic tendinous slips join the midline aponeurosis, intermingling with FIGURE 6.21. Diagram of the harmful effects of downward traction on the
those of the middle tendinous intersection fibers. aponeurosis by a heavy, pendulous belly below the umbilicus.
References
1. Askar o. Surgical anatomy of the anterior abdominal wall aponeuro-
sis. Ann R Coll Surg. 1977;59:313.
2. Askar O. A new concept of the aetiology and surgical repair of the
paraumbilical and epigastric hernias. Ann R Coll Surg of England.
1978;60:42.
3. Askar O. Aponeurotic hernias. Surg Clin North Am. 1984;64:315.
4. Askar 0, et al. The umbilical ring. 1993.
5. Burton C. Fingered fascia lata grafts for repair of incisional hernia.
Surg Gynecol Obstet. 1959;109:621.
6. Cullen TS. Method of dealing with intestinal loops densely adherent
to an umbilical hernia. JAMA. 1922;78:564.
7. Wilkinson WR Epigastric hernia. WV MedJ 1949;45:328.
8. Anson BJ, McVay CB. The anatomy of hernial regions. SurgGynecol Ob-
stet. 1949;89:417.
9. Moschowitz AY. The pathogenesis and treatment of herniae of the
linea alba. Surg Gynecol Obstet. 1914;18:504.
10. Pollock LH. Epigastric hernia. Am J Surg. 1936;34:376.
11. Mayo WV. Radical cure of umbilical hernia.JAMA. 1907;48:1842.
12. Wolmsly WR. The sheath of the rectus abdominis.J Anat. 1937;71:404.
FIGURE 6.22. Diagram of the arrangement of tendinous aponeurotic fibers 13. Rizk N. The aponeurotic expansions of the anterior abdominal wall.
around the umbilical ring. Anatomy thesis. Cairo University, Faculty of Medicine; 1975.
14. Lathrop G. Abdominallipectomy.JAMA. 1916;67:487.
15. McVay CB. In: Christopher textbook of surgery. 7th ed. MD Davis, ed.
Philadelphia: WB Saunders; 1960, pp. 518-540.
developing anterior abdominal wall pass around the umbilical

cord so that when the development of the anterior abdominal
wall is completed, the umbilical cord passes through a rounded Tribute to Omar M. Askar
aperture in the anterior abdominal wall aponeurosis, the umbil-
ical ring. The umbilical ring is formed by aponeurotic fibers " ... I was watching a butcher in my fann deskinning [sic] a lamb which
of both lower tendinous intersections, supplemented from the was killed for a party. The criss-cross decussating pattern of the lamb's
two sides by aponeurotic fibers from the external oblique, in- wide linea alba struck me. I took its abdominal wall aponeurosis and
ternal oblique and transversus abdominis (Fig. 6.22). These looked at it with a magnifYing lens. I saw fine glistening tendons... ."
tendinous aponeurotic fibers surround the umbilical ring in a (Omar M. Askar: personal communication, 27 January, 1991.)
way similar to the shutter mechanism used in optical instru-
ments (Fig. 6.1).1 5 The free mobility of the aponeurotic tendi- I am deeply grateful to Dr. Robert Bendavid for presenting the
nous fibers surrounding the umbilical ring allows the shutter work of my friend and for asking me to write a few words about a
mechanism to close the umbilical ring when the abdominal mus- good man, a great anatomist, and an excellent surgeon, Prof.
cles contract. Omar M. Askar.
Immediately after birth, the infant takes its first breath by the The late Omar M. Askar, of Cairo, Egypt, was a true student of
first contraction of its diaphragm. This is followed by a forcible the anterior abdominal wall. His work is classic, and will remain
contraction of the abdominal muscles which creates a positive in- in the annals of surgical anatomy.
trathoracic pressure which helps to compress air within the lungs I corresponded with Prof. Askar for many years before I finally
to open up the collapsed alveoli and expel excess air up through had the opportunity to meet him. I was invited to visit Cairo for
the larynx, giving the first cry of life, by which the newborn an- the Egyptian Society of Surgeons meeting in 1993. My dear friend
nounces the start of respiration. This forcible contraction of the Omar rolled out the red carpet for me and my wife. It was a great
abdominal wail muscles will put the midline aponeurosis on joy, honor, and privilege to discuss with Omar the anatomy and
stretch. The tendinous aponeurotic fibers encircling the umbili- surgical dimensions of the anterior abdominal wail. His specimens
cal orifice, acted upon by the contracting abdominal muscles, con- were well preserved and clarified for me the bilaminar formation
strict the umbilical ring so that the vessels passing in the umbilical of the aponeuroses of the parietal muscles, as well as the forma-
cord through the constricted umbilicus become completely oc- tion of the linea alba by the decussating fibers of the rectus sheath.
cluded: a very clever device provided by nature to help the new- In 1995, Prof. Askar came to Atlanta, and I had the pleasure of
born to sever relations with the placenta. Failure to produce having him as a guest in my home. His lecture on recurrent para-
efficient constriction of the umbilical ring during or shortly after umbilical hernias at Grand Rounds for the Department of Surgery
birth, as would occur in mild grades of fetal distress in a difficult at Emory University School of Medicine was memorable. I was re-
labor, would delay the healing and closure of the umbilical stump, minded ofa line in another letter, dated 15 March 1994: "I always
and at the same time leave a patulous umbilical ring through which say, 'A good father is a good teacher.''' His chapter is part of his
a hernial sac could find its way. An umbilical hernia is thus quite teaching legacy.
different from other conditions like exomphalos, where the prob-
lem resides with failure of development of a part of the anterior John E. Skandalakis
abdominal wall. Atlanta, Georgia
7
Surgical Anatomy of the Inguinal Region
from a Laparoscopic Perspective
Riccardo Annibali, Robert]. Fitzgibbons,Jr., and Thomas Quinn
Introduction Methods of Dissection

"The operating surgeon knows little of the posterior wall of the in- To identify the anatomical structures that compose the deep sur-
guinal canal, so well is it hidden from his view." (WJ. Lytle, 1945)1 face of the anterior abdominal wall and the inguinal region, we
have performed 14 dissections in 10 male and 4 female cadavers
In 1969, Ravitch stated that the "operations for the cure of hernia whose age ranged from 63 to 100. For the study of the layers of
would seem to be established and well known beyond the possi- the abdominal wall in the majority of the specimens, we initiated
ble need for further discussion and demonstration."2 Actually, the dissection with a standard midline incision. In the last two dis-
before the introduction oflaparoscopic surgery, the "problem her- sections, however, we began with an enlarged bilateral subcostal
nia" seemed to be well defined. The term indicated "the protru- incision in order to preserve the anterior abdominal wall intact.
sion of a loop or knuckle of an organ or tissue through an In all cases, the abdominal viscera were removed to allow unob-
abnormal opening,"3 that needed to be repositioned and kept in structed visualization of the anatomical details in the retroperi-
place with some type of repair. The only variable factor was the toneal space of the lower trunk. Peritoneum that covered the
choice of herniorrhaphy. Today, laparoscopic hernia repair chal- internal surface of the abdominal wall above the inguinal ligament
lenges the surgeon with a new perspective of hernia. was initially left intact to preserve the laparoscopic view.
Most anatomy and surgery textbooks describe the groin and its
layers in the sequence of dissection, proceeding from the super-
ficial to the deep, and giving little consideration to the interior Peritoneum
view of the abdominal wall. To prepare for laparoscopic hernia re-
pair, it is necessary to reverse this approach and begin our anatom- The deep surface of the abdominal wall above the inguinal liga-
ical study with the deepest layers. ment is covered by peritoneum (Figs. 7.1, 7.2A and B, and 7.3; see
color insert). Five peritoneal folds formed by peritoneal reflections
over three underlying cord-like structures in the center, and two
vascular bundles peripherally, are visible below the umbilicus. The
Terminology median umbilical ligament, which represents the obliterated remnant
of the embryonic urachus, lies in the midline and extends from
Concepts of superior and inferior, superficial and deep, anterior the fundus of the bladder to the umbilicus. Two other peritoneal
and posterior have been established by time-honored convention folds, the medial and lateral umbilical ligaments, are bilaterally
and are adhered to even though the surgeon does not operate symmetrical. The medial umbilical ligament consists of a fold of peri-
on patients standing in the "anatomical position." Use of terms toneum covering the distal portion of the umbilical artery. This is
like "down" to mean under the surgeon's hand and "up" to mean usually atrophied and cord-like in the adult, but it is normally
toward the ceiling is inevitable in communication among mem- patent proximally, and gives off the superior vesical arteries to the
bers of an operating team, but in formal notes and descriptions urinary bladder (Figs. 7.1, 7.4, 7.SA, 7.9, 7.10, 7.14B; see color in-
of anatomy and surgical procedure, standard terminology is es- sert). Occasionally, the entire umbilical artery may remain patent. 4
sential. Ambiguity is particularly worrisome in discussions of the In some patients, the medial umbilical fold is particularly promi-
laparoscopic view. When two structures cross, which one is "in nent and may hinder proper dissection. 5 The lateral umbilicalliga-
front" of the other? It is helpful to remember that the patient's ment consists of a fold of peritoneum around the inferior epigastric
physical disposition in space does not depend on the surgeon's vessels, together with a variable amount of fatty tissue.
point of view; with this in mind, when the laparoscopic surgeon It should be noted that some older texts define the fold out-
says "in front" he will always mean "anterior to" in the conven- lined by the umbilical artery as the lateral umbilical ligament, while
tional sense. the fold associated with the inferior epigastric vessels has been
72
7. Surgical Anatomy of the Inguinal Region 73
FIGURE 7.1. Drawing illustrating the anatomy of Remnant of

umbilical a.
the internal surface of the lower abdominal wall,
Medial umbilical Linea semicircularis
inguinal region and lower trunk. (See color in-
ligament Rectus abdom . m.
sert.)
Urachus (median Inferior epigastric
umbilical ligament) a. and v.
Testicular artery
and vein
Anastomotic Falx inguinalis
pubic (Henle's lig.)
Medial fossa Aponeurotic arch
Lateral fossa Superior and
inferior crura
(transversalis
fascia sling)
Femoral canal --'---"7lIIF:~~F.:.t;~"
lIiopubic tract
Deep circumflex
iliac a. and v.
Femoral ring Iliopectineal arch
AnI. pubic branch
Pectineal and iliopubic vein
(Cooper's)
Vas deferens
Obturator foramen,
a. and v. nerve, artery, vein
Psoas minor Femoral nerve
tendon Lateral femoral
cutaneous nerve
Ilioinguinal ne rve
Iliohypogastric nerve
Genitofemoral nerve
Genital branch +
Femoral branch·
called plica epigastrica.3.4.6 In this chapter, we will use more con- cation with the retropubic space of R.etzius. 13 A precise knowledge of
temporary terminology (Table 7.1).7-12 the vascular and neurological structures included in the preperi-
On either side of the midline, the medial and lateral umbilical toneal space of the lower trunk is essential for the laparoscopic
ligaments delineate three shallow fossae (Figs. 7.1, 7.2A,B,C, 7.3) . surgeon intending to perform a hernia repair.
The lateral fossa lies lateral to the inferior epigastric vessels. It is After removal of the peritoneum, the preperitoneal space is en-
the site where indirect hernias pass through the internal inguinal tered. Tobin and, more recently, Arregui, have described a thin
ring. The medial fossa is defined as the space between the lateral fascial layer superficial to the peritoneum known as the preperi-
and the medial umbilical ligament and corresponds to the site of toneal fascia. 14-J 7 The magnification obtained with the laparoscope
development of direct inguinal hernias. The location and size of allows a better identification of this fascia, while in the embalmed
the medial umbilical ligament is variable; it is sometimes super- cadaver its identification is somewhat difficult. In the course of
imposed on the lateral umbilical ligament and should, therefore, 187 laparoscopic hernia repairs in 145 patients, Arregui has
not be considered a consistent landmark. Finally, the supravesical demonstrated that the preperitoneal fascia divides the preperi-
fossa lies between the medial and the median umbilical ligaments. toneal space into two different compartments, and its opening is
It is more or less evident, depending on its depth. The rectus ab- required to enter the preperitoneal space of Bogros proper. As de-
dominis muscle and its sheath confer greater strength to this area, scribed by Arregui,17 the space between the peritoneum and the
making supravesical hernias rare. 8 Condon observed that "the um- preperitoneal fascia contains a small amount of adipose and are-
bilical fossae are rarely noted during intra-abdominal operations olar tissue, the remnant of the umbilical artery, and the inferior
and are of no surgical importance in regard to either the etiology epigastric vessels, which produce the two peritoneal folds on ei-
or the repair of groin hernias." 7 Since the development of la- ther side of the midline. Arregui also maintains that at the level
paroscopic techniques for hernia repair, however, increased at- of the internal inguinal ring, the preperitoneal fascia is intimately
tention has been paid to the internal aspect of the abdominal wall: fused with the peritoneum and provides the conical sheath that is
a consistent relationship between inguinal herniation and the um- visible laparoscopically around the vas deferens and the internal
bilical fossae has been routinely observed. spermatic (testicular) vessels (Fig. 7.6) . It then continues distally,
following the spermatic cord, to form the inner component of the
internal spermatic fascia.15 During laparoscopic repair of an indi-
rect hernia, this conical fascial covering must be entered to clear
Preperitoneal Space the sac from the other structures of the cord in order to reduce,
ligate, and transect the hernial sac. Arreguil7 has also pointed out
The preperitoneal space of Bogros contains a variable amount of con- that the plane between the peritoneum and the preperitoneal fas-
nective tissue, which may be areolar, fatty, or semimembranous cia may be mistakenly entered either during a laparoscopic trans-
(Figs. 7.1, 7.4, 7.5A,B, 7.6, 7.9, 7.14B).7-9 It is in direct communi- abdominal preperitoneal procedure or a totally extraperitoneal
A B
FIGURE 7.2. (A) View of the deep surface of the anterior abdominal wall
in a cadaver preparation, which demonstrates the peritoneal folds and fos-
sae. (B) The peritoneal fossae are better demonstrated with transillumi-
nation of the lower anterior abdominal wall: UM = umbilicus; FB =
fundus of the bladder; U = median umbilical ligament; ML = medial um-
bilical ligament; LL = lateral umbilical ligament (inferior epigastric ves-
sels); SF = supravesical fossa; MF = medial fossa; LF = lateral fossa; IS =
internal spermatic (testicular) vessels; VD = vas deferens; EI = external il-
iac vessels; A = abdominal aorta. The arrow indicates the deep inguinal
ring. (C) Exterior view of the anterior abdominal wall and inguinal region
transilluminated: UM = umbilicus; RM = sheath of rectus muscle; AA =
aponeurotic arch of transversus abdominis muscle; SC = spermatic cord;
IR = area corresponding to the internal inguinal ring; IE = inferior epi-
gastric vessels; LF = lateral fossa; IL = inguinal ligament. Dotted outline
indicates the weak areas included within the inguinal triangle through
which direct hernias occur. (See color insert.)
c
FIGURE 7.3. Peritoneal folds and fossae, as seen at laparoscopy. A direct

hernia is visible bilaterally and appears as a circular defect included be-
tween the aponeurotic arch of the transversus abdominis muscle superi-
orly and the iliopubic tract inferiorly: U = median umbilical ligament;
ML = medial umbilical ligament; LL = lateral umbilical ligament; AA =
aponeurotic arch of the transversus abdominis muscle; IP = iliopubic tract;
SF = supravesical fossa; MF = medial fossa; LF = lateral fossa; VD = vas
deferens; IS = in ternal spermatic (testicular) vessels; EI = external iliac
vessels; B= bladder with Foley catheter inserted. (See color insert.)
74
FIGURE 7.4. Panoramic view of the internal surface of the anterior lower pubic tract; DC = deep circumflex iliac vessels; GN = genitofemoral nerve;
abdominal wall, inguinal regions, lower trunk, and pelvis in a cadaver dis- GB = genital branch of the genitofemoral nerve; FB = femoral branch of
section: UM = umbilicus; LS = linea semicircularis; RM = rectus abdo- the genitofemoral nerve; FN = femoral nerve; LC = lateral femoral cuta-
minis muscle; HT = inguinal (Hesselbach's) triangle; IE = inferior neous nerve; IL = ilioinguinal nerve; 1M = iliacus muscle; PM = psoas ma-
epigastric vessels; AP = anterior pubic branch and iliopubic vein; TS = jor muscle; IS = internal spermatic (testicular) vessels; UR = ureter; A =
transversalis fascia sling; U = urachus; CL = Cooper's ligament; UA = um- abdominal aorta; LV = iliolumbar vessels. Thick black arrow indicates deep
bilical artery; AO = anomalous obturator artery; SV = superior vesical inguinal ring; white arrow, obturator foramen; short arrow, femoral ring.
artery; PB = anastomotic pubic branches; IV = external iliac vein; IA = ex- (See color insert.)
ternal iliac artery; VD = vas deferens; PA = iliopectineal arch; IP = ilio-
A B
FIGURE 7.5. (A) Photograph of a cadaver preparation (right side) showing iliopectineal arch; GN = genitofemoral nerve; GB = genital branch of the
the preperitoneal space at the level of the inguinal area, after removal of genitofemoral nerve; FB = femoral branch of the genitofemoral nerve;
the peritoneum and preperitoneal adipose tissue (the urachus has been FN = femoral nerve; LC = lateral femoral cutaneous nerve; IL = ilioin-
resected and the bladder retracted posteriorly). (B) Same view of (A), but guinal nerve; DC = deep circumflex iliac vessels; V = seminal vesicles;
in a different cadaver. Note the staples correctly positioned just above the UA = umbilical artery; PB = anastomotic pubic branch; AP = anterior pu-
iliopubic tract to tack the inferior border of the mesh. The internal sper- bic branch and accompanying iliopubic vein; RP = retropubic vein; LV =
matic (testicular) vessels have been moved slightly laterally to better show iliolumbar vessels; B= bladder; CI = common iliac artery; M = aponeu-
the external iliac vessels on the floor of the "Triangle of Doom." RM = rotic arch of the transversus abdominis muscle; UR = ureter; 1M = iliacus
rectus abdominis muscle; IE = inferior epigastric vessels; IP = iliopubic muscle; PM = psoas major muscle; TF = transversalis fascia; IF = iliac fas-
tract; CL = Cooper's pectineal ligament; IS = internal spermatic (testicu- cia (reflected in Part (B»; TM = transversus abdominis muscle. (See color
lar) vessels; ES = external spermatic vessels; VD = vas deferens; IA = ex- insert.)
ternal iliac artery; IV = external iliac vein; EI = external iliac vessels; IPA =
75
76 R. Annibali et al.
TABLE 7.1. Different terminologies used to indicate the peritoneal folds of the deep surface of the
anterior abdominal wall
Nomina anatomica Structure determining AI ternative
terminology the fold terminologyb
Median umbilical ligament Urachus Median umbilical ligament

Medial umbilical ligament Obliterated umbilical artery Lateral umbilical ligament
Lateral umbilical ligament Inferior epigastric vessels Plica epigastrica
'Nomina Anatomica, 198012 ; Condon, 19787; Ponka, 19808 ; Gray's Anatomy, 198910; Skandalakis, 1991 21
bZimmermann, 19673; Thorek, 19624; Gullmo, 19846 ; Hollinshead, 1961 43 ; Schaffer, 1953.50
repair. This could result in injury to the bladder if the dissection pierce the transversalis fascia to enter the sheath of the rectus
is carried medial to the medial umbilical ligament. muscle.
The inferior epigastric arteries usually give rise to two branches
in the inguinal region: the cremasteric artery, known formerly as the
Vessels of the Retroperitoneal external spermatic artery (Figs. 7.SA, 7.10, 7.14B), and the anasto-
moticpubicbranch (Figs. 7.1, 7.4, 7.SA, 7.6, 7.7A,B, 7.9, 7.14B). The
and Preperitoneal Space cremasteric artery runs upward from its origin along the medial
aspect of the internal inguinal ring, pierces the transversalis fas-
The importance of a thorough understanding of the vasculature
cia, and crosses the preperitoneal space to join the spermatic cord.
for surgeons who staple prosthetic mesh in the preperitoneal space
The pubic branch courses inferiorly toward the obturator fora-
is self-evident: the vascular structures can easily be damaged, with
men, where it anastomoses with the obturator artery. The anasto-
serious results. The external iliac vessels run on the medial aspect
motic pubic artery sometimes gives rise to an inconstant small
of the psoas muscle over its investing fascia, before passing behind
branch, called the anterior pubic branch, as it crosses the superior
the iliopubic tract and the inguinal ligament to become the
ramus of the pubis. The anterior pubic branch runs along the su-
femoral vessels, within the femoral sheath (Figs. 7.1, 7.2B, 7.3, 7.4,
perior ramus of pubis, toward the body of this bone. This anasto-
7.SA,B, 7.7.A, 7.9, 7.10, 7.14B) . The inferior epigastric vessels nor-
motic ring of arteries, together with their corresponding veins, is
mally originate from the external i1iacs (Figs. 7.1, 7.2A,B,C, 7.4,
sometimes known as the "corona mortis" ("crown of death") be-
7.SA,B, 7.6, 7.7A,B, 7.9, 7.10, 7.14B). They run superiorly and
cause of the bleeding which occurs if it is injured while suturing
medially toward the umbilicus from a point midway between
or applying staples to the pectinal (Cooper's) ligament, or in blind
the anterior superior iliac spine and the symphysis pubis, ascend
medial incision of the lacunar ligament when attempting to free
obliquely along the medial margin of the internal inguinal ring
an incarcerated femoral hernia.
between the transversalis fascia and the peritoneum, and finally
An obturator artery originating from the inferior epigastric or
external iliac has been observed in approximately 30% of the
specimens studied. I 6-19 When the obturator artery is anomalous
in its origin, it usually appears as a sizable branch from the infe-
rior epigastric vessels (Figs. 7.4, 7.9, 7.10). Laceration of these
branches during surgery leads to hematomas in the preperitoneal
space.
The iliopubic vein courses deep to the iliopubic tract (Figs. 7.1,
7.4, 7.SA, 7.6, 7.9, 7.10, 7.14B) and accompanies the anterior pu-
bic branch when this is present. It either empties directly into the
inferior epigastric vein, or joins the venous anastomotic pubic
branch to form a common trunk that drains into the inferior epi-
gastric vein. 13 Another tributary of the inferior epigastric vein, the
rectusial vein, runs along or is embedded within the lower lateral
fibers of the rectus muscle (Figs. 7.9 and 7.10) . According to Ben-
david, who first named this vessel, it consistently forms a venous
anastomotic ring by joining the iliopubic vein above the pubic
crest. 13 We were able to demonstrate this connection in cadaver
dissections; however, these venous anastomoses are better identi-
fied at the operating table than in the anatomy laboratory, as the
small veins are often collapsed and empty in the cadaver, but dark-
FIGURE 7.6. Preperitoneal space seen laparoscopically during a hernia re- ened in color and engorged in the patient undergoing surgery. Fi-
pair: PF = peritoneal flap reflected; IS = internal spermatic (testicular) nally, a small collateral branch of the anastomotic pubic vein is
vessels; VD = vas deferens; CL = Cooper's pectineal ligament; ML = me-
commonly observed on the lower posterior aspect of the pubic
dial umbilical ligament; PB = anastomotic pubic branch; PV = iliopubic
vein; IE = inferior epigastric vessels; SC = superior crus of the transver- ramus, beneath Cooper's pectineal ligament, and has been called
salis fascia sling; IP = iliopubic tract; AA = aponeurotic arch of the trans- the retropubic vein (Figs. 7.SA, 7.9, 7.10, 7.14B). For all surgeons in-
versus abdominis muscle. The arrow points to the deep inguinal ring. (See terested in placing prosthetic materials in the preperitoneal space,
color insert.) the importance of familiarity with the deep inguinal venous cir-
A B
FIGURE 7.7. (A) Cadaver preparation of the inguinal region. Close-up of IE = inferior epigastric vessels; GB = genital branch of the genitofemoral
the area of the right deep inguinal ring. (B) Laparoscopic view of the left nerve; FB = femoral branch of the genitofemoral nerve; FN = femoral
internal inguinal ring. TS = transversalis fascia sling; SC = superior crus nerve; PA = iliopectineal arch; M = aponeurotic arch of the transversus
of the transversalis fascia sling; IC = inferior crus of the transversalis fas- abdominis muscle; DC = deep circumflex iliac vessels; 1M = iliacus mus-
cia sling; IS = internal spermatic (testicular) vessels; VD = vas deferens; cle; PB = anastomotic pubic branch. (See color insert.)
IV = external iliac vein; IA = external iliac artery; IP = iliopubic tract;
culation is self-evident: damage to these structures is easy and usu- names corresponding to the structure covered, such as transver-
ally leads to hematoma formation. salis, psoas, obturator, or iliac, but it is a single fascial envelope
The external iliac vessels are also the origin of the deep circum- that invests the entire abdominal cavity.3 The term transversalis fas-
flex iliac artery and vein (Figs. 7.1, 7.4, 7.5A,B, 7.7A, 7.14B). These cia was coined by Sir Astley Cooper to designate the portion of the
cross laterally over the femoral sheath, run between the iliopubic endoabdominal fascia that covers the internal surface of the trans-
tract and the iliopectineal arch, pierce the transversalis fascia, and versus abdominis muscle. 21 .22
finally end in the space between the transversus abdominis and the In his original description, Cooper reported that the transver-
internal oblique muscles. It is important to note that an anasto- salis fascia is composed of an outer (or anterior), and an inner
mosis exists between the circumflex iliac vessels and the iliolumbar (or posterior) lamina. 23 This bilaminar arrangement has also
and suPerior gluteal vessels (Figs. 7.1, 7.4, 7.5A, 7.14B).7,20 been reported by Cleland and MacKay,24 but McVay, Anson, and
In males, the testicular arteries (formerly called internal spermatic), Condon dispute this. 25 Those who propound the bilaminar trans-
originate from the aorta below the renal arteries (Figs. 7.1, 7.2A, versalis fascia describe an anterior layer closely related to the
7.3,7.4, 7.5A,B, 7.6, 7.7A,B, 7.9, 7.10, 7.14B, 7.15, 7.16) . They then aponeurosis of the transversus abdominis and attached inferiorly
pass inferolaterally behind the peritoneum covering the psoas ma- to the pectineal ligament of Cooper and medially to the rectus
jor muscle. Each passes in front of the genitofemoral nerve, the sheath. 26 In this scheme, the posterior layer blends superiorly with
ureter, and the inferior part of the external iliac vessels. Each tes- the linea semicircularis of Douglas and medially with the linea
ticular artery joins the vas deferens as it enters the inguinal canal alba, and inserts inferiorly on the superior ramus of pubis. Ac-
through the deep inguinal ring, accompanied by its correspond- cording to Read, the inferior epigastric vessels do not lie in the
ing testicular vein. The left testicular vein drains into the renal preperitoneal space proper, but are contained instead between the
vein, while the right empties into the vena cava. two layers of the transversalis fascia.22 While the anterior layer of
The laparoscopic surgeon must appreciate the interrelations of the transversalis fascia is clearly identifiable during anatomical dis-
these vessels to avoid their inadvertent damage during laparo- sections on an embalmed cadaver, the same is not uniformly true
scopic hernia repair. for the posterior layer. Other authors have identified the structure
that Cooper considered the posterior layer of the transversalis fas-
cia with the preperitoneal fascia, discussed earlier. 1,27.28
Transversalis Fascia Since the transversalis fascia is a layer through which inguinal
hernias must pass, it has considerable importance for surgeons. 8
External to the preperitoneal space is the endoabdominal fascia. There is, however, significant confusion and uncertainty about the
This fascia covers separate muscles, aponeuroses, or becomes at- precise role that the transversalis fascia plays in both the origin
tached to the periosteum of interposed bony structures. It acquires and the repair of inguinal hernias. 23,29,30 Some authors feel that
the transversalis fascia is a thin, weak layer with no intrinsic the crura to approximate with each other, further reinforcing
strength. 7,2l,29 Others argue that a resistant and strong transver- the closure of the internal ring and preventing indirect hernia-
salis fascia is essential to the avoidance ofherniation. 8 Indeed, Grif- tion. 7,9,33
fith stated that "the fact that transversalis fascia may be destroyed The iliopubic tract is a fascial condensation connected laterally
by large direct hernias in obese elderly men has led to the con- with the inner lip of the iliac crest, the anterior superior iliac spine,
cept that the transversalis fascia is unimportant. Nothing could be and the iliopectineal arch. It runs parallel to the inguinal liga-
further from the truth. "31 ment, but in a plane posterior to it, crosses the femoral vessels an-
There is general agreement, however, that the deep elements teriorly and forms an inferior border of the deep inguinal ring
of the abdominal wall, including the transversus abdominis mus- before and finally fanning out to attach to the medial portion of
cle with its aponeurosis and the transversalis fascia, constitute the Cooper's ligament and the pubic tubercle 21 ,29,33,34,36 (Figs. 7.1, 7.3,
structure that supports the pressure of the intra-abdominal organs 7.4, 7.5A,B, 7.6, 7.7A,B, 7.8, 7.9, 7.10, 7.13, 7.14B, 7.16). From time
and prevents herniation. 8,32-34 to time, this structure has been referred to as the "bandelette of
The internal (or deep) inguinal ring is located in the lateral fossa Thomson," the "bandelette ilio-pubienne," and the "deep femoral
about 1.25 cm above and slightly lateral to the middle of the in- arch." None of these terms is commonly used in North America,
guinalligament (Figs. 7.1, 7.4, 7.5A,B, 7.6, 7.7.A,B, 7.9, 7.10, 7.13, where the name "iliopubic tract" has been popularized by Nyhus,
7.14B).29,33,34 It is the internal opening of the inguinal canal, al- Condon, and others. 7,29,37 According to some authors, the iliopu-
lowing passage of the vas deferens, the testicular vessels and, nor- bic tract is a tough cord essential for hernia repair. 34,48 Lichten-
mally, the genital branch of the genitofemoral nerve. It is usually stein, however, has found it to be of significant strength only in a
reported as being 2 cm in circumference, but appears nearly closed small number of cases (25%), and does not regard it as a sup-
when viewed laparoscopically. portive structure. 39,40 In a series of 151 dissections of embalmed
During fetal development, the testicle descends from its ab- inguinal regions and in serial sagittal sections of four body halves,
dominallocation to the scrotum. It is accompanied by an oblique Gilroy and coworkers could identifY a substantial structure corre-
cone of transversalis fascia. 7,29,31 This cone of fascia is oriented in- sponding to the iliopubic tract and useful for hernia repair in 42%
feromedially, but less obliquely than the direction of the cord. It of the specimens. 41
is therefore redundant on the medial side of the cord and forms The pectineal (or Cooper's) ligament is difficult to define since the
a sling-shaped, thickened condensation of the transversalis fascia original description of Sir Astley Cooper23 ,30 has been often mod-
that reinforces the medial aspect of the deep ring. 20 ,34 This is called ified (Figs. 7.1, 7.4, 7.5A,B, 7.6, 7.8, 7.9, 7.10, 7.14B). Some have
the transversalis fascia sling; it has superior and inferior extensions described it as the fusion of the periosteum covering the superior
known as the superior and inferior crura (Figs. 7.1, 7.7A,B).7,8 ramus of the pubis lateral to the pubic tubercle with the trans-
This anatomical structure is physiologically important, as it plays versalis fascia and the iliopubic tract. 7,21,33,38,42 Others believe it is
a key role in the sphincteric or valvular mechanism of the internal simply a lateral extension of tendinous fibers from the lacunar lig-
inguinal ring. When the muscular fibers of the transversus abdom- ament. 43 Still others have questioned whether it is appropriate to
inis contract, the transversalis fascia moves along with them, dis- refer to it as a separate ligament. 21 Regardless of its origin or ex-
placing the internal ring laterally and cranially under the muscular act makeup, for practical purposes, the pectineal (Cooper's) liga-
edge of the internal abdominal oblique. 1,35 This action also causes ment is the shiny, fibrous structure covering the superior pubic
PsQlS minot mUlde - - - - - - - - -
Plo.. ""jOt muscle - - - - - - - - - : . . -

Ouadr,"'" "mbonJm mlSdl - - - - - ;
E.tetnal oblique musdo - - - -

InlOrNl oblique muscIo - - - - - - . . ,• •,.
T'",,.,.,susobdOtnlnlsmusclo - - _
IliohypogastJit neM! ----""1
lIloingui....."" - - -- - -
lIi.lcusmuscio - - -- --
Genitolemotai .."" - - - - -
... tetll ..motai"'_""' ..... ---~~
Ing<jOll ligoment -------~
remOtllneM - - - - - - - . . . . -
llio\>«tinellmh - - -- -----
remOtllbronch ------~
GeniQlbrallch - - - - - - - - -
remOtaitino ----------:It
-------'""/1
lIiOllUbic tract
F,mcnl.he.th _------C-
lI_olS tendon ------""""'11.
FIGURE 7.8. Anatomy of the inguinal and
femoral region. (See color insert.)
"co~oined tendon."7,44 This combination, however, has been

found in only 3 to 5% of cases. 7,33,43 In fact, McVay and others
have argued that the conjoined tendon does not exist and that it
is only an artifact of dissection. 38 ,44
A second physiological system, known as the shutter mechanism,
functions in the prevention of direct and indirect herniation. It is
activated when, during straining, the internal oblique and the
transversus abdominis muscle contract simultaneously and ap-
proximate the transversus aponeurotic arch to the iliopubic tract
and inguinal ligament, thus reinforcing the posterior wall of the
inguinal cana1. 7,9,35 In approximately 25% of individuals, however,
the arch cannot descend far enough to reach the inguinal liga-
ment. It may be located too far superiorly or simply be poorly de-
veloped. 9,45 In these cases, a portion of the lower deep abdominal
wall lacks the reinforcement of the aponeurotic arch and is sup-
ported only by the transversalis fascia (Fig. 7.10) .32
FIGURE 7.9. The internal surface of the lower anterior abdominal wall pre- The inguinal (or Hesselbach's) triangle is the Achilles heel of the
pared in a cadaver. The weak areas inside the inguinal triangles through groin (Figs. 7.1, 7.4, 7.5A,B, 7.9, 7.10). According to the original
which direct herniations occur, and included between the aponeurotic description, its boundaries are the inferior epigastric vessels su-
arch of the transversus abdominis muscle superiorly and Cooper's perolaterally, the rectus sheath medially, and Cooper's ligament
pectineal ligament inferiorly, are better demonstrated here by transillu- inferiorly.8,20,21,34 These borders have been modified since then by
mination of the lower anterior abdominal wall. The urachus and the blad- the substitution of the inguinal ligament for Cooper's ligament,
der have been reflected posteriorly. (See color insert.) to allow easier identification of the area by surgeons who use the
traditional anterior approach for herniorrhaphy. For the laparo-
ramus. 5 It is easily identified during laparoscopic surgery and in

the anatomical dissecting room.
The iliopectineal arch is a condensation of the transversalis fas-
cia on the medial side of the iliac fascia. It is attached laterally to
the anterior superior iliac spine, and medially with the il-
iopectineal eminence. It crosses the lateral aspect of the femoral
sheath (Figs. 7.1, 7.4, 7.5A,B, 7.7A, 7.8, 7.9, 7.l4B, 7.16). Part of
the fibers of the external oblique, the internal oblique, the trans-
versus abdominis muscles, and the iliopubic tract originate from
this fibrous structure. The iliopectineal arch is also an important
landmark because it divides the medial vascular compartment (la-
cuna vasorum) and the femoral canal from the lateral muscular
compartment (lacuna musculorum) (Figs. 7.8, 7.14B, 7.16) . In
the former, the femoral vessels and the femoral canal are found;
the latter is occupied primarily by the iliopsoas muscle, but con-
tains also the femoral nerve and the lateral femoral cutaneous
nerve (see below) .
7.10. Same preparation as Fig. 7.9. Close-up of the area of the left
Transversus Abdominis Muscle FIGURE
inguinal (Hesselbach's) triangle: RM = lateral border of the rectus ab-
dominis muscle; LS = linea semicircularis (of Douglas); IE = inferior epi-
The transversus abdominis muscle takes its origin from the lower gastric vessels; ES = external spermatic (cremasteric) vessels; RV =
six ribs, the lumbodorsal fascia, the iliac crest, the iliopubic tract rectusial vein; CL = Cooper's pectineal ligament; IP = iliopubic tract;
and the iliopsoas fascia. These fibers pass transversely around the VA = umbilical arteries; SV = superior vesical artery; HL = falx inguinalis
lateral abdomen to the midline, to form part of the lateral ab- (or Henle's ligament); AA = aponeurotic arch of the transversus abdom-
dominal wall. Lateral to the rectus muscle, the fibers of the trans- inis muscle; VD = vas deferens; IS = internal spermatic (testicular) vessels;
versus abdominis insert on a tendinous aponeurosis. The lower PB = anastomotic pubic branch; AP = anterior pubic branch and iliopu-
bic vein; PV = iliopubic vein; RP = retropubic vein; AO = anomalous
fibers cross downward and medially to form an aponeurotic arch
obturator artery; GB = genital branch of the genitofemoral nerve;
that bridges over the superior margin of the internal inguinal ring
FB = femoral branch of the genitofemoral nerve; LC = lateral femoral cu-
before inserting at the pubic tubercle and the medial side of the taneous nerve; TS = transversalis fascia sling; CI = common iliac artery;
pectineal (Cooper's) ligament (Figs. 7.1, 7.2C, 7.3, 7.5A,B, 7.6, IA = external iliac artery; IV = external iliac vein; PA = iliopectineal arch;
7.7A,B, 7.9, 7.10) .8 Occasionally, these fibers join with parallel FN = femoral nerve; PM = psoas major muscle; 1M = iliacus muscle; A =
lower fibers of the internal oblique as they insert on the pubic tu- abdominal aorta. The thick arrows point to the deep inguinal ring. The
bercle and the superior ramus of the pubis to form the so-called thin arrow indicates the femoral ring. (See color insert.)
scopic procedure, however, it seems more appropriate to return Inguinal Canal and Spermatic Cord
to Hesselbach's original description, since the inguinal ligament
is not visible laparoscopically. The inferior portion of the triangle The inguinal canal is an oblique passage approximately 4 cm long
includes the weak area previously seen in the medial umbilical (Fig. 7.11). It begins at the deep inguinal ring and extends down-
fossa,7,21 where direct hernias develop. Its boundaries are the ward and medially through a gap in the transversus abdominis and
aponeurotic arch superiorly and the iliopubic tract inferiorly (Figs. the internal oblique muscles at a point approximately midway be-
7.1, 7.2C, 7.9, 7.10). tween the anterior superior iliac spine and the pubic tubercle to
Cranial to a line located approximately midway between the um- end at the external (or superficial) inguinal ring. This "ring" is ac-
bilicus and the symphysis pubis, called the linea semicircularis,4,8,10 tually a triangular opening in the aponeurosis of the external
the aponeurotic fibers of the transversus abdominis pass posterior oblique muscle which is located superior to the inguinal ligament
to the rectus abdominis muscle, thus contributing to the forma- and immediately lateral to its insertion on the pubic tubercle. The
tion of the posterior rectus sheath, while caudal to that level they inguinal canal is limited inferiorly by the inguinal ligament, in-
usually cross anteriorly as part of the anterior rectus sheath, leav- feromedially by the lacunar ligament, anteriorly by the aponeu-
ing the rectus sheath deficient below the linea semicircularis, and rosis of the external oblique muscle, laterally and superiorly by the
the rectus abdominis lined only by the transversalis fascia and the fibers of the internal oblique muscle and the aponeurotic arch of
peritoneum (Figs. 7.1, 7.4, 7.9, 7.10). In many cases, the aponeu- the transversus abdominus. 20 The posterior wall, between the
rotic lower portion of the transversus abdominis muscle does not aponeurotic arch superiorly and the iliopubic tract inferiorly, is
end at the rectus sheath but curves down to insert onto the su- formed by the transversalis fascia alone.
perior ramus of the pubis.7 This slip is identified by some as the The inguinal canal is the passageway for the spermatic cord, which
falx inguinalis. 20 ,33,34 According to others, however, the term "falx is formed at the internal inguinal ring where the vas deferens and
inguinalis" should be reserved for a vertical extension (sometimes the internal spermatic (testicular) vessels join together with a ma-
referred to as the ligament of Henle) of the sheath of rectus muscle trix of connective tissue that is continuous with the preperitoneal
that occurs in 30-50% of patients. It attaches to the symphysis pu- connective tissue. The processus vaginaliJB,29,33 is the portion of peri-
bis and Cooper's ligament (Figs. 7.1, 7.9).21,38 toneum that accompanies the testicle during its descent toward
the scrotum in embryonic life. Its funicular portion is commonly
obliterated in the adult, while the testicular portion constitutes the
tunica vaginalis testis. However, 30% to 40% of children three to
Internal and External Oblique Muscles four months old have a patent processus vaginalis. 46 According to
Russell, all indirect inguinal hernias have a congenital origin due
The internal and external oblique muscles form part of the anterior to patency of all or part of the processus vaginalis.47 The cord also
and the lateral abdominal wall. They play a minimal role in in- includes the cremasteric vessels and the artery of the ductus deferens,
guinal hernia formation, limited to an influence on the direction as well as the genital branch of the genitofemoral nerve and il-
of a hernial bulge. 21 ,32 The most inferior portion of the aponeu- ioinguinal nerve. The spermatic vein drains blood from the
rosis of the external oblique forms the inguinal (or Poupart's) lig- pampiniform plexus, a network of smaller veins within the cord,
ament, which extends from the anterior superior iliac spine laterally and empties into the renal vein on the left and into the inferior
to the pubic tubercle medially. Medially, some of its fibers turn to vena cava on the right.
insert in the pectineal (Cooper's) ligament, thus forming the la- The cord is covered by three layers acquired when crossing the
cunar (or Gimbernat's) ligament (Fig. 7.9).7,20 abdominal wall (Fig. 7.11). The internal spermatic fascia is provided
Peritoneum
Median umbilical
Deep inguinal ligament
ring----H-
Rectus abdominis
Transversus muscle
abdominis mU!;Cle·--.,r\1
Pyramidalis
Internal oblique muscle
Aponeurosis of
external oblique Iil,.-,;-o--Superficial inguinal ring
muscle ------'~
Inguinal _ _ _ _ _ _ _~~~~.p.~~~~~~
ligament
Intennediate inguinal ring External spermatic fascia FIGURE 7.11. The inguinal canal. (Modified
from Yaeger W.L. Intermediate inguinal ring.
Clin Anatomy, 5:289-295, 1992. Reproduced
Internal spermatic fascia with permission.)
by the transversalis fascia at the deep inguinal ring and is the innervation of the lower abdominal wall, the inguinal and genital
nermost layer. The fibers of the cremaster muscle and its investing region, the thigh and the leg, are found in the extraperitoneal
fascia are derived from the internal oblique muscle and its fascia space: the ilioinguinal, the iliohypogastric, the genitofemoral, the
on the lateral aspect of the inguinal canal: this forms the middle femoral and the lateral femoral cutaneous (Figs. 7.1,7.4A,B, 7.6,
layer. Yeager has proposed the use of the term intermediate inguinal 7.I2B, 7.I3B,C). These nerves originate from the lumbar plexus
ring to indicate the oval area from which the lower fibers of the in- (T12, Ll, L2, L3, and L4).
ternal oblique emerge to form the cremaster layer. 48 Finally, at the The iliohypogastric nerve (Figs. 7.1, 7.8) appears at the lateral mar-
external inguinal ring, the external oblique muscle fascia reflects gin of the psoas muscle and crosses the quadratus lumborum
onto the cord, forming the external spermatic fascia.9,2o,33 obliquely, passes beneath the inferior pole of the kidney to pierce
the transversus abdominis muscle, and then divides into two
branches, the most important of which is the anterior hypogastric
The Femoral Sheath and Femoral Canal branch. This branch lies between the external and the internal
oblique muscle at the level of the anterior superior iliac spine and
The femoral sheath is a tubular, funnel-shaped expansion of the en- reaches the suprapubic skin by piercing either the external oblique
doabdominal fascia that encompasses the femoral artery, femoral aponeurosis or the anterior rectus sheath. 7•20•29 It innervates the
vein, and the femoral canal in the upper thigh (Figs. 7.8, 7.16). skin of the anterior abdominal wall above the pubis (Fig. 7.12).
The lateral wall of the sheath is almost vertical, whereas the me- The ilioinguinal nerve (Figs. 7.1, 7.4, 7.5A, 7.8, 7.14B) follows a
dial wall points obliquely inferolaterally.3,29 The anterior wall of course similar to that of the iliohypogastric, but more inferiorly.
the femoral sheath is formed by the transversalis fascia and is re- It crosses the quadratus lumborum and the iliacus muscles before
inforced by the iliopubic tract. It is important to notice that the piercing the transversus abdominis just above the anterior portion
inguinal ligament is not in direct contact with the anterior surface of the iliac crest. Mter piercing the internal oblique, it runs along
of the femoral sheath, since the iliopubic tract is interposed be- the inguinal canal, over the cremasteric muscle, and finally exits
tween the two structures. 8,29 Posteriorly, reinforcement is provided through the external inguinal ring to innervate the skin of the su-
by a slip of the pectineus and iliopsoas fascia.8.21.38 The lateral wall peromedial portion of the thigh, the root of the penis, the pubic
is in contact with the iliopectineal arch and is pierced distally by region, and the scrotum or labium m,gus (Fig. 7.12).
the femoral branch of the genitofemoral nerve. 3,29 The sheath is
divided into three compartments by septa of connective tissue. The
lateral compartment is occupied by the femoral artery and the
femoral branch of the genitofemoral nerve. The femoral vein lies
in the middle compartment. The medial area is called the femoral
canal (Figs. 7.8, 7.16). It is conical and about 1.25-2 cm long, ta- iliohypogastric N.
pering to the apex at the approximate level of the fossa ovalis. 9.29 Femoral branch of
Its base is a rigid ring known as the femoral ring (or crural ring, be- genitofemoral N. - - -
tween 0.5 and 1 cm in transverse diameter) (Figs. 7.1, 7.4, 7.9). Ilioinguinal N. - - - -
According to different authors, the anterior border of the femoral Genital branch of
genitofemoral N.----
ring is either the iliopubic tract or the inguinal ligament, or
both. 3,8,9.29 Posteriorly, it is limited by the superior ramus of the ~taral femoral
cutaneous N. - - - - -
pubis, the pectineus muscle and fascia, and Cooper's ligament.
The lateral boundary is the femoral vein. The medial border has
been considered by many authors to be the lacunar ligament. 3
Recently, however, some authors have stated that the reflected
aponeurotic arch of the transversus abdominis onto the pecten
pubis,8,38 or the fan-shaped medial insertion of the iliopubic tract
onto the pubic tubercle, actually forms the medial border. 7•33 Ca-
daver dissections performed by us lead us to agree with this latter
statement.
Saphenous N. -------,r-~~~
The femoral canal is located in the most medial portion of the
femoral sheath. It is clinically important because it is the outlet for
femoral hernias. The proximal entrance to the femoral canal is the
femoral ring. It is usually closed by the septum femorale, composed
of fatty tissue. 45 The femoral canal contains some connective tis-
sue, small lymph nodes, and lymphatic vessels. A large lymph node,
known as the node of Cloquet, is commonly present inside the
femoral triangle of the thigh at the end of the femoral canal.
Innervation
Mter removal of the peritoneum covering the lower portion of the FIGURE 7.12. Areas of sensory innervation in the lower limb of interest to
posterior abdominal wall, five major nerves responsible for the in- the laparoscopic herniorrhaphist.
The genitofemoral nerve (Figs. 7.1, 7.4, 7.5A, 7.8, 7.I4B) emerges
between fibers of the psoas muscle at the level of the third or
fourth lumbar vertebra, and crosses behind the ureter to divide
into the genital and femoral branches at a variable distance from
the iliopubic tract (Fig. 7.1). The genital branch is medial, traverses
the iliac vessels to reach the internal inguinal ring, and runs along
the inguinal canal together with the spermatic cord (Figs. 7.1, 7.4,
7.5A,B, 7.7A, 7.8, 7.9, 7.10, 7.14B, 7.15 [See color insert]). The
genital branch of the genitofemoral nerve provides motor inner-
vation to the cremaster muscle and sensory innervation to the skin
of the penis and scrotum or labia (Fig. 7.12).7,10,20 The femoral
branch lies usually on the lateral edge of the psoas muscle, beneath
the psoas fascia. It is not constantly a single trunk, and may bi-
furcate before crossing the deep circumflex iliac artery to pass un-
der the iliopubic tract just lateral to the testicular vessels (Figs. 7.1,
7.4, 7.5A,B, 7.7A, 7.8, 7.9, 7.10, 7.13, 7.14B, 7.15, 7.16). In the
femoral sheath, it lies on the lateral side of the femoral artery. Af-
FIGURE 7.13. Mter an accurate surgical dissection during a laparoscopic ter piercing the anterior wall of the femoral sheath and the fascia
hernia repair, the femoral branch of the genitofemoral nerve and the lat- lata, it reaches the superior portion of the femoral triangle in the
eral femoral cutaneous nerve have been identified as they approach and thigh and supplies innervation to the femoral triangle and proxi-
pass below the iliopubic tract: IP = iliopubic tract; LC = lateral femoral
mal part of the anterior thigh. It provides sensory innervation to
cutaneous nerve; FB = femoral branch of the genitofemoral nerve. The
the anteromedial surface of the upper thigh (Fig. 7.12).
arrow indicates the enlarged deep inguinal ring, through which an indi-
rect inguinal hernia found its outlet. (See color insert.) The lateral femoral cutaneous nerve emerges from the lateral mar-
gin of the psoas muscle, deep to the peritoneum and iliac fascia,
through which it can often be seen (Figs. 7.1, 7.4, 7.5A,B, 7.7A,
7.8, 7.9, 7.10, 7.13, 7.14B, 7.15). It crosses the iliacus muscle
obliquely toward the anterior superior iliac spine. Medial to the
anterior superior iliac spine, it passes below the iliopubic tract to
reach the thigh and divides into two branches. The anterior
branch becomes superficial at a variable distance below the ante-
A B
FIGURE 7.14. (A) A = area known as the "Triangle of Doom." B = trian- retropubic vein; ES = external spermatic (cremasteric) vessels; IE = infe-
gular area where staples may cause nerve entrapment. (B) Cadaver prepa- rior epigastric vessels; VD = vas deferens; IV = external iliac vein; IA = ex-
ration (right side) that shows the structures included within the Triangle ternal iliac artery; GN = genitofemoral nerve; GB = genital branch of the
of Doom (medial triangle) and the dangerous area beside it, bordered by genitofemoral nerve; FB = femoral branch of the genitofemoral nerve;
the internal spermatic (testicular) vessels inferomedially and the iliopubic IPA = iliopectineal arch; V = ureter; IS = internal spermatic (testicular)
tract superolaterally (lateral triangle), where no staples or sutures may be vessels; DC = deep circumflex iliac vessels; IP = iliopubic tract; FN =
placed: B = bladder (reflected posteriorly); CI = common iliac artery; femoral nerve; LC = lateral femoral cutaneous nerve; IL = ilioinguinal
VA = umbilical artery; CL = Cooper's pectineal ligament; PB = anasto- nerve; PM = psoas major muscle; 1M = iliac muscle; LV = iliolumbar ves-
motic pubic branch; AP = anterior pubic branch and iliopubic vein; RP = sels. (See color insert.)
matic vessels laterallY; (Fig. 7.14A and B) . Its importance is related

to the fact that the external iliac vessels form part of its floor, usu-
ally hidden by the peritoneum and the transversalis fascia. To avoid
injury to these important structures, the common recommenda-
tion is that suturing or stapling be done only medial to the vas
deferens or lateral to the spermatic vessels. 5 In our opinion, how-
ever, this could lead to the false belief that all m,yor dangers in-
volved in laparoscopic herniorrhaphy are located in that triangular
area. As a consequence, the inexperienced laparoscopic surgeon
may acquire false confidence when placing the staples needed to
hold the prosthetic mesh in place. We believe that the borders of
the "dangerous area" should be extended and its contents thor-
oughly understood.
For laparoscopic inguinal herniorrhaphy, the iliopubic tract is
an extremely important landmark to identifY if staples are to be
safely applied. In fact, lateral to the spermatic vessels and im-
mediately below the fibers of the iliopubic tract, lie the genital
FIGURE 7.15. Mesh correctly positioned and tacked with staples to cover and femoral branches of the genitofemoral nerve, the femoral
the three weak areas corresponding to the deep inguinal ring, the inguinal nerve, and the lateral femoral cutaneous nerve. Consequently,
triangle, and the femoral ring: VD = vas deferens; IS = internal spermatic staples placed caudal to the iliopubic tract and lateral to the
(testicular) vessels; IV = external iliac vein; IA = external iliac artery; IP =
femoral vessels can result in transient or permanent neuralgias
iliopubic tract; IE = inferior epigastric vessels; RM = rectus abdominis
muscle; TM = transversus abdominis muscle; 1M = iliacus muscle; PM = involving one or more of the above mentioned nerves or
psoas major muscle; PB = anastomotic pubic branch; LS = linea semicir- branches.
cularis; IPA = iliopectineal arch; CL = Cooper's pectineal ligament; DC = Pain in the groin or lower abdomen indicates injury to the ilio-
deep circumflex iliac vessels; GN = genitofemoral nerve; GB = genital inguinal or the iliohypogastric nerve, whereas pain along the cord
branch of the genitofemoral nerve; FB = femoral branch of the gen- and scrotum occurs if the genital branch of the genitofemoral
itofemoral nerve; FN = femoral nerve; LC = lateral femoral cutaneous nerve has been damaged. 29 Injury to the iliohypogastric and ilio-
nerve; U = ureter; B = bladder (reflected posteriorly) . (See color insert.) inguinal nerves is much less frequent during laparoscopic hernia
repair than it is in conventional anterior inguinal herniorrhaphy,
rior superior iliac spine and innervates the skin of the anterior
and lateral surfaces of the upper thigh as far as the knee (Fig.
7.16). The posterior branch pierces the fascia lata at a higher level
and then runs posteriorly to reach the skin of the lateral aspect of
the thigh. The innervated area extends from the greater tro-
chanter to the midcalflevel (Fig. 7.12).
The femoral nerve is the largest nerve originating from the lum-
bar plexus (Figs. 7.1, 7.4, 7.5B, 7.7A, 7.8, 7.9, 7.14B, 7.15, 7.16 [See
color insert]). It emerges from the inferior aspect of the psoas
muscle, passes along the lateral border, and then runs between
the iliacus and pectineus muscles, covered by a layer of fascia. It
passes below the iliopubic tract, reaches the femoral triangle within
the lacuna musculorum, and finally divides into anterior and pos-
terior branches. The anterior branch originates approximately 8 cm
distal to the inguinal ligament and provides the intermediate femoral
cutaneous and the medial femoral cutaneous nerves to innervate the
skin of the lower anteromedial thigh. The saphenous nerve is the
largest sensory branch of the femoral nerve, and continues to the
leg to innervate the medial aspect of the leg and the great toe
(Fig. 7.13). The posterior branch contains the muscular branches
that provide motor innervation to the pectinus, sartorius, and FIGURE 7.16. Preparation of the femoral triangle to demonstrate the
quadriceps. femoral sheath, iliopectineal arch, and the structures included in the la-
cuna vasorum and lacuna musculorum. 10 = internal oblique muscle;
EO = cut edge of the external oblique muscle; IP = iliopubic tract; LC =
Anatomical Areas Critical in anterior branch of the lateral femoral cutaneous nerve; P = iliopsoas mus-
cle; FN = femoral nerve; PA = iliopectineal arch; FB = femoral branch of
Laparoscopic Hernia Repair the genitofemoral nerve; FS = femoral sheath; IL = inguinal ligament
(sectioned) ; FV = femoral vein; IS = internal spermatic (testicular) ves-
The term "Triangle of Doom," first introduced by Spaw, indicates sels; VD = vas deferens; ES = external spermatic (cremasteric) vessels. The
the triangular area between the vas deferens medially and sper- arrow point~ to the opening of the femoral canal. (See color insert.)
since they lie in a plane superficial to the preperitioneal space. Acknowledgment

On occasion, however, they can be compromised when staples are
deeply placed, especially if a vigorous bimanual technique is used. Figures 7.1, 7.2, 7.3, 7.4, 7.5, 7.6, 7.7, 7.8, 7.9, 7.lO, 7.12, 7.13, 7.14,
The genital branch of the genitofemoral nerve is not encountered com- 7.15 and 7.16 are reprinted from Annibali R, Fitzgibbons RJ]r.,
monly in the area in which staples are applied. It may be dam- Filipi C, et al., Laparoscopic hernia repair. In Greene FL, Ponsky
aged, however, by the maneuvers used to reduce the sac of an JL, Nealon WH, eds. Endoscopic Surgery. © 1993 WB Saunders, with
indirect hernia. In addition, it is not unusual to observe the gen- permission.
ital branch passing below the iliopubic tract in the vicinity of the
deep inguinal ring to enter the inguinal canal from below. This
anatomical variation can put the genital branch in jeopardy. The References
genital branch of the genitofemoral nerve is probably involved in
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8
Fascial Anatomy of the Inguinal Region
Jonathan D. Spitz and Maurice E. Arregui
Introduction but has in any case found this approach suboptimal because of
postmortem changes that obscure the subtle preperitoneal fascial
The overwhelming majority of all hernias in humans occur in the tissue planes, making them more difficult to follow and distin-
area of the inguinal canal and the femoral canal. Approximately guish.
750,000 inguinal hernias are repaired annually in the United
States. In the past, most were repaired by an anterior approach.
Consequently, most surgeons are familiar with the inguinal
anatomy from the anterior perspective. As laparoscopic techniques
Surface Characteristics of the
were applied to inguinal hernia repair, it became important to un- Peritoneum in the Inguinal Region
derstand the inguinal anatomy from a new and largely unfamiliar
preperitoneal perspective. The recent literature on laparoscopy The peritoneal surface of the anterior abdominal wall in the lower
describes the musculoaponeurotic, vascular, and nervous struc- abdomen has several prominent landmarks. These include the me-
tures of the inguinal area from a transabdominal or preperitoneal dian umbilical ligament which is the obliterated embryonic ura-
vantage point. However, there remains significant confusion re- chus connecting the fundus of the bladder to the umbilicus, the
garding the transversalis fascia and the multilayered preperitoneal paired medial umbilical ligaments which are the obliterated um-
fascia. The etiology of inguinal hernia involves the transversalis bilical arteries, and the paired lateral umbilical ligaments which
fascia, the peritoneum, and the preperitoneal fascia. The latter represent the prominence created by the inferior epigastric ves-
two structures are especially important in the case of congenital sels and accompanying fat (Fig. 8.1).1 Just lateral to the epigastric
indirect hernias that develop as a consequence of a patent proces- vessels is the true internal ring which is identified by the conver-
sus vaginalis. There is also a general misunderstanding regarding gence of the vas deferens and the spermatic vessels as they pene-
the presence of the posterior rectus sheath below the level of the trate the transversalis fascia. The transverse vesicular fold can be
arcuate line. seen superomedially to the internal ring and is a thickened band
The purpose of this chapter is to describe the peritoneum and of peritoneum and subperitoneal fibrosis that extends from the
its landmarks, the preperitoneal fascial layers, and the importance posterior aspect of the bladder to the lateral abdominal wall (Fig.
of the posterior rectus space and posterior rectus sheath. The fact 8.2). 2 Between the median and medial umbilical ligaments lies the
that the posterior rectus space is distinct from the true preperi- supravesical fossa in which the infrequent supravesical hernia may
toneal space is a key anatomic concept. The focus of this chapter occur. A direct hernia is located between the medial umbilical fold
will be to maintain clinical relevance for the practicing surgeon and the lateral umbilical fold or epigastric vessels. The indirect
by using photographs taken at the time of laparoscopic surgery to hernia is located lateral to the inferior epigastric vessels at the site
illustrate important aspects of the inguinal anatomy. of the internal ring. A patent processus vaginalis is often seen as
a dimpling of the peritoneum just anterior to the site of conver-
gence of the vas deferens and the spermatic vessels. Occasionally,
an indirect hernia will be identified lateral to the epigastric ves-
Inguinal Preperitoneal Anatomy sels, but medial to the internal ring. We have named this defect
an acquired indirect hernia. The etiology of an acquired indirect
The authors' appreciation of the anatomy of the preperitoneal fas- hernia is from a weakness in the lateral aspect of the transversalis
ciae and spaces is derived from extensive experience with laparo- fascia (Fig. 8.3). This is in contradistinction to a congenital indi-
scopic inguinal herniorrhaphy. During laparoscopic exploration, rect hernia that develops because of a patent processus vaginalis.
structures are magnified, and the multiple fascial planes are more The magnified laparoscopic view of the anterior abdominal wall
clearly defined than with open preperitoneal surgery. In addition offers an excellent view of the peritoneal lining, its rich blood sup-
to detailed laparoscopic dissection, we have reviewed the litera- ply, and the shallow fossae created by the embryonic ligaments
ture, including anatomic textbooks and atlases. The author mentioned above. The vasculature of the peritoneum and the vas
(M.E.A.) has limited experience with dissections in fresh cadavers, deferens is derived from the internal iliac artery, whereas the blood
86
8. Fascial Anatomy of the Inguinal Region 87
FIGURE 8.1. Laparoscopic view of the right groin in an elderly female. The FIGURE 8.3. An acquired indirect hernia. The etiology of this hernia is from
small peritoneal indentation lateral to the inferior epigastric vessels is the a weakness in the lateral transversalis fascia rather than from a congeni-
site of the internal ring where the round ligament enters the inguinal tally patent processus vaginalis. MUL = medial umbilical ligament; IE =
canal: MUL = medial umbilical ligament; OU = obliterated urachus or inferior epigastric vessels; IR = internal ring.
median umbilical ligament; IE = inferior epigastric vessels or lateral um-
bilical ligament; 1VF = transverse vesicular fold; BL = bladder; CL =
Cooper's ligament; IR = internal ring; RL = round ligament. (Reprinted superior aspect of the umbilicus. There is a condensation of trans-
from Annibali R., et al. Anatomical Considerations for Laparoscopic In- verse fibers that reinforce the umbilicus. These fibers have been
guinal Herniorrhaphy, in: Principles of Laparoscopic Surgery. New York: called the umbilical fascia.1.3 If these fibers are absent or attenu-
Springer-Verlag; 1995, with permission.) ated, then an umbilical hernia can develop.
In the lower quarter of the abdominal wall there is a point of
transition as the aponeuroses of the three flat muscles pass pri-
supply to the anterior abdominal wall originates from the inferior
marily anterior to the rectus muscle. However, this point of tran-
epigastric vessels (Fig. 8.4). This fact is important to consider when
sition is not complete. There is a continuation of the posterior
developing the preperitoneal space during a laparoscopic ex-
rectus sheath into the pelvis to the level of the pubis and Cooper's
traperitoneal hernia repair, as this is a relatively avascular plane
ligament. The point at which some of the aponeurotic fibers alter
between the posterior rectus sheath and the umbilical prevesical
their course anteriorly is the arcuate line or the linea semicircu-
fascia (Fig. 8.5).
laris. This line is clearly visible with the laparoscopic perspective.
At the inferior aspect of the umbilicus, the umbilical ligaments
It is well demarcated if the change is abrupt, while it is less de-
converge and penetrate the transversalis fascia. In an identical
fined if there is a gradual change (Fig. 8.6A and B). Externally,
manner, the falciform ligament exits the transversalis fascia at the
the linea semicircularis corresponds to a line roughly 2 cm infe-
rior to the transverse plane created by the umbilicus.
FIGURE 8.2. Laparoscopic view of the right groin in a male. There is a small
patent processus vaginalis (arrow) that marks the site of the true internal
ring: MUL = medial umbilical ligament; IE = inferior epigastric vessels or FIGURE 8.4. The rich vasculature of the peritoneum. These are branches
lateral umbilical ligament; 1VF = transverse vesicular fold; VD = vas def- of the vesical arteries originating from the internal iliac artery. A Foley
erens; SV = spermatic vessels. (Reprinted from Annibali R. , et al. Anatom- catheter is in the bladder. (Reprinted from Annibali R., et al. Anatomical
ical Considerations for Laparoscopic Inguinal Herniorrhaphy, in: Principles Considerations for Laparoscopic Inguinal Herniorrhaphy, in: Principles of
of Laparoscopic Surgery. New York: Springer-Verlag; 1995, with permission.) Laparoscopic Surgery. New York: Springer-Verlag; 1995, with permission.)
88 J.D. Spitz and M.E. Arregui
FIGURE 8.5. The blood supply to the preperitoneal fas-

cia and bladder is separate from the blood supply to
the anterior abdominal wall. The plane between the
umbilical prevesical fascia and the anterior abdomi-
nal wall is a bloodless plane. (Reprinted from Pernkapf
Anatomy, Vol. 2, 3rd ed. Fig. 263. Urban & Schwarzen-
berg; 1989, with permission.)
Preperitoneal Fasciae sheath posteriorly. By breaking through these attenuated fibers

just above Cooper's ligament we enter the preperitoneal space.
When performing a laparoscopic extraperitoneal hernia repair, Because there remains significant confusion regarding the ex-
the surgeon's aim is to develop the plane superficial to the peri- istence of the posterior rectus sheath caudal to the umbilicus, a
toneum and umbilical prevesical fascia within the true preperi- description of the rectus fascia is appropriate here. The covering
toneal space. This space is in direct communication with the space of the rectus muscle is composed of the aponeuroses of the ex-
of Retzius inferior to Cooper's ligament. 4 The posterior rectus ternal and internal oblique muscles and the transversus abdominis
space is distinct from this preperitoneal space, the two being sep- muscles. It was formerly widely held that the aponeuroses of the
arated by the posterior rectus sheath (Fig. 2.2 in Chapter 2). The abdominal wall muscles were composed of only one lamina each.
former is easily entered just below the level of the umbilicus while This lamina was thought to proceed unilaterally to the midline to
the latter is intimately fused with the peritoneum at this level. Dur- contribute to either the anterior or posterior rectus sheath. The
ing laparoscopic extraperitoneal hernia repair we initially enter midline was the end-point of the aponeuroses as there was not
the posterior rectus space. The rectus muscle and the inferior epi- thought to be significant crossing of fascial fibers at the linea alba.
gastric vessels are maintained anteriorly and the attenuated rectus Furthermore, the posterior rectus sheath was considered absent
A B
FIGURE 8.6. (A) A well-demarcated arcuate line in a thin elderly patient. M.E. Surgical Anatomy of the Preperitoneal Fascia and Posterior Trans-
(B) The transverse fibers of the posterior rectus sheath are clearly seen versalis Fasciae in the Inguinal Region, in: Hernias and Surgery of the Ab-
extending below the arcuate (semicircular) line. These fibers become dominal Wall, New York: Springer-Verlag; 1998, with permission.)
fewer and more attenuated toward the groin. (Reprinted from Arregui,
below the arcuate line. All fascial fibers were thought to pass an- Superficial to the peritoneum are areolar tissue, vasculature,
terior to the rectus muscle, contributing only to the anterior rec- umbilical ligaments, and the preperitoneal fasciae. The preperi-
tus sheath. Our current understanding of the composition of the toneal fascia in this area is called the umbilical prevesical fascia,
rectus sheath is largely the result of the work of Rizk and Askar. 5.6 (UPF) which is discrete from the posterior lamina of the trans-
These authors independently reported their anatomical observa- versalis fascia discussed later. The space between the UPF poste-
tions of the anterior abdominal wall, and in doing so changed long riorly and the posterior lamina of the rectus sheath and
held traditional concepts concerning the formation of the rectus transversalis fascia anteriorly is the preperitoneal space. The space
sheath. They depicted a bilaminar composition of the abdominal between the peritoneum and the UPF contains a typically small,
wall flat muscles with each layer contributing fibers to the con- but variable amount of adipose tissue that surrounds the median
tralateral side. According to Rizk, the linea alba should be con- umbilical ligaments, bladder, and blood supply. If this fascial layer
sidered less the insertion of the abdominal muscles, but more the is mistakenly entered medial to the medial umbilical ligament,
common area of decussation of their intermediate aponeuroses. 5 there is risk of injury to the bladder. The UPF is the investing layer
Consequently, the rectus sheath was recognized to be a trilaminar of the bladder medially and the spermatic cord laterally (Fig. 2.6
structure with decussating components from the external and in- in Chapter 2). Contained within the umbilical prevesical fascia is
ternal oblique muscles and the transversus abdominis. They de- the indirect hernia sac, if one is present. The UPF continues with
scribed a "plywood"-like arrangement of the rectus sheath. 5 the cord structures as they enter the inguinal canal, where it is
Physiologically, this plywood arrangement explains the intimate called the internal spermatic fascia (Fig. 8.7A and B). Tobin
approximation of the adjacent layers without actual fusion that pointed out that the connective tissue between the peritoneum
would interfere with free mobility of the abdominal wall. and the body wall forms a continuous lining for the abdomen,
The magnified laparoscopic view of the anterior abdominal wall pelvis, and spermatic cord. 8 This connective tissue is dissectable as
has also revealed that while the arcuate line is a point of transi- three strata: an inner stratum associated with the digestive system,
tion, it is not complete. There are transverse fibers of the poste- an intermediate stratum embedding the adrenals, urogenital sys-
rior rectus sheath that continue to the pubis and Cooper's tem, the aorta, and vena cava, and an outer stratum, which is the
ligament. Supporting this observation, Anson, Morgan and McVay intrinsic fascia of the components of the abdominal wall. 8 In the
have described the low linea semicircularis that results from the region of the kidney, the intermediate layer thickens and is known
posterior fibers of the rectus sheath. Frequently, some of the lower as Gerota's fascia. Caudally, this layer covers the spermatic vessels
aponeurotic fibers of the transversus may pass posterior to the rec- and ureters and is continuous with the connective tissue of the
tus, gaining attachment to the caudal part of the linea alba and bladder (umbilical vesical fascia) . At the level of the internal in-
to the pubis. 7 The sheath is of variable thickness, which likely ac- guinal ring, the intermediate stratum around the vas deferens and
counts for the inconsistent anatomical descriptions in the litera- the indirect hernia sac continues as the innermost layer of the
ture. In summary, the arcuate line is not an absolute point of spermatic cord, the internal spermatic fascia. The spermatic fas-
termination of the posterior rectus sheath. Rather, the posterior cia descends upon the spermatic cord or the round ligament of
rectus sheath continues in an attenuated form to Cooper's liga- the uterus in the female as they emerge from the inguinal canal.
ment. It is typically multilayered and of variable thickness. Its ex- In the male subject, this fascia descends to the lower part of the
istence below the level of the arcuate line is indisputable. testicle, completely surrounding both it and the cord.g
A B
FIGURE 8.7. (A) Preperitoneal view of the right groin. The transversalis fas- access to the indirect hernia sac if one is present, the vas deferens, and
cia (TF) forms a theoretical sling around the cord structures at the inter- the spermatic vessels. (Reprinted from Arregui M.E., DulucqJ.L., Tetik C.,
nal ring. The umbilical prevesical fascia envelops the cord structures and et al. Laparoscopic Inguinal Hernia Repair with Preperitoneal Prosthetic
continues as the internal spermatic fascia (SF). The internal spermatic fas- Replacement, in: Bendavid R. , ed. Prostheses and Abdominal Wall Hernias.
cia is distinct from the fibers of the transversalis fascia. IE = inferior epi- Austin: R.G. Landes Company; 1994.)
gastric vessels. (B) Opening the internal spermatic fascia (SF) permits
Posterior Lamina of the fascia is the source of much disagreement in spite of the fact that
Anson described it as the most effective barrier against direct her-
Transversalis Fascia niation,7 and Condon states that a groin hernia is a defect in the
transversus abdominis, the muscle covered by transversalis fascia.lO
Any attempt to clearly define the transversalis fascia based upon Cooper originally described the transversalis fascia as that struc-
descriptions in the literature will convince the reader that this ture covering the internal surface of the transversus abdominis
structure is many different things to many different people. This muscle. ll He reported that it is a bilaminar structure composed
..
_.......
-_ - ...
a·. L-...I.-oI
... _ _ • CII!Ilquo.
C'. _
FIGURE 8.8. (A) In this anatomical drawing, the layer continuous with
the posterior rectus sheath caudad to the arcuate line is labeled the
transversalis fascia. (Reprinted from Taylor A.N., ed. Atlas of Human
Anatomy. Vol. 2, 11th English ed., Fig. 105. Urban & Schwarzenberg,
1990, with permission.) (B) In this anatomical drawing, the layer con·
tinuous with the posterior rectus sheath caudad to the arcuate line
is labeled the posterior rectus sheath. (Reprinted from Pernkopf
Anatomy, Vol. 2, 3rd ed. Fig. 178, Urban & Schwarzenberg; 1989, with
permission.) Both drawings demonstrate that this fascial layer is dis·
tinct from the preperitoneal fascia covering the bladder and umbili-
B cal ligaments.
of a posterior and an anterior lamina. The inferior epigastric ves- most surgeons are unfamiliar with the fascial planes of the preperi-
sels course between these two laminae immediately after their take- toneal space from the laparoscopic perspective, the procedure has
off from the external iliac vessels. 12,13 McVay criticized various been difficult for most surgeons to perform. Consequently, there
attempts at herniorrhaphy by emphasizing the importance of the has been slow acceptance of this technique. Much of the confu-
transversalis layer stating, " ... methods of hernioplasty are still sion regarding the preperitoneal fascia, the posterior rectus fas-
used which fail to correct the defect in the transversus abdominis cia, and the transversalis fascia may stem from the erroneous
aponeurosis; or they utilize more superficial layers which are of anatomical preconception that all fibers of the rectus sheath pass
only secondary importance."14 Condon gives further significance anterior to the rectus muscle below the arcuate line. As compre-
to the transversalis fascia by describing a fascial fold around the hensive knowledge of the preperitoneal fascial anatomy becomes
internal inguinal ring. This is the so-called transversalis fascia sling more widespread, there likely will be a broader application of the
that provides the functional basis for the inguinal shutter mecha- laparoscopic preperitoneal hernia repair.
nism. 10 Theoretically, with contraction of the transversus abdom-
inis muscle as in coughing or abdominal exertion, the fascial sling
is drawn laterally. By increasing the angle of egress of the sper-
matic cord, the sphincter mechanism is thought to protect against
References
the forces of increased intra-abdominal pressure. 10,15 While the in-
1. Skandalakis]E, Gray SW, Skandalakis LJ, Colborn GL, Pemberton B.
direct inguinal hernia represents a persistence of the processus Surgical anatomy of the inguinal area. WurldJ Surg. 1989; 13:490-498.
vaginalis through the internal inguinal ring with the protrusion of 2. Arregui ME. Surgical anatomy of the preperitoneal fascia and poste-
omentum or abdominal viscus into the preformed sac, direct and rior transversalis fascia in the inguinal region. Hernia. 1997;1:101-110.
femoral hernias occur because of a weakness of the transversalis 3. Chevrel JP. Anatomie clinique. le tronc. Springer-Verlag, Paris Berlin Hei-
fascia in the region of the posterior inguinal wall. In contrast to delberg New York 1994;108-109.
the small indirect hernia, the problem here is the loss of suitably 4. Bogros JA. Essay on the surgical anatomy of the iliac region and de-
strong tissue. scription of a new procedure for the ligation of the epigastric and ex-
Certainly some of the controversy that surrounds precise defi- ternal iliac arteries. Translated by Bendavid RA. Postgrad Gen Surg.
1996;6:4-15.
nition of the posterior lamina of the transversalis fascia stems from
5. Rizk NN. A new description of the anterior abdominal wall in man
the fact that, lateral to the medial umbilical ligaments, there is
and mammals. ] Anat. 1980;131:373-385.
very little preperitoneal fat. Consequently, the peritoneum, pre- 6. Askar OM. Aponeurotic hernias. Recent observation upon paraum-
peritoneal fascia, and posterior lamina of the transversalis fascia bilical and epigastric hernias. Surg Clin North Am. 1984;64:315-333.
are fused, making their individual distinction difficult. However, 7. Anson BJ, Morgan EH, McVay CB. Surgical anatomy of the inguinal
with the improved optics and magnification afforded by the lap- region based upon a study of 500 body-halves. Surg Gynecol Obstet.
aroscope, we have seen, as mentioned earlier, that the posterior 1960;3:707-725.
rectus sheath continues in a variably attenuated fashion below the 8. Tobin CE, Benjamin JA, Wells JC. Continuity of the fasciae lining the
arcuate line. We are also able to see that the posterior rectus sheath abdomen, pelvis, and spermatic cord. Surg Gynecol Obstet. 1946;83:
is comprised of more than one layer in this caudal location infe- 575-596.
rior to the umbilicus. The multilaminar constitution of this layer 9. Morton T, Cadge W. Surgical anatomy of inguinal herniae. In: The sur-
gical anatomy of the principal regions of the human body. London: Taylor,
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Walton and Maberly; 1850.
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10. Condon RE. Surgical anatomy of the transversus abdominis and trans-
salis fascia. It has been our contention that this multilaminar fas- versalis fascia. Ann Surg. 1971;173:1-6.
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with the underlying posterior lamina of the transversalis fascia (Fig. don: Longman and Co.; 1804.
8.8A,B). Simply stated, in the inguinal area the interior lining of 12. Read RC. Cooper's posterior lamina of transversalis fascia. Surg Gynecol
the transversus abdominis muscle has fascial contributions of trans- Obstet. 1992;426-434.
versalis fascia and posterior rectus fascia. 2 13. CleiandJ, MacKay.JY, Young BJ. The relations of the aponeurosis of
the transversalis and internal oblique muscles to the deep epigastric
artery and to the inguinal canal. In: Memoirs and memuranda in anatomy,
Conclusions voL l. London: Williams and Norgate; 1889:142-145.
14. McVay CB. The normal and pathologic anatomy of the transversus ab-
dominis muscle in inguinal and femoral hernia. Surg Clin North Am.
The posterior dissection serving as the early model of the laparo- 1971;51 :6: 1251-1261.
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developing the preperitoneal space of Retzius, the surgeon could cliffe Medical Press; 1994;55-60.
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tle's approach gained little notoriety, and the preperitoneal dis- hernia. BrJ Surg. 1920;2:168.
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18. Stoppa R, Petit I, Henry X. Unsutured Dacron® prosthesis in inguinal
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9
The Ligaments of Cooper and Thomson
J.P. Richer, J.P. Faure, M. Carre tier, and Jacques Barbier
Introduction fluence of several fibrous parts: the aponeurosis of the pectineus,

and, behind, the ligament of Gimbernat, the posterior crus of the
The surgery of groin hernias can be considered in two stages: the inguinal ring . . . and lastly, the transversalis fascia reinforced by
handling of the hernial sac, which necessitates dissection, resec- the ligaments of Henle and Hesselbach .... "6-8
tion, and reduction, and the parietal reconstruction, which calls Testut, in 1911, identified elements arising from the "ad-
upon the existing anatomical structures. Prosthetic material may miniculum linea alba."9 Bardeleben, in 1912, considered the liga-
be required to bridge a defect when the dissection is completed ment of Cooper to be a thickening of the pectineal muscle fascia
and the structures identified to which a prosthesis might be reinforced by fibers from various origins: interfoveolar ligament,
anchored. falx inguinalis, Colles' ligament, as well as fibers from the con-
In man, the inferior borders of the internal oblique and trans- joined tendon, from the psoas minor, and elements from the ad-
versus muscles are far removed from the pubic ramus and its miniculum linea alba.l° The conception that the ligament of
pectineal ligament of Cooper. There exists between them an area Cooper originates as a thickening of the fascia of the pectineus
called the myopectineal orifice, covered by the transversalis fascia muscle along the bony crest of the pubis was taken up and fur-
and its reinforcements. This is a zone of relative weakness, divided ther elaborated upon by Rouviere in France in 1924.n Seelig and
by the inguinal ligament into two parts, inferior (femoral) and su- Chouke, between 1914 and 1927, displayed an interest in the sur-
perior (inguinal). On the posterior aspect of the inguinalliga- gical anatomy of this area. 12 McVay and Anson, between 1938 and
ment, the transversalis fascia consolidates inferiorly into a tract, 1950, brought together all the known facts from the United States
the iliopubic bandelette of Thomson. These substantial anatomic and Europe and confirmed that the fascia transversalis descended
structures (the pectineal ligament of Cooper, the posterior por- as far as the ligament of Cooper and the femoral vascular
tion of the inguinal ligament, the iliopubic tract of Thomson) are sheath.l3-18 Aubaniac and Fortessa, in 1952, recognized the con-
the key structures used in several herniorrhaphy procedures. tribution of fibers from the psoas minor in the constitution of this
"There cannot be any surgery of groin hernias without a close look ligament. 19 Since then, all publications, particularly those of Matt-
at the anatomy of the inguinal area."l son,20 Clark and Hashimoto,21 Donald,22 and Burton23 have un-
derlined the solid adhesion of the ligament of Cooper and its
remarkable strength. Fruchaud, in 1956, emphasized this solidity
History and the surgical interest of its morphology.1
The Pectineal Ligament

The Iliopubic Tract (Bandelette of Thomson)
In 1543, Vesalius 2 described the os coccyx, the abdominal wall and
the inguinal area. In 1561, Franco,3 in his treatise on herniae, Winslow (1732) and Gunz (1744) identified a bandelette or "strap"
shows an interest in their treatment. It is to Sir Astley Cooper that extending from the iliac crest to the pubic spine at the inguinal
we owe the first description, in 1804, of the ligament of the pu- level of the external oblique aponeurosis. Allan Bums, in 1802,
bis: "The pubis is covered by a ligamentous expansion, which forms identified this bandelette as an extension of the fascia iliaca at the
a remarkable strong ridge above the iliopectineal line, extending posterior border of the ligament of Poupart. Hesselbach (1806)
from the spine of the pubis outwards, jutting above the bone along provided the first description of the iliopubic tract as the most sub-
that line. "4,5 stantial fibers of the internal aspect of the inguinalligament. 24
This area of the groin has been particularly well studied because It is to Alex Thomson, in his thorough treatise on the anatomy
of its surgical importance, and the pectineal ligament of Cooper of the lower abdomen and hernias, that we owe the description
has been the subject of several descriptions. Its morphological sig- of this fibrous structure. Interested in the "femorovascular-funnel,"
nificance and its origin remain nevertheless quite controversial. he wrote: "The inferior border of this portion of the pectineo-
Charpy, in 1891, wrote: "The pectineal crest of the pubis is a con- femorovascular sheath is substantially beyond an inch in size and
92
9. The Ligaments of Cooper and Thomson 93
blends with the eccentric layers of the femoral vessels as far as the the thighs. The abdominal wall presents a pronounced dorsoven-
upper level of the saphenous vein. This tract is nearly parallel to tral diameter and provides a hammock for the abdominal con-
the anterior aspect of the thigh. Its fibers fan out from outside-in tents. The inguinal canal has a lengthy course within the muscles
from the midportion of the said sheath. The fibers of the ban- of the abdominal wall. The cord and the femoral vessels, small in
delette are parallel to the superior border of the anterior vascu- size, are closely wrapped by the muscular fibers of the internal
lar sheath, enlarging considerably posteriorly and superiorly to oblique and transversus abdominis, which compress them against
attach between two bundles of the ligament of Cooper on the in- the barely hollowed out anterior border of the iliac bone. The
ternal third of the crest of the pubic bone and on the lateral half pectineal crest is very short. The small ring, closed off by a resis-
of the anterior border of the superior aspect of the body of the tant fascia which joins the vascular sheath, narrows further yet dur-
pubis. This bandelette, with its own fibers of the lateral half of the ing strains or increased abdominal pressure, by the contraction of
ilio-femoral-vascular fascia, is named the iliopubic tract. "24 the muscular arch formed by the internal oblique and the trans-
versus. The aponeurosis of the external oblique is closely joined
by the femoral aponeurotic sheath. 33
The Ligaments of Cooper and Thomson in In primates, and in man especially, the erect posture is linked
to functional and morphological modifications of the pelvis. In
Hernia Surgery man, one can observe a ventral tilt, an increase in width, a lesser
height and frontalization of the pelvis, a flaring of the sacral bones
By the end of the 1800s, the iliopubic tract and pectineal ligaments simulating a funnel for the abdominal viscera, a lengthening of
were used in the surgical treatment of hernias. In 1888, Bassini the iliac crest accompanied by a widening of the iliac alae. The
proposed to suture the conjoined tendon to the iliopubic tract in anterior superior iliac spine seems to project forward and down-
the treatment of inguinal hernias. 25 .26 This technique is repeated ward, and the anterior border of the iliac bone, between the an-
by several authors throughout the world but modified by fixation terior superior iliac spine and the pubic spine, seems to shorten
not to the iliopubic tract, but to the shelving edge of the inguinal and hollow out. The muscles of the inferior limb are considerably
ligament. The ligament of Cooper was first used by Ruggi in 1892 developed: gluteus, psoas, quadriceps, and adductors. These in-
in the treatment of a femoral hernia by approximating and su- sert on the iliac bone along with the abdominal muscles. 33
turing to it the inguinalligament. 27 In 1897, Lotheissen was the With the erect position of the pelvis on the thighs, the inguinal
first to suture the conjoined tendon to the ligament of Cooper crease opens up. It becomes shallow, almost transverse, and short.
during the repair of recurrent hernia. 28 The classical and artificial On a deeper plane, the hollowed out sacral bone provides room
description of the inguinal and femoral areas as two separate en- for the well-developed psoas and the femoral vessels, the caliber
tities was abandoned by the beginning of the 20th century by mod- of which has increased to accommodate the size and function of
em authors who perceived a single anatomical and functional the inferior limb. The inferior borders of the internal oblique and
entity in this area. 1 Since then, McVay and Anson have promoted transversus are more aponeurotic and situated on a higher plane.
throughout the U.S. and Europe the technique whereby the con- The pecten of the pubis lengthens inward. Stretched vertically and
joined tendon is sutured to the ligament of Cooper for all hernias transversely, the inguinal region is therefore poorly adapted to re-
of the groin. 15.16 sist increased abdominal pressure. The wide myopectineal orifice
Laparoscopic approaches, both extraperitoneal and transperi- is sealed by connective tissue, the transversalis fascia, and its rein-
toneal, are being used with increasing frequency in abdominal forcements. This fascia courses along the inferior border of the
surgery.29-32 Structures that are normally visible from the anterior transversus to blend with the iliofemoral sheath. The aponeurosis
viewpoint, such as the inguinal ligament, pubic tubercle, and la- of the external oblique, whose inferior border inserts into the an-
cunar ligament, cannot be seen laparoscopically.29,31 Laparoscopic terior superior iliac spine and the pubic spine, does not entirely
dissection and hernia repair requires precise knowledge of the shield the myopectineal orifice and does not descend to the pu-
anatomic relationships. The surgeon is oriented by identifYing spe- bis. In man, this inguinofemoral region is weakened further
cific anatomic landmarks: the inferior epigastric vessels, the oblit- yet by the aponeurotic and tendinous nature of the muscular
erated umbilical artery, spermatic vessels, Cooper's ligament, and margins. 33,34
the iliopubic tract. 31 .32 Several phylogenetic hypotheses may be proposed for the liga-
ment of Cooper. The pectineal ligament of Cooper, through its
morphology and thickness, may playa protective role for the ves-
Comparative Anatomy sels, as it blunts the cutting edge of the bony pecten of the pubis
(this bone-vessel juxtaposition is not unique to man). The liga-
The evolution of the pelvic girdle in mammals, and more partic- ment is present in several mammals, notably quadrupeds. From
ularly in primates, yields evidence of complex anatomical and func- the phylogenetic viewpoint, it would seem that the pectinealliga-
tional factors: acquisition of an erect posture, support of ment is linked to the considerable development of the pectineus
abdominal viscera, functions of evacuation and parturition (the muscle, which plays a major role in maintaining equilibrium in
human newborn is oflarge size).1,33 the erect posture.
In quadruped domestic mammals, the pelvic girdle is narrow
transversely, but elongated in the craniocaudal direction. The il-
iac bone of these animals is formed parasagitally with its long axis Surgical Anatomy
almost parallel to the spinal cord. Its lower and ventral border is
barely rounded, and the pectineal crest barely developed. The pu- The groin, classically divided into inguinal and femoral regions,
bic symphysis, though protruding, is hidden between the roots of is in fact a single anatomical and functional entity. The modem
94 J.P. Richer et al.
anatomists, Anson,13,14 McVay,15-18 Fruchaud,l and Keith35 have

shown that the groin must be visualized in the standing position,
live and during strain. The weaker layer through which inguinal,
and also femoral, hernias emerge, is delineated above by the in-
ferior margin of the internal oblique; below, by the pecten of the
pubis with its overlying ligament of Cooper; medially by the lat-
eral border of the rectus and laterally by the psoas (Fig. 3.1). This
myopectineal opening is partially covered superficially by the
aponeurosis of the external oblique, the lower margin of which
provides the inguinal ligament. The latter is far removed from the
bony frame of the groin. Thus, the stretched aponeurotic cover
does not extend to the bony structures nor to the pectineal liga-
ment, and it is further weakened by the opening of the superfi-
cial inguinal ring. In fact, only the transversalis fascia covers the
entire myopectineal orifice, closely adhering to the posterior
margin of the inguinal ligament, and reaching inferiorly to the
ligament of Cooper and the femoral vascular sheath. 17 The trans-
versalis fascia is reinforced by additional fibers whose origin and
substance vary. Some are peripheral, such as the aponeurosis of
the transversus abdominis medially near the lateral edge of the
rectus in the form of the wing-shaped falciform ligament of Henle.
Below and deep to the inguinal ligament, recurrent fibers of the FIGURE 9.2. The myopectineal orifice as seen from inside: 1 = ligament of
external oblique aponeurosis form the lacunar ligament of Gim- Cooper; 2 = iliopubic tract (bandelette) of Thomson; 3 = ligament ofHes-
bernat. Laterally, a thickening of iliac fascia from the inguinallig- selbach; 4 = iliopectineal bandelette; 5 = epigastric vessels.
ament to the pubic bone forms the iliopectineal bandelette. Other
additions cross the transversalis fascia at its central portion. The
ligament of Hesselbach is a thickening of connective tissue along is inadequate, repair must consist of a musculoaponeurotic re-
the lateral border of the epigastric vessels. construction, making use of the most substantial anatomic struc-
The transversalis fascia is weakened by the penetration of the tures: the lower border of the internal oblique and transversus,
femoral vessels, the spermatic cord in man and the round liga- classically referred to as the conjoined tendon; the iliopubic tract,
ment in women (Fig. 3.2). Groin hernias are characterized by de- the shelving edge of the inguinal ligament; and above all, the
terioration of the transversalis fascia. Since the transversalis fascia pectineal ligament of Cooper, whose solidity has been acknowl-
edged by all.
The Pectineal Ligament of Cooper

Macroscopically, the pectineal ligament covers the pecten of the
pubis. It has a medial portion at the level of the pubic tubercle,
where the ligament of Gimbernat inserts. Its lateral portion is, how-
ever, more difficult to define as it quickly thins out to blend with
the periosteum and the iliopubic fascia that covers it. As it thins
out laterally, the loss of solidity can be felt as one palpates peri-
osteum. This point can be measured. On average, its length is be-
tween 45 and 65 mm. 32 Its thickness, astride the pecten, is between
2 and 5 mm, as measured by Fruchaud. 1 The thickness is most
pronounced between the external iliac vessels and the pubic
spine. 32 Its shape is crescentic (Fig. 3.3). McVay demonstrated that
the normal insertion of the transversalis fascia and transversus ab-
dominis was into Cooper's ligament, not Poupart's. He recom-
mended a Cooper's ligament repair for direct, large indirect, and
femoral hernias. 16
In laparoscopic repair of inguinal hernias, it is important to
identifY Cooper's ligament, palpable medial to the obliterated um-
bilical artery.31 Branches of the obturator vein may overlie the
pectineal ligament as they travel to empty into the external iliac
FIGURE 9.1. Superficial view of the myopectineal orifice: 1 = ligament of vein (Fig. 3.2). Careful pectineal dissection is required. Cooper's
Cooper; 2 = iliopectineal bandelette; 3 = inguinal ligament; 4 = fascia ligament is used to anchor the medial comer of the prosthetic
transversalis; 5 = internal oblique; 6 = rectus sheath; 7 = ligament of patch. 36 It is also used for the sutures in anti-incontinence
Henle. surgery.37,38 In a cadaver model, bone anchor placed in the pubic
Color Plate I
Remnant of
umbilical a.
Medial umbilical Linea semicircularis
ligament Rectus abdom. m.
Urachus (median Inferior epigastric
umbilical ligament) a. and v.
Testicular artery
ligament and vein
Anastomotic Falx inguinalis
pubic branches (Henle's lig.)
Medial fossa Aponeurotic arch
Superior and
Lateral fossa
inferior crura
Deep inguinal ring (transversalis
fascia sling)
Femoral canal--t-!===-_~. . . . .. ,
lIiopubic tract
Deep circumflex
iliac a. and v.
Femoral ring Iliopectineal arch
AnI. pubic branch
Pectineallig. and iliopubic vein
(Cooper's)
Vas deferens
Ex1ernal iliac Obturator foramen ,
a. and v. nerve, artery, vein
Psoas minor Femoral nerve
tendon Lateral femoral
Iliacus muscle cutaneous nerve
Ilioinguinal nerve
Iliohypogastric nerve
Genitofemoral nerve
Genital branch +
Femoral branch'
FIeURE 7.1. Drawing illustrating the anatomy of the internal surface of the lower abdominal wall, inguinal region and lower trunk. (Reprinted from
Annibali R, Fitzgibbons RJ Jr., Filipi C, et al. Laparoscopic hernia repair. In: Greene FL, Ponsky JL, Nealon WH, eds. Endoscopic Surgery. © 1993 WB
Saunders, with permission.)
Color Plate II
A
B
FIGURE 7.2. (A) View of the deep surface of the anterior abdominal wall
in a cadaver preparation, which demonstrates the peritoneal folds and fos-
sae. (B) The peritoneal fossae are better demonstrated with transillumi-
nation of the lower anterior abdominal wall: UM = umbilicus; FB =
fundus of the bladder; U = median umbilical ligament; ML = medial um-
bilical ligament; LL = lateral umbilical ligament (inferior epigastric ves-
sels); SF = supravesical fossa; MF = medial fossa; LF = lateral fossal; IS =
internal spermatic (testicular) vessels; VD = vas deferens; EI = external il-
iac vessels; A = abdominal aorta. The arrow indicates the deep inguinal
ring. (C) Exterior view of the anterior abdominal wall and inguinal region
transiIIuminated; UM = umbilicus; RM = sheath of rectus muscle; AA =
aponeurotic arch of transverses abdominis muscle; SC = spermatic cord;
IR = area corresponding to the internal inguinal ring; IE = inferior epi-
gastric vessels; LF = latral fossa; IL = inguinal ligament. Dotted outline in-
dicates the weak areas included within the inguinal triangle through which
direct hernias occur. (From Annibali R, Fitzgibbons RJ Jr., Filipi C, et al.
Laparoscopic hernia repair. In: Greene FL, Ponsky JL, Nealon WH , eds.
c Endoscopic Surgery. © 1993 WB Saunders, with permission.)
FIGURE 7.3. Peritoneal folds and fossae, as seen at laparoscopy. A direct

hernia is visible bilaterally and appears as a circular defect included be-
tween the aponeurotic arch of the transversus abdominis muscle superi-
orly and the iliopubic tract inferiorly; U = median umbilical ligament;
ML = medial umbilical ligament; LL = lateral umbilical ligament; AA =
aponeurotic arch of the transversus abdominis muscle; IP = iliopubic tract;
SF = supravesical fossa; MF = medial fossa; LF = lateral fossa; VD = vas
deferens; IS = internal spermatic (testicular) vessels; EI = external iliac
vessels; B = bladder with Foley catheter inserted. (From Annibali R,
Fitzgibbons RJ Jr. , Filipi C, et al. Laparoscopic hernia repair. In: Greene
FL, Ponsky JL, Nealon WH, eds. Endoscopic Surgery. © 1993 WB Saunders,
with permission .)
Color Plate III
FIGURE 7.4. Panoramic view of the internal surface of the anterior lower GB = genital branch of the genitofemoral nerve; FB = femoral branch of
abdominal wall, inguinal regions, lower trunk, and pelvis in a cadaver dis- the genitofemoral nerve; FN = femoral nerve; LC = lateral femoral cuta-
section: UM = umbilicus; LS = linea semicircularis; RM = rectus abdo- neous nerve; IL = ilioinguinal nerve; 1M = iliacus muscle; PM = psoas ma-
minis muscle; HT = inguinal (Hesselbach 's) triangle; IE = inferior jor muscle; IS = internal spermatic (testicular) vessels; UR = ureter; A =
epigastric vessels; AP = anterior pubic branch and iliopubic vein; TS = abdominal aorta; LV = iliolumbar vessels. Thick black arrow indicated
transversalis fascia sling; U = urachus; CL = Cooper's ligament; UA = um- deep inguinal ring; white arrow, obturator foramen; short arrow, femoral
bilical artery; AO = anomalous obturator artery; SV = superior vesical ring. (From Annibali R, Fitzgibbons RJ Jr. , Filipi C, et al. Laparoscopic her-
artery; PB = anastomotic pubic branches; IV = external iliac vein; IA = ex- nia repair. In: Greene FL, Ponsky JL, Nealon WH , eds. Endoscopic Surgery.
ternal iliac artery; VD = vas deferens; PA = iliopectineal arch; IP = iliop- © 1993 WB Saunders, with permission.)
ubic tract; DC = deep circumflex iliac vessels; GN = genitofemoral nerve;
A B
FIGURE 7.5. (A) Photograph of a cadaver preparation (right side) showing nerve; FB = femoral branch of the genitofemoral nerve; FN = femoral
the pre peritoneal space at the level of the inguinal area, after removal of nerve; LC = lateral femoral cutaneous nerve; IL = ilioinguinal nerve;
the peritoneum and preperitoneal adipose tissue (the urachus has been DC = deep circumflex iliac vessels; V = seminal vesicles; UA = umbilical
resected and the bladder retracted posteriorly). (B) Same view of (A) but artery; PB = anastomotic pubic branches; AP = anterior pubic branch and
in a different cadaver. Note the staples correctly positioned just above the accompanying iliopubic vein; RP = retropubic vein; LV = iliolumbar ves-
ilipubic tract to tack the inferior border of the mesh. The internal sper- sels; B = bladder; CI = common iliac artery; AA = aponeurotic arch of the
matic (testicular) vessels have been moved slightly laterally to better show transversus abdominis muscle; UR = ureter; 1M = iliacus muscle; PM =
the external iliac vessels on the floor of the "Triangle of Doom." RM = psoas major muscle; TF = transversalis fascia; IF = iliac fascia (reflected in
rectus abdominis muscle; IE = inferior epigastric vessels; IP = iliopubic part (B) ; TM = transversus abdominis muscle. (From Annibali R, Fitzgib-
tract; CL = Cooper's pectineal ligament; IS = internal spermatic (testicu- bons RJ Jr. , Filipi C, et al. Laparoscopic hernia repair. In: Greene FL, Pon-
lar) vessels; ES = external spermatic vessels; VD = vas deferens; IA = ex- sky JL, Nealon WH, eds. Endoscopic Surgery. © 1993 WB Saunders, with
ternal iliac artery; EI = external iliac vessels; IPA = iliopectineal arch ; permission. )
GN = genitofemoral nerve; GB = genital branch of the ge nitofemoral
Color Plate IV
FIGURE 7.6. Preperitoneal space seen laparoscopically during a hernia re- salis fascia sling; IP = iliopubic tract; AA = aponeurotic arch of the trans-
pair; PF = peritoneal flap reflected; IS = internal spermatic (testicular) versus abdominis muscle. The arrow points to the deep inguinal ring.
vessels; VD = vas deferens; CL = Cooper's pectineal ligament; ML = me- (From Annibali R, Fitzgibbons RJ Jr., Filipi C, et al. Laparoscopic hernia
dial umbilical ligament; PB = anastomotic pubic branch; PV = iliopubic repair. In: Greene FL, Ponsky JL, Nealon WH, eds. Endoscopic Surgery. ©
vein; IE = inferior epigastric vessels; SC = superior crus of the transver- 1993 WB Saunders, with permission.)
A B
FIGURE 7.7. (A) Cadaver preparation of the inguinal region. Close-up of nerve; FB = femoral branch of the genitofemoral nerve; FN = femoral
the area of the right deep inguinal ring. (B) Laparoscopic view of the left nerve; PA = iliopectineal arch; AA = aponeurotic arch of the transversus
internal inguinal ring. TS = transversalis fascia sling; SC = superior crus abdominis muscle; DC = deep circumflex iliac vessels; 1M = iliacus mus-
of the transversalis fascia sling; IC = inferior crus of the transversalis fas- cle; PB = anastomotic pubic branch. (From Annibali R, Fitzgibbons RJ Jr.,
cia sling; IS = internal spermatic (testicular) vessels; VD = vas deferens; Filipi C, et al. Laparoscopic hernia repair. In: Greene FL, Ponsky JL, Nealon
IV = external iliac vein; IA = external iliac artery; IP = iliopubic tract; WH, eds. Endoscopic Surgery. © 1993 WB Saunders, with permission.)
IE = inferior epigastric vessels; GB = genital branch of the genitofemoral
Color Plate V
PI... minor muscll - - - - - - : - - - - - - -
PIo.. rnaj .. muscle - - - - - - - - - : : : : ;
OUOdllWS IumbotlJm muscll - - - - - - : :

em,,,,,1 oblique muIdo - - -- -
In ... 1111 obI~.. muscle ------;:---.
T'&l1svt.fIUS Ibdominis mulde
moh)'poglS.1c neMI ------
lIIoinguln" neM - - - - - - -
IlIu». muscle ---------==
Genitofemoral ntNt - - - - - - - - -
1.1101,1 fem .... «I_out nerve
Inguillllligom." -----~----
r.mor .. n...... - - - - - - - - - - -
lliopec~ne" Irth -------~
r.mer.. brarch - - - - - - - - - -
Genna. brooch - - - -- - - ' "
----------::--:;l.
remor",in;
lliopubic:tt'tt --------'?. . .~.-,
r.m .... ,holln _------"11;-""""
IIlop.ou...,don - - - - - - - -
FIGURE 7.S. Anatomy of the inguinal and femoral region. (From Annibali R, Fitzgibbons RJ Jr. , Filipi C, et al. Laparoscopic hernia repair. In: Greene
FL, Ponsky JL, Nealon WH, eds. Endoscopy Surgery. © 1993 WB Saunders, with permission .)
FIGURE 7.9. The internal surface of the lo wer anterior abdominal wall pre- mination of the lower anterior abdominal wall. The urachus and the blad-
pared in a cadaver. The weak areas inside the inguinal triangles through der have been reflected posteriorly. (From Annibali R, Fitzgibbons RJ Jr.,
which direct herniations occur, and included between the aponeurotic Filipi C, e tal. Laparoscopic hernia repair. In: Greene FL, PonskyJL, Nealon
arch of the transversus abdominis muscle superiorly and Coope r's WH, eds. Endoscopic Surgery. © 1993 WB Saunders, with permission.)
pectineal ligament inferiorly, are better demonstrated here by transillu-
Color Plate VJ
FIGURE 7.10. Same preparation as Fig. 7.9. Close-up of the area of the left alous obturator artery; GB = genital branch of the genitofemoral nerve;
inguinal (Hesselbach's) triangle: RM = lateral border of the rectus abdo- FB = femoral branch of the genitofemoral nerve; LC = late ral femoral cu-
minis muscle; LS = linea semicircularis (of Douglas); IE = inferior epi- taneous nerve; TS = transversalis fascia sling; CI = common iliac artery;
gastric vessels; ES = external spermatic (cremasteric) vessels; RV = IA = external iliac artery; IV = external iliac vein; PA = iliopectineal arch;
rectusial vein; CL = Cooper's pectineal ligame nt; IP = iliopubic tract; FN = femoral nerve; PM = psoas major muscle; 1M = iliacus muscle; A =
UA = umbilical arteries; SV = superior vesical artery; HL = falx inguinal is abdominal aorta. The thick arrows point to the deep inguinal ring. The
(or Henle's ligament); AA = aponeurotic arch of the transversus abdo- thin arrow indicates the femoral ring. (From Annibali R, Fitzgibbons RJ
minis muscle; VD = vas deferens; IS = internal spermatic (testicular) ves- Jr., Filipi C, et al. Laparoscopic hernia repair. In: Greene FL, Ponsky JL,
sels; PB = anastomotic pubic branch; AP = anterior pubic branch and Nealon WH , eds. Endoscopic Surgery. © 1993 WB Saunders, with permis-
iliopublic vein; PV = iliopubic vein; RP = retropubic vein; AO = anom- sion.)
FIGURE 7.13. Mter an accurate surgical dissection during a laparoscpic her- indicates the enlarged deep inguinal ring, through which an indirect in-
nia repair, the femoral branch of the genitofemoral nerve and the lateral guinal hernia found its outlet. (From Annibali R, Fitzgibbons RJ Jr., Filipi
femoral cutaneous nerve have been identified as they approach and pass C, et al. Laparoscopic hernia repair. In: Greene FL, Ponsky JL, Nealon
below the iliopubic tract: IP = iliopubic tract; LC = lateral femoral cuta- WH, eds. Endoscopic Surgery. © 1993 WB Saunders, with permission.)
neous nerve; FB = femoral branch of the genitofemoral nerve. The arrow
Color Plate VII
A 8
FIGURE 7.14. (A) A = area known as the "Triangle of Doom." B = trian- rior epigastric vessels; VD = vas deferens; IV = external iliac vein; IA = ex-
gular area where staples may cause nerve entrapment. (B) Cadaver prepa- ternal iliac artery; GN = genitofemoral nerve; GB = genital branch of the
ration (right side) that shows the structures included within the Triangle genitofemoral nerve; FB = femoral branch of the genitofemoral nerve;
of Doom (medial triangle) and the dangerous area beside it, bordered by IPA = iliopectineal arch; V = ureter; IS = internal spermatic (testicular)
the internal spermatic (testicular) vessels inferomedially and the iliopubic vessels; DC = deep circumflex iliac vessels; 1P = iliopubic tract; FN =
tract superolaterally (lateral triangle) , where no staples or sutures may be femoral nerve; LC = lateral femoral cutaneous nerve; 1L = ilioinguinal
placed: B = bladder (reflected posteriorly); CI = common ilic artery; nerve; PM = psoas major muscle; 1M = iliac muscle; LV = iliolumbar ves-
VA = umbilical artery; C1 = Cooper's pectineal ligament; PB = anasto- sels. (From Annibali R, Fitzgibbons ~ Jr., Filipi C, et al. Laparoscopic her-
motic pubic branch; AP = anterior pubic branch and iliopubic vein; RP = nia repair. In: Greene FL, Ponsky JL, Nealon WH, eds. Endoscopic Surgery.
retropubic vein; ES = external speramtic (cremasteric) vessels; IE = infe- © 1993 WB Saunders, with permission.)
FIGURE 7.15. Mesh correctly positioned and tacked with staples to cover deep circumflex iliac vessels; GN = genitofemoral nerve; GB = genital
the three weak areas corresponding to the deep inguinal ring, the inguinal branch of the genitofemoral nerve; FB = femoral branch of the gen-
triangle, and the femoral ring; VD = vas deferens; IS = internal spermatic itofemoral nerve; FN = femoral nerve; LC = lateral femoral cutaneous
(testicular) vessels; IV = external iliac vein; IA = external iliac artery; IP = nerve; U = ureter; B = bladde r (reflected posteriorly). (From Annibali R,
iliopubic tract; IE = inferior epigastric vessels; RM = rectus abdominis Fitzgibbons ~ Jr. , Filipi C, et al. Laparoscopic hernia repair. In: Greene
muscle; TM = transversus abdom inis muscle; 1M = iliac muscle; PM = FL, Ponsky JL, Nealon WH, eds. Endoscopic Surgery. © 1993 WB Saunders,
psoas major muscle; PB = anastomotic pubic branch; LS = lin ea semicir- with permission.)
cularis; IPA = iliopectineal arch; CL = Coope r's pectineal ligament; DC =
Color Plate VIII
FIGURE 7.16. Preparation of the femoral triangle to demonstrate the cle; FN = femoral nerve; PA = iliopectineal arch; FB = femoral branch of
femoral sheath, iliopectineal arch, and the structures included in the la- the genitofemoral nerve; FS = femoral sheath; IL = inguineal ligament
cuna vasorum and lacuna musculorum . 10 = internal obi que muscle; (sectioned); FV = femoral vein; IS = internal spermatic (testicular) ves-
EO = cut edge of the external oblique muscle; IP = iliopubic tract; LC = sels; VD = vas deferens; ES = external spermatic (cremasteric) vessels. The
anterior branch of the lateral femoral cutaneous nerve; P = iliopsoas mus- arrow points of the opening of the femoral canal.
FIGURE 23.2. Color Doppler ultrasound of testis, showing a patent intra- FIGURE 23.3. Color Doppler ultrasound showing absence of circulation
testicular artery. Courtesy of R. Bendavid and P. Hamilton.) within the testicle but a pronounced flow to the scrotal skin. (Courtesy of
R. Bendavid and P. Hamilton.)
9. The Ligaments of Cooper and Thomson 95
symphysis offers no structural advantage over Cooper's ligament The Iliopubic Bandelette (Tract) of Thomson
fixation. 37 The best point to place the staples in a colposuspen-
sion seems to be at 4 cm from the medial origin ofthis ligament. 38 The iliopubic tract, by strengthening the transversalis fascia, con-
Since it was described by Cooper, the ligament's origin has been tributes to the formation of the posteroinferior wall of inguinal
controversial. In our own dissections, we have appreciated its so- canal. Poorly understood by many authors, the iliopubic tract is
lidity. We have differentiated the pectineal ligament from the in effect hidden by the inguinal ligament. That is why some au-
pectineus muscle fascia with great difficulty, from the periosteum thors, Bassini included, mistook the tract for the posterior aspect
with less difficulty, and more easily still from the lacunar ligament of the inguinal ligament. 25 ,26 But the iliopubic tract exists and is
of Gimbernat. Laterally, the pectineal ligament is independent of an important landmark in laparoscopic surgery.32,41 Clark and
all other ligamentous structures. As to the psoas minor, we have Hashimoto (1946) suggested dissecting and resecting the inguinal
not identified any connection with the pectineal ligament. ligament for better identification of the iliopubic tract. 21 This ap-
Cadaver studies were carried out on pubic bone sections every pears as an elongated band, surgically indistinguishable from
5 mm from the pubic tubercle laterally.39 Macroscopic examina- transversalis fascia. 4
tion revealed a perfect continuity between the ligament and the Certain authors have been able to observe, during anatomic dis-
periosteum posteriorly and the fascia of the pectineus anteriorly. section, easy cleavage laterally between the iliopubic tract and
Stain studies (hemalum, eosin, safran) revealed a dense collage- transversalis fascia, whereas, medially, cleavage was impossible due
nous formation arranged longitudinally and transversely, and in to its close association to the femoral vascular sheath. 24 Solid, of
some areas a fibrohyaline appearance. The vascularization is rela- an aponeurotic appearance, the iliopubic tract is narrow near its
tively substantial. A few striated muscular fibers from the pectineus midportion, but flares at its two extremities. Its medial extremity
were identified. No arcuate periosteal fibers were noted, and the blends with the transversalis fascia and the transversus aponeuro-
pectineus fascia blends without distinction into the ligament of sis near the edge of the rectus, on the pubic tubercle and the me-
Cooper.40 These anatomical and histological findings confirm the dial portion of the ligament of Cooper. The lateral extremity is
thesis of Rouviere that the ligament of Cooper is a thickening of directed toward the anterior superior iliac spine, on the deep as-
the pectineus fascia rather than thickening of the periosteumY pect of the transversus, its inferior border blending with the iliac
Fruchaud, 1 in 1956, wrote: "What is important surgically is to know fascia, leaving a small orifice only for the passage of the deep cir-
that the fibrous strands of the ligament of Cooper present two cumflex iliac vessels. In patients presenting with a weakness of this
sides: an anterosuperior side which juts from the pectineal crest, area, as noted by Burton, the iliopubic tract of Thomson is poorly
and a posteroinferior side which descends 2 mm on the upper developed and offers little support (Fig. 3.2).23 The lateral femoral
part of the posterior aspect of the pubic ramus, that is to say, within cutaneous nerve is located 1.7 cm medial to the anterior superior
the pelvic cavity." The morphology and solidity of this ligament al- iliac spine, along the iliopubic tract. 42 Nerve entrapment sequelae
lowed this writer to insert two rows of sutures, on the anterosu- have been reported and appear to be more commonly associated
peri or and posteroinferior aspects of the ligament (Fig. 3.3).I with the laparoscopic approach. 3o ,42 As it courses medially, the il-
iopublic tract forms the inferior margin of the internal spermatic
ring and the roof of the femoral canal. 31 It is an essential structure
in the laparoscopic repair of both direct and indirect inguinal her-
nia. 31 ,32 All inguinal hernia defects lie anterior to the iliopubic tract,
and femoral hernias lie posterior to the bandelette of Thomson. 31,32
In contrast to the inguinal ligament, the histological analysis of
the iliopubic tract shows a high elastin-to-collagen ratio. 32
Conclusion
Despite the protective mechanisms of the transversalis fascia and
the angled course of the inguinal canal, all groin hernias (in-
guinal and femoral) cross the myopectineal orifice through the
transversalis fascia. However, the breakdown of the fascia and the
weakness of its reinforcements do not constitute the only patho-
physiological mechanism. In addition to acquired or congenital
causes, several authors have suggested alterations in collagen me-
tabolism. 43 ,44,45 Stoppa et al. recognize an imbalance due to the
increase in intra-abdominal pressure seen in certain diseases and
the weakening of musculoaponeurotic structures seen in some
pathophysiological states. 46 Anatomical factors as well will pro-
mote the appearance of hernias, such as a high lower border of
the internal oblique and transversus as they insert into the rectus
sheath; this leaves the medial angle of the floor of the inguinal
canal unprotected. Repair of this area must include not only the
FIGURE 9.3. Pubis and pectineal ligament of Cooper: 1 = ligament of transversalis fascia, but the more substantial neighboring tissues,
Cooper: 2 = pubis; 3 = iliac ala; 4 = obturator foramen. and perhaps the addition of prosthetic material.
96 J.P. Richer et al.
References 24. Thomson A. Ouvrage complet sur l'anatomie du bas ventre et sur les hernies.
Paris: Imprimerie Lange Levy; 1838.
l. Fruchaud H. Anatomie chirurgicale des hernies de l'aine. Paris: G. Doin; 25. Bassini E. Sopra 100 casi di cura radicale dell'ernie inguinale, operata
1956. con metodo dell'autore. ltal Chir Congr. 1888. Arch Soc Med ltal. 1888;
2. Vesalius A. De humani corporis fabrica. J Oporinus Ed.; 1543. 5:315.
3. Franco P. Traite des hernies, par Pierre Franco, de Terriers-ffl-Provence de- 26. Bassini E. Uber die Behandlung des Leistenbruches. Arch Kin Chir.
meurant a present a Orange. A Lyon, par Thibault Payon; 156l. 1890;40:429.
4. Cooper A. The anatomy and surgical treatment of inguinal congenital her- 27. Ruggi G. Metodo operativo nuovo per la cura radicale dell'ernia cru-
nia. London: JT Cox; 1804. rale. Bull Sci Med. (Bologna) 1892;7(3):223.
5. Cooper A. Oeuvres completes de Sir Astley Cooper, traduites par Chassaignac 28. Lotheissen G. Zur radikaloperation der schenkelhernien. Zentralhl Chir.
et Richelot-Bechet jeune. Paris: Librairie de la Faculre de Medecine de 1898;25:548.
Paris; 1835. 29. Ger R, Mishrick A, HurwitzJ, Romero C, Oddsenn R Management of
6. Charpy A. La gaine des muscles droits et la cavite prevesicale. Rev Chir. groin hernias by laparoscopy. World] Surg. 1993;17:46-50.
1888;8:116 etEtudes d'anatomie. Toulouse: Imprimerie Cassan Fils; 189l. 30. Marks SC Jr, Gilroy AM, Page DW. The clinical anatomy of laparo-
7. Charpy A. Sur les sillons du bas-ventre et de la cuisse. Arch Med Toulouse. scopic inguinal hernia repair. Singapore MedJ 1996;37:519-52l.
1910;17:49. 31. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic
8. Charpy A. Le pli de l'aine. Arch Med Toulouse. 1910;17:337, 36l. basis.] Laparoendosc Surg. 1991;1:269-277.
9. Testut L. Traite d'Anatomie Humaine, 6th ed. Paris: G. Doin; 1911. 32. Teoh LS, Hingston G, Al-Ali S, et al. The ilio-pubic tract: an important
10. Bardeleben. Handbuch der Anat der Menshen muskeln der stammes anatomical landmark in surgery.] Anat. 1999;194:137-14l.
bearbeitet bei P. Eisler. lena; 1912 Bd 2; 64l. 33. Grasse P. Traite de zoologie. Anatomie, systematique, biologie. Tome XVI: Mam-
11. Rouviere. Anatomie Humaine, descriptive et topographique. Paris: Masson; miferes, teguments, squelette. Premier fascicule. Paris: Masson; 1967.
1924. 34. Schultz AH. The life of primates. Weidenfeld and Nicolson; 1969.
12. Seelig, Chouke. A fundamental factor in the recurrence of inguinal 35. Keith. On the origin and nature of hernia. Br] Surg. 1923-1924;11:
hernia. Arch Surg. 1923;7:553. 455.
13. Anson BJ, McVay CB. The anatomy of the inguinal and hypogastric re- 36. Felix E, Scott S, Crafton B, et al. Causes of recurrence after laparo-
gions of the abdominal wall. Anat Rec. 1938;70:211. scopic hernioplasty. A multicentric study. Surg Endosc. 1998;12:226-
14. Anson BJ, McVay CB. Inguinal hernia. The anatomy of the region. 23l.
Surg Gynecol Obstet. 1938;66:186. 37. Klutke lJ, Bullock A, Klutke CG. Comparison of anchors used in anti-
15. McVay CB. Inguinal and femoral hernioplasty: anatomic repair. Arch continence surgery. Urology. 1998;52:979-98l.
Surg. 1948;57:524. 38. Perdu M, Darai E, Goffinet F, et al. Etude anatomique du ligament de
16. McVay CB. The anatomic basis for inguinal and femoral hernioplasty. Cooper. Interet dans la cure chirurgicale de l'incontinence urinaire
Surg Gynecol Obstet. 1974;139:931-945. de la femme.] Gynecol Obstet Biol &prod. 1998;27:52-54.
17. McVay CB, Anson BJ. Fascial continuities in the abdominal, perineal 39. Rousseau MA, Perdu M, Ledroux M, et al. Ligament pectineal de
and femoral regions. Anat Rec. 1938;71:4Ol. Cooper. Etude micromorphometrique. Morphologie. 1999;83:67-69.
18. McVay CB, Anson BJ. Aponeurotic and fascial continuities in the ab- 40. Barbier J, Carretier M, Richer JP. Cooper's ligament repair: an update.
domen, pelvis and thigh. Anat Rec. 1938;76:213. World] Surg. 1989;13:499-505.
19. Aubaniac F. L'insertion inff:rieure du petit psoas. Travaux du Laboratoirer 4l. Lichtenstein IL, Amid PK, Shulman AG. The iliopubic tract: the key
d'Anatomie de la Faculte de Medecine d'Algerie (Professeur de Ribet). Algerie: to inguinal herniorrhaphy? lnt Surg. 1990;75:244-246.
Imprimerie Imbert; 1952. 42. Dibenedetto LM, Lei Q, Gilroy AM, et al. Variations in the inferior
20. Mattson. Use of the rectus sheath and superior pubic ligament in di- pelvic pathway of the lateral femoral cutaneous nerve: implications for
rect and recurrent inguinal hernia. Surgery 1946;19:498. laparoscopic hernia repair. Clin Anat. 1996;9:232-236.
2l. Clark, Hashimoto. Use of Henle's ligament, ilio-pubic tract, transver- 43. Condon RE, Carilli S. The biology and anatomy of inguinofemoral
sus abdominis aponeurosis, and Cooper's ligament in inguinal hernior- hernia. Semin Laparosc Surg. 1994;1:75-85.
rhaphy. Surg Gynecol Obstet. 1946;82:480. 44. Ponka JL. Hernias of the abdominal wall. Philadelphia: Saunders; 1980:
22. Donald. The value derived from utilizing the component parts of the 82-87.
transversalis fascia and Cooper's ligament in the repair of large indi- 45. Read RC, White HJ. Inguinal herniation 1777-1977. Am]Surg. 1978;
rect and direct inguinal hernia. Surgery 1948;14:662. 136:651-654.
23. Burton. The criteria, classification and technique of iliopectineal 46. Stoppa R, Verhaeghe P, Marrasse E. Mecanisme des hernies de l'aine.
(Cooper's) ligament hernioplasty. Surg Gynecol Obstet. 1949;89:227. ] Chir. 1987;124:124-43l.
10
The Transversalis Fascia: New Observations
Robert Bendavid
The transversalis fascia is the least understood of all the structures tendons that close the opening are those of the internal oblique
that make up the inguinal region. From the standpoint of anatomy and the transversalis [sic] muscles." The use of the word "trans-
and physiology, little is known about this tissue layer, which was versalis" for the transversus abdominis muscle appears often in the
first described and named by Astley Cooper nearly two centuries older literature: this may have been partly responsible for the con-
ago. l fusion about what "transversalis" means exactly.
Robert Condon writes: "The transversalis fascia is merely a por- Another interesting observation by Anson, McVay, and Morgan 5
tion of the continuous layer of endoabdominal fascia ... in the was the presence of "slit-like gaps between divergent bundles of
groin it tends to be a little thicker and a little stronger than else- fibers ... masses of adipose tissue frequently filled the gap ...
where in the abdominal cavity."2 Lichtenstein has written that "the herniations of adipose preperitoneal tissue passed through the
transversalis fascia bridges the space bounded by the transversus transversus layer to occupy the defects." Are we here looking at
abdominis arch superiorly and the inguinal ligament and Cooper's degenerative changes of muscle fibers with fatty infiltration, as well
ligament inferiorly."3 These descriptions certainly do not apply to as degeneration of the aponeuroses of the internal oblique and
children, young adults, females and most adults who do not have transversus abdominis?
a hernia. Through thousands of inguinal repairs, I have always One feature of the anatomy of the groin which raised my cu-
been impressed by the muscular or musculotendinous makeup of riosity and stimulated my quest for an answer was the depiction in
the posterior inguinal wall of these patients, who usually have an all illustrations of the directions of the fibers within the ligament
indirect hernia. of Gimbernat. They are shown to be vertical to the ligament of
McVay, however, describes the posterior inguinal wall as "the fu- Cooper. In the operating room, close examination reveals those
sion of the transversalis fascia to the transversus abdominis aponeu- fibers to be horizontal and parallel to the iliopectineal eminence
rosis and their insertion on the pubic ramus."4 This is not easily and the ligament of Cooper.
demonstrated in the operating room, although I have seen it on One last puzzling observation of anatomy that has not been sat-
occasion, and if the transversalis fascia is part of the endoabdom- isfactorily answered is the ultimate fate of the external oblique
inal fascia, why is it inserting on the iliopectineal ridge? unless it aponeurosis after it becomes recurved inward in the fold of the
happens to be a "thickening" at that level and then goes on to the groin, where it is then called the inguinal ligament. From the level
pelvis as the endopelvic fascia. of the femoral vessels laterally toward the anterior superior iliac
Anson, Morgan, and McVay observed that "the internal oblique spine, one can see the fibers of the external oblique aponeurosis
extended to the level of the inguinal canal in only 2% of the 500 continue in a horizontal fashion anterior to the iliac vessels. Me-
body-halves. In 75% of cases, the fleshy part covered somewhat dial to the vessels, however, the horizontal fibers continue inward
more than 75% of the inguinal area."5 Chandler and Schadewald6 over the rim of the pubic ramus to become the lacunar ligament,
presented similar findings: the internal oblique covered the in- with horizontal fibers, as can be confirmed in the operating room.
guinal area completely in only 21 % of cases, at least half of the in- This is the only possible way to clearly understand the origin and
guinal area in 46%, while in 33% of cases it failed to cover the insertion of the ligament of Gimbernat, which has never been
inguinal area at all! quite clearly explained in the groin.
It has also been my experience that not only muscular fibers of Certainly, a logical and teleological construction of the groin
the internal oblique are present through the inguinal area, but that would be approved by a structural engineer can be seen in
also an internal oblique aponeurosis which, on several occasions, Fig. 10.1, where the aponeurosis of the external oblique curves
could easily be separated from a deeper and equally substantial under the spermatic cord to join the aponeurosis of the internal
transversus abdominis aponeurosis and, deeper still, a diaphanous oblique and transversus abdominis to become the lacunar liga-
layer: the transversalis fascia proper. ment inserting on the ligament of Cooper. The transversalis fas-
When Astley Cooper demonstrated that the superficial and deep cia is simply lining the inner surface of the transversus abdominis
inguinal rings were not superimposed, he went on to say that "the aponeurosis. Peeling back the transversalis fascia (Fig. 10.2), one
97
98 R. Bendavid
FiGURE 10.1. View of the posterior inguinal wall from the

preperitoneal space. The lower border of the transversalis
fascia in fact joins the endoabdominal fascia.
In emal obhque
Transversus abdomlnls
Transversal s faSCIa
AponeurOSIS 01
ext mal oil,. ue
Deep Inguinal ring
p
ligament
' >-II ... rltv pubic ramus

FIGURE 10.2. Transversalis fascia reflected, showing, as in
most textbooks, an absent posterior inguinal wall below the
Posterior view conjoined tendon and vertical fibers to the lacunar ligament.
Transversalls faSCIa
-11-- Stpem18bC 00fd

at deep Inguinal nng
nng
FiGURE 10.3. A more accurate depiction of the posterior
inguinal wall after the transversalis fascia has been re-
flected. Note the aponeurosis of the transversus abdominis
as well as the horizontal fibers of the lacunar ligament.
10. The Transversalis Fascia 99
Skin
--l'ransversus abdomiOis
Superloal 'a5CIII-~H!fM1l~1
Round ligamenl
Of spermatic coed
~-.~--·u.~~~meM
IngUlnalllgament--II-U~;t; · r:o..--- PecIJneaIll!}8Il18f1t
~I~--I~~~~~ (Coopers)
,:-~,.---Supenor ramus
01 pubis
FIGURE 10.6. Histological appearance of the posterior inguinal wall. The

transversalis fascia is distinct, separate, and of marked cellularity. The in-
ternal oblique and transversus abdominis aponeuroses are separated by
FIGURE 10.4. Three-layered structure of the posterior inguinal wall in an
loose areolar tissue. Above, some cremaster muscle fibers. Magnification =
individual without "hernia diathesis," and therefore without degeneration
100X.
of the aponeurosis of the internal oblique and transversus abdominis mus-
cles.
sees the traditional-but inaccurate-depiction of the lacunar lig- were excised and analyzed by a histologist. 7 The results can be
ament as vertical fibers and an arch, the "transversus arch" or "con- clearly seen in Figure 10.6, Figure 10.7 and Figure 10.8. The trans-
joined tendon," which is rarely the case. A more accurate reflection versalis fascia is a distinct structure with marked cellularity com-
of the anatomy is seen in Figure 10.3, where the aponeurosis of pared to the aponeurotic layers, which show a more fibrous and
the transversus abdominis extends inferiorly and its own horizon- collagenous pattern.
tal fibers form the lacunar ligament inserting into the iliopectineal
ridge and contributing to the ligament of Cooper.
Parasagittal sections (Figs. 10.4 and 10.5) reveal how the exter-
nal oblique aponeurosis joins the combined aponeuroses of the
internal oblique and transversus abdominis. They show the rela-
tive thicknesses of the posterior inguinal wall in males and females
and underline the trilaminar nature of this wall.
It was logical to attempt proof of this macroscopic observation
with microscopic evidence. Segments of the posterior inguinal wall
---Inleirnal oblique
---'rlBl~sy,_C1S abdom
FIGURE 10.5. Three-layered and muscular appearance of the posterior in- FIGURE 10.7. Histologic appearance of the aponeuroses of internal oblique
guinal wall in children, females, and most adult males when "hernia diathe- and the transversus abdominis, cleanly separate. The transversalis fascia is
sis" is not present. markedly thinned out but still distinct. Magnification = 100X.
100 R. Bendavid
The French mathematician Fermat left us a theorem that took

more than 300 years to prove. Let us hope we will not wait that
long with Cooper's transversalis fascia.
Acknowledgment
All figures reprinted from Bendavid R, The transversalis fascia:
new realities, in Surgical Anatomy and Embryology, edited by Skan-
dalakisJE and FlamentJB. Surgical Clinics of North America, Feb-
ruary 2000. © 2000 WB Saunders Co., with permission.
References
1. Cooper A. The anatomy and surgical treatment of inguinal and congenital
FIGURE 10.8. Histological appearance at higher magnification. Again, the hernia. London: T. Bensley, Printers; 1804:5-6.
three layers are easily discerned. The transversalis fascia is strikingly sepa- 2. Condon R. The anatomy of the inguinal region and its relation to groin
rate and easily identified. Magnification = 250x. hernia. In: Nyhus LM, Condon RE, eds. Hernia, 4th ed. Philadelphia:
Lippincott; 1995:35.
3. Lichtenstein IL. Hernia repair without disability, 2nd ed. St Louis, Tokyo:
Ishaku Euroamerica, Inc; 1986:26-29.
To appreciate the anatomy and its variations in the inguinal re- 4. McVay CB. The pathologic anatomy of the more common hernias and their
anatomic repair. Springfield: Charles C. Thomas, Publisher; 1954:16.
gion, the surgeon must perform thousands of herniorrhaphies.
5. Anson Bj, Morgan EH, McVay CB. Surgical anatomy of the inguinal re-
Few surgeons have that opportunity. It is also important to ap-
gion based upon a study of 500 body-halves. Surg Gynecol Obstet.
preciate the new direction of pathology in terms of metabolic dis- 1960;III:707-725.
ease as the etiology of hernia formation. The fact that females 6. Chandler SB, Schadewald M. Studies of inguinal region; conjoined
show a lessened incidence of primary hernias, recurrent hernias, aponeurosis versus conjoined tendon. Anat Rec. 1944;89:339-343.
and incisional hernias may imply a sex-linked transmission as well 7. Bendavid R, Howarth D. The transversalis fascia: new realities. Surg Clin
in the manifestation of hernia diathesis. North Am. In press.
11
The Space of Bogros and the
Interparietoperitoneal Spaces
J. Hureau
Since Vesalius, l research in human anatomy, whether applied or applied himself to the description of what would be later called
fundamental, has had the objective of enhancing medical knowl- the "space of Bogros."
edge. Historically, surgeons have been the main petitioners for Detailing his reports of the anterior aspect of the external iliac
that knowledge. For several decades, investigators with a particu- artery, he stated, "the caecum on the right, the sigmoid on the
lar technique of morphological investigation have pressed for ac- left, as well as the peritoneum on the iliac fossa demarcate that as-
curate anatomical awareness, often in areas that coincided with pect. This segment of the peritoneum, extending from the ante-
their interests. Too often has it been said that all aspects of anatomy rior abdominal wall to the iliac fossa, defines underneath it an
have been described. Nothing is further from the truth. As soon interval of 4.5 to 6.5 mm, where the iliac artery terminates with-
as a new surgical technique appears or a new tool of morpholog- out cover by this serious layer. . . ."
ical investigation is designed, our level of understanding appears A little further on, writing on the origin of the epigastric artery,
suddenly deficient. he states: "A loose layer of cellular tissue separates it from the trans-
The human mind is such that it truly seeks only that of which versalis fascia. Behind, a thicker layer of the same tissue separates
it has an immediate need. Ambroise Pare has stated, "The arts are it from the peritoneum, shortly beyond its origin."
not so accomplished that nothing may be added."2 Moreover" ... the external iliac artery and the first segment of
the epigastric artery course through the iliac portion of the ab-
dominal wall. These vessels are so placed that they are separated
Did Bogros Describe the Space from the lower abdominal cavity by only the peritoneum and a
that Bears His Name? more or less thick cellular layer."
Further study, layer by layer, of the "anterior wall of the iliac
In 1823, the leading investigations centered on a search for sur- area" (inguinal or inguinoabdominal area), Bogros described suc-
gical approaches to arterial ligation in the limbs (Fig. 11.1) . cessively, from the superficial to deep (a surgical approach):
Wounds and aneurysms of the inferior epigastric and external il-
iac arteries, near or above the inguinal ligament, have given rise • the skin;
to three techniques, among others that were extensively discussed • the superficial fascia;
in surgical manuals of the 19th century:3 the procedures of Bogros, • the external oblique aponeurosis;
of Astley Cooper, and of Abernethy. In this era before antisepsis, • the muscular layer made up by the internal oblique and trans-
the major concern was to avoid entering the peritoneal cavity versus muscles;
where suppuration was reputed to be far less "desirable" than in • the fascia transversalis;
the inferior limbs.
and immediately behind the transversalis fascia: " . . . near the
bladder, as well as about the abdominal apertures to the inguinal
What Did Bogros Write? and femoral canals, one finds a thicker cellular layer than in the
rest of this area. The first portion of the epigastric artery, which
"Injury to the epigastric artery is, with just cause, a great fear of is found in this cellular layer, is closer to the fascia transversalis
surgeons every time an operation is performed near its course. Es- than to the peritoneum. . .. The peritoneum, which lines the ab-
pecially during debridement of inguinal and femoral hernias or dominal cavity, covering the anterior aspect of the iliac and hy-
ligation of external iliac artery . . . My aim is to put forth an ap- pogastric areas, is elevated by the umbilical arteries and the
proach for the ligation of the epigastric artery.... As the new pro- urachus, then is reflected about these fibrous cords, forming about
cedure which I propose is based on the study of the relationship them a peritoneal fold. Medially, this serous membrane (peri-
of these arteries to their neighboring structures, it is indispensable toneum) descends within the pelvic cavity and lines the walls of
that I commence by an accurate and perhaps detailed anatomical this cavity as well as many of the contained organs. Laterally, it is
description of the relative as well as the absolute site of these reflected from the iliac area of the abdominal cavity, the caecum
vessels ... "4 on the right, the sigmoid colon on the left, and forms behind the
Such was the dedication and frame of mind with which Bogros intestines, an extensive meso-iliac fold. The peritoneum, extend-
101
102 J. Hureau
the distal peritoneum can be reflected to allow an extraperitoneal

vascular ligation. One cannot deny that the advent of antisepsis
and asepsis has facilitated the opening of a peritoneum and at the
same time, took away from the interest of extraperitoneal surgery.
!;,:," The term "space of Bogros" appeared for the first time in 1912,
. ET. n';:;rr.IATP",ii,'iIt":·n·T! penned by Rouviere in his treatise of human anatomy in Poirier
\.
~.. ... '.' ,:.... '." and Charpy. 5
POtlJ\ FAlB.f! LA. Ll.~.~TUIlB DEs AllThBS EPl.,.sriiIQliiji:";
'",. Ei lL1AQUE !XTB~ic'~r An excellent description, similar to that of Bogros, is taken up
. , '.i:: ~. by Rouviere in all the subsequent editions of his treatise. 6 He
Ti/E~B' ;~8~tee. et', si>ui~lu~ iJ '1~ ;fQc~lte .d~ mid~i~~ d~' :. stated: "The peritoneum, which lines the deep aspect of the ab-
Pa,u~ Ie 29 /lOUt ~8~3~.JK!u~ d6tenir Ie 8rQJe!(fe'Doc~eur: ,:
;. tn 11ltJec;ne; " . ' . "; ", .:':; domino-inguinal wall, is reflected from the abdominal wall toward
",', .:~ the iliac fossa, creating a fold of peritoneum on the shape of a
P.. A. J. BOGRO~.
gutter concave above and behind. This fold of peritoneum is such
that, from the abdominal wall to the iliac fossa, the outer layer of
the peritoneum is in contact with the soft tissues of the iliac fossa
from 1 to 1.5 cm above the inguinal ligament. The peritoneum
thus demarcates, with a dihedral angle formed by the fascia trans-
versalis and the fascia iliaca inferiorly, a triangular, prismatic in-
terval, filled with preperitoneal adipose tissue, called the space of
Bogros" (Fig. 11.2). Testut and LataIjet7 underline the continuity
of the preperitoneal (anterior interparietoperitoneal space) tissue
layer between the peritoneum and transversalis fascia, as did Pa-
FIGURE 11.1. Reproduction of the tide page of the thesis of AJ. Bogros, turet,8 who studied the vascular and neural relationships of this
presented at the Faculty of Medicine in Paris, France, in 1823. space, and who pointed out as well that it is through the space of
Bogros that preperitoneal hernias will emerge.
ing from the iliac portion of the anterior abdominal wall to the il-
iac fossa, leaves in front a space 13.5 to 15.5 mm wide, where the
The Space of Bogros Is Part of a Whole:
external iliac artery terminates." Summarized in this last sentence The Interparietoperitoneal Spaces
is the description which Bogros gave of the interparietoperitoneal
space in the inguinoabdominal area. The recognition of the interparietoperitoneal spaces as greater
channels of diffusion is not recent. Couinaud9 has urged the re-
examination of the work of Delbet at the end of the 19th century
The Concept of the Space of Bogros on the spread of pelvic abscesses in women. He sums up the the-
ses of DrouetlO and Mathis ll on the extraperitoneal spaces. These
The concept of the space of Bogros is not readily appreciated. U n- studies, again, were born out of a need to know the precise modes
til the end of the 19th century, surgical manuals simply made men- of spread in the extra- and retroperitoneal spaces. Drouet's study
tion of the ease with which, in this suprainguinal prevascular space, was avant-garde; Mathis's work had more immediate applications
16
15
14-*&1-• •
12 -¥rrk-\1~'
FIGURE 11.2. Sagittal paramedian sections of the abdominoinguinal region. (A) Lateral to the internal inguinal ring; (B) medial to the internal ring;
(C) more medial still, through the femoral ring. (Mter Rouviere 6.) 1 = transversus abdominis; 2 = anterior parietal peritoneum; 3 = fascia transver-
salis; 4 = iliopubic bandelette; 5 = space of Bogros; 6 = iliac fascia; 7 = deep circumflex iliac vessels; 8 = psoas muscle; 9 = fascia superficialis; 10 =
superficial inguinal nodes; 11 = inguinal ligament; 12 = subcutaneous adiposocellular layer; 13 = fascia superficialis; 14 = internal oblique muscle;
15 = external oblique aponeurosis; 16 = subcutaneous fat; 17 = interfoveolar ligament; 18 = sheath of external iliac vessels; 19 = femoral vein; 20 =
vascular sheath of femoral vessels; 21 = cribriform fascia; 22 = falciform border of the cribriform fascia (ligament of Hey and Allan Burns); 23 = long
saphenous vein; 24 = spermatic cord; 25 = femoral septum; 26 = deep inguinal lymphatics; 27 = co~oined tendon; 28 = pectineus muscle; 29 =
deep inguinal lymphatic vessel; 30 = lowermost node of the middle lymphatic.
11. The Space of Bogros 103
(1959), at a time when the technique of retropneumoperito-

neography was being developed.
Not until the late 1970s and the appearance of computer to-
mography (CT) scans did we realize the inadequacies of out knowl-
edge of anatomy as revealed by this new method of medical imaging
in the normal subject as well as in retroperitoneal pathology. This
was the object of our publications at that time (1978-1981).1 2- 14
The Space of Bogros and the Posterior

Pararenal Space
The posterior pararenal space is formed by, anteriorly and medi-
ally, the posterior layer of the perirenal fascia and its lateral ex-
tension (the lateroconal portion of the fascia propria) and,
posteriorly and laterally, the fascia parietalis (Figs. 11.3 and 11.4).
The space therefore, exists only between the Spigelian line and
the lateral border of the psoas. It contains the pararenal fat pad
(Gerota), which thickens from back to front and is largest between
the posterior leaf of the perirenal fascia (the retrorenal layer of FIGURE 11.4. Left parasagittal section through the midportion of the kid-
Zuckerkandl) and the anterior aspect of the quadratus lumborum ney, pancreas, splenic angle of the colon, and descending colon. 1 = colon
covered by the parietal fascia. In regards to the diaphragm, this (splenic angle); 9 = peritoneal cavity; 12 = descending colon; 13 = iliac
crest; 14 = diaphragm; 16 = space of Bogros; 17 = anterior pararenal
space disappears with the leaf of Zuckerkandl as it mingles with
space; 18 = posterior pararenal space; 19 = anterior perirenal space;
the parietal fascia. Inferiorly, the fatty layer, which is an extension 20 = posterior perirenal space; 21 = stomach; 23 = Toldt's fascia (left);
of the pararenal fat pad, forms an anteromedial partition to a po- 26 = retropancreatic fascia (Toldt's); 27 = iliac fascia (in front of iliacus);
tential space of cleavage situated on the medial aspect of the iliac 29 = interadrenal-renal fascia; 30 = parietal fascia; 31 = perirenal fascia
fossa. The posterolateral partition of this space is represented by (anterior leaf); 32 = perirenal fascia (posterior leaf); 37 = posterior
the iliac muscle covered by a homogeneous fatty layer. It is lim- pararenal fat pad; 40 = mesocolon; 41 = mesogastrosplenic; 42 =
ited superiorly by the adhesion of the parietal fascia to the iliac mesopancreaticosplenic; 43 = iliac muscle; 44 = peritoneum; 46 = left
kidney; 48 = left adrenal; 54 = pancreas; 55 = spleen; 57 = renal fossa;
61 = quadratus lumborum; 68 = pancreatic duct (of Wirsung); 70 =
greater omentum; 73 = rest of transverse mesocolon; 75 = omental bursa
(lesser peritoneal sac).
crest, posteriorly and medially by the dihedral angle of the psoas

and iliac muscles. Inferiorly and anteriorly, at the level of the in-
nominate line of the pelvis and the iliac vessels, it is poorly de-
fined but extends to the deep recesses of the inguinal and femoral
regions. This constant space, empty of all structure, easily cleav-
able, is not bordered by any fascial structure about its walls.
This space, within the internal aspect of the iliac fossa and with-
out its own fascial layer, is an extension of the cleavage plane sit-
uated behind the posterior fatty pararenal pad of Gerota which
originates beneath the diaphragm. It projects inferiorly to blend
with the retroinguinal space described by Bogros. In the same fash-
ion, the pararenal fat pad is in continuity with the anterior preperi-
toneal fat pad which fills the space of Bogros. Through the space
of Bogros, beneath the inferior reflection of the peritoneal fold
within the lower abdominal cavity, there is continuity between the
anterior and posterior interparietoperitoneal spaces.
FIGURE 11.3. Right lateral parasagittal section through the midportion of
the kidney. Note the inferior extension of the posterior pararenal fat pad
of Gerota, the space of Bogros, and its inferior inguinal extension. 9 =
peritoneal cavity; 11 = ascending colon; 13 = iliac crest; 14 = diaphragm; The Space of Bogros and
15 = duodenum (2nd portion); 16 = space of Bogros; 17 = anterior the Retropubic Space
pararenal space; 18 = posterior pararenal space; 19 = anterior perirenal
space; 20 = posterior perirenal space; 22 = fascia of Toldt; 24 = predUG-
The studies of Mathisll under the direction ofCouinaud and con-
denopancreatic fascia; 25 = fascia of Treitz; 29 = interadrenal-renal fas-
cia; 30 = parietal fascia; 31 = perirenal fascia (anterior leaf); 32 = firmed by the research of Agossou-Voyeme15 in our department,
perirenal fascia (posterior leaf); 34 = liver; 37 = pararenal posterior fat have shown that anteriorly and inferiorly, the interparietoperi-
pad; 38 = right coronary ligament of the liver; 40 = mesocolon; 43 = il- toneal space communicates with the retropubic space (Fig. 11.5).
iac muscle; 44 = peritoneum; 45 = right kidney; 47 = right adrenal; The umbilico-prevesical aponeurosis is seen as a thickening of the
61 = quadratus lumborum; 62 = transverse colon; 63 = gall bladder. fascia propria of Cloquet (visceral fascia of Couinaud and Mathis) .
104 J. Hureau
The space of Bogros is hence in continuity with all of the neigh-

boring parieto-visceroperitoneal spaces:
• with the posterior space through the medial iliac fossa space
posteriorly and superiorly;
• with the anterior parietoperitoneal space of the abdominal wall;
• with the retropubic space near the midline;
• with all the pelvic potential spaces, as demonstrated in women
particularly, by Delbet near the end of the 19th century.
Furthermore, as pointed out by Couinaud, "In the deep inguinal
area, the space of Bogros extends anteriorly inside the spermatic
fascia in men, hence toward the scrotum, and the round ligament
in women, that is, toward the labia mcyora."9
The tunica of the spermatic cord on the parietal segment of the
round ligament of the uterus is formed by an evagination of the FIGURE 11.5. Sagittal paramedian section of the abdominoinguinal region
fascia transversalis, a thickening of the parietal fascia. All these through the lacunar ligament. 1 = superior pubic ramus; 2 = pectineal
communicate with the potential cellular spaces which belong to a ligament; 3 = lacunar ligament; 4 = spermatic cord; 5 = anterior inter-
same system of interparietoperitoneal spaces anteriorly and pos- parietoperitoneal space; 6 = peritoneum; 7 = transversalis fascia; 8 = trans-
versus abdominis; 9 = internal oblique; 10 = external oblique aponeurosis;
teriorly. This accounts for the seemingly paradoxical extension to-
11 = skin; 12 = subcutaneous adiposocellular layer; 13 = inguinal skin
ward the scrotum, the labia mcyora, and the potential spaces within
fold; 14 = pectineus muscle; 15 = internal obturator muscle; 16 = exter-
the true pelvis of pathological events, namely: nal obturator muscle; 17 = urinary bladder; 18 = space of Bogros; 19 =
• purulent or necrotizing collections of pancreatic origin; retropubic space; 20 = obturator nerve and vessel; 21 = superficial fascia.
(Mter Testut and LataIjet7.)
• pancreatico-biliary effusions;
• retroperitoneal hematomas;
• tumor extension from the abdominal wall or retroperitoneum.
The Arteries
In the normal subject, a good illustration was provided by pre-
coccygeal insufflation for a retropneumoperitoneum, a practice The external iliac artery, in its vascular sheath, courses along the
that has now been abandoned. medial border of the psoas. The external iliac vein is medial to
the artery and slightly posterior. At this level, the epigastric and
the deep circumflex iliac arteries arise (Fig. 11.6).
The Content of the Space of Bogros The inferior epigastric artery originates on the anteromedial as-
pect of the external iliac artery, between 5 and 20 mm above the
The space of Bogros is a cleavable space, devoid of any real struc- inguinal ligament. It follows a curved course with a superolateral
ture but for a scant amount of adiposocellular tissue in continu- concavity deep to the inguinal floor, circumventing the deep in-
ity above and behind with the inferior portion of the Gerota guinal ring medially. Then, in an oblique superomedial course, it
pararenal fat pad; above and in front with the thin fatty layer of penetrates the rectus muscle near the inferior border of the semi-
the anterior interparietoperitoneal space; and medially with the arcuate line. Near its origin, the inferior epigastric artery gives rise
prevesical fat. to three main branches:
Vessels, nerves, and other elements run along the walls of the
• the cremasteric artery, which takes off from the lateral concav-
space of Bogros, covered by a peritoneal reflection and separated
ity of the inferior epigastric artery, crosses the interfoveolar lig-
from it by a thin layer of adipose tissue. The importance of the
ament of Hesselbach on its posterior aspect, entering the
structures is of interest to the surgeon who is about to insert a
inguinal canal through the deep inguinal ring;
prosthesis in the peritoneal space. A large prosthetic sheet, well
• the anastomotic branch of the obturator artery originates from
splayed, occupies the deep aspect of the space of Bogros, ascend-
the convex aspect of the inferior epigastric artery, coursing
ing above and in front in the interparietoperitoneal of the in-
obliquely down to the inguinal floor, down to the inguinal lig-
guinoabdominal area, behind the inguinal floor, and extending
ament, and the free border of the lacunar ligament of Gimber-
in front of the urinary bladder to the midline in the retropubic
nat where it constitutes a real threat when dissecting free a
space, covering above and behind the external iliac vessels, the
strangulated femoral hernia. Behind the pubis, the anastomotic
separate elements of the spermatic cord in man, ascending later-
branch of the epigastric artery joins the obturator artery as the
ally to the dihedral iliopsoas angle in the direction of the iliac
latter enters the obturator foramen;
fossa, and up to the femoral nerve.
• the subpubic branch of the inferior epigastric artery courses
The "parietalization" of some of these elements, necessary to
transversely, medially on the deep aspect of the fascia transver-
the proper laying down of a prosthesis, will be that much easier,
salis, 1.5 cm above the inguinal ligament and the pubic sym-
since these structures already have a parietal course and do not
physis. Its branches terminate in the adiposocellular interpari-
cross the space of Bogros (Fig. 11.8). It is sufficient, during dis-
etoperitoneal space, hence into the retropubic space, as well as
section, to allow these elements to remain parietally placed, as is
in the pyramidalis and the rectus muscles;
the normal course for them. The femoral nerve is not included
• the internal and external terminal branches reach the rectus,
in these extraperitoneal spaces. It can only be injured by careless
pyramidalis, and the flat abdominal muscles (Fig. 11.8).
suturing of a prosthesis.
The elements down to the inguinal floor warrant particular men- The deep circumflex iliac artery arises from the lateral aspect
tion here. of the external iliac artery, less than 1 cm above the inguinal lig-
11. The Space of Bogros 105
FIGURE 11.6. Parietal arterial network at the level of the space of Bogros.
Posterior view of the inguinal floor. 1 = semiarcuate line of Douglas; 2 = FIGURE 11.7. Parietal venous channels at the level of the space of Bogros.
rectus muscle and sheath; 3 = inferior epigastric artery; 4 = interfoveolar Posterior view of the inguinal canal. 1 = semiarcuate line; 2 = rectus mus-
ligament of Hesselbach; 5 = deep circumflex iliac artery; 6 = iliopsoas cle and sheath; 3 = inferior epigastric vein; 4 = interfoveolar ligament;
muscle; 7 = femoral nerve; 8 = inguinal ligament-posterior reinforce- 5 = deep circumflex iliac veins; 6 = iliopsoas muscle; 7 = femoral nerve;
ment, the iliopubic tract; 9 = iliopectineal bandelette of Thomson; 10 = 8 = inguinal ligament and posteriorly, the iliopubic tract; 9 = iliopectineal
external iliac artery; 11 = external iliac vein; 12 = pectineal ligament of bandelette of Thomson; 10 = external iliac artery; 11 = external iliac vein;
Cooper; 13 = femoral septum; 14 = obturator artery; 15 = anastomotic 12 = pectineal ligament of Cooper; 13 = superior obturator vein; 14 =
branch (inferior epigastric to obturator); 16 = infrapubic branch of infe- anastomosis (between external iliac vein and obturator vein); 15 = infe-
rior epigastric artery; 17 = ligament of Henle; 18 = transversalis fascia; rior obturator vein; 16 = confluent obturator veins; 17 = dorsal vein of
19 = cremasteric artery; 20 = deep inguinal ring; 21 = conjoined tendon; the penis; 18 = internal pudendal vein; 19 = retropubic venous plexus;
22 = muscular branch. 20 = anastomosis (inferior epigastric vein and obturator vein); 21 = anas-
tomotic branch with the retropubic plexus; 22 = suprapubic veins;
23 = cremasteric veins; 24 = ligament of Henle; 25 = venous plexus of
ament which it accompanies to the level of the anterior superior the rectus muscle; 26 = deep inguinal ring; 27 = corUoined tendon; 28 =
iliac spine. Situated in a dihedral angle formed by the fascia iliaca muscle venous branches.
behind and the transversalis fascia in front, it courses along the
lower aspect to the space of Bogros, from medial to lateral. It pro- • a retropubic branch corresponds to the homologous arterial
vides along its way 4 to 5 ascending branches to the deep aspect branch from the epigastric artery;
of the inguinoabdominal region. • anastomosis with the retrosymphyseal network within the retro-
pubic space.
The venous network within the space of Bogros is of major con-
The Veins16,17 cern during inguinal herniorrhaphies through the anterior or
suprapubic preperitoneal approaches, and when inserting pros-
The external iliac vein ascends medially and deeply to its homolo- thetic meshes. Concern stems from the fact that these veins are
gous artery. Within the space of Bogros, it receives two veins which fragile and show stasis; they are more numerous than arteries al-
parallel the arteries: the inferior epigastric vein and the circumflex
though they are not necessarily parallel to the arteries; they ex-
iliac vein, both initially paired but joining to become a single trunk
hibit marked variations; they are richly anastomosed between
prior to entering the external iliac vein. Both of these veins receive
themselves and neighboring networks within the retropubic space
tributaries that are parallel to the smaller arteries described above.
and the rectus muscle.
There are two veins per artery, which give this parietal venous sys-
Although parietal in position, these veins are often described
tem a plexiform aspect, particularly when the anastomoses are ob-
within the thickness of the transversalis fascia and receive numer-
served and especially with the simple or paired voluminous
ous branches from fat pads, especially in the retropubic space.
anastomoses between the obturator and deep epigastric veins (see
They can be cut or tom during cleavage of these interpari-
Fig. 11.7). These anastomoses are parallel to the corresponding ar-
etoperitoneal spaces, even as they seem empty. This underlines the
terial anastomosis, a branch of the inferior epigastric artery.
necessity of careful dissection and hemostasis when preparing the
It must be remembered that the obturator vein often bifurcates
site for prosthesis implant.
into a superior and an inferior branch, each of which has no ar-
terial equivalent. They themselves remain distal from the space of
Bogros. Some of these branches, however, represent the distal pari- The Lymphatics 18
etal terminals of the external iliac vein:
To be identified in the lower part of the space ofBogros (Fig. 11.8)
• a vertical anastomosis situated behind the pubic ramus connects
are the following lymphatic nodes:
the superior obturator vein to the external iliac vein. It is often
parallel to the anastomosis which joins the obturator vein to the • the lowermost node of the external iliac lateral chain of nodes.
deep inferior epigastric vein; It is situated on the anterior aspect of the artery, immediately
106 J. Hureau
internal iliac fossa, in front of the external iliac vessels, between

the urinary bladder and the deep aspect of the space of Bogros
along the line leading from the internal iliac fossa to the deep in-
guinal ring. None of the above structures cross the space of Bogros
(see Fig. 11.8).
Conclusion
The space of Bogros is but a widening of the interparietoperitoneal
space in the dihedral angle between the wall of the internal iliac
fossa and the deep aspect of the inguinoabdominal wall, above the
inguinal ligament, and below the peritoneal reflection.
It is a crossroad that joins the posterior pararenal space, the an-
terior interparietoperitoneal space, the retropubic space, the ex-
traperitoneal pelvic spaces and goes through the inguinal canal,
the cellular and potential spaces of the scrotum or labia majora.
The space of Bogros is empty and cleavable. It is situated in a
zone of transition between the lower limit of the abdomen and
the upper thigh, a vulnerable area of the human body. Man, a
biped with a soft abdomen, walks erect, and as such, exposes the
FIGURE 11.8. The space of Bogros (right side). 1 = anterior parietal peri- neurovascular axes of his lower limbs, making for a fragile ab-
toneum; 2 = deep inguinal ring; 3 = cremasteric artery; 4 = testicular ves- dominal wall. This is the source of a genuine "pathology of the
sels; 5 = inferior node (lateral chain, external iliac); 6 = deep circumflex erect position" in which groin hernias have achieved preeminence.
iliac artery; 7 = genitofemoral nerve; 8 = external iliac artery; 9 = exter-
nal iliac vein; 10 = parietal peritoneum in internal iliac fossa; 11 = vas
deferens and deferens artery; 12 = inferior node (middle chain-external References
iliac); 13 = inferior node (medial chain-external iliac); 14 = node of
I. Vesalius A. De humani ecrrparis fabriea. Basel: J. Oporinus Edit; 1543.
Cloquet; the uppermost deep inguinal node; 15 = inguinal ligament;
2. Pare A. Les oeuvres d 'Ambroise Pare, eonseiller et premier ehirurgien du Roy.
16 = suprapubic vessels; 17 = transversalis fascia; 18 = inferior epigastric
Paris: Gabriel Buon, Edit.; 1585.
vessels; 19 = interfoveolar ligament; 20 = vessels to rectus and pyrami-
3. Chassaignac E. Traite clinique et pratique des operations ehirurgieales ou
dalis; 21 = vessels to flat muscles of the abdomen; 22 = ascending branch
traite de tooapeutique ehirurgical. Paris: Victor Masson et Fil; 1861.
of the deep inferior epigastric artery. (Mter Lambert, in Paturet. 8 )
4. Bogros AJ. Essais sur I'anatomie chirurgicale de la region iliaque et
description d'un nouveau procede pour faire la ligature des arteres
epigastriques et iIiaque externe. These Mid, Paris. W 153,29 Aout 1823.
above the inguinal ligament, near the origin of the inferior epi-
Paris: Didot Ie jeune Edit.; 1823.
gastric and the deep circumflex iliac arteries; 5. Poirier P, Charpy A. Traite d'Anatomie Humaine. Vol. 2, Fasc. I. Paris:
• the lowermost node of the external iliac middle chain of nodes. Masson Edit.; 1912.
It is often absent; 6. Rouviere H, Delmas A. A natomie humaine descriptive, topographique et fone-
• the lowermost node of the external iliac medial chain of nodes. tionnelle. Vol. 2. Paris: Masson et Cie, Edit.; 1974.
It must not be confused with the lymph node of Cloquet, the 7. Testut L, Latarjet A. Traite d'Anatomie Humaine, Vol. I. Paris: G. Doin
uppermost node of the deep inguinal chain of lymph nodes et Cie, Edit.; 1948.
found at the upper end of the femoral canal, between the 8. Paturet G. Traite d'Anatomie Humaine. Vol. I. Paris: Masson et Cie Edit.;
femoral vein laterally and the lacunar ligament of Gimbernat 1951.
9. Couinaud C. Anatomie de l'abdomen. Paris: G. Doin et Cie, Edit.; 1963.
medially. This node of Cloquet may show its upper pole at the
10. Drouet T. Le tissu sous-peritoneal. Montpellier: These Medecine; 1941.
very medial portion of the space of Bogros, through the femoral
II. Mathis C. Le retroperitoine, essai anatomo-c1inique. Paris: These
septum which it displaces. Medecine; 1959.
All the lymphatic chains are parietally situated with respect to 12. Hureauj, Agossou-Voyeme AI(, Germain M, PradelJ. Les espaces in-
terparieto-peritoneaux posterieurs ou les espaces retroperitoneaux:
the space of Bogros.
anatomie topographique normal. ] Radiol. (Paris) 1991;72:101-116.
13. Hureau j, Pradel j, Agossou-Voyeme AI(, Germain M. Les espaces in-
Other Parietal Elements of the terparieto-peritoneaux posterieurs ou les espaces retroperitoneaux:
anatomie tomodensitometrique pathologique. ] Radiol. (Paris) 1991;
Space of Bogros 72:205-227.
14. Hureau j, Pradel J. Tomodensitometrie du trone-anatomie normale et
Nerves pathologique. Padova: Piccin Edit.; 1988; 342.
15. Agossou-Voyeme AK. Les espaces interparietoperitoneaux. Etude
The femoral nerve is far laterally situated, deep to the iliac fascia topographique. Donnes anatomotomodensitometriques. Memoire de
DERBH (3rd cycle). Universite Rene-Descartes, Paris.
in front of the psoas muscle. The genitofemoral nerve descends
16. Bendavid R. The space of Bogros and the deep inguinal venous cir-
in front of the psoas muscle within a split of the iliac fascia, and
culation. Surg Gyneeol Obstet. 1992;174:355-358.
bifurcates into a femoral branch which accompanies the external 17. Farabeuf LH. Les vaisseaux sanguins des organes genitourinaires de pCrinee
iliac artery and a genital branch which enters the inguinal canal et du pelvis. Paris: Masson et Cie, Edit.; 1904.
behind the spermatic cord or the round ligament of the uterus. 18. Rouviere H. Anatomie des lymphatiques de l'homme. Paris: Masson et Cie,
The vas deferens and its vascular pedicle can be parietalized at the Edit.; 1932.
Part III
Epidemiology
12
Epidemiology of Inguinal Hernia:
A Useful Aid for Adequate Surgical Decisions
Alejandro Weber, Denzil Garteiz, and Salvador Valencia
Hernias of the abdominal wall constitute an important public recently published article by Rutkow, which compiles the infor-
health problem and often pose a surgical dilemma even for the mation of large series from the National Hospital Discharge Sur-
most skilled surgeon. l In most countries, hernioplasty and chole- vey (NHDS) and the National Survey of Ambulatory Surgery
cystectomy are the most common forms of elective surgery. In the (NSAS).2
United States alone, between 500,000 and 750,000 patients are op- As in other diseases, the study of the different statistical aspects
erated on for inguinal hernia each year. 2 Yet, in spite of its great of inguinal herniation can be crucial to understanding of such
incidence, precise epidemiological data about inguinal hernia are matters as the magnitude of the problem and its socioeconomic
difficult to obtain. implications, the significance of risk factors, and the treatment ap-
Collection of reliable statistical information depends upon im- proach with the best chance of success in each individual case. A
plementation of appropriate methodology, the clarification of am- clear perception of the different epidemiological aspects of in-
biguities of terminology and other areas of uncertainty, widespread guinal hernia, such as frequency, age, and sex distribution, clini-
agreement on consistent classification practices, and so on. Table cal presentation (unilateral, bilateral, or multiple), occurrence of
12.1 gives examples of factors influencing the reliability of statis- recurrent or complicated hernias, hereditary patterns, and pre-
tics on inguinal hernia. A practical example of these difficulties disposing factors, makes us reflect that a hernia is much more than
appears in the figures of the National Center for Health Statistics a "rupture" to be sutured or patched.
of the United States (NCHS), which compiles data on the surgery For a clear understanding of the epidemiology of inguinal her-
carried out annually in that country. In 1979, this study registered nia, the terms "incidence" and "prevalence" should be defined.
421,000 inguinal hernia repairs, and in 1991 only 143,000. 3 This Incidence is the rate of occurrence of new cases of hernia in the
large difference is explained by the exclusion of outpatient pro- population studied, often expressed as number of cases per thou-
cedures. Another important bias factor is purely medical: a sig- sand per year; prevalence is the total number of persons affected by
nificant percentage of patients with hernias are asymptomatic, or hernia at any given time, expressed as a percentage of the popu-
a hernia may go undetected by the physician. Physical examina- lation studied.
tion, even when performed by experienced surgeons, has a diag-
nostic certainty of only 69% in differentiating between direct and
indirect hernias. 4 In addition, the investigation may be compli-
Epidemiological Aspects
cated by the sheer variety of inguinal hernias (indirect, direct, pan- of Inguinal Hernia
taloon, multiple, and so on) and conditions with which they can
be confused. Inguinal hernia is the most frequent of all abdominal wall hernias.
Although there are many thousands of publications about in- Its prevalence is difficult to establish, however, because it depends
guinal hernia, only a few focus on the epidemiological aspects of upon the age group and sex distribution of the general popula-
this entity. Among the earliest of these studies are those by Arnaud tion. One of the most complete statistical analyses was made by la-
in the pre-Bassini era (1748), who reported that one-eighth of the son in 1941 in New York, showing an estimated prevalence of
population under 30 years of age was "ruptured." One hundred 4.6%.6 In 1979, three-fourths of the abdominal wall hernias oper-
years later, Malgaigne was the first to use mathematical reasoning ated on in the United States were inguinal. From a total of 686,000
to estimate a total rate of prevalence for inguinal hernia of3.2%.5 hernias operated on, 500,000 were inguinal (73%), 65,000 um-
Contrary to what one would expect, there are relatively few reli- bilical (9.5%), 43,000 incisional (6.2%), 19,000 femoral (2.7%),
able modem epidemiologic studies concerning the percentage of and 59,000 were other types of hernias (8.6%).3 Rutkow's most re-
the general population affected and the total number of patients cent review combined the results of the two most important cen-
who have had surgical hernia repairs. For this reason, the true in- ters of health data concentration in the United States in 1996. He
cidence and prevalence of inguinal hernias has not yet been de- found approximately the same proportions: inguinal hernia
termined. However, there are surgeons and investigators who 65.6%, umbilical 15.6%, incisional 9.1 %, femoral 2.3%, and the
recognize the importance of epidemiologic data about hernia. Per- remaining 7.1 % were other hernias (Spigelian, epigastric, and so
haps one of the most complete and reliable studies to date is the on).2 An interesting consideration is that in the near future, we
109
110 A. Weber et al.
TABLE 12.1. Factors influencing the reliability of statistics on inguinal hernia

Data recollection methods Lack of diagnostic certainty
Insurance company survey vs. review of medical Lack of examiner experience

records
Surgical records of inpatient vs. outpatient hospitals Clinically undetected inguinal hernia
Lack of international hernia classification Inguinal hernia vs. inguinal mass
Patient questionnaire vs. physical examination Indirect vs. direct inguinal hernia
Different names for the same thing (hernioplasty, Inguinal hernia vs. femoral hernia
herniorrhaphy, inguinal hernia repair)
Different eponymic terms for surgery Unexplainable chronic inguinal pain
may see a reduction in incisional hernias due to the advent oflap- Age Distribution
aroscopic surgery. This may, however, lead to a new class of her-
nias when trocar site hernias are included as an epidemiological Inguinal hernia in children is generally treated more promptly
category. than in adults. Children are regularly examined by pediatricians,
who recognize and detect the problem earlier and guide the par-
ents to take the child to surgery to avoid complications. Parents,
Sex Distribution in tum, take their affected child to the surgeon as soon as possi-
ble, as they usually take care of their children's health and well-
It is a very well-known fact that the male population is more com- being very conscientiously; adults would do well to pay similar
monly affected with inguinal hernias than the female, but the true attention to their own health.
proportion is still unknown. The first statistical report about the The overall incidence of inguinal hernia in children less than
distribution of inguinal hernia in the general population accord- 18 years old has been reported in ranges from 0.8% to 4.4%.1l It
ing to sex was done by Malgaigne in 1841. 5 He considered that is believed that the origin of indirect inguinal hernia is related to
while 7.7% of men had inguinal hernia, only 1.9% of women were the presence of a patent processus vaginalis (PPV). According to
affected, a frequency almost 4 times greater in men. Recently, el- some authors, PPV exists in approximately 80% of the newborn
Qaderi in Jordan reported a difference twice that of Malgaigne, children, but there is evidence that not all indirect inguinal her-
stating that men are affected 8.2 times more than women. 7 Other nias develop from a ppV.I2
reports, such as that by Wantz, registered a difference of up to 25 The mechanism and the timing of the obliteration of the proces-
times greater. s It is interesting to observe the variations in sex dis- sus vaginalis is not known exactly, but it has been determined that
tribution of primary inguinal hernia reported by large and small 40% are obliterated in the first months of life and another 20%
series throughout time (Table 12.2). The large differences among by the second year. The rest of the children will have a patent
these series, with respect to the male-to-female ratio, probably processus vaginalis for the rest of their lives. I3 Despite this high
reflect the difference in the number of patients, as well as the var- incidence, only 15 to 20% of them will develop an inguinal her-
ious racial, genetic, nutritional, and other differences in the pop- nia.I 4 When the hernia is associated with a PPV, it usually is uni-
ulations studied. lateral and indirect. It is more frequent in boys than in girls, due
Primatesta and colleagues from the Department of Public to the testicular migration from the abdomen to the scrotum dur-
Health and Primary Care of Oxford University reviewed more than ing the fetal period. In boys, right-sided hernia is more common
30,000 operated hernias and estimated that the lifetime risk for because the left testicle reaches the scrotum first, and the left
requiring an inguinal hernia repair in men was 27%, while for processus vaginalis obliterates earlier.
women it was only 3%, a 9 to 1 proportion. 9 These lower figures, In neonatal intensive care units, a high incidence of inguinal
when comparing the operated cases to the reported prevalence of hernia has been noted, especially in premature infants. In a re-
hernia between men and women (9:1 compared to 19:1), may review of more than 1,000 low birth weight survivors, it was found
flect the fact that that in some countries women are operated on that 17% of males and 2% of females had hernias, giving a total
more expeditiously than men. Ponka,1O on the other hand, car- cumulative prevalence of 9.2%. Added to the high frequency of
ried out a study which compared the distribution of the several PPV in these patients, it has been found that low birth weight,
types of inguinal and femoral hernia according to sex, and con- male sex, neonatal intravenous feeding and other factors that in-
cluded that for indirect inguinal hernias the frequency in men is crease abdominal pressure contribute to this high herniation
almost double, while for direct hernias this relationship is 13 times rate. 15
greater. In the case of femoral hernia, the frequency is almost four
times greater in women that in men (Table 12.3).
TABLE 12.3. Distribution of inguinal hernia according to sex and type
Type of hernia Male Female Ratio
TABLE 12.2. Distribution of inguinal hernia according to sex
Number of Indirect 54% 33% 1.6:1
Year Series patients Male Female Ratio Direct 27% 2% 13.5:1
Combined 8% 3% 2.6:1
1910 Coley 70,090 75.7% 24.3% 3:1 Femoral 3% 11% 1:3.6
1993 Shouldice 29,313 95.5% 4.5% 19:1
1998 Rutkow 2,861 95% 5% 19:1 Source: Ponka,]L. Hernias of the Abdominal Wall. Philadelphia: WB. Saun-
ders; 1980, p. 84.
12. Epidemiology of Inguinal Hernia 111
TABLE 12.4. Bilateral hernia reported in different studies
Number of % of
Author hernias Method bilaterality
Ekberg (25) 313 Herniography 20-29%

Abramson (17) 459 Open surgery 6.2%
Weber (unpublished) 259 Open surgery 22%
el-Qaderi (7) 1722 Open surgery 5%
Akin (16) 27,408 Open surgery 6.2%
Rutkow (2) 696,000 Open surgery 25.2%
Weber (26) 313 Laparoscopic surgery 36%
Phillips (28) 379 Laparoscopic surgery 64%
McKernan (27) 296 Laparoscopic surgery 36%
The frequency of inguinal hernia in the young male population only 7%.22 This risk may be increased in patients with other con-
has been the easiest to record because most studies are conducted genital anomalies or collagen diseases like Marfan's or Ehlers-Dan-
in military and other closed group populations, where explo- los syndrome,23 and in children whose mothers smoked more than
rations can be performed on a regular basis by the same medical 20 cigarettes daily during pregnancy.24
staff.I 6 For example, in Turkey, an epidemiological study of 27,408 EI-Qaderi found only 5% bilaterality in 1,722 patients of all ages,
healthy men from a military academy, ranging from 20 to 22 years which correlates with the report of 27,408 healthy young men be-
of age, revealed that 3.2% had inguinal hernia. About ftfty-four tween 20 to 22 years that was carried out in Istanbul. Of those
percent of these were right-sided, 39.7% on the left side and 6.2% men, the incidence of bilaterality was 6.2%.7
bilateral. 16 This correlates with the previous observations of in- Herniography has been very useful in detecting bilateral or mul-
guinal hernia during childhood. tiple hernias, especially in cases with chronic inguinal pain and
Abramson determined that the current prevalence rate in men without palpable mass. With herniography, the presence of uni-
over 25 years in a community of Jerusalem, excluding those op- lateral hernia has been reported from 18 to 28%, multiple ipsi-
erated upon, was 18%, but when he included those who had had lateral hernias from 6.9 to 7.2% and bilateral hernias from 20 to
surgery, the lifetime prevalence rate went up to 24% (much 29%, much larger ftgures than those reported from clinical ex-
higher than the previously reported prevalence in other studies). aminations on the asymptomatic population. 25 In a retrospective
In this study, the prevalence rate of inguinal hernia increased study carried out in a Mexican general hospital, we found that, in
markedly with age. In the group of 65-74 year oIds, it was 40%, a total of 259 open inguinal repairs in adults, 22% had obvious bi-
while in the group aged over 75 years, the ftgure reached 47%. lateral hernias.
Because of these ftndings, he reasoned that if men lived long Until the advent of laparoscopic surgery, bilaterality of inguinal
enough, one-third to one-half of them would eventually develop hernia in adults was not considered as important as in children.
a herniaP In a case when only one side with hernia was clinically evident, a
Consistent with the previous ftndings, when considering the per- contralateral exploration was not even considered. The existence
centage of patients who undergo a hernioplasty, the frequency also of a bilateral hernia was underestimated by the surgeon, and the
increases with age. For instance, out of the total repairs performed patient would most probably refuse the procedure. Laparoscopic
in the U.S. in 1996, 18% were on patients under 15, 29% in the observations of the inguinal region have begun to prove that bi-
15-44 group, 23% in the 45-64 group and 30% in the over 65 lateral hernia is more frequent than previously suspected. Routine
group.2 exploration of the inguinal region during procedures such as
cholecystectomy or antireflux surgery sometimes reveals previously
unsuspected bilateral defects. In addition, during the repair of a
Bilateral Inguinal Hernia clinically evident unilateral hernia, a contralateral asymptomatic
and clinically undetectable defect can be diagnosed. In a report
The ongoing controversy among pediatric surgeons regarding the of more than 300 patients treated by laparoscopy, 13% presented
convenience of exploring both inguinal regions in a boy with a with multiple hernia and 36% with bilateral hernia. Among these,
hernia has encouraged the study of the incidence of bilaterality 60% had indirect bilateral hernia, 23% direct bilateral hernia, and
in congenital inguinal hernia in recent years. The percentage of 17% combined defects. 26 Other authors in large multicentric stud-
bilaterality in male infants is 15%,18 with a higher proportion in ies as Tetik,27 Phillips,28 and Woodward29 have found percentages
female infants, but it may be as high as 40% in premature babies. 19 that go from 20 to 40% bilaterality (Table 12.4).
Usually, pediatric surgeons perform contralateral inguinal explcr
ration when a left inguinal hernia is detected because the chance
of ftnding a coexisting, though asymptomatic, hernia on the right Complex Inguinal Hernia
side can be up to 60%.20 Laparoscopic studies in the pediatric pop-
ulation have detected a contralateral PPV in 27% of the cases,21 It is important that surgeons acknowledge that although the most
but the incidence of children who have undergone a contralateral common ftnding in a patient with hernia is the presence of a sin-
repair in a subsequent surgery has been reported to range from gle defect, there are certain conditions which should arouse sus-
4 to 34%. picion the case may be more complex, either because of the
In a recent meta-analysis, Miltenburg reported that the risk of presence of a bilateral or multiple hernias, or because the recur-
developing a metachronous hernia in patients under 18 years is rence risk is greater.
112 A. Weber et aI.
Felix, in his 1,000 patient laparoscopic surgery series, reported ation to offer a patient with a recurrent or repeatedly recurrent
that 14% of the primary hernias and 27% of the recurrent cases inguinal hernia, to minimize the risk of yet another recurrence.
had a pantaloon defect. 30 In addition, 11 % of the patients had a
femoral defect, a surprisingly high incidence, compared to open
surgery controls. 31- 35 For this reason, he referred to these as com- Risk of an Emergency and Complications
plex defects, concluding that the laparoscopic approach to the
posterior inguinal wall was responsible for the more objective eval- Inguinal hernia repair is most commonly performed on an elec-
uation. We also have found multiple defects in 17% of our lap- tive basis, and the morbidity and mortality rates of the procedure
aroscopic hernia repairs. One of them had bilateral pantaloon and are usually very low. The same is not true for herniorrhaphy per-
femoral defects combined with umbilical and epigastric hernias, formed as an emergency procedure, when it is associated with
which obviously cannot be considered a coincidence. In these pa- strangulation or intestinal obstruction, especially in the elderly, in
tients with multiple defects, the surgeon must make a special ef- whom these emergency procedures are more frequent. Strangu-
fort to treat all possible sites of herniation. lation occurs in 1.3 to 3% of groin hernias. s It has been reported
Expanding Felix's definition, we speak of complex hernias when that while the mortality rate for elective surgery is less than one
one or more of the following conditions are present: family his- death per 10,000 operations, for emergency surgery the figure may
tory of bilateral hernia, recurrent familial hernia, bilateral or re- rise to 5%.40 It is thus important for the surgeon to recognize the
current hernia in the patient himself, or multiple defects. In these risk factors associated with these complications so that prompt sur-
cases, special consideration must be given to the use of a mesh to gical management can be provided. Epidemiological studies which
protect the posterior inguinal wall and to repair simultaneously address these points draw interesting conclusions. Oxford Uni-
all possible hernia sites to avoid recurrences or to prevent new versity, for example, reviewed more than 30,000 cases of inguinal
herniations. These complex hernias are more frequent than ex- hernia repair and found significant risk factors related to age and
pected, and we consider that they could be related to an alteration sex. 9 More than 90% of these repairs were performed on males.
in collagen metabolism, as will be discussed below. 2 Approximately 9% were emergency procedures, and patients over
50 years of age were most likely to fall into this category. This group
also had higher emergency readmission rates and significantly
Recurrent Inguinal Hernia higher mortality than those who underwent elective repairs. Mor-
tality during the first year after the surgery was consistently higher,
Recurrent hernia is an unpleasant situation for both patient and probably because of associated illnesses. However, it was excep-
surgeon. For that reason, for many years surgeons have been in tionally high during the first 30 days after the surgery, which would
relentless, but so far unsuccessful, pursuit of a zero recurrence appear to be related directly to the hernia itself or its complications.
technique. Every surgeon should be acquainted with the failure TheJawaharlal Institute of Postgraduate Medical Education and
rate of current techniques to insure the best choice for the pa- Research of India reviewed the specific risk factors for strangula-
tient. We will not discuss the recurrence rate of each individual tion and intestinal obstruction in groin hernias. 41 The results are
technique, since they are discussed elsewhere. Often, the surgeon summarized in Table 12.5. The cumulative probability of strangu-
does not know his own true rate of failure, for in many patients lation for inguinal and femoral hernias has also been shown to be
recurrence is never detected: patients are lost to follow-up, an- high in a study by Gallegos, with a proportion approximately 10
other surgeon may treat the recurrence, or the surgeon may have times greater for femoral hernias. While for inguinal hernia the
left medical practice by the time the hernia recurs. probability was 2.8% at 3 months and 4.5% at 2 years, for femoral
The overall recurrence rate of hernia repair is of approximately hernia it was 22% and 45%, respectively.42
10% and ranges from 0.2% to 15%.36-37 A significant number The complication rate for pre term or otherwise seriously ill new-
of patients have repeated recurrences, as shown in the study of borns has been reported as high as 31 %, with the potentially life-
Ijzermans, who found a cumulative percentage of repeated re-
current hernia of 23%. The repeated recurrence rates reported
by others range from 8 to 33%, according to the repair technique TABLE 12.5. Risk factors for strangulation and intestinal obstruction
used. The risk of repeated recurrent hernia seems to decrease with
1. Complicated groin hernias occurred most commonly in patients aged
age.ljzermans reported that patients less than 50 years old had a
45-50 years.
recurrence rate of 33% after 5 years; those from 50 to 70 had a 2. In children, the incidence of complicated hernia was higher in the
rate of 22%, and the ones over 70 years only 14%. Almost all of group of less than 2 years.
these recurrences are of the direct type. It is also important to con- 3. The male:female ratio for complicated hernia was 12:1, and for un-
sider that the risk of repeated recurrent hernias after the last op- complicated hernia 25: 1.
eration is reduced significantly when the former procedure was 4. The right:left ratio for strangulated hernia was 3:1, and for simple
done more than 5 years earlier. Other factors such as the number hernia 2:1.
of previous recurrences, site, increase in intra-abdominal pressure, 5. 27% of femoral and 19% of inguinal strangulated hernias had gan-
obesity and the method of anesthesia employed, appear to have grenous contents.
no effect on this recurrence rate. 32 It would appear that if repeated 6. Recurrent inguinal hernias were more frequently strangulated than
recurrences take place more than 1 year after hernia repair, most primary hernias.
7. 65.8% of the patients with complicated hernia had the hernia for less
likely these late recurrences cannot be explained by failure of the than one year.
hernioplasty; more probably, they are local manifestations of a gen-
eralized defect in collagen metabolism. 38-39 Source: Rai S, Chandra SS, Smile SR. A Study of the Risk of Strangulation
Surgeons must consider these facts when deciding which oper- and Obstruction in Groin Hernias. Aust N Z] Surg. 1998;68:650-654.41
threatening consequences of incarceration, intestinal obstruction, The observation that patients who smoke have a higher proba-
and gonadal infarction. 19 bility of developing inguinal hernia has long been reported. Ini-
From these results, it can be seen that the highest risk of her- tially, it was believed to be due to the chronic cough in smokers
nia complication and the need for emergency surgery occurs and the consequent abrupt increases in abdominal pressure. Al-
among older males with any type of hernia, or in children of less though this may be a contributing factor, there are studies that
than two years, and in femoral hernias (especially in females with show a metabolic basis for the association. The theory of "meta-
hernia on the right side). Other facts to consider are that the male static emphysema" was first proposed by Cannon and Read,45 who
to female ratios decrease in emergency cases, that approximately showed that smokers have higher elastolytic activity in their tissues
one-fourth of strangulated hernias may have gangrenous contents, due to an imbalance between protease and antiprotease elements
and that complications are more likely to occur in recurrent her- in the blood. They found specifically that smokers have lower a-
nias. All of these risk factors are increased with hernias of short I-antitrypsin activity that affects not only the lung, but also the tis-
duration. So, in general, a hernia should be operated on as soon sues of the inguinal region. Another interesting study by these
as it is diagnosed, especially when it has a short history, to avoid authors showed an association between smoking, abdominal aor-
complications. Obviously, the mortality rate due to complicated tic aneurysm, and inguinal herniation. 46
hernia is also affected by the presence of concomitant medical ill- Other studies have shown altered healing patterns and collagen
ness, so patients with comorbid conditions should be considered synthesis in surgical wounds of patients who smoke. 47 According
as a higher risk. to Read, this effect of smoking on wound healing is reflected not
only in the occurrence of inguinal hernia, but also in the recur-
rence rate of smokers who have had a hernia repair.48 Finally, an
increased prevalence of congenital inguinal hernia has been re-
Etiologic Aspects of the ported in babies of mothers who smoked more than 20 cigarettes
Epidemiology of Inguinal Hernia a day during pregnancy.24 It is clear that smoking is an important
risk factor for the development of inguinal hernia.
Risk Factors
Throughout history, several risk factors have been associated with Hereditary Factors
the development of inguinal hernia. Unfortunately, most of these
associations have been purely observational, and few have been Review of the literature shows that predisposition to the develop-
studied for statistical significance. Genetic pattern of transmission, ment of an inguinal hernia may be hereditary. Some of the most
bipedalism, increased abdominal effort, previous surgery, obesity, interesting examples are reports of familial inguinal hernia by Kin-
constipation, chronic cough, prostatism, and ascites are all exam- don, Ashley, Mayo, Warren, Smith, and others. 49-53 Other evidence
ples of these alleged risk factors. It seems however, that the risk of of genetic influence appears in a cohort study of 885 patients with
developing an inguinal hernia depends on different conditions, inguinal hernia, which showed that 20.9% had affected first de-
and this has been confirmed by some interesting epidemiologic gree relatives and 16.6% second degree relatives. Unfortunately,
studies. the inheritance pattern has not yet been clearly identified. 15 One
Abrahamson studied a population of young male subjects in a recent epidemiologic study of more than 2,000 cases of congeni-
community in Jerusalem and found an increased prevalence of in- tal hernia found that a girl with an affected sister was at a higher
guinal hernia in men with varicose veins and prostatic hypertro- risk of developing a hernia than a girl or a boy with an affected
phy. An association was also found in thin men with hemorrhoidal brother. According to these results, the authors concluded that
disease and inguinal herniaP Although no mention is made in the pattern of transmission for inguinal hernia must be multifac-
his article about the possible cause of these associations, all of these torial and probably not sex linked. 54 On the other hand, a study
disorders may be indirecdy associated with increased abdominal of 280 families with more than one member affected by inguinal
pressure or connective tissue abnormalities. On the other hand, hernia found a frequent vertical transmission pattern. To these au-
he found a lower prevalence of hernia in overweight patients, sug- thors, the results reflect an autosomic dominant pattern with in-
gesting that obesity may be a protective factor against inguinal her- complete penetrance and sex influence. 55 Although it is clear that
niation. In his study, chronic cough, constipation, and physical familial predispositions exist, there is no conclusive evidence to
effort were not statistically related to inguinal hernia. date of a specific pattern of transmission for inguinal hernia.
A similar epidemiologic study in a female population has been
reported by Liem. 43 The only statistically significant factors asso-
ciated with hernia were a positive family history of this entity and Metabolic Factors
constipation. It is interesting to note that, in females also, obesity
was found to be a probable protective factor against herniation. Hippocrates was the first to observe that inguinal hernia in the
Females who performed exercise on a regular basis also had a adult is probably associated with a metabolic defect. He noticed
lower prevalence of hernia in this study. Regular exercise activi- that during times of famine, people who ingested a certain type
ties must be differentiated from actions that involve lifting heavy of peas, Lathyrus odoratus or Lathyrus sativus, which we now know
objects. While one probably reinforces the abdominal wall and in- contain an active component (beta-aminoproprionitrile) that in-
guinal region, the other contributes to increased abdominal pres- terferes with collagen synthesis, had a tendency to develop giant
sure and hernia formation. Flich demonstrated that both the hernias in many locations, as well as alterations in bones and
weight of the lifted objects and the number of years of lifting con- tendons. 56
tribute to the presence of inguinal herniation. 44 Up until 1922, most surgeons believed mainly in the saccular
114 A. Weber et al.
TABLE 12.6. Disorders of connective tissue associated with inguinal hernia surgery in the United States in the 1990s. Surg Clin Nurth Am. 1998;
78:941-951.
1. Ehlers-Danlos syndrome 3. Rutkow 1M, Robbins AW. Demographic, classificatory, and socioeco-
2. Williams syndrome nomic aspects of hernia repair in the United States. Surg Clin Nurth
3. Androgen insensitivity syndrome Am. 1993;73:413-426.
4. Robinow syndrome 4. Ralphs DNL, Brain AJL, Grundy DJ, Hobsley M. How accurately can
5. Serpentine fibula syndrome direct and indirect inguinal hernias be distinguished? Br Med J 1980;
6. Alport's syndrome 280;1039-1040.
7. Marfan's syndrome 5. MalgaigneJ: Le.;:ons c1iniques sur les hernies. Paris: Bailliere; 1841:19,
8. Tel Hashomer camptodactyly syndrome 174.
9. Leriche's syndrome 6. lason A. The incidence of hernia in man. In: Hernia. Philadelphia:
10. Testicular feminization syndrome Blakiston; 1941:156-179.
11. Rokitansky-Mayer-Kuster syndrome 7. el-Qaderi S, Aligharaibeh Kl, Hani IB, et al. Hernia in northern Jor-
12. Goldenhar syndrome dan. Some epidemiological considerations. Trap Geogr Med. 1992;44:
13. Morris's syndrome 281-283.
14. Hurler-Hunter syndrome 8. Wantz GE. Abdominal wall hernias. In: Schwartz SI, Shires GT, Spencer
15. Gerhardt syndrome FC, et al., eds. Principles of surgery. New York: McGraw-Hill, Inc.; 1999:
16. Menkes disease 1585-1611.
17. Kawasaki disease 9. Primatesta P, Goldcare MJ. Inguinal hernia repair: incidence of elec-
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19. Wiedermann syndrome 1996;25:835-839.
20. Rubenstein-Taybi syndrome 10. Ponka JL. Hernias of the abdominal wall. Philadelphia: W.B. Saunders;
21. Alopecia-photophobia syndrome 1980:82-89.
11. Bronsther B, Abrams MW, Elboim C. Inguinal hernias in children. A
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obstruction in groin hernias. Aust N Z] Surg. 1998;68:650-654. with inguinal herniation. Proc Soc Exp Bioi Med. 1971;137:382.
42. Gallegos NC, Dawson J, Jarvis M, et al. Risk of strangulation in groin 59. Wagh PV; Read RC. Defective collagen synthesis in inguinal hernia-
hernia. Br] Surg. 1991;78:1171-1173. tion. Am] Surg. 1972;124:819-822.
43. Liem MS, van der Graaf Y, Zwart RC, et al. Risk factors for inguinal 60. Wagh PV, Leverich AP, Sun CN, et al. Direct inguinal herniation in
hernia in women: a case-control study. The Coala trial group. Am] men: a disease of collagen.] Surg Res. 1974;17:425-433.
Epidemiol. 1997;146:721-726. 6l. Bellon JM, Bujan J, Honduvilla NG, et al. Study of biochemical sub-
44. F1ich J, Alfonso JL, Delgado F, et al. Inguinal hernia and certain risk strate and role of metalloproteinases in fascia transversalis from her-
factors. Eur] Epidemiol. 1992;8:277-282. nial processes. Eur] Clin Invest. 1997;27(6):510-516.
13
Occult Hernias in the Male Patient
Sam G.G. Smedberg and Leif Spangen
Introduction investigation found that, over the age of 75, almost half of the
male population had a hernia or had been operated on for her-
The following presentation will focus on the understanding of the nia. Similar results were found in a Swedish epidemiological study
origin of groin pain in occult hernia and its differential diagnoses, of men aged 54 years (22%) and 62 years (30%).8
the physical and radiological examination of the patient, and a
discussion of the results of studies.
Hernias may be symptomatic before they are clinically evident. Indirect Hernia
Pain and discomfort, not the bulging of the hernia, are the most
frequent first symptoms of hernia. 1 The pain caused by a nonpal- A patent processus vaginalis is present in all males in the perina-
pable hernia may be intense and disabling, preventing the patient tal period as part of the descent of the testicles to the scrotum.
from working or taking part in sports activities. However, there are Pediatric studies show that the obliteration of the processus vagi-
several conditions that cause similar symptoms. A careful history nalis takes place during the first two years of life, but as many as
of the pain and a thorough investigation demonstrating or ex- 40% remain patent. 9,10 Half of these develop into clinical hernias,
cluding the presence of a hernia are necessary before surgery is and in 20% of males, a patent but undilated processus vaginalis is
decided upon. dormant for the remaining lifetime. 9 ,1l The highest incidence of
An abdominal wall hernia is "the protrusion of some internal hernia occurs during the first year of life, and a second peak in-
body structure through the abdominal wall." The clinical problem cidence of indirect hernia is found in young adults. However, in-
of occult hernias includes not only the diagnosis and treatment of direct hernias continue to appear in all age groups. Not until the
nonpalpable peritoneal sacs but also the protrusion of other tis- seventh decade does the incidence of direct hernia match the in-
sues, of which preperitoneal fat (the so-called hernia lipoma or cidence of indirect hernia in the male.
lipoma of the cord) is the most frequent.
Asymptomatic occult hernias are of clinical interest for pro-
phylactic treatment at the same time as repair of hernia in the Direct Hernia
same groin or on the contralateral side. The transabdominal
preperitoneal (TAPP) laparoscopic procedure has made it possi- Impaired collagen quality12 and accelerated breakdown of colla-
ble to find these hernias, and some authors have recommended gen in the inguinal region 13 have been demonstrated in hernia
the TAPP operation for this reason. 2 In pediatric practice in North patients. Collagen studies show that hereditary factors predispose
America, the contralateral side is often explored to find and treat to these conditions.I 4 Repetitive increase in intra-abdominal pres-
an asymptomatic hernia. Unnecessary operations should be sure, as occurs in sports activities, overloads the thin supportive
avoided, however. Negative findings necessitate a more extensive structures in the inguinal area. In patients with a predisposition
dissection with increased risk of damaging the cord. Selective ex- for hernia, this may accelerate the development of a hernia. A
ploration of the asymptomatic side has been suggested and can high incidence of occult direct hernias, not expected until later
be performed after an examination before or during the opera- in life, was demonstrated by herniography in young athletes. 15
tion to confirm the presence of hernia. Different techniques may
be used, such as herniography,3 ultrasonography,4 intraoperative
pneumoperitoneum,5 and even laparoscopy through the hernia Femoral Hernia
opening on the symptomatic side. 6
The high incidence of femoral hernia in females is found pre-
dominantly in multiparous women. 16 Femoral hernias are more
Epidemiology frequent in females than in males in a ratio of 2.5:1. The ratio of
inguinal to femoral hernias is between 10:1 and 8:1.1 6 Preperi-
In an adult male population examined by surgeons, one out of toneal fat may appear not only as lipomas of the cord in the in-
four had a hernia or had been operated on for hernia. 7 The same guinal canal, but also as fatty tabs in the femoral canal and in the

13. Occult Hernias in the Male Patient 117
obturator foramen. By herniography combined with femoral phle- Localization

bography, Gullmo demonstrated fatty tabs in the femoral canal
compressing the femoral vein during straining, imitating femoral Pain caused by a hernia is inguinal in the majority of cases. Lower
hernias. I7 In elderly women with substantial weight loss, these fatty epigastric pain (the location of the mesenteric root) may be caused
tabs disappear and may be replaced by small femoral and obtura- by omentum trapped in the hernia sac. Scrotal pain or referred
tor hernias. pain along the ilioinguinal nerve are less common. The differen-
tial diagnostic possibilities are, however, numerous, as may be seen
in Table 13.1.
Diagnosis and Differential Diagnosis

Radiation
History
When there is radiation of pain in cases of inguinal hernia, it is
The history of symptoms in patients with obscure groin pain is of often caused by nerve involvement. The pain radiates mainly along
great importance. The history should be explored before the phys- the ilioinguinal nerve, caudally to the upper medial part of the
ical examination is performed or any other investigations are de- thigh or laterally toward the iliac crest. Genitofemoral nerve pain
cided upon. The interpretation may be difficult, however, since radiates to the scrotum·, while pain caused by an obturator hernia
there are several conditions causing similar symptoms. Further- may radiate to the lower medial part of the thigh. Omentum
more, chronic pain tends to become more uniform over time ir- trapped in an occult hernia may cause abdominal pain. Radiation
respective of its origin. For this reason, a systematic analysis of the of pain from the inguinal area to the iliac fossa or even higher up
symptoms is valuable. Pain can be classified according to its evo- on the abdomen may be caused by tendinitis of the rectus abdom-
lution, exact localization, radiation, intensity and character, dura- inis muscle. Radiation in a downward direction on the medial side
tion, and reproducibility. Factors that provoke and relieve the pain of the thigh may be caused by adductor muscle tendinitis. Com-
are of importance. pression of the lateral femoral cutaneous nerve causes pain radi-
ating from the lateral part of the inguinal area to the lateral side
of the thigh, so-called meralgia paresthetica. Pain radiating from the
Evolution groin to the knee or in the opposite direction may be caused by
hip joint arthrosis. In half of patients with ischial lumbago, pain
The very first symptom is often diagnostic, though sometimes dif- radiates to the groin.
ficult for the patient to recollect. Pain will often become dull and
more difficult to localize and characterize after a long period of
symptoms. The first symptom of hernia may be sudden and caused Intensity and Character
by (for example) lifting a heavy object. However, there is often a
gradual onset of the symptoms provoked by activities that increase The parietal pain related to hernia is most pronounced in the early
intra-abdominal pressure. Information about a sudden onset re- development of the hernia due to dilation of the hernia sac. IS
lated to trauma gives the suspicion of a muscular or tendinous When the hernia grows and becomes manifest, this type of pain
rupture or tear. The onset of overuse i~uries is often related to a often disappears. Acute sharp pain may be neuralgic or caused by
change in the pattern of muscular activities, for example, the train- traumatic ruptures of muscles and tendons. Sharp pain in the
ing in athletic sports. The onset of pain could also be related to chronic condition is most likely caused by nerve entrapment. Burn-
previous operations in the lower abdomen and inguinal area such ing sensations are also related to nerve involvement. Intermittent
as herniorrhaphy, appendectomy, and gynecological operations pain of the neuralgic type is sometimes seen in cases with occult
through Pfannenstiel incisions. In these cases, the pain is most of- indirect hernias. Dull pain occurs in a variety of conditions. In
ten caused by postoperative neuralgia, if not a recurrent hernia. long-standing pain it can be difficult to discriminate different con-
Laparoscopic trocars may also cause nerve damage and pain. ditions from one another. Overuse injuries such as tendinitis and
TABLE 13.l. Differential diagnosis in obscure groin pain

Musculoskeletal disorders Urogenital disorders Other disorders
Hip arthrosis Prostatitis Intra-abdominal adhesions

Symphysitis Chronic cystitis Intra-abdominal tumor
Pelvospondylitis Ureteral obstruction Constipation and other functional bowel disease
Spinal disorders Varicocele Nerve entrapment, primary and postoperative
Chronic overuse injuries Hydrocele ilioinguinal nerve
tendinitis iliohypogastric nerve
tenoperiostitis femoral branch of genitofemoral nerve
stress fracture of pubic bone lateral femoral cutaneous nerve
Acute overuse injuries anterior branches of lower intercostal nerves
musculotendinous tears and ruptures Varicose veins
avulsion fracture Hip claudication
Hernia; inguinal, femoral, obturator, Spigelian
118 S.G.G Smedberg and L. Spangen
tenoperiostitis may cause moderate symptoms during the exercise nerve blocks. Injecting an anaesthetic in the area of the pain gives
itself. However, at rest a couple of hours after the sports activities, only limited information. A nerve block should be done at a dis-
the pain often increases and may continue until the next day or tance from the area of the pain, with a long acting drug such as
longer. Elderly patients with groin pain both related to physical bupivacaine. Three to 4 ml just under the external oblique
activity and causing discomfort in the night may suffer from ar- aponeurosis medial and cranial to the anterior superior iliac spine
throsis of the hip joint. is sufficient to block the ilioinguinal and the iliohypogastric nerves.
Numbness of the skin verifies the correct location of the injection,
and banishment of the pain verifies that the nerve is involved in
Duration the symptoms of the patient. If the latter is incomplete, however,
the nerve may still be involved at a more central level. This
The duration of pain caused by a hernia is often limited to the can be verified by a central nerve block using epidural or spinal
duration of the strain that increases intra-abdominal pressure. The anaesthesia.
pain often disappears in a short period of time if the patient can An abdominal examination is performed searching for tender-
relax. Prolonged pain after physical activities suggests a musculo- ness and palpable masses. Small indirect hernias may cause radi-
tendinous origin. In patients with continuing pain varying in ination of pain 3 to 4 cm along the Spigelian aponeurosis, the
tensity, sometimes correlated to straining and sometimes without semilunar line cranial to the internal inguinal ring. The testicles
an obvious explanation, other causes such as nerve involvement, and spermatic cords are palpated. Hydrocele, spermatocele, and
inflammatory conditions or hip arthrosis should be sought. varicocele are excluded. At rectal examination, the prostatic gland
should be evaluated. If there is a suspicion of obturator nerve in-
volvement, the obturator foramen can be reached with the ex-
Reproducibility amining finger through rectal examination. Tenderness of the
symphysis pubis can easily be evaluated by bimanual examination.
Hernia pain is often provoked by Valsalva maneuvers. In the re- The musculoskeletal component of differential diagnosis in
laxed supine position, hernias seldom cause pain. The under- groin pain may necessitate an extensive examination. The main
standing of the symptoms can be improved by relating them to points of interest, however, are passive and active provocation tests
daily life activities such as getting out of bed (rectus abdominis of the rectus abdominis, iliopsoas, rectus femoris, and adductor
muscle), walking upstairs (iliopsoas muscle), stepping into or out muscles and tendons, overuse injuries of the adductor muscles be-
of a car (adductor muscles), lifting heavy objects, laughing, straining the most common. The lower thoracic and lumbar spine,
ing (hernia, spinal disorder), and so on. sacroiliac joints, symphysis pubis, and the hip joints should be eval-
uated. Hip arthrosis can be found in middle-aged patients, not
only in the elderly.
Physical Examination Simple laboratory tests such as an erythrocyte sedimentation
rate and urine microscopy may be of value.
The physical examination should cover the most common differ-
ential diagnoses. Provided a thorough history has been obtained,
the physical examination can focus on the most probable diag- Radiological Examinations
noses. At inspection, with the patient standing, irregularities in the
groin area should be noticed as well as the shape of the lower Normally, the decision to operate on a hernia is based on clinical
back. A leg length difference and muscular atrophies should be findings alone. No other confirmation is necessary. However, when
noted. Palpate for hernias on the standing patient, but without the physical examination fails to reveal the presence of a hernia,
trying to provoke pain at this stage of the examination. Through there are radiological techniques available to aid diagnosis. Ex-
the invaginated scrotal skin, you will reach the external inguinal ploratory operations without a preoperative diagnosis should be a
ring and sometimes into the inguinal canal depending on the last resort in elective surgery. An inguinal operation is not harm-
width of the ring. The patient is asked to strain and cough. A small less, and in a patient with a pain syndrome, the condition may be
indirect hernia can be detected as a soft swelling along the sper- exacerbated after an operation. On the other hand, to wait for
matic cord and an incipient direct hernia will compress the in- physical signs to appear while the patient suffers is an out-of-date
guinal canal from behind. A weakness of the posterior inguinal strategy and no longer necessary, thanks to improved investigative
wall should also be evaluated with the patient at rest in the supine techniques.
position. Femoral hernias are searched for below the line between
the pubic tubercle and the anterior superior iliac spine and me-
dial to the femoral vessels. Herniography
With the patient in the supine position, before pain is provoked,
start the examination by testing the sensitivity of the skin of the A positive contrast examination of the peritoneal lining of the in-
lower abdomen and the thighs. When there is nerve involvement guinal region and the pelvis was introduced in adult patients in
of any kind, you will often find numbness in the area of the nerve the early 1970sP·19 Its use has become widespread in the investi-
and hypersensitivity to pin pricking in the same area. Sometimes gation of groin pain. The technique is not difficult, but since it is
these findings are associated with a trigger point, the point of the an invasive procedure, the indications should be restricted mainly
injury, along the course of the nerve. The dermatomes of the to the investigation of occult hernia. With the patient in the supine
ilioinguinal, the iliohypogastric and the genital branch of the gen- position, the abdominal wall is punctured below the umbilicus on
itofemoral nerves are easily separated. At the end of the exami- the left side with a mandrin-equipped catheter or in the midline
nation, verification of nerve involvement is made by diagnostic with a fine needle, and the contrast medium is injected under flu-
oroscopy control into the abdominal cavity. The patient is turned

to the prone position, and the head of the table is elevated. The
contrast medium will pool in the inguinal region, and during Val-
salva maneuvers hernias and irregularities of the peritoneal lining
will be clearly demonstrated on tangential exposures. 20 Equipment
that allows tilting of the tube is required (Fig. 13.1). Additional
oblique exposures will facilitate the interpretation of the radio-
logical findings. The groin side being investigated is tilted some
20° down to place the inguinal fossae at right angles to the beam
and minimize the overlapping of hernias seen on the radiogram.
Both sides are investigated in the same manner, irrespective of the
location of symptoms. The patient should void before the investi-
gation. Atropine may be administrated to prevent vasovagal reac-
tions. No other preparation of the patient is necessary.
Complications are few and relatively harmless. 21 Occasionally,
the bowel is punctured. The needle is withdrawn and a new punc-
FIGURE 13.2. Herniography in a 30-year-old athlete with right-sided groin
ture can be performed, and the investigation continued. Bleeding
pain and no palpable hernia. A right-sided direct hernia was discovered.
from punctures of intra-abdominal vessels or from the abdominal
wall are rare. Peritoneal reactions to the contrast media described
in early reports are no longer a problem with the isotonic contrast
media now available. herniography. Relief of groin pain was registered in 16 out of 17
The accuracy of herniography concerning the presence of her- patients who subsequently underwent operation. 22 In another se-
nia is generally reported to be high.17.22-24 False positive and false ries of 250 patients with obscure groin pain without previous
negative investigations are rare,25 though not unknown.26 The ac- surgery on the symptomatic side, hernias judged to be the cause
curacy is the same whether the hernia is occult or clinically man- of the pain were found by herniography in III patients. 24 Ninety-
ifest25 (Fig. 13.2). The interpretation of the type of hernia, seven were operated on, all of whom had hernias. In 84 patients
however, is more difficult, and may be misjudged even by an ex- (87%) the pain was relieved. In the remaining cases, whether op-
perienced investigator. Incipient stages of direct hernias may be erated on or not, workup revealed a number of different diag-
difficult to distinguish from deep peritoneal fossae, and direct her- noses. Following this and two further publications, one on groin
nias emanating lateral to the medial umbilical fold may be diffi- pain in patients with previous surgery33 and the other on athletes
cult to differentiate from broad and shallow femoral hernias. with groin pain,1 5 the differential diagnostic (Table 13.1) was put
The usefulness of herniography in occult hernia cases is en- together.34 In more recent publications, similar results have been
couraging. The Swedish series published in the 1980s22- 24 was fol- reproduced. 29 ,3o The technique is being adopted in an increasing
lowed by presentations of results from other countries. 27- 32 In a number of countries.
series of 73 patients with obscure groin pain, Ekberg and cowork- Many reports include herniographic findings of asymptomatic
ers found hernias on the symptomatic side in 26 patients by occult hernias on the contralateral side. The clinical significance
of these findings is not obvious. In a series of 90 male patients with
a symptomatic unilateral indirect hernia, herniography was per-
formed. Contralateral asymptomatic findings were recorded. The
patients were followed up for 3 to 7 years.35 Thirty had no con-
tralateral hernia, and among these, no hernias developed during
the follow-up. Nineteen had a patent processus vaginalis or a small,
diverticular, slightly dilated indirect protrusion, one of which (5%)
developed into a manifest hernia after 4 years. Occult indirect her-
nias located within the inguinal canal were detected in 9 patients
(10%). A clinically manifest hernia developed in 50fthese (56%).
Six out of 27 patients (22%) with direct or combined hernias be-
came clinically manifest. In 1 of 5 patients with an incipient
femoral hernia, a direct hernia developed. On the basis of risks of
complications, the patient with an occult indirect hernia other
than nondilated processus vaginalis on the asymptomatic side
should be offered an operation.
Ultrasonography
The use of ultrasonography in diagnosing occult hernia in adults
has been limited. The supine position commonly used at the ex-
amination makes it difficult to demonstrate small hernias which
FIGURE 13.1. Herniography: positioning of the patient and direction of the are normally detectable only in the upright position during strain-
X-ray beam. ing. Direct hernias may, however, bulge during straining in the
120 S.G.G Smedberg and L. Spangen
supine position. Posterior wall deficiencies were demonstrated ac- cedure is indicated just for diagnostic purposes. The more prefer-
curately by dynamic ultrasound examinations in Australian Rules able totally extraperitoneal (TEP) operation reduces the diagnos-
footballers with chronic groin pain.36 An indirect sign of occult tic value of the laproscopic operation in occult hernias even more.
hernias shown by ultrasonography was reported in pediatric pa- However, there are reports of laparoscopic hernia operations in
tients. The size of the internal inguinal ring on the asymptomatic groin pain cases using the TAPP technique. 44,45 These reports in-
side was measured in boys; in more than 95% of those with clude athletes with groin pain and no palpable hernia. In one, 6
widened internal inguinal rings (over 4 mm), hernias were athletes with unilateral groin pain had small hernias on the symp-
found. 37 The hernia sac in femoral hernia can be demonstrated tomatic side and also a hernia on the contralateral side. 44 Surgery
by ultrasonography. Ultrasonography has also been valuable in the was successful in all. In the other series of 28 athletes, 30 hernia
differential diagnosis of Spigelian hernias. 38 Reports in the litera- operations were performed, 14 conventional and 14 laparoscopic
ture on ultrasonography and hernia, however, mainly concern the (two bilateral).45 All were operated on without a preoperative di-
identification and clarification of lumps in the inguinofemoral agnosis. Hernia findings were not reported. All could return to
region. full sports activities 1 to 9 weeks postoperatively. There were 2 neu-
ralgias settled within 2 months, 1 recurrent pain after 5 months,
and 1 recurrent hernia 22 months after conventional repair.
Computed Tomography (CT)
Like ultrasonography, CT is at its best in distinguishing between Comments
different kinds of lumps in the groin and abdominal wall. The ex-
perience of use of CT for the diagnosis of uncertain findings is Dealing with occult hernias is quite different from treating mani-
limited. A positive finding of an abdominal wall hernia was con- fest hernias. The latter is mainly a matter of surgical repair with
sidered reliable, while a negative finding did not exclude the di- as few complications and recurrences as possible. In occult hernia
agnosis. 39 The use of the Valsalva maneuver increased the cases, the diagnosis must first be established. Several questions
diagnostic accuracy. The use of CT in the diagnosis of abdominal arise. Do the symptoms justify an invasive investigation like
symptoms has improved the preoperative diagnosis in rare condi- herniography or is a less sensitive investigation warranted? Does a
tions like obturator hernias. A study of 36 cases showed that an hernia discovered at the investigation have anything to do with the
accurate preoperative diagnosis was improved from 39% before symptoms? The concern is that surgeons dealing with occult her-
the introduction of CT to 78% after CT was introduced. 40 This nia cases have thorough knowledge of differential diagnosis. When
had, however, no impact on patient outcome. a hernia has been diagnosed, the patient should be examined a
second time to confirm the relation between the hernia and the
symptoms before an operation is decided upon. There are, how-
Magnetic Resonance Imaging (MRI) ever, pitfalls in the judgment of symptoms: overuse injuries 34 due
to pain avoidance strategies, or abdominal pain and neuralgia sec-
MRI has been used to verify the diagnosis in patients with clini- ondary to analgesic drug use. The diagnostic process, though time-
cally evident groin herniations. 41 The experience of MRI for dif- consuming, is an exciting challenge.
ferential diagnostic purposes in the groin area is limited. It has
been used to confirm uncertain diagnoses in chronic pelvic pain.42
In one study including 10 patients with groin pain without physi- References
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22. Ekberg 0, Blomquist P, Olsson S. Positive contrast herniography in nia.] Clin Ultrasound. 1975;3:21l.
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23. Magnusson J, Gustafsson T, Gullstrand P, et al. Herniography-a use- hernias: a preliminary study. Eur RadioL 1997;7:1416--1418.
ful diagnostic method in patients with obscure groin pain. Ann Chir 40. Yokoyama Y, Yamaguchi A, Isogai M, et al. Thirty-six cases of obtura-
et Gyn. 1984;73:91-94. tor hernia: does computed tomography contribute to postoperative
24. Smedberg SGG, Broome AEA, Elmer 0, et al. Herniography in the di- outcome? World] Surg. 1999;23:214-216.
agnosis of obscure groin pain. Acta Chir Scand. 1985;151:66~67. 4l. van den Berg JC, de Valois JC, Go PM, et al. Groin hernia: can dy-
25. Smedberg SGG, Broome AEA, Elmer 0, et al. Herniography in pri- namic magnetic resonance imaging be of help? Eur RadioL 1998;8:
mary inguinal and femoral hernia. An analysis of 283 operated cases. 270--273.
Contemp Surg. 1990;36:48-5l. 42. Carter JE. Surgical treatment for chronic pelvic pain.] Soc Laparoen-
26. Loftus 1M, Ubhi SS, Rodgers PM, et al. A negative herniogram does dosc Surg. 1998;2:129-139.
not exclude the presence of a hernia. Ann R Coll Surg EngL 1997; 43. Gould SWT, Lamb G, Vaughan N, et al. Dynamic magnetic resonance
79:372-375. imaging: a new diagnostic modality for groin pain? Br] Surg. 1998;
27. Fenn K, Keller G, Kuhn R Die Peritoneographie zum Nachweiss nicht Suppll:35.
tastbarer Hernien. Radiologe. 1982;22:166--169. 44. Azurin DJ, Go LS, Schuricht A, et al. Endoscopic preperitoneal
28. Verhaar JAN, PotJH. De waarde de herniografie bij onbegrepen pijn herniorrhaphy in professional athletes with groin pain.] Laparoendosc
in de lies. Ned Tijdschr Geneeskd. 1985;129:359-362. Adv Tech A. 1997;7:7-12.
29. Makela JT, Kiviniemi H, Palm J, et al. The value of herniography in the 45. Ingoldby CJH. Laparoscopic and conventional repair of groin disrup-
diagnosis of unexplained groin pain. Ann Chir GynaecoL 1996;85:300--304. tion in sportsmen. Br] Surg. 1997;84:213--215.
14
Quality Control and Scientific Rigor
Erik Nilsson and Staffan Haapaniemi
Introduction of patients considered rate of recurrence more important than

speed of recovery as outcome measure.I° Marsden ll described re-
The word "quality" occurs with increasing frequency in the med- currence as a weakness in the operation area necessitating a fur-
icalliterature and now appears in the titles of several journals. In ther operation or the provision of a truss. He wrote, "It is a failure
one dictionary, quality is defined as "degree or standard of excel- of the operation and does not include slighter degrees of weak-
lence,"1 and in the ISO (International Standardization Organiza- ness-the significance of which is still controversial." On the other
tion, Geneva, Switzerland) 9000 it is understood as the inherent hand, recurrence was defined as an expansile cough impulse by
properties of an object or a procedure that satisfY explicit or im- Shuttleworth and Davies,12 who added: "Asymptomatic recur-
plicit requirements. In accordance with the principles of benefi- rences make reviews which are not based upon physical examina-
cence and nonmaleficence of biomedical ethics,2 quality may be tion liable to error." The difference between these two concepts
translated into common language as a measure of our capacity to is of considerable practical importance, the more so when follow-
relieve health problems without causing new ones. As demands ex- up examinations are undertaken at frequent intervals and when
ceed resources in all health care systems, we have to include the the recurrence rate is high. If follow-up is undertaken frequently
concepts of justice and rationing in the discussion of quality. In enough, most recurrences will be asymptomatic and hence not de-
cost-utility terms, quality might thus be considered to be the cost tectable through questionnaire and selective follow-up. In a recent
of a procedure in relation to the health improvement it generates. 3 study, only 50% of all recurrences were detected by this method
In the quality control of hernia surgery, we have to define end- as compared to physical examination of all patients. 13 This has a
points, outline goals with respect to these endpoints, and measure great impact upon quality control in cohorts with recurrence rates
to what extent we reach our goals, with cost as a denominator. exceeding, say, 10%, but may be of minor importance with re-
Quality control is related to audit, which refers to an initiative currence rates of 2% or less five years after surgery. In routine
aimed at improving the quality of outcome by examining practices quality control in a busy district hospital, it is difficult to allocate
and results against agreed standards. 4 Both quality control and au- resources for physical examination of all hernia patients on a yearly
dit are components of evidence-based medicine, the aim of which basis when the predictive value of a negative questionnaire answer
is to integrate the best available evidence with clinical practice.5 Re- is 95% or higher (the chance being at least 95% that the patient
search seeks to extend scientific knowledge; quality control and au- at physical examination has no recurrence if the questionnaire an-
dit examine whether practice keeps pace with that knowledge. 6 It swer indicates no bulge and no pain in the operated groin). Pro-
has been emphasized that an intrinsic gap exists between clinical vided case-mix is unaltered and the same follow-up technique with
research and clinical practice. 7 Surgical dexterity and skills such as questionnaire and selective physical examination is used, it is rea-
the ability to select the right procedure for the right patient may sonable to assume that any observed outcome changes reflect vari-
reside in this gap. Quality control reports the outcome of practice. ations in surgical quality. Whatever the control method used, it
should be stated clearly in reports and in quality control docu-
ments. The importance of completeness of follow-up becomes ob-
Endpoints in Hernia Surgery vious if we assume that all nonresponders to follow-up invitations
have recurrences.
Recurrence Whereas the time course of appearance of recurrences follow-
ing musculoaponeurotic repairs is well known,8,14 corresponding
Recurrence rate has been considered the most important end- data for newer methods (open plug and laparoscopic techniques)
point in hernia surgery. It is still the "acid test" of hernia repair. 8 are inadequate or lacking. Cumulative incidence of reoperation
In analyses of defined populations, the percentage of operations following registration of all hernia repairs has been suggested as
performed for recurrent hernia may be used as a crude index of a surrogate endpoint for recurrence. 15,16 Recurrence rate accord-
past surgical quality. 9 ing to Marsden's definition ll was determined by Kald and cowork-
In one of the few studies to address the question, the majority ers with questionnaire and selective follow-up of patients who

14. Quality Control and Scientific Rigor 123
answered questions about pain or bulge in the operated groin. analysis of quality of life following hernia repair.25 EuroQol is a
The authors found that recurrence rate measured in this way ex- simplified questionnaire in which five items can be combined in
ceeded reoperation rate three years after surgery by 40% .15 a common index. 26 ,27 It has been developed for and widely used
in health economy studies, including hernia surgery.lO However,
for many purposes, analogue or rating scales may be adequate for
Complications, Including Mortality, in the estimating patient satisfaction. 28
Immediate Postoperative Period In hernia surgery, information for patients concerning the nor-
mal postoperative course, including instructions for activity and
The frequency of postoperative complications reported after her- self-treatment, is particularly important. 29 If pain is to be treated
nia surgery, whether in randomized controlled trials or in case by analgesics, the patient should be told how much of the drug
series, is inversely related to the degree of scrutiny of the postop- should be taken, how often and for how long.
erative investigation. Whatever method is used for quality control Anticipation may influence outcome of surgical procedures. 30 ,31
or audit, postoperative complications observed by the operating The expectations of patients have been measured in a random-
unit should be recorded and followed over time. Rare and serious ized hernia trial,25 but they are rarely considered in the discussion
complications, particularly those that are procedure related, of outcomes. 32
should be considered central indicators needing individual de-
tailed assessment. This position should also be applied to postop-
erative mortality after elective hernia repair. According to the
Cost
Swedish Hernia Register, the observed 30-day mortality for men
The cost of surgery receives increasing attention. This applies not
following elective inguinal hernia repair was significantly lower
only to direct, but to indirect costs such as compensation for sick
than the expected mortality in the general Sweedish population,
leave. It has been repeatedly reported that both socioeconomic
indicating a preoperative selection of patientsP On the other
factors 33- 35 and the advice given to patients have a great impact
hand, a six to tenfold increase in standardized mortality rate was
on the duration of convalescence and sick leave. 29 ,36 Costs of post-
observed after emergency surgery, and, when bowel resection was
operative complications should be included in the overall cost.
undertaken, it exceeded that of the background population by 13
The expertise of health economists is required for hernia surgeons
to 17 times.
who pursue analyses in this field. 3
Although international variations in hernia repair rates have
Postrepair Pain and Groin Function been demonstrated,37 epidemiological data in the field of hernia
surgery are inadequate.
All hernia surgeons recognize the importance of late (four to six Finally, it is fair to recall that allocation of resources to the health
months after surgery) and chronic pain after hernia repair. How- care sector differs widely between industrialized and developing
ever, hard data on the incidence of this condition are scarce. In countries,38 and that the major problem confronting health pol-
an often-quoted study based upon follow-up of 276 out of 818 pa- icy makers in the industrialized world may be to define in opera-
tients who underwent open herniorrilaphy, postrepair moderate tional terms what is meant by a decent minimum. 2
or severe pain was recognized two years after surgery in 11 %. Of
17 patients referred to a pain specialist, 7 recovered completely or
had pain less frequently than once a week. Nine of the remaining
Problems and Challenges in Quality Control
10 patients were judged to have a somatic ligamentous syndrome, Eponyms
and 2 of these had, in addition, a concurrent and less severe pain
of neuralgic character. From this study, it might be concluded that The problem of eponyms has been clearly stated by Bendavid. 39
neuralgia after herniorrhaphy is an uncommon cause of disabling "No one does a Bassini, a Shouldice, or a Stoppa. Instead surgeons
pain. Chronic pain was also asked about in a recent Swedish co- do a modified Bassini, a modified Shouldice or a modified
hort study based upon physical examination of 219 out of 230 el- Stoppa." In articles comparing repair techniques, a detailed de-
igible patients four years after conventional hernia repair.18 scription of the authors' modification(s) should be given.
Twenty-four patients had moderate or severe pain, and in 4 pa-
tients (1.8%), the pain was of a neuralgic character. More infor-
mation is needed both from epidemiological studies and from Benchmarking
randomized controlled trials concerning postrepair pain follow-
ing hernia surgery.19 Today, no technique or modification of a technique of hernia re-
pair can be considered a gold standard. However, we still need
benchmarking to establish goals for our own units. In this process,
Patient Satisfaction we need randomized controlled trials, epidemiological studies,
analyses of administrative databases and registers, and well-con-
Validated techniques for obtaining information concerning trolled series from specialized centers. The randomized controlled
changes in quality of life of patients undergoing surgical proce- trial is considered the most trustworthy comparison, the outcome
dures are now readily available. The Short Form 36A (SF-36A) is of which is taken as the strongest evidence. 40 ,41 However, in a re-
a comprehensive health survey questionnaire that consists of eight cent systematic review, the external validity (generalizability) and
multi-item dimensions. 20-22 It has been utilized in several ran- power (sample size) of most randomized controlled trials in the
domized trials of hernia repair. 10,23,24 The Nottingham Health Pro- field of hernia surgery were rated as poor. In three other assess-
file Questionnaire (NHPQ) has received attention as a tool in the ment categories (reporting, bias, and confounding), the studies
124 E. Nilsson and S. Haapaniemi
1997 FIGURE 14.1. Methods of repair. (From the Swedish
A Shouldice 24.7 Hernia Register.)

%
...-~~------------l B Conventional open 14.9
B........... C Mesh. groin incision 42.3
o Mesh. abdominal incision 3.2
50 0 - 0 0 0 _ 0 _ '~"~'~":'r.... 0 0 0 0 0 0 0 0 _ 0 0 0 0 0 _ 0 0 0 0 ~ ~~~P 1~:!
...............
25 0 o~
E'" " "

0 0 0 0 0
"
0 0 0 -
" .----- ......

0 0 0 0 0 0 0 0 0 0 0 0
--~~
0 0
"".
..............
"". .
0 0 0 0
-
.. ~.:.~
"". :x' .
... - - - -
. . ._ 0 o,co 0 0 0 0
..................•
0 0 0
o~~~~~~~==~----~-=~~
Hernia
1992 1993 1994 1995 1996 1997
repairs 1689 1645 2285 3324 4054 5872
ranged from poor to good. 42 One interesting and neglected ques- Results
tion concerns the consequences of the trial for the participating
units. What happened at these units one year after the trial? The number of hospitals included has gradually increased from
eight in 1992 to 29 in 1997. By the end of 1997, 18,869 hernior-
rhaphies had been recorded; 15,091 (84.3%) primary and 2,968
The Swedish Hernia Register (15.7%) recurrent hernia repairs; 17,471 unilateral and 699 bi-
lateral operations had been done within the frame of the register
Prerequisites and Aims upon 17,061 patients, 91.6% of whom were men and 8.4% women.
The methods of repair used changed greatly over the 6 years cov-
The register has been described previously.16,43 The use of each ered by this audit. The most remarkable changes were the reduc-
individual's Person Number makes it possible to follow patients tion in traditional open pure tissue techniques from 68% in 1992
over time and to adjust life tables for death of patients. The aim to 15% in 1997, and the increased use of mesh (open and lap-
of the register is to describe and analyze hernia surgery in partic- aroscopic) methods from 6% to 61 % (Fig. 14.1). At 5 years, mean
ipating units and to support local audit programs. It is not its func- and 95% confidence intervals of cumulative incidence of reoper-
tion to produce ranking lists, and it has not been used in that way. ation was 5.7% (4.9-6.4%) and 10.1 % (8.2-12.0%) for primary
Cumulative incidence
0.12 r;:::======:::::=::::;-7"",-:---;,--;-,--;---;-,-;-,----:'1
0.11 - Primary hernias .. 7...... .. :........ 7...... -:- ...... i ...... -:- ...... f ...... -:-
0.10 ___ J ____ ___ l ____ ___ J, ____ ,I ____ "
- Recurrent hernias'
~
,
J __ _
'"
~
0.09 •
, I I I I • I
0.08
0.07
0.06
0.05
0.04
0.03
0.02
0.01
0.00 ....=0........l000l0.I.I0................................''''''''''''".................'''''''''''........''''''''''''''.............''''''''''''''''''''"'...............,..,,,
o 6 12 18 24 30 36 42 48 54 60 66 72
Time after surgery (months)
Primary hernias n = 15 901 5-year: 5.7% 95% CI (4.9 - 6.4%) FIGURE 14.2. Cumulative incidence of reoperation,
1992-1997; 18,869 hernia repairs. (From the Swedish
Recurrent hernias n = 2 968 5-year: 10.1% 95% CI (8.2 - 12.0%) Hernia Register.)
TABLE 14.1. Variables associated with increased relative risk for reoperation due to recurrent hernia;
adjusted for methods of repair, multivariate Cox analysis I, 1992-1997, 18,869 hernia repairs!
Number of operations Relative risk 95% CI
Recurrent operation vs. primary operation 2968 1.87 1.53-2.29

Absorbable suture vs. nonabsorbable suture 3634 1.43 1.15-1.78
Direct hernia vs. other hernia types 8163 1.70 1.42-2.02
Postoperative complication vs. no complication 1774 2.36 1.89-2.96
Period 1992-1995 vs. 1996--1997 8993 1.66 1.27-2.17
!Relative risk was estimated with the Cox proportional hazards model, first performing univariate analy-
sis of assumed risk variables, and then selecting variables with the highest "univariate" relative risk for
multivariate analysis. The proportional hazards assumption was exanIined as part of the Cox analysis.
Interaction between risk factors was also introduced and examined in the multivariate analysis. (From
the Swedish Hernia Register.)
and recurrent hernias respectively (Fig. 14.2). Since the register which from 1999 onward will collect data for all hernia repairs per
was established, a reduction in reoperation rate has been observed. hospital, whether ambulatory or inpatient procedures.
From Table 14.1, it is evident that an operation carried out be-
tween 1992 and 1995 was 1.66 times more likely to be followed by
a reoperation than an operation performed in 1996 or 1997. The Quality Control and Cost-Utility
relative risk of the various methods used during the whole period
from 1992 to 1997 is illustrated in Table 14.2. It must be added For 1998, the Swedish Hernia Register received approximately
that these data demonstrate the effectiveness of the methods used $50,000 (in United States dollars) from its sponsors, the Depart-
with learning curves included, but not their efficacy. Effectiveness ment of Health and Welfare and the County Councils of Sweden,
of the methods used (i.e., outcome in routine practice with learn- for running the register. As over 8,000 hernia repairs were regis-
ing curves included) is distinct from efficacy (i.e., results produced tered that year, the cost per operation registered would amount
by experts under optimal conditions).44 Data from the Swedish to approximately $6. For secretarial assistance at the participating
Hernia Register may be supplemented by follow-up studies, hospital, an amount of $4 has to be added for each operation.
such as the longitudinal study of outcome quality from a single Hence, a rough estimate of the overall cost of quality control
hospital. 45 through a register of this type would be $10 per operation. Does
register participation benefit those most concerned, the hernia pa-
tients? To answer this question, reoperation rates for 1992 and
A udit of the Audit 1995-1996 were compared between hospitals that joined the reg-
ister in 1995, and hospitals that had participated in register work
A quality control program must itself be audited. Data in the since its start in 1992. Reoperation rates after hernia repairs per-
Swedish Hernia Register were validated in 1996. 16 This was re- formed in the two groups in 1992 were almost identical. But re-
peated in 1998, and we have plans to do this on a yearly basis. Fur- operation rates following hernia repairs done in 1995-1996 were
ther validation of the Swedish Hernia Register may also be significantly lower in units that had been involved in the register
obtained by comparison with data from the Hospital Discharge since its start in 1992, compared to hospitals that joined the reg-
Database at the National Board of Health and Welfare in Sweden, ister in 1995. This seems to indicate that register participation,
TABLE 14.2. Relative risk of operation-methods of repair; adjusted for factors in I, multivariate Cox
analysis II, 1992-1997, 18,869 hernia repairs!
Number of operations Relative risk 95% CI
Shouldice 5,578 1.00 reference

Conventional open2 5,379 1.44 1.14-1.82
Mesh, groin incision 4,189 0.93 0.65-1.34
Mesh, abdominal incision 730 1.13 0.70-1.81
Transabdominal preperitoneal (TAPP) 1,796 0.94 0.66--1.33
Totally extraperitoneal (TEP) 1,197 1.91 1.21-3.02
!Relative risk was estimated with the Cox proportional hazards model, first performing univariate analy-
sis of assumed risk variables, and then selecting variables with the highest "univariate" relative risk for
multivariate analysis. The proportional hazards assumption was examined as part of the Cox analysis.
Interaction between risk factors was also introduced and examined in the multivariate analysis. (From
the Swedish Hernia Register.)
2Bassini, Marcy, McVay, et al.
126 E. Nilsson and S. Haapaniemi
with its associated aim of improving work, might benefit outcome Acknowledgments
quality.43 However, as all units increase their outcome quality, such
differences can be expected to fade away. In 1997, the following hospitals were enrolled in the register: Er-
sta sjukhus Stockholm; Falkoping; Falun; Huddinge sjukhus Stock-
holm; Hudiksvall; Kalix; Kalmar; Karolinska sjukhuset Stockholm;
Where to from Here? Lidkoping; Lindesberg; Linkoping; Ludvika; Lycksele; Mora; Mo-
tala; Norrkoping/Finspang; Norrtiilje; Pitea; Skene; St. COrans
Improvement in Surgical Education ~ukhus Stockholm; Skelleftea, Siiffle, Viirnamo; Viistervik/Oskars-
hamn; Uddevalla/Stromstad, Viistra Frolunda; and Ostersund. Fi-
Inadequate surgical education is the main obstacle to better out- nancial support for the Swedish Hernia Register is received from
come in nonspecialized units. 46 The motives of surgeons (best pos- the National Board of Health and Welfare and the Federation of
sible care to individual patients) and of society (best possible County Councils, Sweden. The authors thank hernia surgeons in
service for everybody at lowest possible cost) must coincide if qual- participating hospitals for their collaboration. Secretary Gunnel
ity control is to play its proper role in improving hernia surgery. Nordberg and statistician Lennart Gustafsson, Ph.D., have pro-
vided invaluable help during the preparation of this manuscript.
Consider the Care Chain

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31. Johnson AG. Surgery as placebo. Lancet. 1994;344:1140-1142. 47. O'Connor GT. Every system is designed to get the results it gets. BM]
32. Leibl B, Diiubler P, Schwartz J, et al. Standardisierte laparoskopische 1997;315:897-898.
15
Classification of Inguinal Hernias
V. Schumpelick and K-H. Treutner
Introduction may be that proposals do not cover all types of inguinal hernias,
the size of the fascial defect is not precisely measured, or the sys-
The results of inguinal hernia repair are related to the location of tem is too complicated for clinical routine.
the hernial orifice and the size of the fascial defect. Recurrence The simple classification of "direct" and "indirect" hernias dates
rates after operation on a large direct hernia are about five times back to Cooper in 1844. 3 Hesselbach defined the inferior epigas-
higher than those after repair of a small indirect hernia. Classifi- tric vessels as the reference point and used the terms "external"
cation of inguinal hernias is a prerequisite for planning, con- and "internal" hernia. 4 Casten presented a classification in 1967
ducting, and discussing clinical trials on this subject. Precise based on functional anatomy and surgical repair. As stage 1, he
documentation of location and size of the defect of the abdomi- describes an indirect hernia with a normal internal ring as seen
nal wall is crucial information for critical analysis of recurrence in infants and children, treated by high ligation of the sac. Stage
rates when evaluating different surgical techniques. It serves the 2 encompasses those indirect hernias with an enlargement of the
same purpose as the TNM classification of malignant tumors, mak- internal ring to be repaired by excision of the sac and recon-
ing clinical studies reproducible and therapeutic regimens com- struction of the internal ring. All direct and femoral hernias were
parable. I summarized under stage 3 with the indication of a Cooper's liga-
The classification should include all types of inguinal hernias, ment repair.5
and should work equally well for classical open surgery and lap- In 1970, Halverson and McVay published a classification based
aroscopic repairs. Valid objective comparisons of the results, com- on a description of the fascial defect and the repair technique.
plications, and recurrences of the relatively new minimal access Their categories included small indirect inguinal hernias, medium
techniques with those of the traditional surgical methods depend indirect inguinal hernias, large indirect and direct inguinal her-
upon the development and acceptance of such a classification. nias, and femoral hernias. They recommend high ligation of the
The classification should be clear and simple to allow unam- neck of the sac followed by reconstruction of the internal inguinal
biguous typing in a routine clinical setting. The surgeon must be ring for the first entity. For all the other types they recommended
able to assign each patient to one definite category with ease and the procedures known by their own names. 6
reliability. The use of any classification with a multitude of param- Gilbert presented a classification in 1989 which takes into ac-
eters and subtypes will be restricted to a few centers specialized in count the anatomical and functional integrity of the internal ring
hernia surgery. The aim, however, must be to gather and analyze and the tissue quality within Hesselbach's triangle. Types I to III
the experience on large numbers of patients beyond the borders are indirect hernias, types IV and V are medial defects of the in-
of single departments. 2 guinal canal; femoral hernias are not classified. In type I there is
Accumulation of data on the relationship between different a hernial sac of any size passing through a small and firm inter-
methods of hernia repair and the varying parameters of inguinal nal ring. Types II and III show enlargement of the internal ring
hernias will establish the most successful treatment for any given to admit one or two fingers, respectively. Hernias with a large de-
combination of the location and size of the fascial defect. These fect of the canal floor are called type IV, whereas those with a small
findings could be the solid ground for evidence-based surgery and medial orifice are named type V (Fig. 15.1).7 Rutkow and Robbins
quality control in the field of inguinal hernia. added a type VI for hernias with both indirect and direct compo-
nents, and a type VII for femoral hernias. 8
The classification published by Nyhus in 1993 differentiates
Classifications among four types. It is based on the size of the fascial defect and
the strength of the posterior wall of the inguinal canal. However,
A review of the literature reveals a number of classifications of there is neither a clear separation between direct, indirect, and
groin hernias. None of them, however, had achieved widespread femoral hernias, nor precise measurements. In type I there is an
acceptance. Unlike the TNM system, no single system of classifi- indirect hernia with an internal abdominal ring of normal size,
cation has yet been accorded the consensus of the surgical com- usually found in infants, children, and young adults. Indirect in-
munity. The reasons for this lack of an international agreement guinal hernias with enlargement of the internal ring are catego-

15. Classification of Inguinal Hernias 129
TABLE 15.2. Aachen classification of groin hernias
Localization of defect Size of defect
L = lateral/indirect 1< 1.5 cm

M = medial/direct II 1.5-3.0 cm
Mc = combined III> 3.0 cm
F = femoral
Discussion
Rational choice of the most effective method of repair for any type
of hernia, and consequent improvement in results, must be based
upon a functional classification system. This point of view is
strongly supported by our own experience. Between 1986 and
1992, we performed 370 Shouldice repairs for recurrent inguinal
FIGURE 15.1. The Gilbert classification. hernias. The patients were followed up for S to 10 years. There
were no re-recurrences after surgery for small and medium-sized
lateral hernias (L I to II) or medial hernias less than l.S cm (M
rized as type II. The crucial factor in type III is a defect of the pos- I). Recurrence rates for large indirect (L III) and medium direct
terior wall of the inguinal canal summarizing all direct hernias (III (M II) hernias were l.9% and l.6%, respectively. Shouldice repair
A), indirect hernias with a large dilated ring (III B), and femoral of recurrent inguinal hernias classified M III (2.4%) and Mc II
hernias (III C). Type IV covers all recurrent groin hernias either (2.6%) resulted in slightly higher figures. Follow-up of hernio-
direct (IV A), indirect (IV B), femoral (IV C), or a combination plasty for large combined hernias with a total fascial defect greater
thereof (IV D) (Table IS.I).9 than 3 cm (Me III), however, revealed a re-recurrence rate of7.7%
In 1993, Bendavid presented another system for the description (Table IS.3).1I
of groin hernias. The TSD classification is based on three para- The analysis of this group of patients clearly demonstrates a re-
meters: type (T), stage (S), and diameter (D). He differentiates lation between the type and size of the hernia and the long-term
among five types: anterolateral (formerly indirect) hernias (type outcome. Those patients with large direct and combined hernias
I), anteromedial (formerly direct) hernias (type II), posterome- are considerably more prone to re-recurrence than those with
dial (formerly femoral) hernias (type III), posterolateral (formerly small lateral and small to medium-sized medial fascial defects. We
prevascular) hernias (type IV), anteroposterior (formerly in- therefore introduced a new regimen for surgical treatment of re-
guinofemoral) hernias (type V). All types are further categorized current inguinal hernias. Whereas those classified as L I to II and
by three stages (S I to S III) denoting the extent of the protrusion M I to II are still repaired by the Shouldice procedure, direct her-
of the hernial sac and the diameter of the fascial defect (D) mea- nias with an orifice greater than 3 cm and all combined hernias
sured in centimeters at the level of the abdominal wall. Further are now operated on using mesh material.
details can be registered by additional letters such as "R" for re- In another group of 380 patients with recurrent inguinal her-
currence, "s" for slider, or "L" for lipoma. This allows for a very nias operated on between 1994 and 1996, we performed a TIPP
accurate description of all groin hernias. 1o repair (transinguinal preperitoneal prosthesis) in 94 cases. All
In 1994, another classification of inguinal and femoral hernias those hernias were intraoperatively classified either as combined
was published by Schumpelick et al. This intraoperative catego- type (Mc), large direct (M III), or indirect (L III) hernias. The
rization is based on the location ("M," medial/direct; "L," lat- latest follow-up of these patients revealed only two re-recurrences
eral/indirect; "F," femoral) and the transverse diameter (I < l.S after 12 and 24 months, respectively (2.1 %). Modification of the
cm, II l.S to 3.0 cm, III > 3.0 cm) of the hernial orifice. In cases treatment protocol according to classification of the abdominal
of combined direct and indirect hernias, the diameters of both wall defect resulted in lower recurrence rates. 12
fascial defects is added up. Those hernias are classified according Now, more than 100 years after the introduction of scientifically
to the part of major importance for the development of recur- based hernia repair by Bassini, hernioplasties are the most com-
rences, the medial defect, with the index "c." This classification mon procedure in general surgery. The time has come for an ev-
can be applied to open as well as laparoscopic approaches. The idence-based system for choice of technique. This calls for a joint
diameter of the tip of the index finger or the length of the branch effort to find a consensus on a clear and simple but valid and re-
of standard endoscopic scissors (l.S cm), respectively, serve as ref- liable classification of inguinal hernias.
erences for measurement (Table IS.2) .1.2
TABLE 15.3. Results of Should ice repair for recurrent inguinal hernia
TABLE 15.1. Nyhus classification (1991) according to the Aachen classification of groin hernias (n = 370)
Type I Indirect with normal internal ring II III
Type II Indirect with dilated ring, normal floor
Type III A. Direct inguinal hernia L 0% 0% 1.9%
B. Large indirect inguinal hernia M 0% 1.6% 2.4%
C. Femoral Mc 2.6% 7.7%
Type IV Recurrent hernias
L = lateral/indirect; M = medial/direct; Mc = combined.
130 V. Schumpelick and K-H. Treutner
References applied. Because they all tend to be similar in many ways, they are
hard to remember individually.
1. Schumpelick v, Treutner K-H, Arlt G. Inguinal hernia repair in adults. No classification can cover all abdominal wall hernias, nor
Lancet. 1994;344:375-379. should it. According to the 1997 statistics of the Shouldice Hos-
2. Schumpelick V, Treutner K-H, Arlt G. Klassifikation von Inguinal- pital, 7,273 abdominal wall hernia operations were performed. In-
hernien. Chirurg. 1994;65:877-879. guinal and femoral hernias numbered 6,653 or 91.5%. Of all
3. Cooper A Anatomy and surgical treatment of abdominal hernia. 1st Amer-
inguinal and femoral hernias, 60.98% were indirect inguinal her-
ican ed from 2nd London ed. Philadelphia: Lea and Blanchard; 1844.
4. Marcy HO. The anatomy and surgical treatment of hernia. New York: D.
nias (4,057 patients); 36.98% direct inguinal hernias (2,460 pa-
Appleton and Co.; 1892:66. tients) and 1.95% femoral hernias (160 patients); these accounted
5. Casten DF. Functional anatomy of the groin area as related to the clas- for 99.91 % of all groin hernias. The rare prevascular, paravascu-
sification and treatment of groin hernias. AmJ Surg. 1967; 114:894-899. lar, or Spigelian hernias made up 0.09% and should be excluded
6. Halverson K, McVay CB. Inguinal and femoral hernioplasty. Arch Surg. as statistically nonsignificant. Thus, it would be sufficient for a clas-
1970;101:127-135. sification to cover indirect, direct, and femoral hernias, names that
7. Gilbert AI. An anatomic and functional classification for the diagno- have been here for a long time and which appear with every at-
sis and treatment of inguinal hernia. Am J Surg. 1989;157:331-333. tempt at classification: I = indirect, D = direct, and F = femoral.
8. Rutkow 1M, Robbins AW. "Tension-free" inguinal herniorrhaphy: a pre- The widest dimension of the neck of a defect should be used to
liminary report on the "mesh plug" technique. Surgery. 1993;114:3-8.
denote the size of a defect. A 2 em hernia will be an 12 or a D2
9. Nyhus LM. Individualization of hernia repair: a new era. Surgery.
or an E2. If a direct and indirect hernia, each 2 em, are present,
1993;114:1-2.
10. Bendavid R. The TSD classification. A nomenclature for groin hernias. then the hernia would be denoted 12-D2. Whether a peritoneal
GREPA. 1993;15:9-12. sac or lipoma protrudes is not important for this purpose: only
11. Treutner K-H, Arlt G, Schumpelick V. Shouldice repair for recurrent the size of the defect is. Recurrence should be designated R. Two
inguinal hernia-a ten-year follow-up. In: Schumpelick V, Kingsnorth previous attempts at surgery would be 2 X R, 3 attempts 3 X R,
AN, eds. Incisional Hernia. Berlin-Heidelberg-New York: Springer; and so on.
1999:359-366. Since preoperative diagnosis is seldom accurate, the operative
12. Arlt G, Schumpelick V. Transinguinal preperitoneal prosthesis place- diagnosis must be the criterion on which communication and
ment under local anesthesia-management and follow-up of 100 pa- modality of treatment must rest.
tients. In: Schumpelick V, Kingsnorth AN, eds. Incisional Hernia.
An indirect hernia 3 em in diameter at its neck, present with a
Berlin-Heidelberg-New York: Springer; 1999:389-395.
direct inguinal hernia 4 em in widest dimension and a femoral
hernia 1 em wide at its neck with 4 previous attempts at repair
would be labeled at surgery and for the chart as "Right 4 X
R-I3--D4-F1."
IDF classification would always use the three letters, and if no
Commentary hernia is present (zero), then 10 or DO or FO should be recorded.
For the chart and computer entry, a simple grid could be devised,
Robert Bendavid as in this sample:
Discussions on the issue of hernia classification seem to have taken
place in the Tower of Babel. Schumpelick and Treutner have been Recurrences Indirect Direct Femoral
eyewitnesses to these discussions as well as active participants. For
my part, my TSD classification, though complete, suffers from the Right 4 3 4 1
same deficiency as all the other classifications: it has to be con- 0 0
Left 0 0
sulted, like a book of spells, before the correct designation can be
Part IV
Pathology
16
Mechanisms of Hernia Formation
Jack Abrahamson
Introduction versus abdominis muscles (the "conjoined tendon") and below by

the pectineal line of the superior pubic ramus. This opening in
Hernias emerge through preformed or acquired defects or weak the lower abdominal wall allows the passage of blood vessels,
areas of the abdominal wall unprotected by muscle or aponeuro- nerves, lymphatics, muscles, and tendons between the abdomen
sis. These defects could be evolutionary, such as the myopectineal and the lower limb. The opening is divided into upper and lower
orifice of Fruchaud,I-3 or the superior and inferior lumbar spaces, halves by the lower free edge of the external oblique aponeurosis
or congenital, such as a patent processus vaginalis in the newborn (the inguinal ligament) . The space is closed off posteriorly by the
or adult, or a patent umbilical defect at birth. The weakness could fascia transversalis, which is the only structure in this area sepa-
be an acquired scar such as the umbilicus, or a poorly healed ab- rating the abdominal cavity from the lower limb, and which must
dominal incision or a scarred over defect resulting from loss of resist the intra-abdominal pressure unsupported by muscles or
part of the abdominal wall through trauma, excision, or infection, aponeurosis. This situation, and the absence of the posterior rec-
or after disinsertion of the abdominal wall muscles from the iliac tus sheath below the arcuate line, is a surprising and unfortunate
crest following harvesting of bone for grafting. Rarely, blunt evolutionary defect, which is compounded in humans by the adop-
trauma to the abdominal wall may cause disruption of the flat mus- tion of upright posture and bipedal locomotion. Bipedalism has
cles and allow a hernia to pass through the tear. However, the de- opened up and stretched the groin region and changed its func-
velopment of a hernia is usually multifactorial with one or more tional anatomy in such a way as to interfere with the mechanical
factors applying in any particular case. efficiency of the shutter mechanisms of the abdominal wall, caus-
ing a greater tendency in man to develop groin hernias. 6 Most
mammals that walk on all four limbs have a lower abdominal wall
Hernias Occurring in Unprotected Areas structure similar to that of humans and may even have a perma-
nently patent processus vaginalis, yet they rarely develop inguinal
These hernias include the groin hernias, all of which emerge
hernias. The reason for this is that in mammalian quadrupeds, the
through the myopectineal orifice of Fruchaud. They constitute by
thigh is flexed sharply forward, the groin structures are neither
far the biggest group of hernias. Less common hernias through
stretched nor under tension, and the inguinal canal runs in an
unprotected areas include epigastric and paraumbilical hernias
upward direction. The groin is at a higher level than the abdomen
passing through defects between the decussating fibers of the linea
so that the weight of the abdominal contents is directed cranially
alba,4,5 Spigelian hernias through gaps between the microtendons
forward and downward, away from the inguinal region onto the
of the aponeurosis of the transversus abdominis muscles along the
anterior wall of the upper abdomen, which is structurally more
semilunar line, lumbar hernias passing through the superior and
suited to bear it and is also reinforced by the lower thoracic cage.
inferior lumbar triangles, and subcostal hernias emerging through
Thus, the inguinal canal is not subjected to significant gravitational
defects in the attachments of the flat abdominal muscles to the
stress. In bipedal man, so the theory goes, the exact opposite has
costal arch.
occurred. The upright posture causes the weight of the abdomi-
nal contents to be directed caudally downward so that the gravi-
Groin Hernias tational stress passes down onto the lower abdominal wall which
evolution has inadequately adapted for its new role. When man is
Evolution upright, the unsupported fascia transversalis is constantly exposed
to this weight. This is thought by some to be a significant factor
Since groin hernias are the commonest of hernias, they will be dis- in weakening the transversalis fascia and causing groin hernias. 6
cussed in detail. Fruchaud, when describing the myopectineal ori- Groin hernias occur when the fascia transversalis fails to with-
fice that bears his name, urged a more holistic concept of groin stand the stresses of normal or increased intra-abdominal pres-
hernias, all of which pass through the fascia transversalis and the sure. If one takes into account the anatomical factors discussed
myopectineal orifice, which is bounded above by the myoaponeu- above, it may be surprising that less than 5% of the human race
rotic arch of the lower edges of the internal oblique and trans- develops groin hernias. The factors that bring about failure of the
133
134 J. Abrahamson
fascia transversalis in the small number of humans who develop spermatic cord. As these muscles contract, the fibers of the arch
groin hernias must be studied as well as those that contribute to shorten, the arch straightens, and descends to lie close to or
its integrity in over 95% of people. against the inguinal ligament anterior to the posterior wall of the
inguinal canal. At the same time, the shutter passes down in front
of the internal ring as well and counteracts the pressure on the
Patent Processus Vaginalis ring from inside the abdomen. The fascia transversalis, which con-
tributes to the border of the internal ring, is pulled up and tensed
The development of the processus vaginalis, its migration into the by the contracting transversus abdominis muscles, causing the ring
scrotum, and its final obliteration are intimately linked to the de- to close like a sphincter snugly around the cord. Contraction of
scent of the testis from the abdomen into the scrotum. These the external oblique muscle may also contribute to the shutter
processes are initiated and controlled by the calcitonin gene-re- mechanism; its aponeurosis forms the anterior wall of the inguinal
lated peptide (CGRP) released by the genitofemoral nerve under canal and, when tensed, presses on the internal ring, thus rein-
the influence of fetal androgens. 7 The testis descends through the forcing the weak posterior wall of the canal by counterpressure
internal ring, across the primitive inguinal canal, out through the against the intra-abdominal forces. The same contraction also pulls
external ring, and into the scrotum between the 26th and the 40th the inguinal ligament upward to some degree to meet the de-
week of gestation. It is preceded and guided by the processus vagi- scending shutter. The acts of coughing, straining, or lifting which
nalis. Mter completion of testicular descent, the lumen of the tend to blowout the internal ring and the fascia transversalis thus
processus vaginalis is obliterated between the internal ring and the act simultaneously to bring into action the protective physiologi-
upper pole of the testis. The mechanisms involved in the obliter- cal mechanisms that oppose those tendencies.
ation of the processus vaginalis are unknown. The entire proces-
sus vaginalis, or parts of it, may remain patent, sometimes
becoming the site of an indirect inguinal hernia, a scrotal hydro-
cele, or an encysted hydrocele of the cord or of the canal of Nuck
Lipomas of the Cord
in the female. In the female fetus, the processus vaginalis and the
These are usually not true lipomas (i.e., not new growth) but
round ligament descend into the labia majora, but the descent of
masses of varying sizes and amounts of extraperitoneal fat cover-
the ovary is arrested at the rim of the true pelvis. 8
ing and adherent to the cord both in front of and behind the in-
A patent processus vaginalis is the prime cause of indirect in-
ternal ring. Since they prolapse out of the abdominal cavity
guinal hernia in infants and children in whom it is cured by sim-
through a defect in the abdominal wall, they may be considered
ple ligation at the internal ring: herniotomy.9 In adults as well, a
a type of hernia. However, it is rare to find a lipoma of the cord
completely patent or only partially obliterated processus vaginalis
passing out of the abdomen without the presence of a hernial sac
may be the basic cause of an indirect hernia. However, simple
as well. This indicates that one is dealing with a hernia accompa-
herniotomy in adults is followed by a high rate of recurrent indi-
nied by prolapse of some extraperitoneal fat. It has been suggested
rect inguinal hernia, indicating that additional etiological factors
that adiposity may be a protective factor against the development
are present which are not dealt with by simple herniotomy.
of an indirect inguinal hernia because extraperitoneal deposits of
On the other hand, the presence of a patent processus vaginalis
fat lie above the internal ring, plugging it. However, the contrary
does not necessarily indicate that an indirect inguinal hernia is
has also been suggested: due to the upright bipedal stance of man,
present, nor does it mean that one will necessarily develop in the
the extraperitoneal fat at the internal ring is pressed down by the
future. Hughson found a patent processus vaginalis in 20% of adult
weight of the abdominal contents and the intra-abdominal pres-
autopsy examinations, yet none of the subjects suffered from her-
sure and acts as a bougie to dilate the internal ring and allow a
nia during life. 10 Gullmo noted an open processus vaginalis in 5%
hernia to develop.15
of young women having hysterosalpingography, yet none had clin-
Some surgeons make a point of carefully dissecting off and ex-
ically detectable hernias. ll This finding has been confirmed by
cising all the fat around the cord when repairing a hernia. Oth-
others.l 2- 14 So additional factors must be present to produce an
ers simply return the lipomas through the internal ring into the
indirect inguinal hernia even when a patent processus vaginalis is
abdominal cavity with equally good results.
present.
The Shutter Mechanism Raised Intra-Abdominal Pressure

Extremely high intra-abdominal pressures are generated during When the intra-abdominal pressure is actively raised, as in cough-
normal daily activities such as coughing, straining, and lifting heavy ing, straining, or lifting, the countermechanisms are automatically
weights, yet in the overwhelming majority of individuals, the nat- activated and, together with the transversalis fascia, are usually suf-
urally weak areas of the groin, such as the internal inguinal ring ficient to resist the increased pressure, and a hernia does not ap-
and the fascia transversalis, do not give way, and a groin hernia pear. However, when the intra-abdominal pressure rises passively
does not develop, even in those with an open internal ring and a and the abdominal muscles are relaxed, these mechanisms are not
patent processus vaginalis. This is due to the remarkable physio- activated, and the fascia transversalis is left on its own to withstand
logic "shutter mechanism" that is automatically activated by the the increased intra-abdominal pressure. If a patent processus vagi-
same contraction of the abdominal muscles that raises the intra- nalis is present or if the fascia transversalis is not sufficiently strong
abdominal pressure. The lower fibers of the internal oblique and or becomes attenuated by the prolonged pressure and stretching,
transversus abdominis muscles form the myoaponeurotic roof of it gives way. The internal ring will be stretched open, and an in-
the inguinal canal, the "conjoined tendon," that arches over the direct hernia will appear.
16. Mechanisms of Hernia Fonnation 135
In the same way, attenuation and stretching of the fascia trans- these families there is a higher incidence of patent processus vagi-
versalis at the posterior wall of the inguinal canal will result in a nalis, or a defect in the structure of the fascia transversalis, or both.
direct hernia. In pregnancy, the abdominal wall is passively The role of connective tissue pathology in the genesis of groin
stretched and the intra-abdominal pressure rises, and a groin her- hernia has recently been further elucidated. The collagen frame-
nia may appear for the first time and may even "disappear" after work of the transversalis fascia in patients with groin hernia was
the birth. This is usually an indirect hernia that appears in a patent found to be disorganized and modified, with increased vascular-
processus vaginalis that has been present as a latent hernia, but ization and cellularity. These changes were present mainly in pa-
direct and femoral hernias may also appear during pregnancy. tients with direct hernias in whom the fascia transversalis of the
Groin hernias and often umbilical hernias are produced by a sim- opposite, nonherniated side showed the same changes,24 findings
ilar mechanism in the presence of chronic ascites caused by liver reported also by Read and others. 25 ,26 A decrease in oxytalan fibers
cirrhosis,16 and in ventriculoperitoneal shunting and peritoneal and an increase in the amorphous substance of the elastic fibers
dialysis, where the fascia transversalis together with the rest of the as a function of age may be responsible for alterations in the re-
abdominal wall become passively stretched and thinned yet must sistance of the transversalis fascia and the high incidence of groin
withstand the weight of the large quantity of accumulated intra- hernias in older men. 27
abdominal fluid and increased hydrostatic pressure.5,17-20 The ap- Read has investigated the normal and abnormal metabolism of
pearance of a groin hernia caused by malignant ascites may be the collagen and its relationship to the causation of hernia, especially
first indication of intra-abdominal cancer. Excess body weight is in smokers. 28 ,29 He found that substances in cigarette smoke de-
no longer considered to be a factor in the development of groin activate antiproteases in lung tissue. The integrity of the lung tis-
hernias. In fact, adiposity may even have a protective influence sue depends on the balance of the protease/antiprotease system,
against the development of a groin hernia. 21 and deactivation of antiproteases leads to its destruction and to
The balance between the resistance of the abdominal wall and emphysema. The free, unbound, and active protease and elastase
the intra-abdominal pressure may be upset even in a fit young man compounds are also found in the serum of smokers, apparently
who is suddenly called upon to lift or to hold an extremely heavy discharged by the increased number of white blood cells circulat-
weight to which he is not accustomed or trained; he immediately ing in the blood and lungs of smokers. These circulating unop-
develops pain in the groin and a groin hernia even down to the posed enzymes upset the protease/antiprotease system in the
scrotum. The hernia is usually indirect and the abdominal wall blood and bring about destruction of elastin and collagen of the
"rupture" probably occurs in the presence of a patent processus rectus sheath and fascia transversalis, and so cause their attenua-
vaginalis, the opening up of which the countermechanisms have tion and a predisposition to herniation in cigarette smokers. 3o
resisted until the overwhelming increase in pressure occurred. The Read furthermore noted that, among smokers, the levels of cir-
probable presence of a preformed sac of patent processus vagi- culating serum elastolytic and protease substances is higher in the
nalis, as opposed to the sudden increased workload, is often the blood of patients with hernias than in controls, in those with di-
basis of workmen's compensation litigation. 5 A similar phenome- rect compared with indirect hernias, and still higher in those with
non occurs in older men where only a moderate effort seems suf- bilateral direct inguinal hernias.
ficient to suddenly produce a groin hernia. Groin hernias, An increase in the levels of circulating proteases and elastases oc-
especially direct inguinal hernias, are most common in men over curs in many other conditions not associated with smoking, causing
the age of 50 years. 22 ,23 Lack of physical fitness, the aging process, a disturbed protease/antiprotease balance and destruction of tis-
and the stresses of life appear to weaken the abdominal muscles, sues leading to herniation. These conditions include many situa-
the shutter mechanism, and the fascia transversalis so that the tions of stress and systemic illnesses that lead to an enhanced
usual counterforces fail. Consequently, an indirect inguinal her- leukocyte response and the discharge of proteases and oxidants
nia appears through a preexisting patent processus vaginalis or a from the leukocytes, with a rise of elastase in the blood, leading to
direct hernia through a sudden tear or "rupture" of the fascia a relative decrease in antiprotease activity.25,29 These mechanisms
transversalis, or a bulging direct hernia may simply stretch and bal- may be partly responsible for attenuation of the fascia transversalis
loon the attenuated fascia transversalis in front of it. and hernia formation in nonsmokers in a fashion similar to smok-
ers24 and may explain the appearance of hernias in patients recov-
ering from surgical operations, infections, and systemic illnesses.
The Integrity of the Fascia Transversalis
The ability of the fascia transversalis to withstand physiological and General Factors
pathologic elevations in the intra-abdominal pressure is depen-
dent on the state of the collagen fibers that make up its tissues The ability of the abdominal wall in the groin and elsewhere to
and give it its strength. Collagen is an active, live tissue maintained withstand the forces favoring herniation may be reduced by the
by a constant balanced state of production and absorption. Fac- weakening of the muscles and fasciae with advancing age, lack of
tors that interfere with this balance or cause production of ab- physical exercise, adiposity, multiple pregnancies, and loss of
normal collagen fibers will bring about attenuation and weakening weight and body fitness, such as may occur after illness, operation,
of the fascia transversalis. These factors include certain congeni- or prolonged bedrest.
tal connective tissue disorders such as Marfan's, Ehlers-Danlos, and
Hurler-Hunter syndromes, and certain mesenchymal metabolic
defects that cause collagen deficiency and structural abnormali- Surgical Incisions
ties of the collagen fibers. Heredity also plays a part as evidenced
by higher incidence than that of the general population of her- Certain "cosmetic" operative incisions, such as very low and un-
nias in several generations of a family. It is not clear whether in duly long transverse abdominal incisions for gynecologic or uro-
136 J. Abrahamson
logic procedures or "cosmetic" appendectomy incisions, may be bites of each thin layer, often lead to tearing out of the sutures as
followed by the appearance of a groin hernia caused by cutting well as necrosis of the tissues along the suture linep,31-36
into the myoaponeurotic arch of the lower fibers of the internal
oblique and transversus abdominis muscles and/or cutting across
the motor or sensory nerves of the groin, causing atrophy of the Suture Material and Technique
muscles. The consequent damage to the muscles of the groin re-
gion and their weakening and the postoperative fibrosis in the re- The use of inappropriate suture material, mainly absorbable su-
gion interferes with the action of the shutter mechanism and tures that do not support the wound for a sufficient length of time,
promotes the development of a groin hernia. will lead to separation and hernia formation. Approximately 80%
of the final wound strength is reached after six months, so the
wound must be supported for at least this time. Of the suture ma-
Physical Activity terials available today, only the synthetic nonabsorbable sutures
can reliably give this support. Attention should be paid to the su-
Strenuous physical activity alone does not cause hernias: the inci- turing technique. A fairly heavy thread of synthetic nonabsorbable
dence of groin hernia is the same in sedentary workers as in heavy suture material, at least four times the length of the wound, should
manual laborers. However, it does bring about a rise in the intra- be used for the single layer mass closure of the abdominal inci-
abdominal pressure and so may cause an existing small and un- sion. The sutures should be about 1 cm apart and pass through
noticed groin hernia to expand and become clinically obvious. It the abdominal wall except for the skin and peritoneum,37-40 about
may also be the final factor bringing on a hernia in those already 3 cm from the cut edge so as to avoid cutting out of the sutures.
predisposed to herniation by other more basic causes, as previ- Tension is a potent cause of the failure of abdominal wound cla-
ously discussed. sure. 41 The lateral pull of the abdominal muscles against the su-
ture leads to progressive ischemic pressure necrosis at the point
where the tissues meet the suture, until the sutured edges sepa-
Incisional Hernias rate. 42 Tension is avoided by using an appropriately long length
of suture as previously mentioned.
Postoperative ventral abdominal incisional hernias develop by
pathophysiological mechanisms different from those of the pri-
mary hernias discussed above. The many etiological factors in- Sepsis
volved will be briefly discussed in this section but further
elaborated in Chapter 20. Sepsis is the second major cause of early wound failure and is a
Many factors, singly or in various combinations, may interfere contributing factor, if not the most important one, in more than
with satisfactory healing of the wound, resulting in the failure of 50% of postoperative hernias that develop within one year after
the lines of closure of the abdominal wall following laparotomy the operation. It may range from frank acute cellulitis and necro-
and leading to the development of a postoperative hernia. The sis of the tissues on each side of the incision, to low-grade chronic
main causes are poor surgical technique and sepsis. Incisional her- sepsis around sutures such as braided or twisted silk. The infec-
nias may be divided into early and late types. tion causes inflammation and edema of the tissues, which become
so soft and weak that the sutures tear through and pull out under
the strain of the intra-abdominal pressure.l7,43
Early Hernias
These may appear within days, weeks, or months of the original Drainage Tubes
laparotomy closure. They often involve the whole length of the
wound, grow rapidly, and become large. They are mainly the re- Drainage tubes brought out through the wound leave a track of
sult of technical failure on the part of the surgeon. unsutured wound, and thus may act as a passage for organisms
from the skin to go into the depths of the wound. They may also
irritate the tissues, leading to edema and softening and tearing of
Surgical Incisions the tissues.
Nonanatomical incisions that cut across muscles, nerves, and

blood vessels, cause atrophy of the muscles. The vertical pararec- Obesity
tus incision along the outside of the lateral border of the rectus
sheath is typical of this type of incision. Obesity is associated with a threefold increase in incisional herni-
ation and recurrence of repaired incisional hernias. 5,28,36,44 Inci-
sions through obese abdomens, with the forceful retraction
Layered Closures needed, are associated with a higher rate of wound infection. The
fatty tissues do not hold the sutures, especially against the enor-
Layered closures are followed by a greater incidence of postoper- mous tension of the weight of masses of intra- and extra-abdomi-
ative hernias than are wounds closed by the single layer mass clo- nal fat. Furthermore, obese patients have a higher rate of
sure technique. Many small sutures, closely placed and taking small postoperative complications such as paralytic ileus, atelectasis,
16. Mechanisms of Hernia Formation 137
pneumonia, and deep venous thrombosis that raise the incidence state of health all play their part. Besides maintaining general body
of incisional hernia. fitness and not smoking tobacco, there is little one can do to avoid
this common affliction. On the other hand, incisional hernias are
largely due to easily controllable human factors and can be avoided
General Condition by choosing an experienced surgeon with a particular interest in
and understanding of the anatomy and pathophysiology of the ab-
The general condition of the patient influences the rate of post- dominal wall. He will choose the most suitable incision, which he
operative ventral hernia. The factors are generally those that neg- will close in conformity with the highest standards, using the best
atively influence the processes involved in wound healing and materials and techniques to avoid tension and infection.
include age, generalized wasting, malnutrition and starvation, hy-
poproteinemia, avitaminosis, malignant disease, anemia,jaundice,
diabetes mellitus, chronic renal failure, liver failure, ascites, pro-
longed steroid therapy, immunosuppressive therapy, and alco- References
holism.
1. Fruchaud H. Du retentissement de la posluon debout propre a
l'homme sur l'anatomie de la region de l'aine. Consequences chirur-
gicales. Les bases anatomiques du traitement chirurgical des hernies
Postoperative Complications de l'aine. Mim Acad Chir. 1953;63:652-661.
2. Fruchaud H. Anatomie chirurgicale des hernies de l'aine. Paris: Doin; 1956.
Postoperative complications increase the incidence of postopera- 3. Fruchaud H. Traitement chirurgical des hernies de l'aine. Paris: Doin; 1957.
tive hernias, especially prolonged postoperative paralytic ileus and 4. Askar OM. Aponeurotic hernias: epigastric, umbilical, paraumbilical,
intestinal obstruction. These are accompanied by abdominal dis- hypogastric. In: Bendavid R, ed. Prostheses and abdominal wall hernias.
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the wound, and this, together with the concomitant increase in 5. Abrahamson]. Hernias. In: Zinner MJ, ed. Maingot's abdominalopera-
the girth of the abdomen, causes enormous tension on the suture tions. lOth ed. Stamford: Appleton and Lange; 1997:479-580.
6. McArdle G. Is inguinal hernia a defect in human evolution and would
line, with necrosis and separation, and inevitably, a postoperative
this insight improve concepts for methods of surgical repair? Clin Anat.
hernia. 45 Pulmonary complications also increase the incidence of 1997;10:47-55.
postoperative hernia, especially in smokers. Postoperative wound 7. Clamette TD, HutsonJM. The genitofemoral nerve may link testicu-
dehiscence or "burst abdomen," whether covered by skin or with lar inguinoscrotal descent with congenital inguinal hernia. Aust N Z]
frank evisceration, is often followed by postoperative hernia Surg. 1996;66:612-617.
whether resutured or treated by the open method. This is not sur- 8. Skandalakis JE, Colborn GL, Skandalakis L]. The embryology of the
prising, since practically all the conditions mentioned previously inguinofemoral area: an overview. Hernia. 1997;1:45-54.
are also causal factors in burst abdomen. 9. Abrahamson]. Repair of inguinal hernias in infants and children: the
approaches of a pediatric surgeon. Clin Pediatr. 1973;12:617-621.
10. Hughson W. The persistent or preformed sac in relation to oblique
inguinal hernia. Surg Gynecol Obstet. 1925;41:610.
Late Hernias 11. Giillmo A, Broome A, Smedberg S. Herniography. Surg Clin North Am
1984;64:229-244.
The etiology of the late occurring incisional hernias is not clear. 12. Jan TC, Wu CC, Yang CC, et al. Detection of open processus vaginalis
The hernia develops in what apparently is a perfectly healed by radionuclide scintigraphy. Kao Hsiung I Hsueh Ko Hsueh Tsa Chih.
wound that has functioned satisfactorily for five, 10 or more years 1992;8:54-58.
after the operation. 46 The incident is not related to the method 13. Surana R, Puri P. Fate of patent processus vaginalis: A case against rou-
used for closing the original incision and is presumably the result tine contralateral exploration for unilateral inguinal hernia in chil-
of the failure of the collagen in the scar, although there seems to dren. Pediatr Surg Int. 1993;8:412-414.
be no obvious reason why mature collagen that has served well for 14. Surana R, Puri P. Is contralateral exploration necessary in infants with
a number of years should change its structure. Degenerative unilateral inguinal hernia? ] Pediatr Surg. 1993;28:1026-1027.
15. Stoppa R Hernia of the abdominal wall. In: ChevrelJP, ed. Surgery of
changes in the quality of collagen have been shown to be related
the abdominal wall. Berlin: Springer-Verlag; 1985:155-224.
to age 27 and may be a factor in decreased resistance of the ab-
16. BelghitiJ, Panis Y Herniorrhaphy in cirrhotic patients with umbilical
dominal wall scar tissue. Abnormal collagen production and main- hernia. Postgrad Gen Surg. 1992;4:129-130.
tenance in smokers may also be a factor in the late development 17. Abrahamson]. Factors and mechanisms leading to recurrence. In: Ben-
of incisional hernia. There is a deficiency of collagen and abnor- david R, ed. Prostheses and abdominal wall hernias. Austin: RG. Landes
malities in its physiochemical structure, manifesting in reduced Company; 1994:138-170.
hydroxyproline production and in changes in the diameter of the 18. Brown MV, Hamilton DNH, Junor BJR Surgical complications in pa-
collagen fibers associated with an imbalance between proteolytic tients on continuous ambulatory dialysis.] R Coll Surg Edinb. 1983;28:
enzymes and their anti-enzymes. 25 141-146.
19. GrosfeldJLI, Minnick K, Shedd F, et al. Inguinal hernia in children:
factors affecting recurrence in 62 cases.]Pediatr Surg. 1991 ;26:28~287.
20. Tsai TC, Huang FY, Hsu JC, et al. Continuous ambulatory peritoneal
Conclusion dialysis complicating with abdominal hernias in children. Acta Paedi-
atr Sin. 1996;37:26~265.
The cause of primary groin hernia and the less common primary 21. AbramsonJH, GofinJ, Hopp C, et al. The epidemiology of inguinal
hernias of the abdominal wall is multifactorial. Evolutionary, hernia: a survey in Western Jerusalem. ] Epidemiol Community Health.
hereditary, congenital and environmental aspects, and the general 1978;32:59-67.
138 ]. Abrahamson
22. Wantz GE. Clinical crossroads. A 65-year-old man with an inguinal her- 34. Ellis H, Coleridge-Smith PD, joyce AD. Abdominal incisions: vertical
nia. ]AMA. 1997;277:663-669. or transverse? Postgrad Med] 1984;60:407-410.
23. Wantz GE. Letter.]AMA. 1997;277:1679. 35. Chevrel]p. Postoperative complications. In: Chevrel jP, ed. Surgery of
24. Pans A, Pierard GE. Immunohistochemical study of the rectus sheath the abdominal wall Berlin: Springer-Verlag; 1987:83-91.
and transversalis fascia in adult groin hernias. Hernia. 1998;2(Suppll): 36. Manninen Mj, Lavonius M, Perhoniemi VJ. Results of incisional her-
13. nia repair. A retrospective study of 172 unselected hernioplasties. Eur
25. Read RC. The metabolic role in the attenuation of transversalis fascia ] Surg. 1991;157:29-31.
found in patients with groin herniation. Hernia. 1998;2 (Suppl 1):17. 37. Ellis H, Heddle R. Does the peritoneum need to be closed at lapa-
26. Peacock EE. Reflections on hernias as a systemic disease. In: Bendavid rotomy? Br] Surg. 1977;64:733-736.
R, ed. Prostheses and abdominal wall hernias. Austin: R.G. Landes Co., 38. Ellis H. Internal overhealing: the problem of intraperitoneal adhe-
1994:171-179. sions. World] Surg. 1980;4:303-306.
27. Rodrigues-junior Aj, de Tolosa EM, de Carualho CA. Electron micro- 39. Elkins TE, Stovall TG, Warren j, et al. A histologic evaluation of peri-
scopic study on the elastic and elastic related fibres in the human fas- toneal injury and repair: implications for adhesion formation. Obstet
cia transversalis at different ages. Gegenbaurs Morphol]ahrb. 1990;136: Gynecol 1987;70:225-228.
645. 40. Stark M. Suturing of peritoneum. World] Surg. 1993;17:419.
28. Read RC, Yoder G. Recent trends in the management of incisional her- 41. Abrahamson]. Factors and mechanisms leading to recurrence. Probl
niation. Arch Surg. 1989;124:485-488. Gen Surg. 1995;12:59-67.
29. Read RC. Blood protease/antiprotease imbalance in patients with ac- 42. Bartlett LC. Pressure necrosis is the primary cause of wound dehis-
quired herniation. Prob Gen Surg. 1995;12:41-46. cence. Can] Surg. 1985;28:27-30.
30. Lehnert B, Wadouh F. High coincidence of inguinal hernias and ab- 43. Abrahamson j. Etiology and pathophysiology of primary and recurrent
dominal aortic aneurysms. Ann Vase Surg. 1992;6:134-137. groin hernia formation. Surg Clin North Am. 1998;78:953-972.
31. Abrahamson]. Epigastric, umbilical and ventral hernia. In: CameronjL, 44. Bucknall TE, Cox Pj, Ellis H. Burst abdomen and incisional hernia: a
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32. Pollock AV. Laparotomy.] Roy Soc Med. 1981;74:480-484. 45. jenkins TPN. Incisional hernia repair: a mechanical approach. Br]
33. Richards PC, Balch CM, Aldrete jS. Abdominal wound closure. A ran- Surg. 1980;67:335-336.
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sus interrupted suture techniques. Ann Surg. 1983;197:238-243. Br] Surg. 1983;70:290--291.
17
Metabolic Aspects of Hernia Disease
Raymond C. Read
Introduction They are certainly alive, and the fact that hernias are so often mul-
tiple in middle-aged and old people leads me to suspect that a
Modem herniology began during the golden age of anatomy pathological change in the connective tissues of the belly wall may
(1750-1850), the underlying assumption then being that the tis- render certain individuals particularly liable to hernia." And fur-
sues lining the various abdominal defects were normal and would ther, "It is most important that surgeons should form a just and
stay that way. Causation was attributed to a mechanical disparity true opinion concerning the manner in which hernias arise. If
between visceral pressure and the resistance of the musculature. they occur only in those who have hernial sacs already formed dur-
Cooperl (1804) not only described the transversalis fascia and its ing fetal life, then we must either excise the sacs at birth or stand
role in preventing groin herniation, but listed factors which in- by and do nothing but trust to luck. But if . . . the occurrence of
crease intra-abdominal pressure: cough, obesity, constipation, hernia is due to circumstances over which we have control, then
pregnancy, ascites, and unusual exertion such as heavy lifting. The the prevention of hernia is a matter worthy of our serious study."
strength of the abdominal wall was considered to be diminished Andrews (1924)6 followed, suggesting that atrophy of the con-
by congenital deficiency, debility, or aging. Rupture of the peri- joined tendon played a role. Little attention was paid to these pi-
toneum or abdominal musculature (Galen)la was disproved as a oneers. Thus, Zimmerman and Anson,7 in their 1967 textbook,
significant factor by dissection and the fact that trauma, unless continued to state that inguinal herniation developed as a result
massive, did not result in herniation. of a congenital anatomical predisposition. Indirect hernias were
Even though it was well known that, at autopsy, persistence of a ascribed to the presence of a preformed sac; direct herniation was
patent processus vaginalis did not equate with herniation (Clo- explained by the absence of the lowermost fibers of the internal
quet, 1819),2 surgical thought regarding etiology came to be dom- oblique muscle, leaving the transversalis fascial floor of the in-
inated by Russell's saccular theory,3 "which rejects the view that guinal floor unsupported. It was not until 1964 that the first ex-
hernia can ever be 'acquired' in the pathological sense ... the perimental evidence pointing to connective tissue abnormalities
presence of a developmental diverticulum is a necessary anas a possible cause of herniation in humans was made. Wirtschafter
tecedent in every case," and "we may have an open funicular peri- and BentleyS cited an increased incidence of hernia in patients
toneum with perfectly formed muscles: we may have congenitally with lathyrism coupled with the induction of herniation in animals
weak muscles with a perfectly closed funicular peritoneum, and using lathyrogens.
we may have them separately or together in infinitely variable gra- My own interest in the role of metabolic factors in hernial cau-
dations." Harrison (1922)4 was the first to question this dictum: sation was stimulated by a finding made in the late 1960s9 during
"When we consider the dozens and hundreds of men who first the development of a modified McEvedy posterior preperitoneal
show a hernia at 50 or 60, after their active life is over, the hy- approach to the repair of inguinal hernias. The rectus sheath,
pothesis [saccular] becomes improbable to say the least. However, some centimeters above the defects, appeared thinner than nor-
the main objection to the theory is that even if true, it gives us no mal lO and felt greasy. Samples of constant size weighed significantly
useful guidance. In and of itself, the persistence of a more or less less than those taken from matched controls operated upon for
elongated narrow processus vaginalis should not predispose to a other conditions. Patients with direct or bilateral hernias showed
future hernia if all elements of strength present in the wall of the more attenuation than those with indirect defects. ll Atrophy was
abdomen were also present in the wall of the processus ... the unrelated to age or muscle mass. 12 Hydroxyproline content and
muscles, however, appeared to be normal. . . . The natural con- therefore collagen, which comprises 80% of the rectus sheath, was
clusion is that the cause of an indirect hernia as of a direct her- strikingly decreased. Collagen showed altered salt precipitability
nia is the failure of the transversalis fascia to withstand the and impaired hydroxylation with decreased amounts of mature in-
intra-abdominal pressure to which it is subjected." soluble (polymeric) collagen.I 3 Cultured fibroplasts proliferated
The following year, Sir Arthur Keith 5 dealt another blow to the less and had reduced uptake of radioactive proline. Collagen fi-
saccular concept, stating, "We are so apt to look on tendons, fas- brils on electron microscopy showed irregular periodicity and vari-
cial structures, and connective tissues as dead passive structures. able diameters, with some intracellular positioning. These changes
139
140 R.C. Read
in ultrastructure were later confirmed (1990) by Nikolov and capacity. Neutrophils showed enlarged zymogen granules and were
Bettsher. 14 Similar findings were present in pericardial and skin primed for proteolysis. The changes were more marked in direct
biopsies. 15 Since, as McVay16 emphasized, the anterior rectus herniation and those with bilateral defects,23 suggesting that the
sheath is continuous with the transversalis fascia (as demonstrated presence of a preformed sac allowed indirect herniation with less
historically by the success of relaxing incisions in the former to re- attenuation of the transversalis fascia than was seen with direct
duce suture tension after herniorrhaphy), the data reflected protrusions. The age distribution of 2,500 hernia cases admitted
changes in the floor of the inguinal canal unaffected by scarring, to our surgical service resembled that of 500 patients treated for
secondary to the protrusion itself. lung cancer and another 3,000 cases with cardiovascular diseases
related to chronic smoking.
The changes in collagen that we observed in our patients were
Hypothesis described later (1984) by Berliner, who concluded that fascia and
aponeuroses are dynamic, metabolically active structures charac-
Veterans were presenting in late middle-age with a surprisingly terized by an ongoing balance of collagen synthesis and enzymatic
high incidence of primary inguinal herniation, almost half having lysis. Basic concepts concerning the pathogenesis and repair of
direct or bilateral defects. They showed evidence of widespread groin hernias revolve around this essential point. 24 In 1998, Pans
damage to connective tissue, different from that seen in lathyrism and Pierard, using biomechanics and immunochemistry, con-
because cross-linking of collagen was unaffected. Almost all cluded, "The collagen framework of the transversalis fascia was
smoked heavily, having become addicted to nicotine when ciga- modified, mainly in the direct hernia group, associated with in-
rettes were sent with the rations during World War II. Many had creased vascularity and cellularity. Similar changes were observed
already suffered the consequences-emphysema, lung cancer, ac- on the nonherniated sides, suggesting that connective tissue
celerated atherosclerosis, and so on. Since the collagen changes pathology plays a role in the genesis of groin hernias."25,26 This
in their skin biopsies (similar to those in the groin) resembled degeneration resembles that previously described in the skin of
those seen in the skin and lungs of patients with pulmonary em- smokers (wrinkles).27 Peacock, while maintaining that the con-
physema, with or without deficiency of a-l-antitrypsin,l7 it seemed nective tissue changes in adults with groin herniation are restricted
likely that smoke was damaging not only their lungs but, by a sys- to the groin, also allowed that the pathology was present on the
temic effect, the abdominal wall. This allowed herniation through clinically normal side. 28
a locus minoris resistentiae, the inguinal canal. The conclusion was In 1988, the use of tobacco was reported to be significantly more
that long-term excessive exposure to tobacco smoke was a risk common in patients presenting with hernia, especially women. 29
factor for groin herniation. To ascertain the mechanism involved, Ten years later, Scott found that the use of tobacco was twice as
we first considered what was known about how smoking damages common in 130 patients operated on for recurrence, compared
the lung. to those treated for primary herniation. 3o In the late 1980s, Weitz
Prior to 1962, clinicians speculated that destruction of alveoli and his colleagues31 provided independent support for the
in this condition resulted from mechanical factors (cough and metastatic emphysema hypothesis when they unequivocably re-
forced expiration against resistance) similar to those to which her- covered the "fingerprints" of free active neutrophil elastase (in-
nias were once ascribed. However, Laurell and Eriksson'sl8 report creased fivefold) from the plasma of cigarette smokers by
of predisposition to this disease secondary to an inherited defi- measuring a specific fibronopeptide cleavage product of fibrino-
ciency of a-I-antitrypsin, coupled with its experimental produc- gen identified by radioimmune assay. They concluded, "Our find-
tion by Gross et aI., using tracheal instillation of proteolytic ings raise the possibility that other systemic complications of
enzymes,19 led to the now accepted protease-antiprotease imbal- cigarette smoking (for example, atherosclerotic disease) may be
ance theory. Smoking stimulates a neutrophil-macrophage re- the result of uncontrolled neutrophil elastase activity." Most re-
sponse. Their five- to-tenfold concentration in the lungs, with cently (1998), Jorgensen et al.,32 in an elegant prospective ran-
activation and release of zymogen elastase, is the prime mover. domized study, matched young male and female volunteers, 19
Further, oxidant combustion products of tobacco damage an- smokers and 18 nonsmokers. Deposition of total protein and ma-
tiprotease defenses. 2o ture collagen was assessed in a wound healing model implanted
To explain the systemic effects of smoking, and in particular the subcutaneously for 10 days. Nonsmokers produced almost twice
effect on connective tissue, we envisaged that the chronic inflam- the amount of hydroxyproline in granulation tissue as their coun-
matory response in the lungs was spilling over into the systemic terparts, who smoked an average of 20 cigarettes a day. Other pro-
circulation. Uninhibited proteolytic activity and large numbers of teins were unaffected. Thus, they were able to demonstrate that
activated neutrophils and macrophages, along with products of to- in humans, smoking specifically impedes collagen synthesis.
bacco combustion, were causing collagenolysis and inhibiting re-
pair.21 The process (metastatic emphysema) would be analogous
to distant damage to the lung and skin seen in acute pancreatitis Proteolysis in Patients with Aneurysm
or the secondary pulmonary effects of visceral or extremity
ischemia. 22 Yet another abdominal protrusion, aortic aneurysm, was once
blamed on mechanical factors, turbulence, and hypertension and
aging abetted by atherosclerosis. Nevertheless, smoking was shown
Supporting Data to be a risk factor in 1968. 33 Auerbach 34 later found nonsmokers
with aortic aneurysm to be outnumbered eight to one, while Cro-
Our patients with inguinal herniation, many of whom had associ- nenwett35 determined that the presence of obstructive pulmonary
ated pulmonary emphysema, had leukocytosis with elevated cir- disease was the best predictor of rupture. In 1980, Swanson et al. 36
culating elastolytic activity and a reduced antiproteolytic inhibitory for the first time invoked a metabolic factor, endogenous collage-
17. Metabolic Aspects of Hernia Disease 141
nase, in the pathogenesis of ruptured aneurysm. Busutill et al.,37 In 1992, Deak et al. 51 demonstrated abnormal synthesis (colla-
the same year, reported that elastase caused aneurysm, with its 70 gen gene expression) in cultured skin fibroblasts taken from two
to 80% loss of elastin, but prevented occlusive disease. They sug- patients with multiple aneurysms, suggesting sporadic mutation.
gested the enzyme originated in neutrophils or monocytes. Two However, a number of individuals with single aneurysms showed
years later, we 38 reported that smokers with aortic aneurysm, but no such change despite a positive family history. The following
not Leriche's syndrome, demonstrated leukocytosis with elevated year, this group studied nine men, 17 to 67 years of age, with ei-
serum and leukocyte elastase activity (later to be confirmed, even ther indirect or direct inguinal herniation. Few smoked, some had
after excision of the aneurysm 39 ) and reduced antiproteolytic ca- a familial history, and a third demonstrated joint hypermobility.
pacity. Smoking was then experimentally shown to increase aortic Isotopically labeled skin fibroblasts secreted twice as much type III
elastase content. 40 collagen (one of the two most common among the 29 different
Since these findings were similar to those previously described forms) as controls. This altered ratio with the usually predominant
by us in patients with hernia, we investigated the possibility of an type I collagen, led to a decrease in insoluble (polymeric) fibrils,
association between the two conditions. We found inguinal her- confirming our original observations. Thus the proportion of col-
niation to be twice as common in patients with aneurysm, com- lagen types regulates fibrillogenesis, fibril diameter, and bundle
pared to those having Leriche's syndrome thrombotic occlusion architecture. They commented, "An increase in type III collagen,
of the aorta. In addition, the former had more severe fascial at- (a metabolic abnormality of production) may predispose certain
tenuation with earlier and larger, mainly direct, recurrent or bi- individuals to the development of inguinal herniation and recur-
lateral hernial defects. 23 This significant association was confirmed rence after corrective surgery. "52 Genitourinary prolapse in women
by Lehnert and Wadouh in 1992.41 They reported herniation af- was shown53 in 1990 to be similarly associated with hypermobility,
fecting 1 of 3 patients with infrarenal aortic aneurysm. A similar suggesting an underlying connective tissue disorder. In 1996,
relationship was later shown42 and repeatedly confirmed43 ,44 to collagen deficiency with increased cross-linking and decreased
hold true for incisional herniation after resection of an aneurysm, solubility associated with collagenolysis was identified54 in this
but not for occlusion with aortofemoral prosthetic interposition. condition.
In 1984, Brown et al. 45 reported increased serum monocyte de-
rived circulating elastase activity persisting long after the aneurysm
was excised, proving that these proteases do not originate in the Conclusion
smooth muscle cells of the aneurysmal wall. Rizzo et al.,46 in
1988, described inflammatory infiltrates permeating the wall of In infancy, herniation is known to relate to prematurity or known
aneurysms. connective tissue disorders. In adults, cigarette smoking has been
Cigarette smoking has also been correlated with the formation, shown to damage connective tissue, causing attenuation of the
expansion, and rupture of saccular aneurysms arising in the in- transversalis fascia, thus leading to inguinal and incisional herni-
tracerebral arteries, previously thought to be congenital. 47 The fact ation (metastatic emphysema). Genetic mutation can also inter-
that pancreatic trypsins and elastase have been identified in the fere with collagen type I and III synthesis, thereby playing a role
blood of smokers and may contribute to the development of ab- in herniogenesis. Thus, Keith's suggestion 75 years ago that a
dominal aortic aneurysm emphasizes the damage inflicted by to- pathological change in connective tissue could cause herniation
bacco use on protective circulating antiprotease mechanisms. 48 has been confirmed by a number of investigators. These findings
Thus, in smokers, aneurysm, like herniation, has to be considered support the increasingly widespread use of prostheses in the re-
the result ofa systemic protease-antiprotease imbalance. This con- pair of abdominal herniation, as well as the need to widely en-
clusion is supported by a reported eightfold increase in the inci- compass Fruchaud's myopectineal orifice.55
dence of cerebral aneurysm in patients with a-I-antitrypsin
deficiency correlated with a similar change in plasma elastase. 49
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Smoking does not always lead to death from lung cancer or a heart
1a. Stoppa R, Wantz GE, Munegato G, Pulchinotta A. Hernia Healers: An
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hood. Recently (1997), autosomal dominant polycystic kidney
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142 R.C. Read
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] Surg. 1970;120:610-614. in relation to smoking habits and age. Chest. 1980;78:805--809.
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sheath and transversalis fascia in adult groin hernias. Hernia. 1999; 49. Baker Cj, Flore A, Connolly ES Jr, et al. Serum elastase and alpha-l-
111:45-51. antitrypsin levels in patients with ruptured and unruptured cerebral
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premature facial wrinkling. Ann Intern Med. 1991;114:84()-.844. 50. Morris-Stiff G, Coles G, Moore R, et al. Abdominal wall hernia in
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development of inguinal hernia? Pol Tyg Lek. 1988;43:974-976. sis of type III procollagen in cultured skin fibroblasts from two patients
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Society, Miami Beach, FL, Feb. 1998. gene expression and protein synthesis in patients with inguinal her-
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activity in cigarette smokers. Ann Intern Med. 1987;107:680-682. 53. Baker NP, Baker J, Sharp H, et al. Genitourinary prolapse: relation-
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aneurysm. Arch Environ Health. 1969;19:167-182. 55. Fruchaud H. Traitement ehirurgieal des hernies de l'aine. Paris: Doin; 1957.
18
Pathological Tissue Changes
and Hernia Formation
Alain Pans
Introduction preperitoneal space. Once the preperitoneal dissection was ac-

complished, good exposure of the posterior wall of the inguinal
Classically, inguinal hernias are considered the result of a multi- canal was obtained. Biopsies of constant surface area were taken
factorial process linking predisposing anatomical and dynamic from the transversalis fascia, on the left and right sides, as well as
factors: intra-abdominal pressure acting on a weak area, the myo- from the anterior rectus sheath. Analogous samples were taken
pectineal orifice, which is sealed by the transversalis fascia. All from a control group made up of autopsy subjects within 24 hours
groin hernias are therefore characterized by the displacement of of death and of organ donors.
this fascia by a peritoneal sac. There are individual anatomical vari- The study included 63 patients (89% men) with 88 groin her-
ations that aggravate the fragility of the inguinal region, enlarg- nias. Mean age of patients was 57.7 years. The hernias were in-
ing the weak area and rendering less effective the physiological dexed according to the classification of Nyhus. s Eligible for the
protective mechanisms of the inguinal region. l To these are added study were 38 fascias from nonherniated groins, 32 from indirect
histobiochemical factors, which are unquestionably the least hernias (type II), 40 from direct hernias (type IlIa). The mean
known at present, but very likely playa key role in the genesis of age of the 30 control subjects (63% men) was 59.5 years.
inguinal hernias. In the light of the work of Peacock and Madden2 The biomechanical properties of these tissues were evaluated
and Wagh, Read, and Cannon,3-6 it appeared that hernia forma- using a commercially available apparatus, the Cutometer® SEM
tion was actually based on much more fundamental metabolic col- 474 (C&K Electronics, Cologne, Germany) equipped with an as-
lagen anomalies. Hence, inguinal hernia could be considered a pirator probe 2 mm in diameter. The deformation of the tissue in
local manifestation of systemic collagen pathology. This aspect has, the opening of the probe was registered by computer. Three cy-
however, been studied very little up to now. This is why we un- cles of 5 seconds of traction under negative pressure of 50 and
dertook a detailed study of the transversalis fascia and the sheath 200 millibars, separated by periods of relaxation of 5 seconds, were
of the rectus abdominis muscle in control groups and in patients successively applied to each specimen. The application of the first
with inguinal hernias. We first analyzed the macroscopic biome- cycle of suction resulted in an immediate elastic distension (ED 1) ,
chanical properties of these structures, then proceeded to the mi- recorded at 0.15 s, followed by a delayed viscoelastic distension
croscopic level in an attempt to clarify them by means of their and ending with measurement of the maximum distension (MDl)
histologic characteristics. of the tissue obtained after 5 s of traction (Fig. 18.1). When trac-
tion was discontinued, the tissue tended to return to its initial
shape. During that phase, the immediate elastic retraction (ERl)
after 0.1 s of relaxation and the resilient distension (RDl) after a
Biomechanical Characteristics of the 5 s relaxation time were recorded. The differential distension
(DD) was calculated as the difference in maximum distension be-
Transversalis Fascia and the Anterior tween the third (MD3) and the first (MDl) cycles. Calculated in
Rectus Sheath addition were the viscoelastic ratio (VER), the biological elasticity
(BE), the elastic function (EF), and the relative elastic recovery
We have at our disposal very little information concerning the me- (RER) (Table 18.1). The indicator 50 or 200 was added to each
chanical properties of the transversalis fascia. Minns and Tinck- biomechanical variable to indicate whether the measure was per-
ler7 have studied the mechanical characteristics of the transversalis formed at 50 or 200 millibars respectively.
fascia of inguinal hernia patients. The ultimate tensile strength of Our study is original in that it employs in hernia pathology re-
these tissues was lower than that of controls. cent evaluative technology developed for pathologies of the skin.
All the patients in our study underwent bilateral inguinal her- Actually, the Cutometer was initially intended to identify the me-
nia repairs, whether the condition was itself bilateral or whether chanical properties of healthy and pathological skin in vivo. The
it was decided, with the patient's consent, to treat the unaffected suction levels of 50 and 200 mb correspond to physiological pres-
side preventively. The technique used was a midline suprapubic sures exerted upon the transversalis fascia, at rest and while cough-
approach with placement of a prosthesis on each side in the ing respectively. 9
143
144 A. Pans
in maximum distension at 200 mbar compared to controls, they

0.5
constituted nevertheless an entirely separate pathological group,
as we have shown in an earlier work. IO
0.4 Two highly significant correlations appeared entirely character-
istic of direct hernias: at 200 mbar, as MD and ED increased, EF
E diminished. This means that the more the fascia is stretched out,
S 0.3 the less readily it springs back to its original position. One may
c:
0 therefore suspect that there is an impediment to the immediate
~
> rebound of the fascia, in keeping with an architectural disorgani-
Q) 0.2
iii zation of the collagen lattice.
We have also demonstrated that in the herniated fascias, as well
0.1 as in those from nonhernia sites, the difficulty in returning to their
initial position was proportional to the importance of the stress to
which they had been submitted. This is in good agreement with
0.0
0 5 10 15 20 25 30 the clinical history of hernias whose volume increases progressively
with time, evidence that the transversalis fascia returns less and
Time (5) less to its original state.
FIGURE 18.1. Biomechanical parameters recorded during the elevation of
the transversalis fascia over time. Pressure: 200 mbar. ED1, elastic (imme-
diate) distension (0.15 s); MD1, maximum distension at the end of the Analogy with Skin at 50 mbar
first traction (5 s); ER1, elastic (immediate) retraction (5.1 s); RD1, re-
silient distension at the end of the first cycle (10 s); MD3, maximum dis- The fascias of direct hernias and of nonhernia sites show an in-
tension at the end of the third traction (25 s). crease in extensibility (MD and ED) and of elasticity (BE and
RER). Such biomechanical characteristics were observed in the
In the study of the mechanisms contributing to the creation of skin of patients with Ehlers-Danlos syndrome, mainly of types I
an inguinal hernia, it seems to us important to sample the trans- and nY
versalis fascia at the level of the posterior wall of the inguinal canal
itself, the quintessential "critically weak" area, forming the bed of
future direct hernias. As for the rectus sheath, it is considered an Analogy with Skin at 200 mbar
indicator of systemic pathology of connective tissue.
The mechanical behavior of the transversalis fascia was markedly The fascias of direct hernias and of nonhernia sites show above
different from that of the rectus sheath, a thicker and more solid all an increase in extensibility (MD and ED). The increase in elas-
structure macroscopically. The fascia showed much less elasticity, ticity is significant only for direct hernias and to a degree 20 times
a clearly increased viscoelasticity, and increased deformability dur- less than that at 50 mbar. This comes closer to the biomechanical
ing successive applications of mechanical stress. characteristics of stretch marks following childbirth. 12 However, in
Overall, we did not observe any important difference in the me- that cutaneous pathology, the elasticity parameters are no differ-
chanical characteristics of the rectus sheaths of patients and con- ent from those of healthy skin.
trols. This would seem to not support a major systemic pathology
of connective tissue.
Nevertheless, the transversalis fascias from direct hernia patients Influence of in vivo and ex vivo Conditions
showed an extensibility (MD, ED-50 and -200) and elasticity (BE-
50) very significantly higher than those of controls. This differ- It is also necessary to take into consideration the fact that our mea-
ence in elasticity leveled off at 200 mb. The same characteristics surements were made on loose excised samples, hence the elimi-
were seen, to a slightly lesser extent, in the fascias from non her- nation of tensions transmitted to them by neighboring tissues. As
nia sides, regardless of the type of hernia (direct or indirect) on far as skin is concerned, the biomechanical properties of normal
the affected side. MD and ED-50 and -200 were significantly higher, skin ex vivo appear identical to those of the skin in vivo. 13 By con-
whereas the significant elevation of BE disappeared at 200 mbar. trast, this is not the case with stretch marks. Extensibility remains
We may conclude that the fascia, presumed healthy at the time of increased, but the elasticity of stretch marks ex vivo is significantly
the intervention, also showed pathological characteristics. Thus, reduced, while it does not appear to be altered in vivo. This is
the observed changes appear to be the cause, rather than the con- probably due to the presence of traction in situ which maintains
sequence, of hernia. stretch marks under relative tension.
Although fascias from indirect hernias alone showed an increase From the sum total of these comparisons, it appears once more
that the best correlation is observed between the biomechanical
behavior of the fascias of direct hernias and nonhernia sites (at
TABLE 18.1. Biomechanical parameters 50 mbar) and that of the skin of patients with type I and II Ehlers-
Extensibility parameters Elasticity parameters Danlos syndrome.
The etiology of these two types of Ehlers-Danlos syndrome is not
MD (mm) BE = 102 (MD1 - RDI)MDI-I (%) yet known; however, the gene coding for the al chain of type V
ED (mm) EF = 102 (MD1 - ER1)EOl- 1 (%)
collagen appears to be implicated. 14 Recently, a mutation in the
DD = MD3 - MD1 (mm) RER = 102 (MOl - ER1)MD- 1 (%)
C-propeptide of the pro-al chain of type V collagen was demon-
VER = 102 (MD1 - ED1)EOl-I (%)
strated, which carries with it a diminished synthesis of type V col-
18. Tissue Pathology and Hernia Formation 145
lagen and in this way causes an anomaly in the fibrillogenesis of

type I collagen.15
Immunohistological Characteristics
of the Transversalis Fascia and
the Rectus Sheath
There are only a few histologic studies of the anatomical struc-
tures of the inguinal region. Berliner16 observed in certain cases
a scarcity and fragmentation of the elastic fibers as well as degen-
erative changes (unspecified) in the transversalis fascia taken from
the site of a hernia. Weinstein and Roberts l7 have studied the ex-
ternal oblique aponeurosis in 20 patients operated on for inguinal
hernia, among whom the age varied between 3 and 80 years. They
noted the same relative proportion of collagen fibers and elastic
fibers in all the age groups, with a predominance of collagen fibers
and few blood vessels. Panou de Faymoreau l8 carried out, during
hernia treatment, the removal of samples containing transversalis
fascia and the aponeurotic structures of the region. He observed
a predominance of fatty tissue, abundant and congested vascular-
ity, disorientation of aponeurotic fibers, and fragmentation of elas-
tic fibers surrounded by sclerosis. None of these mainly qualitative
studies makes reference to control tissues.
On the samples obtained for the biomechanical study, we per-
FIGURE 18.2. Thick parallel collagen bundles packed in a control rectus
formed a histologic study. The detailed information on the histo-
sheath, with the fine collagen network connecting the subcutaneous tis-
logic techniques used can be found in our original paper. l9 This sue and sheath (XIO, transverse section, Masson trichrome) .
study included 10 rectus sheaths of patients and controls, 15 con-
trol fascias, 15 direct hernia fascias, 15 indirect hernia fascias, and We have not observed any architectural difference between the
21 fascias taken from nonherniated sites. The latter were subdi- sheaths of controls and those of patients in relation either to the
vided into two groups according to whether the contralateral side elastic fibers or to the bundles of collagen. Nor did the two groups
showed a direct (n = 9) or indirect (n = 11) hernia. present any significant difference in terms of the quantity of
The sections were carried out in three spatial planes (coronal, adipocytes, of cellularity, or of the number of vessels per field.
transverse, and sagittal) , whenever the quantity of material allowed.
They were stained with hematoxylin and eosin, with Masson's
trichrome and the double stain of mixed picrosirius red and or- Fascias
cein. An immunohistochemical study was carried out in order to
demonstrate the endothelial cells with the help of Ulex europaeus Smooth Muscle Fibers
lectin and a polyclonal antibody. The enumeration of elastic fibers
stained with orcein was done by a computerized system for ana-
It is necessary to note the presence of smooth muscle fibers (SMF)
lyzing images (analySIS®, Soft-Imaging Software GmbH, Munster, within the fascia itself, in the same amount in both controls and
Germany).
Rectus Sheaths
Sections of the anterior rectus sheath from control subjects were
characterized by a regular three-dimensional structure of collagen
bundles. This consisted of thick bundles always arranged parallel
among themselves, usually transversely (that is to say, perpendic-
ular to the linea alba) or occasionally obliquely, depending on the
location (Fig. 18.2).
Consistently, there was a fine network of interwoven collagen
fibers insuring the connection of subcutaneous tissue and the
sheath (Fig. 18.3). This network was observed much less often be-
tween the sheath and the muscle.
Elastic fibers within the sheath itself were few, regularly distrib-
uted, sometimes cut crosswise, sometimes lengthwise in the same
plane. They were much more abundant in the fine subcutaneous,
preaponeurotic lattice of collagen fibers. Their plane of section FIGURE 18.3. Fine collagen network connecting the subcutaneous tissue
was similarly variable, depending on location (Fig. 18.4) . and sheath (X20, picrosirius red in polarized light).
146 A. Pans
same way that striated muscle fibers come to be inserted in their

tendon. It is therefore not impossible that these smooth muscle
fibers confer a certain contractile function on the transversalis fas-
cia, enabling it to participate in the protection of the inguinal re-
gion against abdominal pressure.
Adipocytes
The proportion of adipocytes observed in the control fascias (0:
4 cases; +: 6 cases; + +: 4 cases; + + +: 1 case) did not differ sig-
nificantly from that observed in the different groups of pathology.
We did not think, therefore, that the phenomenon of fatty de-
generation was an essential element of hernia disease.
FIGURE 18.4. Elastic fibers (in black) in the preaponeurotic network (X20, Number of Vessels and Cells per Field
orcein and picrosirius red) .
The number of vessels and cells per field was significantly in-
creased in the group of direct hernias. No inflammatory infiltrate
patients. These fibers were grouped in bundles and formed an in- was observed in any of the fascias.
This agrees with the observations of Panou de Faymoreau 18 de-
tegral part of the supporting tissue of the transversalis fascia, as
shown in Fig. 18.5. scribing abundant, congested vascularity in inguinal tissues taken
To our knowledge, this has never been described in the litera- from a hernia site. However, the mean diameter of the vessels ob-
ture. Of course, insertion of the cremaster into the transversalis served in our study was 50 /-Lm. The vascular walls were normal. It
fascia is mentioned. 2o By analogy, we have searched for smooth is thus not a matter of newly formed vessels, such as one might
muscle fibers in the spermatic cord, an anatomical structure in see in granulation tissue.
close contact with the transversalis fascia. To do this, we harvested Two hypotheses may explain this observation and could in any
a spermatic cord together with the transversalis fascia of the in- case coexist. The first is that an actual increase in vascularization
guinal floor of an autopsy subject 45 years of age. The same ap- came into being well before the development of the hernia. But,
in that case, it would be a very early phenomenon in the genesis
pearance of smooth muscle fibers, not forming part of a vascular
wall or the vas deferens, was identified in the cord. The smooth of the hernia, as the same normal mature vessels are observed on
muscle nature of these fibers was confirmed by an immunohisto- the nonhernia side. In essence, our earlier biomechanical study
and the histological considerations which follow argue for the fact
chemical stain with the aid of murine monoclonal antibodies
that the non hernia side is already at a preclinical stage of hernia
against a-actin of smooth muscle (Fig. 18.6).
The literature makes no mention of the presence of smooth development.
The second hypothesis would move mainly in the direction of
muscle fibers within the spermatic cord,21 although they are de-
scribed in the round ligament. 22 However, some 10 cases ofleiomy- relative growth of the vascularization in direct hernias. It is in fact
logical to think that the vessels of the transversalis fascia are
oma of the spermatic cord, a very rare smooth muscle tumor, have
stretched by the volume of the actual underlying hernia. Once the
been reported in the literature. 23
fascia is excised, this extrinsic tension disappears, and it is possi-
One may consider that the smooth muscle fibers of the sper-
matic cord come to be inserted in the transversalis fascia in the ble that the vessels then take a more tortuous form due to their
relatively excessive length. From a histologic point of view, this
would mean that the plane of section could cut across a winding
vessel many times, leading to an apparent increase in the number
of vessels per field. The latter hypothesis seems to us likely.
As for the increase in the cellularity per field in the direct her-
nia group, it is probably due in part to the increase in the num-
ber of vessels per field. We have not observed any inflammatory
infiltrate.
Elastic Fibers
Elastic fibers were present throughout the thickness of the trans-
versalis fascia. Their configuration was sometimes longitudinal,
sometimes fragmented depending on the plane of section. The
elastic fibers of the fascias of patients presented a morphology and
a distribution similar to those of controls (Fig. 18.7). There was
FIGURE 18.5. Smooth muscle fibers (S.M.F.) in the thickness of a control no difference in terms of percentage of surface area occupied by
transversalis fascia (X 10, frontal section, Masson trichrome) . elastic fibers .
A 8
FIGURE 18.6. Spermatic cord (autopsy). The side of the transversalis fascia (B) Smooth muscle fibers stained by antismooth muscle antibodies. The
is stained in black by India ink. (A) Striated cremasteric muscle fibers cremasteric muscle is not stained. Reprinted from Hernia 1999;3:45-51 ,
(C.M.) and smooth muscle fibers (S.M.F.) (X4, Masson trichrome). with permission.
We confirm, therefore, the fragmented appearance of elastic logical fascias and to augmentation of the number of fibers in di-
fibers, according to location, observed by Berliner 16 and Panou de rect hernias and in nonhernia sites. The proportion of cases show-
Faymoreau. 18 But this fragmentation is also seen in control fascias. ing zones of architectural disorganization was significantly more
Consequently, we think that it is rather a case of a characteristic elevated in the direct hernia group and the nonhernia sites of
linked to the plane of section through the elastic fibers. In a par- which the other side was also a direct hernia.
ticular plane, elastic fibers can be sectioned transversely, obliquely, These semiquantitative results were confirmed and refined by
or longitudinally according to their arrangement. By analogy with studying the number of interactions of the collagen lattice with
skin,24 it is also necessary to take into consideration the fact that a line traced perpendicular to the general orientation (Fig. 18.9).
fragmentation of elastic fibers can also be a result of aging. Three zones of the section were considered, the architectural
zone most representative of the totality of the section, as well
as two other zones as different as possible from each other on
Collagen Lattice the architectural plane. The notion of variability was studied,
calculating for each section the difference between the two
The transversalis fascia was characterized by an architectural or- most extreme values. The mean of these differences was then
ganization much more heterogeneous than that of the rectus calculated.
sheath. In general, it was a weave of bundles of collagen present- By comparison with the control group, a significant progressive
ing, according to the plane of section, a preferential orientation. increase in the number of intersections in the representative zone
The quantity of bundles, fascicles, and fibers of collagen was es- of each section was observed in the indirect hernia group, the non-
timated in a semiquantitative manner according to the score 0, +, hernia sites, and direct hernias respectively. This increase in the
++, +++ (Fig. 18.8). We observed a tendency toward diminu- nonhernia group was observed independent of the type of hernia
tion of the number of fascicles in the three categories of patho- on the other side. This signifies, therefore, that if the number of
FIGURE 18.7. Elastic fibers in a control transversalis fascia (X20, longitu- FIGURE 18.8. Fibers, fascicles, and collagen bundles in a control fascia (Mas-
dinal section, orcein and picrosirius red) . son trichrome) . Reprinted from Hernia 1999; 3:45-51, with permission.
148 A. Pans
-:: .,,; '~~-".. ' ~• . ,'\,'\' i.!. ~J.l.~'\ " ,;:'f'" J", ;'
I, ;.. • _ ~ I ' .. '" '. ~ -.,.~ \ '\ • (" ""
~ .......c. - t ....... \ ' . ' , \ \ • .
p ~"
.. '.";,,....ttr...........
. .......
oJ. \"'-f\~i~" "-:
,
_4._~.. ~""" '.

~.... .# • .,....,
.• " .• ) -, \. .-.~1 .,.It ~-T\" ,
_. '!\~~~~ ~_.~...~ ~;,~ ; l;.~~
..'
. .,. . . . . --
, _~''''''.' •
_.~ : .........,...
.'- .~..-..II"'
.-:....
. ' _-"0.:'\\
•
. '. ~'
~
-"'.' l.I ....c,...
:_. ,~ ~ ~I' , .• -
">?!I
. . . ' .' .'
c"-" . • . -~
. - . - .::&
.. •• _ . ~~.T';' ~ ... ,
A ~:.;; \
<011.. - . . " -...",. . : . - ~. ~
'_.~ ~ ::."l .
.'---;.
- .i"'!:' "~~/'-~
. ' ..... 1 ' 1 ( . . . . .
~
~~
\
"'~~~"-':"~-'
-.»-.... . : . . '.i'
.
'~ " .,:!' .~ .... ~. .
. .~, ,
rr .. t
....
' : ' .".,.. .
. ...
• ,) . ~.,. '. . '.J" .
~~ - -- ". . ~--
~-. ~ .:.
~. '== /•.' , . •: '
:~ -
.:.... ' ",' "",." ~'l_~_... , '.......
.. - "
."
_ .
." ... - :;r~
.' ,J
'. '
'.. ~ . ...
'-':
- ~ ..• .~
'\
.• ' I
FIGURE 18.10. Disorganized collagen framework in a direct hernia trans-

versalis fascia (X 20, transverse section, Masson trichrome) .
General Summary and

Etiopathogenic Hypotheses
Direct Hernias
FIGURE 18.9. Count of the intersections of the collagen framework with a
line perpendicular to its orientation. The inserted rectangle is a magnifi- The fascia samples taken from direct hernia sites are those that
cation of a part of this line. show the most obvious biomechanical and histological changes.
This is why one observes a significant increase in extensibility and
elasticity at 50 and 200 mbar, independently of the volume and
the duration of the hernia. From the histological point of view, let
interactions increases, it is because the number of fine fascicles us remember the important architectural disorganization of the
and isolated fibers is increased. collagen lattice with increased numbers of fine fascicles and iso-
The study of the difference between the extreme values revealed lated fibers. These are associated with enhanced vascularity and
a very significant increase in the variability of the number of in- cellularity.
tersections in the nonhernia group, regardless of the type of her-
nia on the other side, but more marked when it was a direct hernia.
This could indicate a dynamic process evolving eventually toward Indirect Hernias
the more stable pathologic state represented by the established
hernia. We observed a similar variability in the direct hernia and In relation to indirect hernias, the fascias show increased extensi-
indirect hernia groups. But there is nevertheless, in these two bility at 200 mbar, regardless of the volume and duration of the
states, a very clear tendency to an increase in variability compared hernia. The collagen lattice is characterized above all by an in-
to control tissues (p = .14 for direct hernias and p = .07 for indi- crease in the number of fine fascicles and isolated fibers.
rect) .
One of the elements that best characterizes the fascia of direct
hernias is the disorganization of the collagen lattice, with an in- Nonhernia Sites
dication of disintegration of bundles into fibers (Fig. 18.10). This
does not correspond to the histologic appearance usually seen in The most interesting point is that the fascia from the nonhernia
stretch marks, where the collagen is arranged in bundles parallel site also shows multiple biomechanical and histological anomalies.
to each other and lying in the direction of the mechanical There is an increase in extensibility at 50 and 200 mb as well as
stress. 25- 27 an increase in elasticity at 50 mbar. The collagen lattice similarly
On the other hand, this architectural disorganization of colla- shows structurally disorganized zones with increased numbers of
gen is one of the possible histologic characteristics of the skin in fine fascicles and isolated fibers. We also observe a much more im-
type I and II Ehlers-Danlos syndrome. Although the histologic portant architectural variability in this group that may indicate a
changes of this syndrome are often nonspecific and inconstant, it dynamic process of connective tissue realignment. All of these
is nevertheless described as a disorganization of the architectural anomalies are seen, independent of the type of hernia (direct or
pattern of collagen, with irregularity of form and size, thinning of indirect) on the other side.
the bundles of collagen, and diminution of their number. 15,28-30 According to these observations, it seems to us the transversalis
The increase in extensibility of the skin observed in these two types fascia excised from nonhernia sites must be considered a patho-
of Ehlers-Danlos syndrome probably results from this architectural logical fascia. It may correspond to a preclinical stage of hernia
disorganization of collagen. ll ,29 disease.
The characteristics of the nonhernia side lead us also to con- dominal wall: principles and management. 4th ed. Philadelphia: J.B. Lip-
sider that a connective tissue pathology appears implicated in the pincott Company; 1995:153--177.
genesis of inguinal hernias and that this appears mainly to affect 9. Pans A, Pierard GE, Albert A, et al. Biomechanical assessmentof the
collagen fibers. The increase in extensibility of pathological fas- transversalis fascia and rectus abdominis aponeurosis in inguinal her-
niation-preliminary results. Hernia. 1997;1:27-30.
cias is very probably secondary to the architectural disorganization
10. Pans A, Pierard GE, Albert A, et al. Adult groin hernias: a new insight
of the collagen fubric. By analogy with what one sees in the Ehlers-
into their biomechanical characteristics. Eur] Clin Invest. 1997;27:
Danlos syndrome, the increase in elasticity is only a consequence 863-868.
of the structural alteration of the collagen, given the tight rela- 11. Henry F, Goffin V, Pierard-Franchimont C, et al. Mechanical proper-
tions among the fibers of collagen, elastic fibers, and ground sub- ties of skin in Ehlers-Danlos syndrome, type I, II, and III. Pediatr Der-
stance, whose three dimensional design is in the end responsible mato! 1996;13:464-467.
for the macroscopic biomechanical properties of the anatomical 12. Henry F, Pierard-Franchimont C, Pans A, et al. Striae distensae of preg-
structure under consideration. According to this hypothesis, it nancy. An in vivo biomechanical evaluation. Int] DermatoZ. 1997;
would thus be a matter of connective tissue pathology expressed 36:506-508.
preferentially in the inguinal region, since we have observed no 13. Pierard GE, NizetJL, AdantJP, et al. Tensile properties of relaxed ex-
cised skin from the breast exhibiting striae distensae.] Med Eng Tech-
m.yor difference between the rectus sheaths of controls and those
no! 1999;23:69-72.
of patients. If this is the case, inguinal hernia would be nothing
14. Burrows NP, Nicholls AC, Yates JR, et al. Genetic linkage to the colla-
but the manifestation, at the site of least resistance when submit- gen ll'] (V) gene (COL5A1) in two British Ehlers-Danlos syndrome
ted to important mechanical stresses, of a more generalized prob- families with variable type I and II phenotypes. Clin Exp Dermatol.
lem of collagen metabolism. Eventually, genetic factors currently 1997;22:174-176.
unknown may also be involved in the particular expression of this 15. De Paepe A, Nuytinck L, Hausser I, et al. Mutations in the COL5A1
disease. The same problems are encountered in the study of the gene are causal in the Ehlers-Danlos syndrome I and II. Am] Hum
different types of Ehlers-Danlos syndrome. In this condition, not Genet. 1997;60:547-554.
all connective tissues are altered in the same way, and symptoms 16. Berliner SD. Adult inguinal hernia: pathophysiology and repair. Surg
are manifest, to different degrees, in skin, joints, vessels or in yet Ann. 1983;15:307-329.
17. Weinstein M, Roberts M. Recurrent inguinal hernia. Follow-up study
other structures. 31
of 100 postoperative patients. Am] Surg. 1975;129:564-569.
However, to support this hypothesis, it is necessary to pursue the
18. Panou de Faymoreau T. Les plasties locales par plaque de nylon dans
investigations. We have initiated a study of the different types of la cure chirurgicale des hernies inguinales et des eventrations. These
collagen present in the transversalis fascia, as well as a study in the pour Ie Doctorat en Medecine. 1976; Dniversite de Nantes. D.e.r. de
measurement of collagen extraction, which reflects the degree of medecine et techniques medicales de Nantes.
collagen molecular cross-linking. Our first results, yet to be ana- 19. Pans A, Pierard GE, Albert A. Immunohistochemical study of the rec-
lyzed and published, appear to demonstrate a normal proportion tus sheath and transversalis fascia in adult groin hernias. Hernia. 1999;
of type I and type III collagen in hernia fascias, with, however, an 3:45-51.
increase in the extraction of collagen in fascias of not only direct 20. Redman JF. Applied anatomy of the cremasteric muscle and fascia.
hernia, but also of nonhernia sites. Clearly, only knowledge of the ] Urol. 1996;156:1337-1340.
21. Skandalakis JE, Colborn GL, Androulakis JA, et al. Embryologic and
molecular level will permit us to answer in the future the princi-
anatomic basis of inguinal herniorrhaphy. Surg Clin North Am. 1993;
pal practical question raised by our preliminary work: can the non-
73:799-836.
hernia side be treated preventively? 22. Rouviere H. Anatomie humaine descriptive, topographique et fonc-
tionnelle. Vol. 2. Le Tronc. (onzieme ed). Paris: Masson; 1978:167.
References 23. Sarma DP, Weilbaecher TG. Leiomyoma of the spermatic cord.] Surg
Oncol. 1985;28:318-320.
1. Stoppa R, Verhaeghe P, Marrasse E. Mecanisme des hernies de l'aine. 24. Ditto J, Fazio MJ, Olsen DR. Molecular mechanisms of cutaneous ag-
] Chir (Paris). 1987;124:125-131. ing. Age-associated connective tissue alterations in the dermis.] Am
2. Peacock EE, Madden JW. Studies on the biology and treatment of re- Acad Dermatol. 1989;21:614-622.
current inguinal hernia: II. Morphological changes. Ann Surg. 1974; 25. Zheng P, Lavker RM, Kligman AM. Anatomy of striae. Br] Dermatol.
179:567-571. 1985;112:185-193.
3. Wagh PV, Read RC. Collagen deficiency in rectus sheath of patients 26. Nigam PK. Striae cutis distensae. Int] Dermatol. 1989;28:426-428.
with inguinal herniation. Proc Soc Exp Biol Med. 1971;137:382-384. 27. White DJ, Schnur PL. Striae distensae after augmentation mammo-
4. Wagh PV, Read RC. Defective collagen synthesis in inguinal hernia- plasty. Ann Plast Surg. 1995;34:16-22.
tion. Am] Surg. 1972;124:819-822. 28. Lever WF, Schaumburg-Lever G. Histopathology of the skin. 7th ed.
5. Wagh PV, Leverich AP, Sun CN, et al. Direct inguinal herniation in Philadelphia: J.B. Lippincott Company; 1990:87-89.
men: a disease of collagen.] Surg Res. 1974;17:425-433. 29. Pierard GE, Pierard-Franchimont C, Lapiere CM. Histopathological
6. Cannon DJ, Read RC. Metastatic emphysema: a mechanism for ac- aid in the diagnosis of the Ehlers-Danlos syndrome, gravis and mitis
quiring inguinal herniation. Ann Surg. 1981;194:270-278. types. Int] Dermatol. 1983;22:300-304.
7. Minns RJ, Tinckler LF. Structural and mechanical aspects of prosthetic 30. Hymes SR. Disorders of collagen. In: Farmer ER, Hood AF, eds. Pathol-
herniorrhaphy. ] Biomech. 1976;9:435-438. ogy of the skin. Norwalk: Appleton & Lange; 1990:408-411.
8. Nyhus LM. The preperitoneal approach and iliopubic tract repair of 31. Lapiere CM. Ehlers-Danlos syndrome. In: Lapiere CM, Krieg T, eds.
inguinal hernias. In LM Nyhus, RE Condon, eds. Hernias of the ab- Connective tissue diseases of the skin. New York: Dekker; 1993:185-192.
19
The Role of Collagen in Hernia Genesis
Lars Nannestad Jorgensen and Finn Gottrup
There is a discrepancy between the number of publications on congenital hip dislocation in children was associated with an oc-
hernia in general and those addressing the role of collagen as an currence of inguinal hernia five times greater in girls and three
important pathophysiological factor in the development of her- times greater in boys.4 Curiously, it has been reported that patients
nia. On Medline, the search for "hernia" produces more than with indirect inguinal hernia tend to be hypermobile, as gauged
14,000 references, whereas the search for "hernia" plus "collagen" by modified Carter-Wilkinson criteria: the ability to oppose pas-
or "connective tissue" yields only 25. This difference clearly illus- sively both thumbs to the volar aspect of the forearms, or to hy-
trates that the pathophysiological factors for hernia formation perextend the fifth finger to more than 55 or the elbow to more
0
have yet to be fully defined. Many papers address different surgi- than 190 Patients who exhibited two of these three criteria were
0
•
cal techniques and their outcomes. The aim of this chapter is to defined as hypermobile. 5 In a small study, 33% of patients with in-
give an overview of the literature on the role of collagen in her- direct inguinal hernia were found to be hypermobile versus 5%
nia genesis, with a focus on biomechanical tissue features. in the general population. 6 That patients with aneurysm of the ab-
dominal aorta also are predisposed to hernia formation will be dis-
cussed later.
Is Groin Hernia Secondary There is much evidence to suggest that hernia formation may
to Systemic Disease? depend on a systemic predisposition and that this may in tum be
associated with abnormal metabolism of connective tissue.
In addition to individual predisposition, many other factors are
involved in the development of a hernia. For example, chronically
raised intra-abdominal pressure secondary to obstructive pul- Wound Healing and Collagen Formation
monary disease, ascites, hyperplasia of the prostate, constipation,
and pregnancy, is considered a risk factor. l As pointed out by Pea- The development of biomechanical strength in wound tissue de-
cock and Madden, indirect inguinal hernia may appear first in a pends on several complicated steps in the formation of mature
man over 40 years of age. This is not clearly explained by failure collagen. In brief, proliferating fibroblasts produce and secrete
of the processus vaginalis to become obliterated during develop- procollagen. These long triple helix molecules contain high con-
ment. In fact, 20% of males pass into adulthood with a patent centrations of lysine and proline. In the presence of oxygen, vit-
processus vaginalis, but less than 50% of these develop clinical her- amin C, and Fe++, they undergo hydroxylation, with conversion
niation. 2,3 Clearly, factors other than an open processus vaginalis of these amino acids to hydroxylysine and hydroxyproline. Pro-
must playa role in the development of an indirect hernia. Re- collagen converts extracellulary to tropocollagen. Strong cross-
current indirect hernia may follow high amputation of the peri- links between several aligned tropocollagen molecules are created
toneal sac, but here too, more is at work than simple failure on making up collagen fibrils and fibers in the wound cleft. The most
the part of the surgeon. 3 abundant component of the later scar tissue is type I collagen.
Mter day 5, there is a rapid increase in tensile strength of the
wound in almost all types of tissue. Mter the proliferation phase
Other Diseases Associated with an Increased of healing, the maturation phase involves equilibration between
Risk of Hernia Formation formation and degradation of collagen. Collagen fibers are re-
oriented and redistributed, leaving them more compact, thick-
Epidemiological data show increased prevalence of inguinal her- ened, and parallel to one another. Incremental increases in
nia in some patients who exhibit altered connective tissue forma- wound strength have been observed up to one year after wound-
tion, as in osteogenesis imperfecta, cutis taxa, Ehlers-Danlos ing. During the healing process, the wound contracts due to the
syndrome, and Marfan's syndrome. A Swedish study found that action of myofibroblasts.

19. The Role of Collagen in Hernia Genesis 151
Experimental Studies on
the Formation of Hernia 50
Male rats have been used for a hernia model. They have a peri- XH
toneum-lined sac extending into the scrotum on both sides. A fat ~40
deposit at the level of the abdominal wall prevents the transit of #.
abdominal organs into the scrotum. The importance of the colla- ~30
I
gen integrity for the prevention of hernia formation was shown by w
Conner and Peacock. 2 Removal of the fat pad or transection of !Xl 20
the external ring resulted in hernia formation in none of the an- IH
imals, compared with 20% of the animals when the internal ring
was transected. However, if systemic treatment with the lathyro- 10 CF
genic agent beta-amino-proprionitrile (BAPN) was applied with no

concomitant surgery, 6 to 10% of the animals developed a hernia.
When the internal ring was transected and BAPN was adminis- 0 50 150 250
tered, 90% of the animals developed a hernia. BAPN is a highly MO-50 (I-lm)
effective blocker of the enzyme lysyl oxidase, which reduces hy-
droxylysine and impairs cross-link formation between collagen FIGURE 19.1. Plot of the biological elasticity at 50 mbar (BE-50) and max-
imum distension (MD) values. The rectangles are delineated by the mean
molecules. Collagen then becomes more soluble, with significantly
value ± 2 S.E.M. for the transversalis fascia from the control subjects (CF),
less tensile strength. The combination of an anatomical defect and the indirect hernias (IH), the direct hernias (DH) and the nonherniated
an abnormality of collagen cross-linking was needed to produce fascias (NH). Reprinted from Pans A, Pierard GE, Albert A, et al.,JO with
herniation in most animals. permission.
In a previous study, Wirtschafter and Bentley showed that the
effect of a lathyrogenic agent on hernia formation was dependent
the dry weight of this tissue. In a later study from the same cen-
on the age of the rat. 7 Fifty percent of male rats 30 days old ac-
ter, the mean collagen content of anterior rectus sheath tissue as-
quired a hernia after eating the lathyrogenic agent versus none of
sessed as weight of hydroxyproline per weight of defatted fascia
the rats 88 days old. This supports the view that the effect of lath-
was 90 ILg/mg for controls, 82 ILg/mg for indirect hernia patients,
yrism is due to failure in maturation of collagen fibers rather than
and 75 ILg/mg for direct hernia patients. The differences were sig-
collagenolysis.
nificant between controls and patients with direct hernia and be-
tween patients with indirect and direct hernia. 9
A large recent study supported the conclusion that tissue pathol-
Human Studies on the ogy is involved in hernia genesis. 10 Biopsies were taken during
Formation of Hernia open preperitoneal hernia repairs from the transversalis fascia and
rectus abdominis sheath on both sides in 63 hernia patients and
Structural Studies on the Abdominal Wall 30 controls. The biopsies were subjected to biomechanical testing.
Despite the difference in collagen content of the anterior rectus
Peacock and Madden found major structural changes in the trans- sheaths, no difference in elasticity or maximal distension was
versalis fascia of patients undergoing repair of either a unilateral found between the groups. However, the biopsies from the trans-
indirect hernia appearing after the age of 40 years or a recurrent versalis fascia showed significantly higher levels of biological elas-
unilateral hernia of any kind without obvious cause for the re- ticity and maximal distension in direct hernia, compared with
currence. 3 In all the patients, a preperitoneal approach was used controls. Elasticity and distension measurements of the fascia in
to expose both inguinal regions. Biopsies from the transversalis indirect hernia showed intermediate values (Fig. 19.1). Indepen-
fascia were obtained from the edge of the defect and from an iden- dent of the hernia type, there was a significant difference between
tical location in the fascia of the contralateral side. More than half the contralateral nonherniated fascia and the fascia of the con-
of the patients had attenuation of the endopelvic fascia of the trols. The fascia of the asymptomatic side of the hernia patient
asymptomatic side, suggesting a metabolic abnormality of con- thus already presents pathological features at the time of surgery.
nective tissues in the area of the internal ring. It was concluded This supports the proposition that the alterations of the fascia are
that a patent processus vaginalis does not by itself lead to hernia- the cause and not the product of hernia.
tion: structural abnormalities of the internal ring, acquired atten-
uation of transversalis fascia, or abnormal muscle function
accompanying the congenital defect must also be present. The fas- Studies on Proliferation and Synthesis
cial defects were often noted on both sides of the epigastric ves-
sels. The uncontrolled design of this study is a drawback. Cultured fibroblasts from biopsies showed a longer generation
Read took perioperative biopsies from the anterior rectus ab- time and a lower incorporation of radioactively labeled (C14) pro-
dominis sheath close to the midline in patients referred with in- line in patients with hernia, indicating lower rates of cell prolif-
direct or direct inguinal hernias. 8 Control samples were obtained eration and retarded cellular biosynthesis. The lowest values were
similarly from patients without a hernia undergoing other surgi- found in patients with direct hernia, but the number of patients
cal procedures. The anterior rectus sheath was found to be thin- was too small to allow for a proper statistical evaluation.l 1 In a
ner in patients with hernia. Collagen normally contributes 80% to larger study, it was found that fibroblasts obtained from the in-
152 L.N. Jorgensen and F. Gottrup
ternal oblique muscle and the cremasteric muscle in hernia pa- 7

tients had a significant decrease of cell proliferation rates com-
pared to controls.l 2 In addition, the incorporation of radioactively 6
labeled proline in the tissue from cultured fibroblasts was signifi-
cantly depressed, suggesting a lower rate of synthesis of matrix in 5
hernia patients.
Type I : Type III 4
collagen
3 *
Stability of Collagen
2
The hydroxyl groups of hydroxyproline are essential for both the
formation and the stability of the collagen molecule. 9 In addition,
lysine hydroxylation is necessary for sufficient inter- and in-
tramolecular cross-linking and glycosylation of collagen. There o
seem to be significantly lower levels of proline and lysine hydrox- Controls Hemias
ylation in fascia samples from direct hernia patients compared to 6.3 ± 0.34 3.0±O.25
those from indirect hernia patients. I,13 This indicates that in pa- N =15 N=9
tients with direct hernias, the stability of the collagen in the trans-
FIGURE 19.2. Type I:type III collagen ratios in fibroblast cultures from con-
versus abdominis aponeurosis is compromised. trol patients and from patients with inguinal hernias. All data expressed
as mean::': S.E.M; .p < .001 as compared to controls. Reprinted from Fried-
man DW, Boyd CD, Norton P, et al.,6 with permission.
Studies on the Ultrastructure of Collagen
An abnormality of collagen in rectus sheath biopsies from patients
with direct inguinal hernia has been suggested in electron mi- Higher levels of soluble collagen in hernia patients have also
croscopic studies. 13 The diameters of collagen fibrils in patients been observed by Wagh and coworkers. 9 ,11,13 It is hypothesized that
with direct hernia were quite variable, with a mean of 1060 A ver- nonpolymerized collagen relatively rich in type III collagen is not
sus 1250 A in the controls. The mean periodicity of collagen fi- sufficient as a biomechanical barrier in the abdominal wall and
brils also turned out to be different: 520 to 620 Aversus 640 A. may predispose some individuals to formation of hernia or per-
However, these differences in collagen ultrastructure were not haps recurrence after primary repair. 6
found between patients with indirect hernia and controls. Neither Interestingly, hernia patients with joint hypermobility were
the collagen measurements nor the ultrastructural findings of the found to have a lower type I to type III collagen ratio compared
rectus sheath biopsies showed any association with the age or the with the other hernia patients. 6
muscular status of the patients. Interestingly, the changes observed
in the rectus sheath biopsies from patients with direct hernia have
also been found in other tissues such as the pericardium, sup-
porting the view that the disease is systemic.l 4
Studies on Collagenolysis and Proteases
Significantly higher blood levels of elastin degrading activity have
been measured in smokers with inguinal hernia, especially the di-
Type I to Type III Collagen Ratio rect type.l 5 In addition, the serum a-I-antitrypsin capacity was sig-
nificantly lower in these patients. The authors hypothesized that
Type I and type III collagen are two of the major fibrillar colla- there is an imbalance between protease and antiprotease in smok-
gens in wound healing. Type III collagen dominates during the ers which may alter the architecture of the connective tissue of the
early stage, while type I is the collagen of the mature, stronger groin. A similar imbalance has been found in smokers with ab-
wound/scar. Often the type I to type III collagen ratio is altered dominal aortic aneurysms. The prevalence of an inguinal hernia
in patients with an abnormal collagen metabolism. High levels of was significantly higher in aneurysm patients (26 to 41 %) com-
type III collagen relative to type I collagen may result in non- pared to controls (15 to 19%), supporting the view that there is a
polymeric soluble collagen because the associative properties of common causative proteolytic activity factor.l 6,17
collagen I are diminished. Bellon found no difference in collagen Ajabnoor compared biopsies from the internal oblique muscle
fibril diameter in the transversalis fascia between patients with di- of21 patients operated on for reasons other than hernia with those
rect and indirect hernia, I nor was there any difference in the type of 130 hernia patients. 12 The collagenase activity data showed no
I to type III collagen ratio.I,6 However, Friedman found a signifi- detectable differences between the two groups in rates of collagen
cantly lower type I to type III procollagen ratio when analyzing se- breakdown.
creted material from skin fibroblasts obtained from hernia patients Metalloproteinase II (MMP-2) is an enzyme that degrades types
(3.0 ± 0.3) compared to controls (6.3 ± 0.3).6 The difference was IV, V, VII, X, and XI collagens, gelatin, elastin, fibronectin and
due to a higher level of type III procollagen production by the other matrix components. High levels of MMP-2 are found in ly-
hernia patients (Fig. 19.2). This was also reflected by the finding sis of the basement membrane as seen in metastatic invasion. Sig-
of a significant increase of recovery of a 1 (III) procollagen mRNA nificantly higher levels of MMP-2 have been found in transversus
in hernia patients (Fig. 19.3). abdominis biopsies from patients with direct inguinal hernia com-
FIGURE 19.3. Steady-state levels of (A)

al (I)
A 9 B 9
procollagen mRNA and (B) al (III) pro-
collagen mRNA in fibroblasts from control 8 8
**
patients and from patients with inguinal
7
* 7
hernias. All data expressed as mean::'::
S.E.M; 'p = NS, "p < .0004. Reprinted 6 6
from Friedman DW, Boyd CD, Norton P,
et al.,6 with permission. 1X1 (I) procollagen 5 1X1 (III) procollagen 5
mANA: mANA:
y-actin mANA 4 y-actin mANA 4
3 3
2 2
o o
Controls Hernias Controls Hernias
5.5 ± 0.65 7.0 ± 0.52 2.7 ± 0.27 7.3 ± 1.20
N=8 N=4 N=8 N=4
pared to patients with indirect hernia: this may reflect an overall has been argued in many papers that patients with inguinal her-
proteolytic effect (Fig. 19.4).I nia present a generalized defect in fibrillogenesis. The use of au-
tologous tissue may not be the perfect solution, therefore, as this
tissue may express the same abnormalities. There is reason to be-
Healing Mter Surgery lieve that synthetic materials such as polypropylene are to be pre-
ferred. Such materials provide a scaffolding, and induce an intense
The amount of literature on objectively measured collagen and inflammatory response with brisk secondary fibrillogenesis.
other quantitative healing parameters after hernia repair is limited. In experimental studies, the implantation of type I collagen
sponges seeded with fibroblasts or coated with basic fibroblast
growth factor raised the collagen deposition and the tensile
strength of dermal wounds. 19 Future clinical studies will show
Use of Autologous Tissue or Synthetic whether there is a place for the application in hernia wounds of
Mesh and Matrices similar material with stimulatory effects on collagen synthesis and
deposition resulting in more durable tissues.
Transplantation of autologous tissue such as the anterior rectus There is still too little knowledge on how to classify hernia pa-
sheath or the fascia lata has been shown to accelerate the synthe- tients into different categories of risk for compromised healing. If
sis and deposition of collagen for at least two years. 18 However, it simple and relevant assays on collagen metabolism should become
available in the future, hernia treatment choices could then be in-
fluenced by the individual patient's wound healing potential.
25 D Direct
• Indirect
Studies on Collagenolysis and
20
* Proteases in Hernia Patients
15 We recently assessed the possible link between concentrations of
Activity (%) collagenases (MMP-2 and MMP-9) in the wound fluid from her-
nia patients and the amount of collagen deposited in an implanted
10
expanded polytetrafluoroethylene (ePTFE) model within the sur-
gical wound. 2o High levels ofMMP-9 were found 24 h after surgery
5 with a significant decline after 48 h, reflecting the inflammatory
phase of healing: MMP-9 is primarily derived from neutrophils.
The concentration of MMP-9 more than 24 h after surgery corre-
0+-''----
lated negatively with the amount of collagen deposited in the im-
MMP-1 MMP-2 planted ePTFE fiber. It was concluded that MMP-9 may be a
predictor of healing in this type of wound. There are still no data,
FIGURE 19.4. Quantification of metalloproteinase immunostaining in fas-
cia transversalis. Sections were stained with anti-MMP-l or anti-MMP-2 an- however, on whether the wound fluid is representative of the
tibodies, and the intensity of this reaction was evaluated directly under the processes taking place in the healing of the transversalis fascia.
microscope using a Microm® image analysis system. Data are expressed in There is evidence that MMP-2 is important during the prolonged
arbitrary units; p < .001. Reprinted from Bellon ]M, Bujan], Honduvilla remodeling phase, whereas MMP-9 is associated with the early re-
NG, et al., I with permission. pair processes. 21
154 L.N. Jorgensen and F. Cottrup
Studies on Collagenolysis and Proteases connective tissue and the development of an inguinal hernia. Ex-
perimental studies have shown that treatment with certain drugs
in Nonhernia Patients and in that impair collagen formation increases the occurrence of her-
Experimental Studies nia. In human studies, a difference in biomechanical parameters
has been observed in hernia patients, especially in direct hernia.
In surgical nonhernia patients, an association between high per- Other studies on cells and biopsies from these types of patients
sistent postoperative levels of MMP-9 and compromised healing suggest a diminished synthesis of matrix, a stability defect, and an
has been found. 22 Also, in experimental studies on healing of rat abnormality of the ultrastructure of collagen. From differences in
colon, the MMPs appeared to contribute to impaired healing as collagen types between patients with hernia and controls, it is hy-
assessed by anastomotic dehiscence. 23 Witte and coworkers re- pothesized that nonpolymerized collagen is not sufficient as a
cently showed in a rat model that the application of an MMP in- biomechanical barrier in the abdominal wall. Predominance of
hibitor (GM6001) results in a significant elevation of wound this type of collagen may predispose to formation of hernia or re-
mechanical strength even though collagen deposition did not in- currence after primary repair.
crease. This response may be due to lower collagen turnover or Collagenolytic activity has also been found to be different in pa-
an increase of maturation and cross-linking of the collagen.24 tients with or without hernia. Specific metalloproteinases, which
Compromised healing, as experienced both in the elderly and in are related to different stages in the healing process, playa major
human chronic wounds, is also associated with increased concen- role in the deposition of collagen, and this may be associated with
tration and activity of both MMP-2 and MMP_9. 22 ,25,26 Reduced lev- later recurrence.
els of the tissue inhibitor of matrix metalloproteinases (TIMP-l Finally, the influence of tension and surgical technique have
and -2) have also been found in the elderly.27 These findings may been discussed. A certain degree of tension has a beneficial effect
contribute to the late occurrence of both direct and indirect in- on the healing process, but there are practical impediments to the
guinal hernia in many patients. consistent application of such a therapy in the operating room. In
late hernia recurrence, systemic patient factors appear to be just
as important as the surgical technique applied.
Wound Tension
It is generally considerd that a hernioplasty performed under ten- Conclusion
sion predisposes to reherniation. There is, however, some contro-
versy, because experimental studies suggest that the tensile It is concluded that systemic metabolic disorders resulting in a re-
strength of skin wounds in rats was significantly higher when they duced quality and amount of collagen are important factors in the
were closed under some tension. 28 This was suggested by a higher genesis of especially direct inguinal hernia. The general assump-
fibroblast activity and collagen deposition during the first two tion that development of incisional and recurrent hernia after
weeks of healing, while a higher degree of organization and cross- surgery is always due to defective surgical technique may have to
linking between the collagen fibers were dominant factors in the be revised.
late healing phase in wounds with tension.
Unfortunately, we have not found studies on the same condi-
tions in hernia repair.
References
In conclusion, there is some evidence that limited tension of a 1. Bellon JM, Bujan J, Honduvilla NC, et al. Study of biochemical sub-
closed hernioplasty without tissue tearing by the sutures results in strate and role of metalloproteinases in fascia transversalis from her-
higher tissue tensile strength. nial processes. Eur] Glin Invest. 1997;27:510-516.
2. Conner WT, Peacock EE Jr. Some studies on the etiology of inguinal
hernia. Am] Surg. 1973;126:732-735.
Recurrent and Incisional Hernia 3. Peacock EE Jr, Madden.JW. Studies on the biology and treatment of
recurrent inguinal hernia: II. Morphological changes. Ann Surg. 1974;
There are little objective data on the healing process or quality as- 179:567-571.
4. Uden A, Iindhagen T. Inguinal hernia in patients with congenital dis-
sessments of the abdominal wall in patients operated on for re-
location of the hip. A sign of general connective tissue disorder. Acta
current groin or abdominal incisional hernia. It is known that the
Orthop Scand. 1988;59:667-668.
success rate associated with the classic repair of recurrent inguinal 5. Jessee EF, Owen DS, Sagar KD. The benign hyperrnobile joint syn-
hernia is low (70%).3 drome. Arthritis Rheum. 1980;23:1053-1056.
Inguinal hernias may recur as long as 15 years following the ini- 6. Friedman DW, Boyd CD, Norton P, et al. Increases in type III collagen
tial surgery, those due to technical failures appearing within the gene expression and protein synthesis in patients with inguinal her-
first 6 months postoperatively. Recurrences later than 6 to 9 nias. Ann Surg. 1993;218:754-760.
months may be considered continuing disease rather than the ap- 7. Wirtschafter ZT, Bentley]p. Hernias as a collagen maturation defect.
plication of an inferior surgical technique. 3,6 Further studies are Ann Surg. 1969;160:852-859.
needed in this field. 8. Read RC. Attenuation of the rectus sheath in inguinal herniation. Am
] Surg. 1970;120:610-614.
9. Wagh PV, Read RC. Collagen deficiency in rectus sheath of patients
with inguinal herniation. Proc Soc Exp BioI Med. 1971;137:382-384.
Summary 10. Pans A, Pierard CE, AlbertA, et al. Adult groin hernias: new insight into
their biomechanical characteristics. Eur] Glin Invest. 1997;27:863-868.
From the literature available, there is strong evidence for an as- 11. Wagh PV, Read RC. Defective collagen synthesis in inguinal hernia-
sociation between systemic diseases with abnormal metabolism of tion. Am] Surg. 1972;124:819-822.
12. Ajabnoor MA, Mokhtar AM, Rafee AA, et al. Defective collagen metab- 22. Tarlton JF, Vickery CJ, Leaper DJ, et al. Postsurgical wound progres-
olism in Saudi patients with hernia. Ann Clin Biochem. 1992;29:430-436. sion monitored by temporal changes in the expression of matrix me-
13. Wagh PV, Leverich AP, Sun CN, et al. Direct inguinal herniation in talloproteinase-9. Br] DermatoL 1997;137:506-516.
men: a disease of collagen.] Surg &so 1974;17:425-433. 23. Savage FJ, Lacombe DLP, Hembry RM, et al. Effect of colonic ob-
14. White HJ, Sun CN, Read RC. Inguinal hernia: a true COllagen disease. struction on the distribution of matrix metalloproteinases during anas-
Lab Invest. 1977;36:359. tomotic healing. Br] Surg. 1998;85:72-75.
15. Cannon DJ, Read RC. Metastatic emphysema: a mechanism for ac- 24. Witte MB, Thornton l'J, Kiyama T, et al. Metalloproteinase inhibitors
quiring inguinal herniation. Ann Surg. 1981;194:270-278. and wound healing: a novel enhancer of wound strength. Surgery.
16. Cannon DJ, Casteel L, Read RC. Abdominal aortic aneurysm, Leriche's 1998;124:464-470.
syndrome, inguinal herniation, and smoking. Arch Surg. 1984;119: 25. Ashcroft GS, Horan MA, Herrick SE, et al. Age-related differences in
387-389. the temporal and spatial regulation of matrix metalloproteinases
17. Lehnert B, Wadouh F. High coincidence of inguinal hernias and ab- (MMPs) in normal skin and acute cutaneous wounds of healthy hu-
dominal aortic aneurysms. Ann Vase Surg. 1992;6:134-137. mans. Ceu Tissue &so 1997;290:581-591.
18. Peacock EEJr. Subcutaneous extraperitoneal repair of ventral hernias: 26. Yager DR, Zhang lrY, Liang H-X, et al. Wound fluids from human pres-
a biological basis for fascial transplantation. Ann Surg. 1975;181:722- sure ulcers contain elevated matrix metalloproteinase levels and ac-
727. tivity compared to surgical wound fluids. ] Invest DermatoL 1996;
19. Marks MG, Doillon C, Silver FH. Effects of fibroblasts and basic fi- lO7:743-748.
broblast growth factor on facilitation of dermal wound healing by type 27. Ashcroft GS, Herrick SE, Tarnuzzer RW, et al. Human ageing impairs
I collagen matrices.] Biomed Mater &so 1991;25:683-696. injury-induced in vivo expression of tissue inhibitor of matrix metal-
20. Agren MS,Jorgensen LN, Andersen M, et al. Matrix metalloproteinase loproteinases (TIMP)-l and -2 proteins and mRNA. ] PathoL 1997;
9 level predicts optimal collagen deposition during early wound repair 183:169-176.
in humans. Br] Surg. 1998;85:68-71. 28. Pickett BP, Burgess LP, Livermore GH, et al. Tensile strength versus
21. Agren MS. Gelatinase activity during wound healing. Br] DermatoL healing time for wounds closed under tension. Arch Otolaryngol Head
1994;131:634-640. Neck Surg. 1996;122:565-568.
20
Recurrent Herniation: Etiology and Mechanisms
Jack Abrahamson
Introduction suturing under tension, to minimize the tissue damage, hema-

tomas, and infection that almost inevitably lead to recurrence. Spe-
A recurrent hernia is a source of anguish and disappointment for cialization in dedicated hernia centers advances the surgeon's
the patient and of resentment on the part of the surgeon. The pa- expertise and lowers his recurrence rate even to 0.1 % for primary
tient feels that the surgeon has failed him: he has suffered an un- repair of groin hernias and to 1 to 2% for incisional hernias.6-8
necessary, unsuccessful operation and faces another attempt. The
surgeon feels that somehow the patient has let him down: in spite
of the dexterous operation he performed, the ungrateful patient Tension
developed a recurrence. The patient expects the repair to last the
rest of his life, but unfortunately, between 10 and 30% of primary "The basic reason for poor results of primary and recurrent her-
inguinal hernias and 50% of incisional hernias repaired today will nias is the approximation of tissues under tension."9,lo It is due
recur. Yet specialized hernia centers report recurrence rates ofless to ischemic pressure necrosis of the tissues by the sutures under
than 1% in primary and 5% in incisional hernias. l-4 What accounts inordinate tension, causing them to cut out. A hernia repaired un-
for these dramatic differences? What is really at work in the cre- der tension is doomed to failure. Tissues sutured under tension
ation of recurrent herniation? tend to pull apart but are prevented from doing so by the sutures;
The longer and more complete the follow up, the higher the however, the tissues pulling on the sutures create an area of isch-
recurrence rate. The rate also increases with the number of at- emic pressure necrosis at the point where the suture meets the tis-
tempts at repair of the hernia. The larger group of "early" recur- sue. This process ofischemic pressure necrosis progresses until the
rences that appear within two to three years of the operation is tissues have separated sufficiently and there is no longer any ten-
thought to be due mainly to failure on the part of the surgeon sion, which usually occurs when the tissues have returned to the
and to infection. The smaller "late" group appears thereafter, even previous unsutured position. The hernia will recur through the re-
many years later, and is attributed to "tissue failure," an ill-defined sultant gap.
and poorly understood collective term that appears to exonerate In more extreme cases, when the tension is greater than the
the surgeon. However, even in these late cases of recurrence, the strength or holding capacity of the tissues, the sutures simply tear
surgeon is not blameless, since late recurrences of groin hernias through the tissues, leaving a gap for a recurrent hernia. The like-
occur mainly because the surgeon failed to reinforce the poste- lihood of this depends not only on the inherent strength of the
rior wall of the inguinal canal. Late recurrences following inci- tissues, but also on the distance of the suture from the edge of the
sional hernia repair are due mainly to faulty judgment in choosing defect and the angle that the sutures make with the tissue fibers.
the method of repair and failing to use prosthetic mesh in cases Greater suture tension will be needed to tear the tissues if the su-
where it is clearly indicated. 5 ture pulls across the fibers at a right angle, as in a transverse or
oblique abdominal incision, or in classical open groin hernia re-
pairs, compared to the situation in midline or paramedian hernia
Early Recurrence repairs where the suture pulls in the same direction as the fibers,
separating the tissue fibers.!l
The success of hernia surgery depends almost entirely on the skill,
knowledge, and experience of the surgeon and the effort he is
prepared to invest in perfecting his method of repair and his op- Local Anatomy
erating technique. However, the surgeon must also be familiar with
other methods of repair of hernias and be prepared to depart The classic open primary and recurrent inguinal hernia repairs
from his standard technique and adapt these other methods to are based on the Bassini principle of suturing the conjoined ten-
the particular hernia he is repairing. He must perform careful, don to the inguinal ligament. The ease with which this can be
atraumatic dissection, handle and retract tissues gently, and avoid done depends on the individual anatomy of the patient. The con-

20. Recurrent Herniation 157
figuration of the myopectineal orifice of Fruchaud is variable. 12 In Mesh Infection

some cases, the musculoaponeurotic arch is low and close to the
inguinal ligament, but in others, the vertical measurement of the Infection of any hernia repair where synthetic mesh has been im-
orifice is greater, and the two structures, separated by a wider gap, planted is a major complication with a high rate of recurrence.
can be approximated only under excessive tension. Some opera- The mesh acts as a large foreign body which perpetuates the in-
tors attempt to compensate by using a "relaxing incision" on the fection. Meshes made of multifilament fibers, such as polyester, or
anterior rectus sheath, but the effectiveness of this maneuver in with fine spaces, such as expanded polytetrafluoroethylene
reducing the incidence of recurrence is questionable. lO (PTFE), tend to harbor organisms. Mesh knitted with monofila-
Tissues tend to hold sutures well when much aponeurotic tis- ment thread, such as polypropylene, is much less likely to per-
sue is involved. The index of aponeurosis to muscle in the mus- petuate infection.I 3
cUloaponeurotic arch varies widely in individuals, from internal
oblique and transversus abdominis aponeuroses that start welllat-
erally, to mainly fleshy muscles whose aponeuroses begin close to Degrees of Infection
the rectus sheath. The more fleshy muscular arch will be cut
Wound infection varies in degree from the mildest and most in-
through more easily when sutured under tension.
significant to the catastrophic. Slight redness of the skin edges, a
small, clear serous discharge, or a localized stitch abscess do not
influence the recurrence rate. But a frank acute cellulitis in and
Recurrent Hernia
around the wound may progress to fasciitis and necrosis of the tis-
sues, and to deep abscess formation with purulent discharge from
The problem of closing the gap is compounded in a recurrent in-
the open wound. The acute phase may finally settle down, and the
cisional or groin hernia or in other hernias where the tissues are
wound may heal, but it may be followed by low-grade sepsis with
scarred, ischemic, and unyielding, especially after more than one
sinus formation and intermittent discharge of pus and sutures. Or-
attempt at repair. Because extreme tension is needed to approxi-
ganisms are particularly attracted to biological suture material
mate the tissues in these situations, failue of the repair is inevitable.
such as silk. They adhere to the surface and penetrate the crevices
Tension is also responsible for the high rate of recurrence of
of the suture where the much larger leukocytes cannot reach to
femoral hernias, for the common "diverticular" or "punched out"
eradicate them. Certain types of sutures are more prone to infec-
direct recurrent inguinal hernias that protrude through rounded
tion, depending on their material and construction, such as mul-
localized defects in the reconstructed posterior wall of the inguinal
tifilament, braided, or twisted sutures. The worst offenders are the
canal, and also for the lateral, satellite, or "buttonhole" hernias on
biological sutures.
either side of the scar after laparotomy closure or repair of an in-
cisional hernia. The sawing effect of a nonabsorbable suture over
a long period of time may also contribute to satellite hernia for- Survival of Organisms
mation.
Tension can partially or completely destroy the inguinal liga- The organisms may remain quiescent for varying periods of time
ment and conjoined tendon, making attempts to repair the ensu- and be activated for unknown reasons, perhaps by mild local
ing recurrent hernia essentially futile. The highly successful newer trauma or alterations in the host defense mechanisms.I 4,15 Wound
techniques of groin hernia repair-the tensionless repair of Licht- infections can develop in apparently perfectly healed wounds af-
enstein, the sutureless technique of Gilbert, and the mesh plug ter some months or even 30 or 40 years after the operation. Or-
hernioplasty of Rutkow-are all based on absolute elimination of ganism survival complicates repair of recurrent hernias arising
tension.3.6· 7 from postoperative infection. The new operation may reactivate
the organisms, leading to infection of the new wound and to a
new recurrence. Repair of incisional and other recurrent hernias
Infection should therefore be regarded as contaminated procedures re-
quiring perioperative antibiotics.l,16,17
Incidence
This is one of the most serious complications of closure of ab- Pathophysiology of Wound Breakdown
dominal incisions and hernia repairs of all types. Probably 50% of
recurrent hernias are due to infection. One-third or more of in- The pathophysiology of the process by which wounds break down
fected groin hernia repairs result in recurrent hernias. In spe- has not been adequately investigated. The tensile strength of a su-
cialized ambulatory surgery units and in private office-based tured wound drops to about half during the first three to four
operating suites dedicated to the surgery of clean groin hernia days, the "lag phase," after which the "healing phase" sets in and
cases done by teams of hernia specialists, the incidence of post- the tensile strength of the wound progressively increases until it
operative wound infection is less than 1%. In general hospitals, reaches about 70 to 80% of its final strength at six months. Dur-
the incidence may be 5% or more; however, these statistics are ing these first months, the integrity of the wound is entirely de-
confused by varying criteria of wound infection, more or less bi- pendent on the sutures holding the wound surfaces in apposition.
ased observation, and the length of postoperative follow-up. Sur- As healing takes place, the natural wound strength takes over and
veys show that 50 to 70% of groin hernia wound infection occurs the role of the sutures becomes less important. The process of
after the patients have left the hospital. The overall incidence may healing, involving the production, maturation, and remodeling of
therefore be four or five times that reported.8-12 collagen, takes approximately one year. 18 ,19
158 J. Abrahamson
Infection interferes with the natural process of healing and quate exposure and avoid strong retraction, which increases the
causes tissue destruction. The products of cellular breakdown incidence of wound infection. The preferred incision is a trans-
brought about by the toxins and enzymes of the infecting organ- verse one, centered over the internal ring. The incision can be
isms set off the process of inflammation, which attracts vast num- conveniently closed with a continuous intradermal suture of 5/0
bers of polymorphonuclear leukocytes and macrophages to the synthetic absorbable material. Sutures piercing the skin increase the
site. These white blood cells discharge their azurophil zymogen risk of wound infection and should be avoided. In the newer, ten-
granules containing proteases, superoxidases, and other free rad- sionless primary mesh repairs of groin hernias, the tendency is to
icals that destroy elastin, collagen, and other supporting structures. make shorter incisions, sometimes just sufficient to pass a finger. 20
Tissue disintegration is enhanced by a host of other autolyzing en-
zymes and substances produced by the inflammatory process and
cellular breakdown, leading to further cellular death and disrup- Suture Material
tion and destruction of the intercellular material. The suture ma-
terial acts as a foreign body, concentrating the inflammatory . Sutures are entirely responsible for the integrity of the wound for
reaction around it, leading to weakening and breakdown of the the first six months until the tissues themselves reach a sufficient
tissues in contact with the sutures. These are the very tissues that degree of healing and strength. Any material that does not sur-
need to withstand the strain of the sutures but, as they disinte- vive and maintain most of its strength for this time is unsuitable
grate, the repair breaks down with them. for hernia repair or wound closure. Catgut and the synthetic ab-
Frank cellulitis with fasciitis and wide necrosis of the tissues leads sorbable sutures of polyglactin, polyglycolic acid, and polydiox-
to complete breakdown of the wound. In less severe reactions, sev- anone lose 50 to 80% of their tensile strength within 14 days and
eral processes take place, leading to the sutures "cutting out" of disintegrate within a few weeks. Biological materials such as silk,
the tissues. Where absorbable sutures or nonabsorbable biologic cotton, and linen lose 40% of their strength within 6 weeks and
sutures have been used, the breakdown products of the inflam- begin to disintegrate by three months. They also cause much tis-
matory process hasten the disintegration of the sutures, and the sue reaction, perpetuate infection, and behave as foreign bodies,
unsupported wound falls open. More commonly, and especially causing chronic sinuses in infected wounds, and become a major
where nonabsorbable synthetic sutures have been used, the su- cause of tissue breakdown. Even polyester and nylon sutures may
tures maintain their strength, but the weakened, inflamed and harbor organisms and perpetuate sepsis when twisted or braided.
edematous tissues are unable to hold the sutures against the Monofilament stainless steel wire is inert, causes little tissue re-
stresses and strains to which the wound is subjected, so that the action, remains intact, retains its strength almost indefinitely and
sutures tear the tissues and cut out. is therefore the ideal suture for closure of abdominal wounds and
The inflammation and edema of the tissues brought about by the repair of groin and incisional hernias. It is, however, difficult to
infection cause them to swell so that a larger volume of tissue is en- handle. Most surgeons prefer monofilament polyamide or poly-
closed within the unyielding ring of the suture, leading to pressure propylene sutures. These monofilament nonabsorbable synthetic
necrosis of the tissues. The final result is that, even though the wound sutures maintain their strength and are practically indestructible
may heal and the sinuses close, the sutures no longer give their vi- in human tissues. They are strong, smooth, and inert and excite
tal support to the tissues. The repair heals with scar tissue that is un- very little tissue reaction. When exposed in a purulent wound, they
able to withstand the stress of the rise and fall of the intra-abdominal become covered by healthy granulation tissue and do not inter-
pressure and finally gives way to a recurrent hernia. 1,16 fere with healing. For these reasons, abdominal wounds and groin
and incisional hernias closed with continuous monofilament syn-
thetic nonabsorbable sutures heal well and seldom recur even if
Types of Incision infected.
Abdominal Incisions
Suturing Technique
The simplest, quickest and best incisions for access to the ab-
dominal cavity are anatomically sound midline, transverse, or The Mass Suture
oblique incisions. 18,19 The lateral paramedian incision may also
have a low incidence of postoperative hernia, but it is more com- The mass suture technique has been one of the most important
plicated and time consuming to perform. Nonanatomic incisions developments in prevention of burst abdomen and early and late
are typified by the vertical pararectus incision along the outside incisional hernias as well as recurrent incisional and groin hernias.
of the lateral border of the rectus sheath. They destroy the nerve It is still widely-but erroneously-believed that many small su-
and vascular supply to the tissues medial to the incision, leading tures, each taking a small bite of tissue, closely placed and tightly
to atrophy and postoperative ventral hernia. It was believed that tied, and suturing each anatomic layer separately, make a neat and
midline incisions are more likely to fail than transverse or oblique effective closure for an abdominal incision or inguinal incision.
ones, but it has been shown that, with proper mass closure tech- The truth is that small sutures enclose only a small amount of tis-
niques, this is not so.18,19 sue close to the edge of the sutured layer, often within the area of
the normal collagenolysis of a wound, and tend to cut out. Each
small, tightly tied suture causes a triangular area of ischemia and
Groin Incisions necrosis of the tissues it encircles, together with an area on eacb
side of the suture. When these sutures are placed close to each
Most inguinal hernias are repaired by the anterior or groin ap- other, their ischemic areas overlap and cause a strip of necrosis
proach. The skin incision must be long enough to allow for ade- along the sutured edges, which separate from the rest of the tis-
sues together with the sutures so that the apposed and sutured Side
edges separate.
The mass closure technique for closing abdominal incisions con- There is no evidence that either side has a more or less predilection
sists of taking large bites of the full thickness of the abdominal for recurrence of an inguinal hernia. About 60% of recurrent in-
wall, excepting the skin and subcutaneous fat and not including guinal hernias occur on the right side and 40% on the left side, but
the peritoneum, where possible. The suture passes through the this is approximately the distribution of primary inguinal hernias.
abdominal wall, preferably 3 cm from the edge of the incision, but
not less than 1 cm. The sutures should be 1 to 2 cm apart, de-
pending on the width of the abdominal wall enclosed. When the Sex
sutures pass through the abdominal wall further from the edge of
the incision they may be further apart, and vice versa, but they must There is no significant difference in the recurrence rate following
not be less than 1 cm apart. Closer together, they may cause tissue repair of inguinal hernias in males or females. The entire inguinal
ischemia and necrosis; further apart, they may leave gaps through canal as well as the internal and external rings can be closed in
which bowel or omentum may prolapse. When the interrupted the female without having to leave a passage for the spermatic
technique is used, the sutures should not be tightly tied, but just cord, yet the recurrence rate is the same for both sexes. The suc-
enough to approximate the cut edges. Remarkable results have cess of repair of incisional hernia is also independent of the sex
been obtained in several clinical series, with almost complete elim- of the patient.
ination of burst abdomen, eventration, and incisional hernia. 1.21
Anesthesia
The Continuous Suture The tendency today is to repair groin hernias using local anes-
thesia in an ambulatory setting, but many hernia repairs are still
Continuous suturing techniques have a greater resistance to done with general, spinal, or epidural anesthesia. The type of anes-
wound bursting pressure than simple interrupted methods. A con- thesia does not influence the recurrence rate.
tinuous suture may be perceived as a spiral, giving a better distri-
bution of tension along the entire length of the approximated
tissues. A continuous suture spiral can lengthen and shorten with General Condition of the Patient
the wound, and the smooth, pliable suture can slide through the
tissues to areas of greater or lesser tension to equalize and spread It seems reasonable to suppose that a young, fit patient would heal
the tension. Also, the monofilament polyamide or polypropylene more strongly and successfully than an elderly one beset by a host
sutures used for continuous mass suturing have excellent exten- of chronic cardiac, respiratory, renal, and other problems, yet
sile strength, adding the ability to "give" or stretch without break- there is no real evidence to corroborate this. Factors considered
ing. They are therefore most suitable for the continuous mass to have a negative influence on the success of hernia surgery in-
suture technique. clude generalized wasting, malnutrition and starvation, hypopro-
When used for abdominal wound closure, the length of the su- teinemia (especially hypoalbuminemia), avitaminosis (especially
ture material should be at least four times the length of the inci- Vitamin C) anemia,jaundice, diabetes mellitus, chronic renal fail-
sion. This will ensure that there will be sufficient "give" in the ure, ascites, prolonged steroid therapy, immunosuppressive ther-
thread and the tissues to avoid tension and pressure on the tissues apy, alcoholism, and malignant disease. Most of these factors
which could lead to dehiscence. If the thread is too short, post- interfere with collagen production and wound healing. Malnutri-
operative abdominal distension causing 30% wound lengthening, tion and growth failure were found to be associated with recur-
such as may occur in postoperative paralytic ileus, would theoret- rent inguinal hernia in infants and children.
ically make disruption inevitable.
Jaundice
General Factors It has been shown experimentally and clinically that the presence
of jaundice interferes with wound healing. When laparotomy
Age wounds were closed in layers, there was a higher rate of wound
dehiscence and incisional hernia in jaundiced patients than in the
Age, as such, is not a factor in the failure of a hernia repair.1 Con- nonjaundiced group. Yet, if the laparotomy wound was closed by
trary to the common belief, there is much evidence that the re- the mass closure technique, the dehiscence rate and the incidence
currence rate is actually lower following repair of primary or of incisional hernia was the same for both groups.22 The obvious
recurrent inguinal hernia in older age groups than in younger pa- conclusion is that one should refrain from operating on a jaun-
tients. How the surgeon repairs the hernia is more important than diced patient, but when this is unavoidable, the wound should be
the age of the patient as far as the recurrence rate is concerned. closed by the mass technique.
Incisional hernia is more common in patients over the age of 60
years, but this may reflect the incidence of more serious condi-
tions and history of more major surgical operations in this age Body Weight
group, rather than some inherent tissues defect in the elderly. In
infants, however, prematurity does increase the recurrence rate of Overweight or adiposity does not appear to be a factor in recur-
the repair of an inguinal hernia by herniotomy. rence after repair of a primary or recurrent inguinal hernia.1.23.24
160 J. Abrahamson
No relationship has been established between body weight and re- Increased Intra-Abdominal Pressure and Ascites
currence. The markedly overweight patient is not at increased risk
of developing a recurrent inguinal hernia. A slightly larger pro- Increased intra-abdominal hydrostatic pressure due to ascites is not
portion of patients with recurrent inguinal hernias are near or be- only a cause of inguinal and umbilical hernias, but is also a clear
low ideal body weight. Markedly underweight patients are probably etiological factor in the development of recurrent inguinal, um-
at a greater risk for recurrent groin hernias. 25 This situation is bilical, and incisional hernias. Stretching and thinning of parietal
quite the opposite when dealing with postoperative ventral ab- tissues due to increased intra-abdominal pressure and volume also
dominal (incisional) hernias. Overweight plays a major role in the occur commonly in children with ventriculoperitoneal shunts for
failure of laparotomy wound closure and in recurrence after re- hydrocephalus and in patients on chronic peritoneal dialysis. 27,28
pair of incisional hernias. 1O,17 Obesity is associated with at least a Refractory ascites due to liver cirrhosis is a common etiological
threefold increase in herniation and recurrence. factor of abdominal wall hernias and recurrences after repair. Um-
The major negative part played by adiposity in recurrence after bilical hernia develops in 20% of cirrhotic patients who develop
repair of an incisional hernia is not disputed, yet it is difficult to ascites. The treatment of the ascites is a major determinant of the
explain. Cutting through large masses of fat and the increased re- success of the repair of the various types of hernia, so much so,
traction needed may raise the infection rate in these obese patients. that it is advised that in cases where the ascites cannot be con-
Tissues infiltrated with fat may not be able to hold sutures, espe- trolled by medical means, a peritoneovenous shunt should be done
cially since the accumulation of many kilograms of intra- and ex- prior to or concomitantly with the herniorrhaphy.29 Synhetic non-
tra-abdominal fat may add greatly to the tension on sutures passing absorbable sutures should be used for the repair, and a primary
through tissues already weakened by fatty infiltration. Furthermore, prosthetic mesh repair should be considered in all patients. Stoppa
obese patients tend to develop postoperative complications such as advises his giant prosthesis for the reinforcement of the visceral
paralytic ileus, atelectasis, pneumonia, and deep venous thrombo- sac (GPRVS) for the repair of any groin hernia in cirrhosis pa-
sis, which may increase the incidence of incisional hernia. tients. 30
Smoking Growth Factors

A higher percentage of smokers than nonsmokers develop her- A number of naturally occurring polypeptides are involved in
nias, as well as recurrences after repair.26 Persons who smoke have wound healing. These growth factors and chemical immunomod-
higher circulating serum elastolytic and protease activity than con- ulators stimulate angiogenesis and granulation tissue production,
trols who do not smoke. The levels of these circulating serum elas- increase wound cellularity, fibroblast proliferation, collagen pro-
tolytic and protease substances are higher in the blood of smokers duction, extracellular matrix production, and increase the break-
with direct than in those with indirect hernias, and higher still in ing strength ofwounds. 31 ,32 This leads to the accelerated healing
those with bilateral direct inguinal hernias. Substances in cigarette of surgical wounds, especially chronic wounds or wounds with spe-
smoke inactivate antiproteases and so upset the normal balanced cific healing deficiencies. Several of these factors can be produced
protease-antiprotease system. The consequent impairment of col- in relatively large quantities with recombinant technology. This
lagen production and maintenance and its unbalanced destruc- new field of study, "wound pharmacology,"33 may prove to be of
tion interferes with the normal healing of wounds, and so leads benefit in hernia surgery, providing substances that will promote
to the production of incisional as well as recurrent groin and in- rapid, firm healing, and perhaps also assays to determine a pa-
cisional hernias. tient's wound healing profile.
Cough, Chronic Bronchitis, Metabolic Defects

and Respiratory Insufficiency
In certain persons, mesenchymal metabolic defects with abnor-
Contrary to common belief, there is no significant independent malities in collagen synthesis and breakdown cause a deficiency
evidence that chronic cough, bronchitis, and chronic lung disease of collagen and abnormalities in its physicochemical structure,
negatively influence the outcome of incisional hernia repair, nor such as reduced hydroxyproline production and changes in the
are they associated with inguinal hernia recurrence. diameter of the collagen fibers. These changes have been demon-
strated in sites such as skin, lung, pericardium and aorta as well
as the abdominal wall. 34,35 Besides being related to the occurrence
Prostatic Hypertrophy and recurrence of inguinal hernia, these collagen mechanisms
may playa part in the development of late postoperative hernias,
Unsupported statements may be found in the literature to the ef- may also be linked to the growth factors previously discussed, and
fect that straining and the consequent increase in intra-abdomi- may be the underlying cause of so-called "aging tissues" and "late
nal pressure associated with prostatic hypertrophy can cause a tissue failure."
hernia to develop or bring about a recurrence, but it has been Children as well as adults with certain hereditary connective tis-
shown that prostatism is of no significance in the development of sue disorders such as the Ehlers-Danlos, Hurler-Hunter, and Mar-
hernias or recurrences. 23 Prostatism may not be a causal factor, fan's syndromes have a disproportionate incidence of primary
but it is certainly a common concomitant, perhaps reflecting the groin hernia as well as a high rate of recurrent hernia after repair
prevalence of both conditions among middle-aged and elderly of inguinal and umbilical hernias. These patients either do not
persons. produce collagen, or not enough of it, or produce abnormal or
poor quality collagen, so that a high proportion of repaired her- erative ventral abdominal hernias with a prosthetic mesh, irre-
nias recur. Stoppa recommends the use of his GPRVS when perspective of the width of the opening.
forming groin hernia repair in patients with these syndromes.
Emergency Versus Planned Repair

Local Factors
Emergency repair of a strangulated inguinal hernia in infants and
Previous Operative Trauma children is followed by a higher rate of recurrence than for
planned repairs. 27 The sac and the tissues are edematous and fri-
Infants and children may develop unusual recurrent hernias after able, and the internal ring is widely dilated by the prolapsed bowel.
indirect inguinal hernia repair by herniotomy. These include di- The tissues are difficult to handle and to suture, and wound in-
rect inguinal, femoral, or prevascular hernias. The cause is prob- fection is more common. However, in adults, the available evi-
ably damage to the tissues at the original operation such as tearing dence indicates that recurrence is not more common after
of the musculoaponeurotic arch, overstretching of the internal emergency repair of a strangulated hernia.
ring, or tearing of the fascia transversalis in the posterior wall of
the inguinal canal. 36
Repeated operative trauma is a cause of incisional hernia and Prophylactic Perioperative Antibiotics
recurrences. Early re-exploration, especially within the first six
months postoperatively, or later relaparotomy through the origi- There is no evidence to show that the postoperative infection rate
nal incision, leads to increased incidence of incisional hernia, as or the recurrence rate is lower when antibiotics are given system-
do repeated incisions through the same site, such as repeated ce- ically or irrigated locally for a routine groin or umbilical hernia
sarean sections. 37 repair. Detailed attention to technique is probably more impor-
Not only does the recurrence rate rise with the number of pre- tant. Antibiotics cannot cover up for bad surgery. However, with
vious repairs, but also the time between the operations and the very large hernias, recurrent hernias, or incisional hernias, or her-
recurrences gets shorter. This is because the defect grows larger nias with infected granulomas from previous operations, periop-
with each unsuccessful attempt at repair, and the tissues become erative antibiotics are commonly used. It is also recommended
progressively scarred, ragged, thinned out, stiff, and unyielding, where large sheets of nonabsorbable mesh are implanted and
as well as relatively avascular. Repeated attempts to bring together whenever previous surgery was known to have become in-
the almost solid edges of the defect under tension lead to further fected. I5 ,40
tissue necrosis and breakdown. Prosthetic mesh is the preferred
method for curing recurrent inguinal and incisional hernia where
the edges cannot be easily brought together without tension. Many Preoperative Skin Preparation
surgeons recommend that all recurrent hernias, irrespective of the
size of the defect or the elasticity of the tissues, be repaired with Several efficient scrubs and solutions are available for routine
a synthetic prosthetic mesh without any attempt at bringing to- cleansing of the skin preoperatively. Those commonly used are
gether the edges of the defect. Indeed, the tendency today is to based on povidone iodine or chlorhexidine. When dealing with
repair all primary groin and incisional hernias routinely with mesh. large groin or incisional hernias, especially in obese patients, at-
tention must be given to the deep folds of skin between the her-
nia and the abdominal wall where chronic moist dermatitis,
Size of Hernia intertrigo, and excoriated and infected areas are often present.
Several days of treatment may be required to clean and dry these
There is a direct relationship between the size of the hernia and areas in order to reduce the bacterial population of the skin and
the rate of recurrence, and large inguinal hernias recur twice as reduce risk of postoperative infection.1°
often as small ones. 38 The tissues used for the repair have been
stretched, thinned out, or destroyed by the hernia. The fascia
transversalis has, for practical purposes, disappeared, and the at- Groin Hernias
tenuated musculoaponeurotic arch has been displaced further
from the inguinal ligament. The internal and external rings are Certain factors specific to groin hernias are involved in inducing
wide and displaced until they are opposite each other and the recurrence of repaired hernias. I7
usual oblique line of the inguinal canal has disappeared. The wide
dissection of the large hernia leads to tissue damage and
hematomas which increase the risk of infection and recurrence. The Dissection
The width of the gap in the abdominal wall through which the
hernia protrudes determines the method of repair of the hernia. 5 Dissection throughout the operation must be meticulous, and
Incisional hernias with a narrow gap can be simply resutured by careful hemostasis must be observed. There is no need to widely
the continuous mass closure technique. For wider defects, the au- dissect the fat off the aponeurosis. These large skin flaps create
thor's shoelace repair (q.v.) can be used,5,39 but attempts at clo- extensive raw surfaces which bleed and ooze serum, collections of
sure of very wide gaps by these methods will inevitably lead to which promote infection that may spread to the rest of the wound.
tension, necrosis, tearing out of the sutures, and recurrence of the The superior leaf of the aponeurosis of the external oblique
hernia. Incisional hernias with wide gaps demand repair with pros- must be widely mobilized cranially and medially from the aponeu-
thetic mesh. Indeed, many surgeons advise repairing all postop- rosis of the internal oblique muscle and the anterior rectus sheath
162 J. Abrahamson
so as to expose a wide area of strong, healthy aponeurotic tissue Inadequate Reconstruction of the Internal Ring
for the repair, well away from the canal. Sutures placed through
red muscle tissue close to the canal will cut out and lead to early Dissection and exposure of the internal ring, thinning the cord,
recurrence. and closing the ring snugly around it, have always been stressed
as important steps in the classic open herniorrhaphies. However,
in the newer tensionless primary prosthetic mesh repairs, less at-
"Skeletonization" of the Cord tention is paid to this step since a new functional internal ring is
constructed by the crossed-over tails of mesh embracing the cord
Routine division and excision of the cremaster muscle as well as as it emerges from the internal ring. 2,3,7
other coverings and fat of the cord and the so-called "lipomas" to
gain complete exposure of the posterior wall of the canal and in-
ternal ring led to a dramatic fall in the recurrence rate. A bulky Failure to Buttress the Posterior Wall
cord interferes with the closure of the internal ring and may be
compressed and strangulated in the reconstructed inguinal canal. Reinforcement of the posterior wall of the canal is not necessary
With the popularization of the tension-free primary mesh rein repair of infants' and children's hernias and may even cause re-
pairs of inguinal hernias, less stress has been placed on denuding currence by damaging the tissues. 36 In adults, all inguinal hernia
the cord since, in these procedures, there is no longer a need for repairs, regardless of the type of hernia, should include a proce-
direct reconstruction of the internal ring and posterior wall of the dure to buttress the posterior wall of the canal. This may be a pure
canal. In the Lichtenstein, Gilbert, and Rutkow repairs, the cord tissue repair such as the multilayered Shouldice technique, a ny-
is mobilized to expose the posterior wall of the canal, but the cre- lon darn, a mixed tissue and prosthesis repair, or a prosthesis only
master is not excised. It is opened only at the internal ring to al- repair.
low access to the sac of an indirect hernia. The common direct recurrent hernia in the angle between the
rectus sheath and the inguinal ligament is due to failure to take
the buttress far enough medial to the pubic tubercle, or to ap-
"Missed Hernias" proximation under tension with cutting out of the sutures.
A "missed" or overlooked sac may be the cause of a "recurrent"

hernia. When repairing a direct inguinal hernia, failure to explore Type of Repair Operation
the cord for a concomitant indirect sac or even a small protrusion
of peritoneum at the internal ring may lead to the development of Some surgeons advocate the selective use of different types and
an indirect recurrence. In infants and children, the sac may be ex- degrees of repairs tailored to the types and degrees of herniation
tremely thin-walled, and some fascial strands in the cord may be according to several available classifications. Others do the same
excised in the belief that these constitute the sac. The hernia "re- repair whatever the type of hernia. However, all get equally good
curs" immediately after the operation. This may occur in adults as results with recurrence rates in the region of 1% or less. It would
well. Small herniations of preperitoneal fat through the conjoined seem that the type of repair, as long as it is recognized and
tendon may be missed and later develop into recurrent direct her- accepted, is less important than the skill and experience of the
nias. They should be excised and the opening carefully sutured. surgeon.
A femoral sac may be missed when repairing an inguinal her-
nia and appear soon afterward as a femoral hernia, due to failure
to examine the femoral canal at the time of the operation. A Orchiectomy
femoral hernia may also appear following repair of an inguinal
hernia because upward traction of the inguinal ligament widens Excision of the testis and cord up to the internal ring is sometimes
the orifice of the potential femoral canal. advocated to reduce the risk of recurrent hernia, especially in el-
derly patients, since it allows for complete closure of the internal
and external rings and elimination of the inguinal canal. However,
Inadequate Dissection of the Sac there is no evidence in favor of this. Furthermore, females in whom
the internal ring and canal are usually closed when repairing an
High ligation and excision of the sac do not influence the recur- inguinal hernia, have the same recurrence rate as males in whom
rence rate and are generally regarded as unnecessary, though this these steps are not taken. There is no justification for removing a
has recently been questioned. 1,41 However, the sac should be dis- testis in the hope of influencing the recurrence rate.
sected off the cord well up into the retroperitoneum and freed
from the edges of the internal ring to allow for clear exposure of
the ring. Short sacs may be simply replaced into the abdominal Drains
cavity. Longer sacs may be transected and the upper stump freed
and replaced in the abdominal cavity without suture or ligation. There is little, if any, indication for the use of drains in the rou-
Inadequate dissection of the sac and/or leaving a stump of the tine repair of groin hernias. Postoperative drainage can reduce
upper end below the internal ring will leave a diverticulum of the the incidence of hematoma, seroma, and infection which could
peritoneum and may lead to early recurrence of the hernia. Slid- lead to recurrence following very extensive operations. The closed
ing hernias, unopened or opened, may be simply rolled back into system, vacuum suction type of drains should be used selectively,
the abdominal cavity and the internal ring closed. Any peritoneal brought out through separate stab wounds away from the main in-
defect will heal within hours or days. cision. They should be removed after 24 hours, or as soon as pos-
sible after this, to reduce the risk of retrograde infection which major cause of recurrence. The pioneer concept of tension-free
could lead to recurrence of the hernia. repair of primary inguinal hernias using synthetic mesh was in-
troduced by Lichtenstein6 and developed further by Gilbert3 and
Rutkow. 7 These techniques are now also used for the repair of re-
Postoperative Activity current groin hernias. The advantages of these methods include
standardization, simplicity, minimal dissection, and the substitu-
Early mobilization and discharge from hospital, resumption of tion of a strong mesh buttress for the attenuated fascia transver-
normal, unrestricted physical activities, and hard work in the im- salis, contributing to a rapid return to full activities and a minimal
mediate postoperative period do not cause recurrences. On the recurrence rate well below 1 %.
contrary, persons with sedentary occupations suffer double the Synthetic mesh has also revolutionized the repair of incisional
number of recurrences than those performing heavy manual hernias. The complicated tissue repairs involving sliding and trans-
labor.! planting muscles and fascia and suturing tissues under tension, re-
sulting in high recurrence rates, have been relegated to surgical
history. These modern methods have reduced the recurrence rate
Simultaneous Bilateral Hernia Repair from almost 50% to less than 5%.
In infants and children, bilateral inguinal hernias are repaired at

the same operation with no evidence that it raises the recurrence Selecting the Type of Synthetic Mesh
rate. In adults as well, bilateral simultaneous inguinal herniorrha-
phy is safe, economical, and convenient for the patient and does Only nonabsorbable synthetic mesh should be used for planned
not increase the recurrence rate. However, it is safer to defer the repairs of hernias. There is no place for absorbable mesh except
second side if the first is very large, difficult or prolonged, or in- under very exceptional circumstances, usually as a temporary mea-
volves more dissection than usual. sure in the presence of purulent peritonitis, where the abdomen
cannot be closed without tension. The most popular nonabsorbable
meshes available for hernia repair are knitted polypropylene and
Combined Procedures knitted polyester, which are rapidly fixed and incorporated into the
tissues. Expanded polytetrafluoroethylene fixes very slowly and in-
Unilateral or bilateral repair of groin hernias by any standard completely, is only partially incorporated into the tissues, and is
method can be combined with almost any other clean surgical pro- used only in special circumstances.
cedure without compromising the recurrence rate. It is most com-
monly performed with prostatectomy done by any route. 42
Herniorrhaphy may also be combined with thyroid, breast, biliary, The Size of the Mesh
gynecologic, and other operations, with no added morbidity.
Endoscopic or open hernia repair can be done together with en- Small pieces of mesh lead to a high recurrence rate. It is better to
doscopic surgical or gynecologic procedures. Unnecessary proce- err on the wide side. The mesh must be sufficiently large to over-
dures through the hernia opening that introduce an element of lap the defect with an apron of a few centimeters to allow a wide
risk of infection, such as appendectomy, should be avoided. area for its incorporation and fixation. The wider the area of over-
Similarly, incisional hernias may be repaired when operating for lap, the stronger will be the force holding the mesh against the
an abdominal emergency or as a planned procedure at the time opposite force of the intra-abdominal pressure that tends to push
of another abdominal operation. Nonabsorbable prosthetic mesh the mesh outward and prolapse it through the defect.
should be avoided when repairing the hernia in combination with
an infected or potentially infected procedure.
Fixation of the Mesh
Late Recurrence The periphery of the mesh must be firmly fixed by sutures or sta-
ples to prevent the mesh from sliding away from the defect or
Most recurrent hernias or new incisional hernias appear within rolling up on itself, exposing all or part of the hernial defect once
the first few years after the operation, but they may develop many more. The sutures or staples must be placed in healthy tissues, as
years later when, for no obvious reason, the mature collagen that far as possible from the weakened areas around the hernia open-
has successfully maintained the repair, fails. Aging tissues, weak- ing. Under certain circumstances, the mesh is not fixed at all but
ening of the muscles, and loss of body vigor are suggested as pos- is held by the intra-abdominal pressure, in obedience to Pascal's
sible causes, but the basic mechanisms are not known. It is assumed law, against the abdominal wall until it is incorporated. The very
that the failure is due to a breakdown in the metabolic system re- force that caused the hernia is exploited to repair it. This concept
sponsible for the balanced integrity of collagen. is used in Stoppa's procedure of GPRVS,38 in Gilbert's "sutureless"
repair,3 and in Rutkow's open mesh plug hernioplasty.7
Prosthetic Mesh and Recurrent Hernias

The Level of the Mesh
The advent of synthetic mesh that can bridge large gaps in tissues
has made it possible to cure every primary or recurrent groin or The deeper the level of the mesh, the less likely a recurrence of
incisional hernia, regardless of size or shape, without tension, the the hernia. 10 The best location is the plane of the "underlay" graft,
164 J. Abrahamson
between the peritoneum and the inner surface of the abdominal est in hernia surgery. In this way, the prime causes of recurrence-
wall, as in the Stoppa GPRVS or Wantz's "unilateral GPRVS,"43 tension, infection, incorrect suture materials, and poor suturing
when placing the mesh laparoscopically, and in the Rives opera- technique--can be avoided. Poor general condition of the patient,
tion in which the anterior open groin approach is used to place tobacco smoking, ascites, obesity, and certain connective tissue and
the mesh in the preperitoneal space. In the same plane, Pascal's mesenchymal metabolic disorders contribute to the failure of a re-
law and mesh prostheses are exploited in the repair of a subcostal, pair. Correct management of the hernia sac and the construction
lumbar, or postappendectomy incisional hernia. 44 Also considered of a strong buttress to reinforce the posterior wall of the inguinal
an underlay is the somewhat more superficial but still retromus- canal, as well as the use of large sheets of prosthetic synthetic mesh
cular placement of mesh between the anterior surface of the pos- in the repair of wide incisional hernias, are essential local factors
terior rectus sheaths and the rectus abdominis muscles for in the success of the repair.
repairing a midline or paramedian incisional hernia. Placing mesh
at the deepest possible level isolates it from any possible infection
in the superficial layers of the wound. References
The "inlay" mesh position, where the mesh is cut to conform to
the shape of the hernial opening and sutured edge to edge to the 1. AbrahamsonJ. Factors and mechanisms leading to recurrence. In: Ben-
david R, ed. Prostheses and abdominal wall hernias. Austin: RG. Landes
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Company; 1994:138-170.
abdominal pressure is applied behind the unsupported mesh. The 2. Amid PK Routine mesh repair. Crucial Contr Surg 1997;4B:63-70.
sutures tend to tear out of the scarred tissues, and the hernia re- 3. Gilbert AI, Graham MF. Improved sutureless technique-advice to ex-
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chanical disadvantage. The intra-abdominal pressure applied to 5. Eldar S, Abrahamson J. Venral-incisional hernia. Tissue repair. In:
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10. Abrahamson J. Hernias. In: Zinner MJ, ed. Maingat's abdominal opera-
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traperitoneal space was too small and was not anchored to the fas- A random controlled clinical trial. BrJ Surg. 1980;67:188-194.
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20. Vgahary F, Simmermacher RKJ. Groin hernia repair via a grid-iron in-
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21. Abrahamson J, Eldar S. The nylon darn repair for primary and re-
current inguinal hernias. Contemp Surg. 1988;32:33-45.
Conclusion 22. Taube M, Ellis H. Mass closure of abdominal wounds following major
laparotomy in jaundiced patients. Ann Roy Coll Surg Engl 1987;69:
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trolled human factors and can be avoided by choosing a skillful, hernia-a survey in Western Jerusalem. ] Epidemiol Community Health.
knowledgeable, and experienced surgeon with a particular inter- 1978;32:59-67.
24. Wantz GE. The Canadian repair: personal observations. World] Surg. 35. Read RC. A review: the role of protease-antiprotease imbalance in the
1989;13:516-521. pathogenesis of herniation and abdominal aortic aneurysm in certain
25. Thomas ST, BarnesJP Jr. Recurrent inguinal hernia in relation to ideal smokers. Postgrad Gen Surg. 1992;4:161-165.
body weight. Surg Gynecol Obstet. 1990;170:510-512. 36. AbrahamsonJ. Repair of inguinal hernias in infants and children. The
26. Read RC. The metabolic role in the attenuation of transversalis fascia approaches of a pediatric surgeon. Clin Pediatr. 1973;12:617-621.
found in patients with groin herniation. Hernia. 1998;2 (Suppl 1):17. 37. Lamont PM, Ellis H. Incisional hernia in re-opened abdominal inci-
27. Grosfeld JL, Minnick K, Shedd F, et al. Inguinal hernia in children: sions: an overlooked risk factor. Br] Surg. 1988;75:374-376.
factors affecting recurrence in 62 cases.] Pediatr Surg. 1991 ;26:283-287. 38. Stoppa R The treatment of complicated groin and incisional hernias.
28. Brown MW, Hamilton DNH, Junor BJR Surgical complications in pa- World] Surg. 1989;13:545-554.
tients on continuous ambulatory dialysis. ] Roy CoU Surg Edinb. 1983; 39. Abrahamson J, Eldar S. "Shoelace" repair of large postoperative ven-
28:141-146. tral abdominal hernias: a simple extraperitoneal technique. Contemp
29. Belghiti J, Panis Y Herniorrhaphy in cirrhotic patients with umbilical Surg. 1988;32:24-34.
hernia. Postgrad Gen Surg. 1992;4:129-130. 40. Read RC. Editorial comment. Curr Surg. 1990;47:278.
30. Stoppa RE. Giant prosthetic reinforcement of the visceral sac for re- 41. Wantz GE, Fischer E. Is high ligation of the indirect hernia sac es-
pair of a re-recurrent inguinal hernia. Postgrad Gen Surg. 1992;4: sential in inguinal hernioplasty? Hernia. 1998;2:131-132.
109-113. 42. Issaq E, AbrahamsonJ, Eldar S, et al. Economic and other advantages
31. GailitJ, Clark RA. Wound repair in the context of extracellular main combined prostatectomy and hernia repair. Theor Surg. 1987;2:78.
trix. Curr opin Ceu BioL 1994;6:717-725. 43. Wantz GE. Atlas ofHernia Surgery. New York: Raven Press; 1991: 133-151.
32. Witte MB, Barbul A General principles of wound healing. Surg Clin 44. Abrahamson J. Treatment of a giant abdominal incisional hernia by
North Am. 1997;77:509-528. intraperitoneal Teflon® mesh implant. Postgrad Gen Surg. 1992;4:
33. Folkman J. Is there a field of wound pharmacology? Ann Surg. 1992; 121-125.
215:1-2. 45. Gecelter GR Ventral-incisional hernia. Laparoscopic perspectives. In:
34. Read RC. Blood protease/antiprotease imbalance in patients with ac- Schein M, Wise L, eds. Crucial contrrroersies in surgery. Vol 3. Philadel-
quired herniation. Probl Gen Surg. 1995;12:41-46. phia: Lippincott, Williams & Wilkins; 1999: 145-148.
21
Respiratory Pathophysiology
and Giant Incisional Hernias
Giovanni Trivellini and Piergiorgio Danelli
When confronting a massive incisional hernia, a surgeon needs to several authors, have been less thoroughly investigated. Studies on
know not only the particulars of the case before him, but also the colon motility have shown that intestinal transit slows down in re-
characteristics and hazards of this class of disorder. A postopera- sponse to decreased intra-abdominal pressure and the associated
tive incisional hernia cannot be understood simply as a hole in an increase in intraluminal pressure. Caval and portal venous
abdominal wall in need of suturing, but rather as a condition that drainage is reduced for the same reasons. Some authors consider
Jean Rives identified in 1973 as "incisional hernia disease." The the abdominal musculature important in preserving the normal
implication is that the hernia itself is but one of many manifesta- curvature of the lumbar spine in the standing position.1,4,9 Finally,
tions of that disease. the skin and subcutaneous tissues may ulcerate, due to the effects
Contributing to the herniation is partial or complete disinsertion of altered abdominal pressure and the weight of the viscera in the
of the flat abdominal muscles from the linea alba and linea semi- hernial sac upon vascular and cutaneous integrity.
lunaris. Following the breakout of the hernia sac and its contents,
the drop in intra-abdominal pressure itself promotes lateral retrac-
tion and wider muscle disinsertion. Respiratory, vascular, and pos- Chronic Disturbances
tural disturbances follow. Finally, disruption of the function of the
abdominal wall muscles tends to aggravate coexistent problems. 1- 7
of Respiratory Mechanics
The normal respiratory function relies on good performance of
Etiology the chest wall, specifically on the coordination between chest wall,
diaphragm, and abdominal wall. The transdiaphragmatic pressure
In the literature, incisional hernias reportedly occur in 1 to 2% of is the fulcrum and equilibrium point of the whole system. In in-
laparotomies. 4 The most important causes are infections of surgi- cisional hernia, the changes in the abdominal wall and drop in in-
cal wounds, errors in suturing technique, inadequate suture ma- tra-abdominal pressure alter the transdiaphragmatic pressure, and
terial, careless sectioning of vessels, nerves and abdominal muscles, diaphragmatic movements are impaired. Furthermore, the nor-
and, above all, excessive abdominal wall tension. It has been es- mal resistance and support offered by abdominal viscera to the in-
tablished that suturing the wound edges under tension prevents ferior diaphragmatic surface is reduced, for the abdominal
adequate healing. That is why any condition producing abdomi- muscles cannot act upon the hernial sac and its contents. In this
nal wall tension (obesity, chronic cough, prostatic hypertrophy, as- situation, most of the contraction of the diaphragm is spent on
cites, etc.) will promote the appearance of hernias. Proper mooring itself rather than accomplishing respiratory work. As a
deposition of collagen fibers takes about six months to insure good consequence, the excursions of the thoracic diameters are shal-
mechanical strength in the scar. s Anything that interferes with lower than normal, as revealed clinically by effort dyspnea. At rest-
healing and puts a strain on immature scar formation will con- ing respiratory volumes, these mechanical alterations are masked
tribute to wound breakdown. For purely mechanical reasons, mid- by compensatory mechanisms, particularly by the accessory respi-
line and particularly paramedian laparotomy incisions are more ratory muscles, which can normalize respiratory exchanges at the
prone to incisional hernia formation than transverse incisions. cost of increased respiratory work. This explains the frequent find-
ing of normal results in basal respiratory function tests and arter-
ial blood gases in patients without preexisting obstructive or
Effects of Giant Incisional Hernias restrictive respiratory pathologies. 6,7,lO,1l
Decreased intra-abdominal pressure and disinsertion of the flat

abdominal muscles are the causes of the functional changes pro- Muscle Alterations
duced by incisional hernias. In nosographic terms, changes in res-
piratory mechanics and muscle function are the important results. The disinsertion of the flat abdominal muscles caused by an inci-
Visceral, vascular, and postural disturbances, though reported by sional hernia brings about changes in muscle structure and con-

21. Respiratory Pathophysiology and Giant Incisional Hernias 167
tractility. The disinserted muscle retracts and is initially hypertonic. Practical Implications
The strength of contractility, measured in skeletal muscles by their
length-tension relation, then progressively declines. Prolonged Careful preoperative evaluation of the patient is essential to the
disinsertion-induced activity causes a hypertonic state accompa- achievement of a satisfactory surgical cure. Cardiovascular pathol-
nied by histologic changes in the muscle fibers ranging from ogy, even severe, does not constitute a contraindication for surgery,
interstitial lipomatosis to hypertrophy and sclera-hyaline degen- unless the operation threatens to worsen an already compromised
eration. Later, ultrastructural changes and hypotonicity occur. respiratory function. Our technique includes measurement, be-
Collaboration with investigators from the University of Rheims in- fore surgery, of the chronic mechanical respiratory deficit and in-
dicates that, at this stage, mere reinsertion of muscles in the mid- traoperative evaluation of the possibility of acute respiratory failure
line at the right length and tension is not sufficient to restore upon awakening. Specific technical devices make it possible to
appropriate function. In the presence of such severe changes in monitor the respiratory function intraoperatively and to reinsert
abdominal muscles, the risk of recurrent herniation is increased. the wide muscles at the midline with the most appropriate tension
In these cases, therefore, it is inappropriate to approximate the and length for efficient contractile function.
edges of the defect. The use of prostheses to achieve anatomical
continuity appears preferable. 2•12
Evaluation of the Chronic
Respiratory Deficit
Incisional Herniorrhaphy Options
The movement of the diaphragm resembles that of a piston within
If an incisional hernia has been present for a prolonged period, a cylinder. Each movement is accompanied by a change in pres-
and chronic respiratory, muscular, and visceral alterations have sta- sure over both surfaces of the piston. By analogy, each excursion
bilized, it is no longer possible to reintegrate the viscera into the of the diaphragm is accompanied by a variation of transdi-
abdominal cavity. Adhesions within the hernial sac give rise to a aphragmatic pressure. The measurement, therefore, of transdi-
situation where, in fact, two abdominal cavities are present, and aphragmatic pressure during respiratory activity provides a good
viscera have lost the right of domain within the abdomen. In such index of diaphragmatic movement (Figs. 21.1 and 21.2). If respi-
cases, the reduction of herniated viscera in the absence of preop- ratory volumes are monitored at the same time, respiratory me-
erative and intraoperative measures creates an unacceptable pres- chanics can be fairly precisely evaluated. The transdiaphragmatic
sure increase and subsequent immobilization of the diaphragm. pressure is measured by a two-window, open-ended catheter con-
The latter, suddenly displaced upward, is forced to work against nected to pressure transducers in a continuous perfusion system.
an elastic charge which is clearly too high. The possibility of acute Recording leads are located 15 em apart. Respiratory volumes are
postoperative respiratory failure forces the surgeon to reject the measured by a pneumotachograph, connected to a volume-flux
operation in some cases. This increase in abdominal pressure,
which can reach five times normal values, cannot be avoided un-
less the abdominal cavity is restored in advance to its normal ca-
pacity.
To re-establish normal volumes of the abdominal cavity, three
methods have been proposed in the past: progressive pneu-
moperitoneum according to the technique of Goni-Moreno, re-
laxing incisions on the aponeuroses of the flat muscles of the
abdomen, and insertion of slowly absorbable meshes.3.4,13-15
A disadvantage of the pneumoperitoneum is that it stretches the
wide abdominal musculature and aggravates the histological le-
sions already present. In our opinion, pneumoperitoneum is in-
dicated only at the stage of muscle hypertonicity; it cannot be used
in emergencies or in incisional hernias associated with various de-
grees of intestinal occlusion.
Relaxing incisions on muscle aponeuroses may make it feasible
to approximate the abdominal muscles at the midline, with a
proper muscle flap and tension, but instrument monitoring of
the abdominal wall tension is required. In cases involving severe
loss of tissue, relaxing incisions are of no value. Through the use
of slowly absorbable mesh, sutured to abdominal muscle fascia, it
is possible to repair, even in emergency conditions, substantial
losses of wall tissue. By this method, the volume of the peritoneal
cavity can be increased at will without overstretching the abdom-
FIGURE 21.1. Preoperative transdiaphragmatic manometry. The upper line
inal muscles and thus without further compromising their resid-
shows the esophageal pressure, the second line shows the abdominal pres-
ual function. sure, the lower line shows the respiratory volume. Arrows indicate the four
In our experience, only one emergency case of giant incisional phases of respiration at high volumes. The most evident anomalies con-
hernia required intestinal resection to close the hernial defect in cern the latest expiratory phase (phase 4), where only precocious con-
spite of the use of a resorbable mesh. traction of abdominal muscles permits the expiration to end.
168 G. Trivellini and P. Danelli
Intraoperative Evaluation of Acute

Respiratory Failure Syndrome
The sudden increase of intra-abdominal pressure, occurring when
herniated viscera are reduced into the abdomen, pushes the di-
aphragm upward and limits its mobility. The patient cannot
breathe, and respiration must be mechanically assisted, even post-
operatively. We measure, therefore, intraoperative abdominal pres-
sure and the elastic respiratory work. The latter is quite easily
evaluated in the anesthetized and curarized patient by measuring
thoracopulmonary compliance. Thoracopulmonary compliance is
defined as the volume variation per unit pressure change under
static conditions, that is, in the absence of movement. The alveo-
lar pressure is directly measured through the endotracheal anes-
thesia tube, and volume changes are measured and displayed by
a graduated piston.
It is reasonable to postulate that after anesthetic induction,
pulmonary compliance does not vary during the course of the op-
eration, therefore, the measured compliance changes reflect al-
terations in thoracic compliance, that is, in that component which
is modified by the hernioplastic surgical procedure. The abdomi-
FIGURE 21.2. Same case, 15 days after surgery. Note the decrease of internal pressure is simultaneously measured through an open-ended,
vention of abdominal muscles during forced expiration. infinitesimally continuous perfusion (3 ml/hour) catheter posi-
tioned in the sigmoid colon, about 30 cm away from the anal
sphincter (Figs. 21.3, 21.4, and 21.5).
The increase in elastic respiratory work, which is inversely re-
lated to thoracopulmonary compliance, parallels the abdominal
pressure. Technical maneuvers which can increase the diameter,
integrator. Both types of data are currently recorded on disk and
the curvature radius, and the volume of the abdominal cavity can
processed by computer.
also normalize these two parameters, eliminating the enhanced
The alterations in the chest wall system dynamics are more evi-
risk of acute respiratory failure upon awakening. This is obtained
dent during respiratory activity at maximal volumes, and they are
therefore evaluated under such conditions. During inspiration, we
observe an abdominal pressure that is lower than normal due to
reduced diaphragmatic mobility. During forced expiration we ob-
serve a major early contribution of the abdominal torque, which
helps to accomplish by means of a large pressure increase, an oth-
erwise impossible expiration.
Measured respiratory volumes, however, are often normal, thanks
to the contribution of the accessory respiratory muscles which
compensate the unbalanced chest wall system. As these muscles un-
dergo fatigue, due to the excessive functional requirements, dys-
pnea ensues, even at a mild degree of strain. Transdiaphragmatic
manometry associated with spirometry constitutes a slightly inva- Pressure
sive examination which is well tolerated and easily repeated. A con-
trol test 15 days postoperatively permits the evaluation of the
functional results achieved. Among our patients, by the time of dis-
charge, 90% display normal transdiaphragmatic pressure during
maximal inspiration, while the contribution of the abdominal
torque is reduced only during the final phase of forced expiration. Large
Comparisons of preoperative and postoperative data demonstrate, graduated
with statistical significance, the normalization of intra-abdominal syringe
pressure, a decrease in compensatory mechanisms, and recovery
of consistent and normal respiratory volumes. This is accompanied Endotracheal anesthesia tube ~a==t::::J
clinically by the clear-cut reduction, or disappearance, of effort dys-
pnea. This simple examination, which we have been lately associ-
ating with surface electromyography of wide abdominal muscles,
V.N. =80-120 ml/cmH 20
assists in evaluating the severity of the respiratory alterations pro-
duced by the incisional hernia as well as gauging the possibilities FIGURE 21.3. Design of intraoperative measurement of thoracopulmonary
of correction through surgery.g,]] compliance.
TABLE 21.1. Transdiaphragrnatic manometry and spirometry-preopera-

Perfusion tive and postoperative mean values in 82 patients
Preoperative Postoperative
Basal abdominal pressure 5.4mm Hg 10.7 mm Hg

Abdominal pressure (phase 4) 16.3 mm Hg 7.5 mm Hg
Inspiratory volume 1554 ml 2331 ml
Expiratory volume 2703 ml 2531 ml
Polygraph
transducer Intraoperative Evaluation of
Abdominal Wall Tension
When the problem of elevated abdominal pressure has been re-
solved, residual tension may persist, opposing the closure of the
hernial defect. This observation led us to measure the effective
tension of the abdominal wall during the phases of the surgical
procedure (Figs. 2l.6, 2l. 7, 21.8, 2l.9).
Since 1980, with the collaboration of the Department of Physics
of the University of Milan, we have assembled a measuring device
FIGURE 21.4. The design of intraoperative measurement of abdominal comprised of two strain-gauge meters, measuring bars, and a dig-
pressure. ital display, interfaced to a polygraph system which also records
abdominal pressure and thoracopulmonary compliance. The mea-
suring bars are applied to the edges of the hernial defect, ren-
dering these edges rigid. The two strain-gauge meters positioned
on the bars keep the fascial defect closed and record the tension
of the whole abdominal wall under the conditions which the ab-
by means of relaxing incisions made on the abdominal muscle dominal wall will face postoperatively. The continuous (dynamic)
aponeuroses or by positioning a slowly absorbable mesh as previ- recording of the abdominal wall tension yields information on the
ously described (Table 2l.1). We point out that, thanks to the in- absolute value of tension as well as on the variations in wall ten-
traoperative evaluation and monitoring of thoracopulmonary sion induced by mechanical respiration or by lung inflation dur-
compliance and intra-abdominal pressure, we have been able to ing thoracopulmonary compliance measurements.
operate without preoperative assessments and during emergen- A major tension increase during any change in the system, lung
cies, even on patients affected by severe obstructive and/or post- inflation for example, indicates that the abdominal wall is unduly
operative complications.9•11 ,15,16 stretched. This observation has a well-defined pathophysiological
Thoraco-pulmonary compliance Intra-abdominal pressure

cmH2 0
/\
16
T1 - - • Basal .................. AV/AP = 69 mllcm. H20
T2 - - x Abdomen closed ......... AVIAP = 28 mllcm. H20 12
T 3 - - 0 After detension incisions ... AVlAP = 59 mVcm. H20 8
4 •
mlgm o '----'---'---'--~
T1 T2 T3
1000
750
FIGURE 21.5. Intraoperative measurement of abdomi-
nal pressure and thoracopulmonary compliance. In ev- 500
idence is the increase in abdominal pressure (+400%)
and the decrease in thoracopulmonary compliance at 250
closure of the hernial defect (T2) in comparison to
basal tests (Tl). Mter relaxing incisions, the values are
normal again (T3).
FIGURE 21.6. Measuring device for abdominal wall tension. There are two
measuring bars and two strain-gauge meters. The wall tension is in g/ cm.
Bars vary in length, depending on the hernial defect. In our experience, the
normal value of the wall tension is about 50 g/ cm in the curarized patient. FIGURE 21.9. Same case after relaxing incisions on muscle aponeuroses.
The decrease of wall tension is evident both in absolute value and during
lung inflation. The abdominal pressure and thoracopulmonary compli-
ance are not modified.
c ,
.Q
(f) ,I
c I
~ Active / Passive
\/'
/'\
/' \
FIGURE 21.7. Intraoperative measurement of abdominal wall tension. The /'
...-'
fascial defect has been closed by means of the two strain-gauge meters /'
fixed to the measuring bars.
Length
FIGURE 21.10. Tension to length relation for skeletal muscle.
FIGURE 21.8. Intraoperative recording of abdominal wall tension. The up-

per line shows the alveolar pressure during lung inflation, with air volumes
of 500, lOOO, and 1500 cc to evaluate the thoracopulmonary compliance;
the second line shows the abdominal pressure; the third and fourth lines
show abdominal tension measured by means of two strain-gauge meters. FIGURE 21.11. Mechanism ofrelaxing incisions.
170
TABLE 21.2. Functional results as measured by transdiaphragmatic manom-

etry and spirometry-preoperative and postoperative mean values in 82
patients
Excellent results 68 patients 83%
Unchanged 11 patients 13.4%
Worse 3 patients 3.6%
basis. The tension:length relation for skeletal muscle indicates that

the total force developed by a muscle depends on the muscle fiber
length and equals the sum of two components: active tension and
passive tension (Fig. 21.10). The intraoperative measurement of
wall tension is obviously related to passive tension of the abdomi-
nal muscles in the anesthetized and curarized patient.
Relaxing incisions decrease tension and, as a consequence, al-
FIGURE 21.12. Example ofreJaxing incisions on the anterior sheaths of the te r the muscle fiber length. It is evident that by changing the wide
rectus muscles. The incisions are small and asymmetrical, so as to reduce muscle length, their working condition and the force they will ex-
and balance the wall tension along the suture line. ert in the conscious patient are changed as well. By means of these
relaxing incisions, we can therefore reinsert the wide muscles at
the midline at the appropriate tension and length for the best pos-
sible functional result (Figs. 21.11 and 21.12). Relaxing incisions
can also modify the curvature radius of the abdominal wall and,
in short, its overall elastic properties. By incising the anterior
sheaths of the rectus muscles, we produce an elongation of the
posterior ones (when they are present) that can reach 4 cm per
side. The abdominal wall is now able to uniformly sustain the func-
tional stresses with no points of weakness. It is evident that, by po-
sitioning an absorbable prosthesis between the muscle fasciae, a
similar effect is achievedY The abdominal cavity volume can be
markedly increased, if necessary, and the prosthesis makes it pos-
sible to reinsert the wide muscles without excessive stretch, mod-
ifying the curvature radius and elastic properties of the wall (Figs.
21.13 and 21.14; Table 21.2).
Conclusion
FIGURE 21.13. Clinical case: giant midline incisional hernia with skin al- We believe that large incisional hernias should be viewed as a se-
teration and wide disinsertion of abdominal muscles. vere systemic disease. Precise knowledge of the multiple patho-
physiologic aspects of the condition and the use of increasingly
sophisticated techniques are required to obtain the best results.
The analysis of our experience, dating back to 1974, particularly
of our failures, demonstrates that success can only be achieved by
means of careful selection, awareness of indications, thorough pre-
operative evaluation, and precise multidisciplinary refinement of
the surgical techniques.
References
1. Caix M, Champault G, Hureauj, et al. Chirurgie des parois de l'abdomen.
Berlin, Heidelberg, New York, Tokyo: Springer-Verlag; 1985:27-56.
2. Caix M, Outrequin G, Grousseau D, et al. Anatomie fonctionelle de
la paroi abdominale: Analyse eIectromyographique et histoenzy-
mologique. Relation entre la tonicite parietale et la pression intracav-
itaire abdominale. Rapport d'Anatomie du 65eme Congres de
l'Association des Anatomists de langue franc;:aise. Limoges, 1982.
3. Descottes B, Rousseau D, Pouget X, et al. II problema del trattamento
chiurugico del laparocele. Arch Atti Soc It Chir Relaz 82 Congr, Roma.
FIGURE 21.14. Same patient two months after surgery. Reapproximation of 1980:1134-1167.
the flat abdominal muscles to repair the incisional hernia became possi- 4. ChevreJ JP, Flament JB. Les eventrations de La paroi abdominale. Paris, Mi-
ble with operation based on pathophysiological criteria. lan, Barcelona, Mexico: Editions Masson; 1990.
172 G. Trivellini and P. Danelli
5. FlamentJB, Clement C. Les variations de la pression abdominale dans 16. Trivellini G, Danelli PG, FumagaIli G. Influence de l'etude pen-
la region sousdiaphragmatique, au cours de la respiration. Nouv hesse operatoire de la pression abdominale de la compliance thoracopul-
Med. 1978;8:8. monaire et de la tension des sutures sur Ie choix d'une technique
6. Rives J, Lardennois B, Pire JCI, et al. Les grandes eventrations. Im- chirurgicale dans Ie traitement des grandes eventrations. GREPA. 1986;
portance du "volet abdominal" et des troubles respiratoires qui lui sont 8:3~36.
secondaires. Chirurgie. 99:547.
7. Champetier J, Laborde Y, Letoublond C, et al. Traitement des even-
trations abdominales postoperatoires: Bases biomecaniques elemen-
taires. ] Chir. 1978;115:11:585-590.
8. Maffei, Faccioli A, PelizZQ ML, et al. I laparoceli. Considerazione fi- Commentary
siopatologiche, etiopatogenetiche e sintomatologiche. Arch Atti Soc It
Chir Relaz 82 Congr, Roma. 1980:1106-1118.
9. Rossi R, Trivellini G, Danelli PG. La chirurgia riparativa su base fun-
Robert Bendavid
zionale dei voluminosi laparaoceli. Atti 90 Congr Soc It Chir Roma.
1988:295-317.
Trivellini and Danelli have shown an unusual interest in the patho-
10. Comroe J. Fisiologia della respirazione. n Pensiero Scientifico. 1975. physiology of the "incisional hernia disease" of Jean Rives. They
II. Trivellini G, Danelli PG, Cortese L, et al. Problemi di fisiopatologia have presented a stimulating technique in the management of in-
respiratoria ed abdominale nei grandi laparoceli: Indagini intraoper- cisional hernia based on the histology of "disinserted" muscula-
atorie. Atti Cong ACO!, Rimini. 1990:215-230. ture, the respiratory changes secondary to the giant hernias and,
12. Flament JB, Palot JP, Pluot G, et al. Histological and clinical consid- most important of all, a method of calibrating a repair according
erations on 224 muscle biopsies in incisional hernias. Abstract book, sec- to the pathologic changes in a particular patient. As a medical stu-
ond world week of professional updating in surgery, Milan. 1990: 176. dent, I had a wonderful professor of physiology, Dr. Joseph Doupe,
13. Clotteau JE, Premont M. Cure des grandes eventrations cicatricielles
who left with me an indelible comment: "If you cannot measure
medianes par un procede de plastie aponevrotique. Chir. 1979;105:
it, I am not interested."
344-346.
14. Goiii-Moreno I. Les pneumoperitoines dans la preparation preopera- My only reservation about this chapter has to do with the "slowly
toire des grandes eventrations. Chirurgie. 1970;9:581-585. absorbable mesh." I would strongly recommend the use of non-
15. Trivellini G, Zanella G, Danelli PG, et al. Traitement chirurgical des absorbable mesh instead. The evidence powerfully rejects the use
grandes eventrations. Etude d'une technique adaptee aux troubles de of absorbable meshes in incisional hernias (see Chapter 20 on
la compliance respiratoire. Chir. 1984;110:116-122. mechanisms of recurrence) .
22
Undescended and Cryptorchid Testes
John M. Hutson and Suzanne Hasthorpe
Embryology may prevent the ovary ascending as far as occurs in other species.
In the male, by contrast, the enlarged gubernaculum holds the
Testicular Descent testis near the groin, in the absence of any counteraction from the
regressed cranial ligament (Fig. 22.1).
The testes develop in the abdominal cavity as part of the urogen- The inguinal canal is formed as the anterior abdominal wall
ital ridge. The prenatal descent from their initial intra-abdominal muscles develop around the gelatinous caudal end of the enlarged
position to the scrotum requires the formation of the inguinal gubernaculum. 5 The processus vaginalis develops as a peritoneal
canal as a way of allowing the testes to exit from the abdominal evagination within the gubernaculum. Mter 20 to 25 weeks of ges-
cavity. Hence, the process of testicular descent is ultimately the tation, the gubernaculum, and the processus vaginalis within it,
cause of inguinal hernias. begin to elongate toward the scrotum, until the peritoneal cavity
Mammals have gained evolutionary advantage from testicular extends into the scrotum. The testis and tail of the epididymis re-
descent by allowing the testis to function at a lower temperature, 1 main attached to the tip of the gubernaculum by a central column
which in humans is about 33° C.2 The mechanism of descent has of mesenchyme known as the plica gubernaculi.
evolved over 100 million years with several anatomical structures The testis descends rapidly through the preformed inguinal
and different hormones being utilized for what is, in modem mam- canal between week 25 and week 30 and then migrates down in-
mals, a complex multistage process. 3 side the processus vaginalis to the scrotum. 12 During this second
The fetal gonads occupy similar positions in both sexes in the phase of descent, known as the "inguinoscrotal phase," the gu-
first seven to eight weeks of gestation. Once testicular develop- bernaculum is loose within the subcutaneous tissues and acquires
ment is initiated by the sex-determining region on the Y chromo- secondary attachment inside the scrotum. The cremaster muscle
some ("SRY" gene), the developing seminiferous tubules begin develops in the mesenchymal sleeve surrounding the processus
producing Mullerian inhibiting substance (MIS), which is also vaginalis, known as the pars vaginalis.
known as anti-Mullerian hormone. 4 Androgens also are produced The inguinoscrotal phase is controlled by androgens, as it is
by fetal Leydig cells. These two hormones (and perhaps others) completely absent in complete androgen resistance. The exact
control the gonadal position by acting on the cranial suspensory mechanism of androgen action remains obscure, but the gen-
ligament at the upper pole and the caudal suspensory ligament, itofemoral nerve has been shown to have a major role. 13-18 Calci-
or gubernaculum, at the lower pole. 5 tonin gene-related peptide is apparently released from the sensory
The transabdominal or first phase of testicular descent takes place branches of the genitofemoral nerve and causes rhythmic con-
largely by relative growth. Androgens stimulate regression of the cra- tractility of the gubernaculum in rodents. This movement may be
nial suspensory ligament, freeing the upper pole,6 while the guber- a way of orienting the tip of the gubernaculum so that it will grow
naculum enlarges caudally, becoming a short, thick anchoring and elongate toward the scrotum. The physical force needed for
ligament ending in the abdominal wall. This latter process remains elongation is probably contributed by the intra-abdominal pres-
poorly understood, but is known to occur without androgens. There sure acting via the patent processus vaginalis. Hence, muscle ac-
are conflicting views on the role of MIS in gubernacular growth7-10 tion does not "pull" or "push" the gubernaculum, but is likely to
but a recent study from our own laboratory of MIS receptor-deficient "steer" it, which is remarkably close to the original definition of
mutant mice shows deficiency of cremaster muscle development in the word, as first applied by John Hunter. 19
the so-called "swelling reaction" (Bartlett & Hutson, submitted).
At between 10 and 15 weeks of gestation, the positions of the Processus Vaginalis
testis and ovary diverge. In the female, the cranial suspensory lig-
ament persists (androgens are absent), and the gubernaculum Following testicular descent, the processus vaginalis closes and
does not undergo a swelling reaction. These anatomical features eventually obliterates. At birth the patency rate is about 70 to 80%,
ensure that the ovary moves higher up in the abdominal cavity this decreases to 30 to 40% by 3 to 4 years of age. Closure of the
compared with the testis, particularly in ungulates and rodents. ll processus occurs more frequently on the left, with 40% closed at
In humans, the greater degree of fusion of the Mullerian ducts birth compared with the right side. 2o
173
174 J.M. Hutson and S. Hasthorpe
TIOHT-t dominal phase will lead to intra-abdominal testes that are truly
- regression 01 cryptorchid, or "hidden," although here we use the word cryp-
cranial ligament torchidism more loosely, to mean any testis not in the scrotum. 26
Transabdominal Intra-abdominal testes are uncommon (less than 5 to 10% of
(1~) MlS/oIherhonnone _
undescended testes), as are intracanalicular testes. In both cases
-t gubemacular the external inguinal ring may be absent if gubernacular migra-
_ • •11 growlh tion does not occur.
Most undescended testes are located just outside the external
inguinal ring in the "superficial inguinal pouch," where the tunica
vaginalis and its retained testis are displaced just lateral to the ex-
ternal inguinal ring, beneath the superficial abdominal fascia of
TIOHT-t Scarpa. 27 There is a fascial barrier preventing these testes from en-
migration controlled tering the scrotum.
by genilofemoral
netve The cause of undescended testes in the superficial inguinal
pouch is likely to be a mechanical failure of gubernacular migra-
tion, the cause of which is uncertain. Some of these boys may have
a defect in the hypothalamic-pituitary-gonadal axis,28 and re-
cently it has been suggested that placental deficiency of human
chorionic gonadotrophin in the third trimester may be impor-
tant. 29
Rarely, undescended testes are found in aberrant (ectopic) po-
sitions, such as the thigh (femoral), perineum, base of the penis
FIGURE 22.1. Schema showing the two proposed steps in testicular descent. (pubopenile), or even in the contralateral inguinal canal (trans-
In the transabdominal phase (10 to 15 weeks), the cranial suspensory lig- verse testicular ectopia). The causes of these abnormal locations
ament regresses and the gubernaculum enlarges, holding the testis near vary. Ipsilateral abnormal migration may be secondary to an ab-
the groin. In the inguinoscrotal phase (25 to 35 weeks), the gubernacu- normally sited genitofemoral nerve. 26 In transverse ectopia, rup-
lum migrates to the scrotum. ture of the gubernaculum can be the cause, allowing accidental
descent into the contralateral processus vaginalis. Alternatively,
transverse ectopia may be caused by an abnormality in the gene
The first event in closure of the processus vaginalis is fusion of for MIS or its receptor, leading to persisting Mullerian duct syn-
its lumen, followed by disappearance of the mesenchyme,20 al- drome. 3o In this rare anomaly, the gubernaculum is abnormally
though how this occurs is unknown. The high incidence of a long, similar to a round ligament, and the retained uterus and
patent processus vaginalis in boys with cryptorchidism suggests that broad ligament keeps the two testes close together, causing both
closure may not occur without testicular descent. 21 testes to prolapse through the same inguinal canal. 31
Closure of the processus vaginalis is defective in complete an- Cryptorchidism is common in multiple malformation syn-
drogen resistance, suggesting that the mechanism requires an- dromes, with a variety of causes. In prune belly syndrome, the baby
drogenic action. 22 In addition, treatment with luteinizing (usually male) is born with a redundant, wrinkled abdominal wall,
hormone-releasing hormone (LH-RH) and human chorionic go- urinary tract dilatation and intra-abdominal testes. A mesodermal
nadotrophin can reduce the frequency of patency from 69 to 31 % defect in the abdominal wall, urinary tract, and gubernaculum is
in children with cryptorchidism. 23 Despite these studies implicat- one proposed explanation,32 but an alternative cause is gross en-
ing androgen in closure, androgen receptors have not been found largement of the bladder, preventing the testes from entering the
in the patent processus at inguinal herniotomy.24 internal inguinal ring. 33 Similar pathology may lead to cryptorchid
Recent studies from our laboratory suggest that androgens may testes in males with posterior urethral valves.
act on closure of the processus vaginalis via the genitofemoral Exomphalos and gastroschisis have a high incidence of cryp-
nerve and release of calcitonin gene-related peptide. 25 We found torchidism (33% and 15% respectively), the cause of which may
that fusion of the processus vaginalis, removed at inguinal be lower abdominal pressure, ruptured gubernaculum, or con-
herniotomy, was induced in vitro by calcitonin gene-related pep- comitant brain malformations. 34 Neurological anomalies are com-
tide, but not by dihydrotestosterone. Fusion was accompanied by monly associated with cryptorchidism, which may be related to
transformation of the epithelium and also occurred with hepato- hypothalamic defects (and androgen deficiency) or anomalies of
cyte growth factor/scatter factor, which may be an intermediary the genitofemoral nerve, as in high lumbar spina bifida (Fig.
in the fusion cascade. These experiments suggest that hernia clo- 22.2).35
sure may be responsive to local trophic agents, which raises the
possibility of nonsurgical treatment by injection of chemicals that
trigger fusion in vivo. Acquired Undescended Testis
The possibility that cryptorchidism may be acquired remains con-
Cryptorchidism troversial. The difference between "retractile," "ascending," and
cryptorchid testes is not clear. Retraction of the testis out of the
Congenital Undescended Testis scrotum is a normal reflex response to trauma or low tempera-
ture. The reflex is absent or weak at birth and becomes more ac-
Any anomaly in the anatomical structures or their hormonal reg- tive after the first year of age, reaching a peak response in 5- to
ulation will lead to congenital maldescent. Failure of the transab- 12-year-old boys.
22. Undescended and Cryptorchid Testes 175
FIGURE 22.2. Schema showing the time scale for inguinoscro-

Inguinoscrotal Processus vaginalis
tal migration of the testis and subsequent fusion and disap-
Migration Fusion & disappearance
pearance of the processus vaginalis. Presumed genitofemoral
nerve dysfunction prenatally may lead to congenital unde-
scended testis, while postnatal dysfunction might lead to
hernia, hydrocele, or ascending testis.
28 weeks Birth 6 months 1 Year
gestation
~,--------,~~--------~#
• •
GFN dysfunction (?) GFN dysfunction (?)
Congenital UDT 1. Congenital inguinal hernia

2. Scrotal hydrocele
3. Ascending testis
Retractile testes can be pulled down into the scrotum during a plies a congenital, possibly hormonal cause, but the subsequent
physical examination, but may retract back up into the groin on ascent seems to have the same cause as retractile testis. 37
release. Retractability has been assumed to be caused by increased Persistence of a fibrous remnant of the processus vaginalis sug-
cremaster contraction, but recently it has been suggested that re- gests that apparently acquired cryptorchidism (that is, retractile
traction is secondary to a short spermatic cord. 36 Between birth and ascending testis) may be causally related to inguinal hernia
and lO years of age, the normal spermatic cord elongates from 5 and hydrocele. 39
cm to nearly 10 cm. Acquired cryptorchidism would occur if this
elongation failed to occur, and failure of complete obliteration of
the processus vaginalis has been proposed as the cause, as resid-
ual fibrous tissue may prevent postnatal elongation of the vas and
Effects of Cryptorchidism
vessels (Fig. 22.3).37 Chronic cremaster muscle spasm, as seen in
Undescended testes are clearly dysfunctional, but whether the
cerebral palsy, is now a recognized cause of acquired, pathologi-
anomaly is congenital or acquired is not fully resolved. There is
cally retractile testes. 38
reasonable consensus, however, that most, if not all of the effect
Ascending testis is a variant of the retractile testis, in which there
is acquired, secondary to the abnormally high temperature of the
is a history of delayed descent of the testis to the scrotum in the
testis in the extrascrotal position. Testosterone and gonadotrophin
first 12 weeks after birth, and then subsequent "ascent" out of the
levels are diminished in infants between 1 and 4 months of age,
scrotum later in childhood. The delayed descent postnatally im-
but androgen receptors are usually normal. 40-42 Secretion of MIS
is diminished between 4 and 12 months. 43
Germ cell numbers are diminished from shortly after birth in
Birth Later In
childhood cryptorchid testes, with some reports even suggesting a prenatal
deficiency.44 Between 4 and 12 months of age, the gonocytes nor-
mally transform into type A spermatogonia, but in cryptorchidism,
this process is inhibited. 45 ,46 Both low postnatal testosterone and
low MIS levels have been proposed as causes for failure of germ
cell maturation. 46 ,47 Deficient germ cell development is a likely
cause of subsequent infertility and malignancy,48 although it has
been suggested that carcinoma-in-situ cells may be congenital. 49
~ ............ Stationary
position
ottestls
Diagnosis
The aim of the clinical examination is to find the gonad and then
~
determine the lowest position it can occupy without undue ten-
sion, which is likely to correspond to the lowest limit of the tunica
vaginalis. 5o In early infancy, the thin, pendulous scrotum makes
Downward
growthot intrascrotal testes conspicuous. By contrast, in 5- to 100year olds,
scrotum the small, contracted scrotum can conceal the testes. Hypoplasia
of the hemiscrotum indicates congenital failure of descent, while
FIGURE 22.3. Schema illustrating "ascent" of the testis. The testis is fully
descended at birth. With further growth postnatally, the fibrous remnant
a closed external inguinal ring indicates that the testis is intra-
of the processus vaginalis prevents elongation of the vas deferens and go- abdominal, intracanalicular, or absent.
nadal vessels. Note that the position of the testis in relation to the inguinal For impalpable testes, hormone tests (for example, human
canal has not changed, but appears to ascend out of the scrotum as the chorionic gonadotrophin stimulation test or MIS assay) need to
scrotum grows downward. (Reprinted from Hernia. 1999;3:97-102, with be performed to confirm the presence of testicular tissue. Ultra-
permission.) sound, computed tomography (CT) scan, or magnetic resonance
176 J.M. Hutson and S. Hasthorpe
imaging (MRI) scan have all been used to locate the intra- difficult to ascertain because of the time lag between treatment
abdominal testis, with mixed success. Their role in the diagnostic (for example, 6 months for congenital undescended testis and
workup remains controversial. Laparoscopy is currently the best about 5 to 10 years for acquired undescended testis) and outcome
method of identifying an impalpable testis, although in about one- (20 to 30 years of age). The literature does not show any obvious
third of cases the gonad will have undergone atrophy, probably advantage of surgery between 4 and 14 years,64,65 although recent
secondary to prenatal torsion (the "vanishing testis"). knowledge of germ cell biology suggests this is still too old to pre-
vent dysplasia. Improved fertility is predicted from very early or-
chidopexy, although it will be another decade before data are
available which will prove or disprove this. 46
Treatment Testicular cancer is known to occur in cryptorchid testes at a
frequency of 5 to 10 times greater than in normal men. 66 Whether
Both hormonal and surgical treatments are available, although the
this risk ratio will improve with very early orchidopexy remains to
former remains controversial. The rationale for human chorionic
be determined. Tumor formation between 20 and 40 years of age
gonadotrophin or LH-RH therapy is a presumed defect in the hy-
is known to be associated with atrophic undescended testes and
pothalamic-pituitary-gonadal axis. 51 ,52 Success rates varying from
the presence of carcinoma-in-situ cells (which are presumed to be
10 to 50% have been reported, with randomized, double-blind,
premalignant germ cells). Gonadal biopsy in adolescence, partic-
placebo-controlled trials showing only a marginal benefit. 53,54 The
ularly if the testicular size is decreased, is recommended by some
mechanical factors involved in testicular descent may be too com-
as a way of screening for patients at risk of subsequent seminoma. 67
plex for this simple approach to be successful, even though hor-
mones are crucial for the process.
Surgical therapy aims to prevent subsequent infertility and ma- References
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8. Fentener van Vlissingen MF, van Zoelen ElI, Ursem PJF, et al. In vitro
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14. Goh DW, Momose Y, Middlesworth W, et al. The relationship among
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22. Undescended and Cryptorchid Testes 177
16. Terada M, HutsonJM, Fanner PJ, et al. The role of the genitofemoral 43. Yamanaka J, Baker JL, Metcalfe S, et al. Serum levels of Mullerian in-
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23
Testicular Atrophy
Robert M. Zollinger, Jr.
Introduction pIe veins (the pampiniform plexus) that tend to consolidate into
two groups and join alongside the testicular artery as they head
Testicular atrophy is a rare but distressing entity. While not unex- into the preperitoneal space. The principal testicular vein on the
pected in patients undergoing operations for torsion or an unde- right side drains into the inferior vena cava, whereas the left tes-
scended testicle, atrophy is seen most often following inguinal ticular vein flows to the left renal vein. Two additional sources of
herniorrhaphy in adult males. The typical patient has an appar- venous drainage of the testicle derive from the cremasteric vein,
ently routine herniorrhaphy followed by an unexpected and pro- which flows into the inferior epigastric vein and secondly, from
longed episode of ischemic orchitis that provokes great anxiety. the deferential vein, which flows into the pampiniform plexus or
Multiple office visits start within days after surgery, and the orchi- the vesical plexus, which drains into the internal iliac vein by way
tis eventually subsides after several weeks. Over the following of the prostatic venous plexus. 4•6
months, testicular atrophy may occur in the patient, with resultant
professional liability for the surgeon.
Several mechanisms have been proposed for testicular atrophy.
Most relate to an altered arterial blood supply. Because of the re- Incidence
dundant arterial collaterals, the testicle is rarely devascularized in
anyone operation, except in failed attempts at staged repairs of A significant incidence of testicular atrophy has been reported af-
an undescended testis. Accordingly, most authors, such as Wantz, 1 ter operations for torsion of the testicle, complex staged repairs
Devlin, 2 and Stoppa, 3 postulate that complex inguinal operations, for cryptorchidism in young children,8 and as a consequence of
or multiple procedures that sequentially compromise the vascular testicular compression due to incarcerated inguinal hernias in in-
supply of the testicle, create the most common setting for testic- fants. 9 The older surgical literature confirms that complete divi-
ular atrophy. sion of the entire spermatic cord results in testicular atrophy in
about one-third of patients. In the surgical era from 1930 until
1960 in the United States, it was commonly recommended that
complete division of the cord be considered an "aid" to the repair
Blood Supply of the Testicle of difficult hernias. "Difficult" was defined as large sliding, very
large scrotal, and multiply recurrent inguinal hernias. lO It was be-
The circulation to the testicle is well documented in the surgical lieved that this deliberate "closure of the entire inguinal canal"
literature.4-7 There are three major arteries within the spermatic with sutures offered the best chance of preventing recurrence. It
cord that supply the testicle: the testicular artery arising from the should be remembered that this was the era of the modified Bassini
aorta; the cremasteric artery arising from the inferior epigastric repair under tension, when primary hernias had a 10% recurrence
artery; and the deferential artery arising from a branch of the su- rate and re-recurrence rates of 20 to 40%. Therefore, this tech-
perior vesical artery. Anatomists state that there are numerous nique replaced orchiectomyll and was utilized in older males for
anastomoses between the testicular and deferential arteries in most a unilateral procedure after obtaining informed consent prior to
males. However, collaterals exist between these two arteries and surgery.
the cremasteric artery in only two-thirds of patients. Additional Many authors of that era emphasized that it was important not
collaterals are provided by the scrotal artery( s), arising from the to disturb the testicle and its scrotal collaterals.I 1.12 This literature
external pudendal artery as well as by anastomoses between on complete division of the cord is summarized by Heifetz. 13 His
branches of the vesical artery, the prostatic artery, and the perineal original 1952 series reported the division of23 cords in 20 patients
branch of the internal pudendal. The result is a scrotal anterior with 4 subsequent atrophies, an 18% incidence. His later 1971 se-
and posterior arterial supply that creates collaterals in the lower ries lO with 112 operations in 101 patients between 1950 and 1970
part of the testicle. 6 The arterial circulation is summarized in reported atrophy in 39 (35 %). This same article lists literature ref-
Fig. 23.1. 7 erences to Burdick and Higinbotham,12 who in 1935 reported an
The returning venous supply from the testicle begins as multi- incidence of testicular atrophy of 11 % and testicular necrosis of
179
180 R.M. Zollinger
complete division of the cord, the incidence would appear to be

... ,.------ 77 in 447 operations or 18%.
In more current times testicular sacrifice or complete division
of the cord is a rare event. However, ischemic orchitis and testic-
Ddtl'f I.
ular atrophy still occur after seemingly uneventful inguinal
perior I • herniorrhaphies. In a Shouldice Clinic series of 28,760 inguinal
hernias reported in 1965 by Iies,17 he recorded a 1% incidence of
atrophy, noting that it was 0.5% in primary herniorrhaphies and
nearly 5% in recurrent repairs. A comparable number of 2% was
reported by McGregor, Halverson, and McVay18 in their 1980 se-
ries for children. In 1982 George Wantz l9 published a personal se-
ries where atrophy was noted in 2 patients (0.1 %) among 2,240
elective primary inguinal hernias done by the Shouldice method.
There were 7 patients in this group with ischemic orchitis. This
implies that only 2 of 7 orchitis patients progressed to atrophy
IL
(30%). More importantly, he noted a 3% rate of atrophy among
__ __ l'rmI lie • . a subgroup of 229 patients having repairs of recurrent inguinal
hernias. As a consequence, Wantz advocated a limited dissection
of the cord in large inguinal-scrotal hernias and a transection of
the hernia sac leaving the distal component undisturbed in the
scrotum. He postulated that dissection done bluntly with forceps
Scroll' • or gauze sponge was traumatic to the small veins of the cord and
'pidid m'
could initiate a cascading venous thrombosis, and that mobiliza-
tion of the distal sac and testicle could interrupt important arter-
ial and venous collaterals. In addition, Wantz advocated the
preperitoneal placement of mesh for recurrent hernias as pro-
posed by Stoppa, in order to avoid any dissection of the cord or
sac. His resultant follow-up series, published by Fong and Wantz 7
in 1992, documented a significant reduction in ischemic orchitis
and testicular atrophy for both primary and recurrent hernia re-
pairs. The risk of atrophy after primary repair decreased to 0.03%,
and after recurrent repair to 0.85%.
Similar results were reported by Bendavid,2o who surveyed the
FIGURE 23.1. Blood supply to the testicle. (Reprinted from Fong Y, Wantz Shouldice Clinic experience between 1986 and 1993. He found
CE. Prevention of ischemic orchitis during inguinal herniorrhaphy. Surg 52 episodes of testicular atrophy after 52,847 operations, for a
GynecolObstet. 1992;174(5)401 , with permission.) 0.08% incidence. Bendavid noted that the risk for atrophy was sig-
nificantly less after primary herniorrhaphy (0.04%) than after re-
current inguinal herniorrhaphy (0.46%). He also documented
2% in 200 patients; a 1937 series by Grace andJohnson 14 in which that the risk increased with each subsequent recurrence and re-
2.5% of 125 patients experienced testicular necrosis; a 1940 series pair. 2o In this series, surprisingly and contrary to Wantz's thinking,
by Neuhof and Mencher4 where 24 patients had no necrosis but there appeared to be a correlation of atrophy after operation for
a 25% rate of atrophy; and a 1963 series by Singha l5 in which 10 direct recurrences. Unfortunately, the numbers were too small to
patients had atrophy among the 84 with follow-up for an incidence reach statistical significance when correlating the type of hernia
of 12%. Additionally, Bodhe l6 published his 1959 series of 27 pa- (indirect, direct, or combined) and the postoperative risk of tes-
tients, among whom there was no testicular atrophy, but 2 patients ticular atrophy. Last, in 1996 Skandalakis5 reported a 0.1 % inci-
experienced ischemic orchitis. Thus, in summation, of the five dence of atrophy among 3,010 patients undergoing primary
studies listed above in which testicular atrophy was reported after inguinal herniorrhaphy. The data from these series are summa-
TABLE 23.1. Atrophies recorded for the years 1986 through 1993 1
Primary hernias Recurrent hernias
Number of Number of
Number of patients testicular atrophies Number of patients testicular atrophies
Direct 19,235 9 3,629 19

Indirect 26,315 8 2,243 8
Combined 624 2 801 6
Totals 46,174 19 6,673 33
1Total 52,847; atrophies 52. No patient had a vasectomy.

23. Testicular Atrophy 181
rized in Table 23.1. Using only the cases reported after 1970, the
incidence of testicular atrophy following adult inguinal hernior-
rhaphy is less than 0.1 % for primary repair, whereas it approxi-
mates 0.5%, or 1 in 200, following recurrent herniorrhaphy. These
conclusions are probably correct in magnitude for the incidence,
but the values of 0.1 % and 0.5% are heavily weighted by the very
large Shouldice Clinic numbers.
Clinical Course
Ischemic orchitis beginning 2 to 4 days after an inguinal hernior-
rhaphy is the usual prelude to testicular atrophy. The patient ini-
tially notices a low-grade fever on the first or second day after
surgery. Atelectasis or a wound infection is often suspected, and
the white blood cell (WBC) count may be elevated. However, the
WBC count and its differential are more consistent with an in-
flammatory reaction than a bacterial infection. Within a day, the
testicle swells to 2 or 3 times its usual size. It becomes firm and
FIGURE 23.2. Color Doppler ultrasound of testis, showing a patent intra-
very tender. Edema of the scrotum occurs and may be quite strik-
testicular artery. (Courtesy of R. Bendavid and P. Hamilton.) (See color
ing. The orchitis may last as long as 6 to 12 weeks, but most insert.)
episodes resolve in half that time. Narcotics for pain relief, scro-
tal support, and decreased exertional activities are recommended the patient and his physician may not be aware atrophy has oc-
as the initial treatment. Additional comfort may be obtained early curred unless the testicle is specifically examined. The end result
with ice and later with heat. Antibiotics, steroids, NSAIDs, and is a painless, non tender testicle that is not only smaller, but firmer
anticoagulants probably do not accelerate healing or affect the and located higher in the scrotum.
outcome. 1,3,21
On examination of the scrotum, it is important to first rule out
infection and then differentiate ischemic orchitis from a hematoma Clinical Conclusions
of the cord. Hematomas tend to be contained in the upper scro-
tum. Ecchymosis and scrotal edema are common. The testicle is 1. Ischemic orchitis that progresses to testicular atrophy is a pos-
not swollen, and it is only minimally tender. Gamma camera scintig- sibility after any inguinal herniorrhaphy. Although the inci-
raphy of the affected testicle after administration of an appropri- dence is rare, the short- and long-term consequences of
ate radionuclide, may be used to assess its viability, but most testicular atrophy are significant to the patient, who should be
clinicians use the simpler and more readily available ultrasound informed of this possibility-especially in preparation for re-
studies. Gray scale ultrasonography (B mode imaging) can deter- operations upon multiply recurrent hernias where the inci-
mine the size and state of the testicle versus a hematoma, but du- dence may be 0.5% or higher.
plex ultrasound with color flow allows Doppler imaging of the
blood flow both to and within the testicle. In a study by Hamilton,
Murphy, and Bendavid,22 of 10 patients with postoperative swollen
testicles, it was found that evaluation of the blood vessels within the
spermatic cord was difficult and operator dependent. However, an
evaluation of blood flow within the substance of the testicle could
be readily documented (Figs. 23.2, and 23.3; see color insert) . In
this series, the 4 patients with normal blood flow within the testi-
cle had a benign recovery, whereas the 6 with absent or markedly
decreased flow (compared to the control contralateral testes)
demonstrated no recovery with progressive testicular atrophy.
There are few studies that document the long-term follow-up or
outcome for either ischemic orchitis or testicular atrophy. Those
that do tend to be found in the older surgical literature following
"complete division of the cord." Today, most authors report that
the incidence of ischemic orchitis is higher after repair of recur-
rent inguinal hernias-perhaps as high as 1 to 5%-whereas the
range may be from 0.1 to 1% after primary repairs.2,3,7 Testicular
atrophy is rare without the swelling of ischemic orchitis; however,
Heifetz recorded that the degree of the swelling did not correlate
with the degree of final atrophy. 13Additionally, only 30 to 50% of FIGURE 23.3. Color Doppler ultrasound showing absence of circulation
the testicles with ischemic orchitis progress to atrophy.3,4,13,14 This within the testicle but a pronounced flow to the scrotal skin. (Courtesy of
progression occurs silently over several months to a year. In fact, R. Bendavid and P. Hamilton .) (See color insert.)
182 RM. Zollinger
2. If the patient has had previous scrotal surgery, such as vasec- repair of recurrent and other difficult inguinal hernias. J Int Coli Surg.
tomy, hydroceloectomy, or varicoceloectomy, or if such scrotal 1952;18(4):498-512.
surgery is planned concurrently with an inguinal herniorrhaphy, 14. Grace RV,johnson VS. Results of herniotomy in patients of more than
extra care must be taken to preserve the vascular supply of the fifty years of age. Ann Surg. 1937;106(3):347-362.
testicle. Accordingly, these circumstances may constitute an in- 15. Singha HSK Closure of the inguinal canal in the treatment of hernia.
Br MedJ 1963;1:227-229.
dication to do only one side or inguinal hernia at a time, or to
16. Bodhe YG. Condition of testicle after division of cord in treatment of
do staged hernia and scrotal procedures in younger patients. hernias. Br MedJ 1959;6:1507-1510.
3. In the presence of a very large inguinal-scrotal hernia, it is rec- 17. Iles JDH. Specialization in elective herniorrhaphy. Lancet. 1965;1:
ommended that the surgeon not mobilize the testicle or cord 751-755.
beyond the external ring. Consideration should be given to 18. McGregor DB, Halverson K, McVay CB. The unilateral pediatric in-
transecting the sac whose distal portion may be left undisturbed guinal hernias: should the contralateral side be explored? J Pediatr
along the cord near the testicle. This may be an indication to Surg. 1980;15(3):313-317.
consider the use of preperitoneal mesh by either the Wantz- 19. Wantz GE. Testicular atrophy as a risk of inguinal herniorrhaphy. Surg
Stoppa or laparoscopic technique. GynecolObstet. 1982;154:570-571.
4. Gentle, careful dissection of the sac from the blood vessels of 20. Bendavid R, Andrews DF, Gilbert AI. Testicular atrophy: incidence and
relationship to the type of hernia and to multiple recurrent hernias.
the cord and the vas should be performed to minimize trauma
Probl Gen Surg. 1995;12(2):225-227.
to both the arterial and venous blood supply of the testicle. 21. Wantz GE. Complications of inguinal hernia repair. Surg Clin NMth
Brute force sweeping with a gauze sponge or pulling with a Am. 1984;64(2):287-288.
smooth forceps must be avoided. In general, the cord as a whole 22. Hamilton P, Murphy J, Bendavid R Color Doppler ultrasound in the
should not be mobilized beyond the level of the external ring assessment of ischemic orchitis after inguinal herniorrhaphy. Probl Gen
or pubis in order to maintain all possible scrotal collaterals. Surg. 1995;12(2):229-232.
5. Venous infarction as a cause of testicular atrophy appears to be
a rare event. Nevertheless, the cord should be observed for ve-
nous congestion after closure of the external and internal rings
during an open anterior repair. The traditional teaching is that Commentary
each opening should allow the easy passage of a Kelly hemo-
stat tip along with the cord at the new internal ring. Robert Bendavid
6. If ischemic orchitis arises during the first few days after surgery,
duplex ultrasound with Doppler color flow evaluation of the Does previous vasectomy increase the incidence of testicular at-
circulation within the testicle may give reassurance to the pa- rophy in a patient undergoing inguinal herniorrhaphy?
tient and surgeon, or prepare both for the possibility of testic- At a trial in London, a surgeon was sued by a former patient for
ular atrophy. negligence. The patient had suffered a testicular atrophy follow-
ing inguinal hernia repair. The "negligence" aspect stemmed from
the fact that the patient had had a vasectomy and had not been
References warned by the surgeon that a vasectomy constituted an added risk
of testicular atrophy following an inguinal herniorrhaphy.
1. Wantz GE. Testicular atrophy and chronic residual neuralgia as risks
of inguinal hernioplasty. Surg Clin NMth Am. 1993;73(3):571-581.
The surgeon, the defendant in the case, was seeking informa-
2. Devlin HB. Groin hernias; a personal approach. In: Nyhus LM, Con- tion to substantiate or disprove this allegation. I was approached
don RE, eds. Hernia. 4th ed. Philadelphia: J.B. Lippincott Co.; 1995: to provide evidence based on the large experience of the
211-215. Shouldice Hospital.
3. Stoppa R Hernias of the abdominal wall. In: Chevrel JP, ed. Hernias I had not previously been aware of any such association, nor had
and surgery of the abdominal walL 2nd ed. Berlin: Springer-Verlag; any of my nine colleagues. My investigation took three directions.
1998:171-177.
4. Neuhof H, Mencher WH. The viability of the testis following complete
severance of the spermatic cord. Surgery 1940;8:672-685. Review
5. Skandalakis JE, Skandalakis LJ, Colborn GL. Testicular atrophy and
neuropathy in herniorrhaphy. Am Surg. 1996;62:775-782. A review of 52 testicular atrophies that had taken place between
6. Koontz AM. Atrophy of the testicle as a surgical risk. Surg Gynecol Db- 1986 and 1993 (both years inclusive). There were 52,847 patients
stet. 1965;12(3):511-513. in this series (Table 23.1). The charts of these 52 patients did not
7. Fong Y, Wantz GE. Prevention of ischemic orchitis during inguinal reveal a history of vasectomy.
herniorrhaphy. Surg Gynecol Obstet. 1992;174(5):399-402.
8. Zer M, Wolloch Y, Dintsman M. Staged orchiorrhaphy. Arch Surg.
1975;110:387-390. Questionnaire
9. Hager j, Menardi G. Ischemic damage of the testes as a complication
of incarcerated hernia in the infant. Padiatr Padol. 1986;21(1):17-24. The patients with inguinal hernias on whom I had personally op-
10. Heifetz CJ. Resection of the spermatic cord in selected inguinal her- erated in 1986 numbered 507. A questionnaire sent to each was
nias. Arch Surg. 1971;102(1):36-39.
designed to find out if there had been any changes in testicular
11. Koontz AR. Resection of the cord in inguinal hernia repair. Am Surg.
1957;23:1072-1073. size. Three hundred eighty-one patients responded (a 75% follow-
12. Burdick CG, Higinbotham NL. Division of the spermatic cord as an up rate). Among these, 49 had had a vasectomy prior to their
aid in operating on selected types of inguinal hernias. Ann Surg. herniorrhaphy, a 12.8% incidence. Six of the 49 felt there was some
1935; 102 (5) :863-874. change, but were not certain. Because of distance, they never
13. Heifetz Cj, Goldfarb A. Division of the spermatic cord as an aid in the showed up for examination, but their discharge note 72 hours
23. Testicular Atrophy 183
postoperatively had shown normal testicles and scrotum, and thus rhaphy. At discharge 72 hours later, none showed any evidence of
no likelihood that testicular problems were to develop. testicular problems.
From this study, it could be projected that there had been 6,764
patients with a history of vasectomy during the period from 1986
through 1993.
Conclusion
Discharge Study Given the rich collateral arterial supply of the testicle, there is lit-
tle likelihood that the severance of a deferential artery at a previ-
Twenty-eight consecutive patients with a history of vasectomy, ad- ous vasectomy would constitute a threat of testicular atrophy
mitted in the space of three months, underwent inguinal hernior- following inguinal herniorrhaphy.
24
Unexpected Findings in Inguinal Hernia Surgery
Enrico Nicolo
Introduction The inflamed viscus may already be in the hernia sac, may en-
ter the sac later, or may never reach the hernia sac, remaining in
Regardless of how well an operation for repair of an inguinal her- the proximity of the hernia defect.
nia seems to be going, a surgeon can encounter the unexpected Hernia appendicitis2 is a relatively frequent cause of inflamed
at any stage and experience the great challenge of intraoperative hernia. The inflamed appendix is easily attracted to the right in-
recognition and response. It is important to be prepared to detect guinal sac, can cause perihernial abscess by lymphatic diffusion to
unusual intraoperative findings and to apply prompt and appro- the subserosal tissue, and, when not contained in the hernia sac,
priate corrective measures. can inflame the hernia by contiguity just because it is near the her-
nia sac, as in pelvic inflammatory disease.
It is difficult to explain the inflammation of the hernia sac con-
Inguinal Hernia taining only omentum, inflammation of an empty sac, or inflam-
mation of an obliterated sac no longer communicating with the
Contents of the Sac abdominal cavity. Most probably, the herniated inflamed bowel ini-
tiates the inflammatory process while in the sac, then returns to
The sac of the inguinal hernia may contain: the abdominal cavity, and the inflammation of the hernia sac
persists.
1. normal abdominal organs (omentum, small bowel, large bowel, Acute and chronic inflammatory processes of the peritoneal
bladder, ureter, ovaries, uterus, and tubes); serosa, especially tubercular peritonitis,3 can spread to the hernia
2. pathological abdominal or pelvic organs (bowel with tumor, sac. The inflammation of the superficial layers of the covering of
bowel with Meckel's diverticulum, bladder diverticulum, pyo- the sac can also spread to the hernia sac. Furthermore, the translo-
salpinx seminoma ovarian cyst, and so on); cation of micro-organisms following incarceration and strangula-
3. free bodies, pathologic elements detached from abdominal and tion 4 can produce inflamed hernia.
pelvic organs (free simple or calcified lipomas, uterine fibro- In general, the exudate of the inflamed hernia can be adhesive,
myomas detached from the uterus, free ovarian cyst, echino- serous or serofibrinous, or purulent. Inflammation with adhesive
coccal cyst, and so on); exudate is a chronic, slow, non tubercular process, which causes
4. foreign bodies (needles, toothpicks, fragments of bones, for ex- the hernia sac to become thickened and contracted, and creates
ample); adhesions between the sac and the herniated viscera, and between
5. ascites, blood, chyle, bile, meconium. the viscera. Inflammation of the herniated omentum creates ad-
hesions between the thickened and nodular omentum and the sac.
Inflammation with serous or serofibrinous exudate is a subacute
Inflamed Hernia process, usually tubercular, in which the serosa of the sac is im-
planted with small miliary tubercles, and filled with serous or
Inflamed hernial is an inflammatory process that involves the her- serofibrinous fluid containing Koch bacilli.
nia sac and its contents. The inflammation of the hernia can be Inflammation with purulent exudate is an acute process usually
due to trauma, single but violent in the form of a blow or a kick, due to intestinal perforation, in which the sac and its contents be-
or multiple, but superficial, in the form of rubbing or repeated come hyperemic and edematous. Fibrinous and purulent exudate
attempts at taxis. The most common cause of inflamed hernia is accumulates in the sac, creating adhesions between the sac and
infection, usually an inflammation of the intra-abdominal viscera. the viscera, and between the viscera. This inflammatory process
Foreign bodies, inflammatory bowel disease, tuberculosis, appen- can spread from the sac either to the peritoneal cavity, producing
dicitis, and so on can cause bowel perforation followed by hernia generalized peritonitis, or to the covering of the sac, producing
peritonitis. perihernial abscess.

24. The Unexpected in Hernia Surgery 185
Benign tumors,5 and especially malignant tumors, can create in- sac to assess the extent of the disease. Laparoscopy through the
flammatory adhesions in the hernia sac and between the sac and hernia sac openinglO can be employed in doubtful circumstances
the herniated viscus containing the tumor, by diffusion or invasion. as a means of establishing the diagnosis: characteristic peritoneal
nodules are visible, and peritoneal biopsy can be taken to docu-
ment the tubercular granulomas. Laparoscopy is risky and con-
Hernial Tuberculosis traindicated when extensive and firm adhesions are present in the
hernia sac. Most of the time, resection of the involved bowel is not
Although it has always been a significant problem in underdevel- indicated, either for diffuse tubercular lesions because it is im-
oped countries, tuberculosis in the United States once again is be- possible to resect the entire involved bowel, or for localized lesions
coming increasingly common, especially in high risk patients such because they have a tendency to heal without surgery.
as immigrants from poor countries, native Americans, urban poor, Bowel resection can be necessary in the presence of strictures,
nursing home residents, patients on peritoneal dialysis, and pa- firm adhesions, and localized ulcerative lesions, as well as in stran-
tients with HIV disease. Hernial tuberculosis should be suspected gulation and incarceration. The operation includes repair of the
in these high risk patients, as well as in women of childbearing inguinal hernia, wide resection of the sac, and the resection of the
age, and in older men with liver cirrhosis. The infecting micro- involved omentum. The sac is suture ligated, excised, and the
organism is Mycobacterium tuberculosis. This disease occurs in ex- stump is inverted with a Lembert-type suture to avoid the spread
trapulmonary sites in 10% of non-HIV infected patients, and in of tubercular infection to the wound. The operation is terminated
70% or more of HIV infected patients. Tuberculosis extends to with the repair of the inguinal hernia. When the process is ex-
the hernia sac from infected ascitic fluid, bowel, a mesenteric tended to the peritoneal serosa, laparotomy can be indicated to
lymph node, a fallopian tube, and through hematogenous spread try to eradicate the intraperitoneal tubercular involvement. All pa-
from distant sites. 6.7 tients should receive a full course of antitubercular drug therapy.
Hernial tuberculosis involves the sac, its contents, or both. In
children it affects only the sac, because the sac is usually empty,
and the concomitant visceral involvement usually affects the gen- Foreign Bodies in Inguinal Hernia
ital organs. In adults, hernial tuberculosis involves both the sac
and its contents. s As a rule, when tuberculosis affects the viscera, Foreign bodies may be found in the herniated bowel or appen-
the hernia sac is always involved, and when it affects the hernia dix, partially in the bowel or hernia sac, perforating the bowel wall,
sac, the entire peritoneal surface is also involved. 9 Tuberculosis of enveloped by omentum contained in the hernia sac, or free in the
the hernia sac is usually diffuse, rarely localized. In the localized hernia sac.
form, the sac can have a normal appearance, and the tubercles Foreign bodies are usually found in the hernia sac of a con-
are present only in the neck or in the fundus, infiltrating the her- genital or an acquired inguinal hernia. l They have included
niated small bowel loop. The diffuse tuberculosis is the most com- chicken, pork, and fish bones, shrimp, a piece of wooden pencil,
mon. The entire sac is involved, as well as the visceral and parietal toothpicks, needles (one with thread), a wood splinter, safety pins
peritoneum. (one that was open), a piece of glass, a biliary stent, thumbtacks,n
There are three forms of hernial tuberculosis: miliary or ascitic, nails, and a bullet. These foreign bodies may reach the hernia sac
ulcerocaseous, and fibrous or dry. In the miliary form, the hernia in different ways: from the bowel lumen, if ingested, or left in the
sac is scattered with small miliary tubercles and always filled with abdomen by a surgeon (sponges, instruments), or through the ab-
serous, sometimes cloudy, rarely bloody, ascitic fluid which com- dominal wall (needles, bullets, and bits of clothing). Foreign bod-
municates with the abdominal cavity. The ulcerocaseous form is ies may also migrate from another area of the peritoneal cavity,
rare and is characterized by the presence of a thick exudate that such as gallstones spilled free during laparoscopic cholecystec-
glues loops of bowel together, and to the sac. Ulcerations and ab- tomy. Another unusual way in which foreign bodies can reach the
scesses can develop. The fibrous or dry form is the rarest, and rep- hernia sac from the outside is by penetrating the skin and the cov-
resen ts the healing progression of the miliary or the ulcerocaseous ering of the sac.
variety. Fibrous nodules can become very adherent to the sac and The gastrointestinal tract is the most common route by which
its contents, as well as to the structures of the inguinal canal. The the foreign body reaches the hernia sac, although most of the
clinical manifestations of patients with hernial tuberculosis are time this cannot be demonstrated clinically or during the opera-
pain, change in size and consistency of the hernia bulge, and in- tion. The history can help to reveal how the foreign body reached
carceration. 3 Incarceration is the most constant manifestation. the hernia sac. For instance, a woman recalled that while eating
Low-grade fever, anorexia, and weight loss are nonspecific, but can soup she accidentally ingested a match, which was incidentally
be present. Accurate diagnosis usually requires bacteriologic ex- found free in the hernia sac months later during a right inguinal
amination of tissue samples for Mycobacterium tuberculosis. The sur- hernia repair; obviously, the match had perforated the intestine.
gical intervention for tuberculosis hernia has two main objectives: Another patient recalled that a needle had penetrated the ab-
to eradicate the tubercular process localized to the hernia, and to dominal wall on the left side of the umbilicus. The needle was
improve or to enhance the possibility of a cure when the process later found in the hernia sac: eventually the needle had worked
is diffuse. When the hernial tuberculosis is an epiphenomenon its way through the abdominal wall, reaching the peritoneal cav-
of an acute diffuse miliary process, or an advanced pulmonary ity, where the omentum enveloped it and carried it down to the
form, the operation is not indicated except for strangulation and hernia sac. A sponge, which was left in the peritoneal cavity by a
incarceration. surgeon two years prior, was found in the patient's hernia sac af-
If the herniated bowel shows tubercular lesions, in absence of ter having been enveloped by the omentum and carried down to
adhesions, the rest of the bowel can be run at the opening of the the hernia sac.
186 E. Nicolo
A foreign body either free in the peritoneal cavity, or contained Peritoneal Free Bodies
in the bowel lumen, is usually attracted in the inguinal hernia sac.
If the foreign body is large and blunt, it may have difficulty pro- Peritoneal free bodies, although very important pathological en-
gressing in the herniated small bowel or cecum, and can be the tities, have little or no clinical significance. They can be found
cause of incarceration. completely free in the hernia sac. They can be attached to the
If the foreign body is sharp, it can perforate and go all the way serosa of the sac, to the bowel, or to the mesentery and omentum
through the bowel wall either outside the hernia sac, ending up with a firm or loose pedicle. Torsion and thrombosis of the ap-
free in the peritoneal cavity, encapsulated by the omentum, and pendices epiploicae can produce necrosis and degenerate to form
pulled down into the hernia sac; or, it can perforate the bowel wall small myxomata or lipomyxomata as free bodies in the peritoneal
inside the hernia sac where it can be found partially in the bowel cavity, and may end up in the hernia sac. The appendices epi-
and partially in the sac, or completely outside the bowel, free in ploicae can be strangulated within the hernia sac and become de-
the hernia sac. Furthermore, a sharp foreign body can perforate tached free bodies within the sac.
the herniated bowel wall and fall free into the hernia sac. The Free bodies can derive from the omentum after torsion or in-
bowel retracts into the peritoneal cavity and then the omentum farct,14-16 from a uterine fibromyoma detached from its pedicle,
encapsulates the foreign body in the sac. from fragments of intra-abdominal tumor detached from the main
The foreign body contained in the bowel lumen, or encapsu- tumor mass, and tubercular nodules of chronic localized tuber-
lated by the omentum has a tendency to make the hernia irre- culoperitonitis detached from their pedicles. Most of the time, a
ducible. Nearly all of the reported cases of hernias containing free body is encapsulated within a fibrous capsule, or covered by
foreign bodies were incarcerated. an endothelial layer that allows the free body to continue to re-
Foreign bodies are occasionally found in the lumen or in the main viable, embedded in the peritoneal fluid, and not reabsorbed.
wall of the herniated appendix. The elements found are the same The peritoneal free body can remain in the peritoneal cavity or
as described with the bowel. 12 In addition, parasites such as tape- in the hernia sac inert, innocuous, and silent. In the same way as
worm, ascaris lumbricoides, Trichuris bilharzia, and echinococci a foreign body, a free peritoneal body causes the hernia to become
have been found. irreducible, and this can be the first clinical manifestation of its
Foreign bodies can be aseptic and may stay in the hernia sac for presence. Furthermore, the free body, when still attached with a
a long period of time and be simply walled off by fibrous tissue firm pedicle, can create in the hernia sac firm adhesions in which
and adhere to the serosa of the sac, of the bowel, and of the mesen- an intestinal loop can become incarcerated and obstructed.
tery, and give rise to no clinical manifestations. In other cases, the
foreign body can produce peritonitis localized in the hernia sac
with an abscess of the sac and its covering. Furthermore, the for- Granulomatous Lesions
eign body may lead to generalized peritonitis and/or a formation
of an abscess with fever, chills, toxicity, and leucocytosis. The ab- Granulomatous lesions are also called pseudotuberculosis of the
scess can drain spontaneously, or, in some rare cases, may create peritoneum for their resemblance to tuberculous lesions, but with
an enterocutaneous fistula. negative culture for Mycobactmum tuberculosis.
There are no signs or symptoms that can reveal, with absolute Granulomatous lesions can involve the hernia sac, and like for-
certainty, the presence of a foreign body. In a rare case, the foreign bodies and free bodies, can cause incarcerations. These gran-
eign body manifested itself in a patient in which a pin perforated ulomas form on eggs of tinea coming from a perforated appendix, 2
the tip of a herniated appendix, then the hernia sac and testicle, or on a ruptured ovarian cyst, or ingested food, especially vegeta-
and finally made its way out of the scrotum.I 3 bles, spilled into the peritoneal cavity from a perforated gastro-
Incarceration can be the first sign of the presence of the for- duodenal ulcer or carcinoma; they may form on a ruptured
eign body. Two days after a patient ingested a foreign body, the echinococcal cyst, talc, starch, mineral oil, spores, and so on.
hernia, which was easily reducible, became incarcerated. Rarely The gross appearance of these granulomas ranges from a stud-
can the diagnosis be made prior to the operation. Only postop- ding of the serous membrane of the sac with nodules resembling
eratively will the signs and symptoms be explained, as in a patient tubercles or larger .masses, to the formation of dense fibrous ad-
whose melena was due to perforation by a toothpick found in the hesions. Microscopically, the reaction is seen to be the formation
sac a few days later. of a chronic granuloma with monocytes, epitheloid cells, giant
At operation, if a foreign body in the herniated bowel is freely cells, lymphocytes, plasma cells, fibroblasts, and sometimes areas
movable, it is left in, the bowel is reduced into the abdomen, and of necrosis. Most of the time, it is possible to recognize and to
the hernia repaired. The foreign body will pass "per viam natu- identity the particles that initiated the granulomatous reaction.
ralem."
When the foreign body is found free and "sterile" within the
hernia sac, or enveloped by the omentum, it can be removed and
the hernia repaired.
Torsion of the Omentum
When the foreign body is found partially in the sac and partially and Inguinal Hernia
in the bowel wall, it should be removed and the bowel perfora-
tion sutured. The decision to repair the inguinal hernia is dictated Torsion of the omentum (Fig. 24.1) is a pathological condition in
by the amount of contamination present at the time of surgery. which the organ twists along its own axis,14-16 and it can be pri-
When diffuse contamination is present, the repair of the in- mary or secondary. Primary torsion is rare and is always unipolar,
guinal hernia should be postponed after management of the per- with only one locus of fixation, that is, the normal attachment of
forated bowel and possible drainage. the omentum to the transverse colon. The displacement and move-
abdomen, and the mass can be palpable. Cutaneous hyperesthe-

sia is present. If the process is chronic and the torsion is incom-
plete, the symptoms are more attenuated and mild. This could
elicit segmental infarction of the omentum, and the formation of
a free body into the peritoneal cavity. The correct diagnosis is
rarely made preoperatively. At the operation for the repair of the
right inguinal hernia, the inguinal sac is opened, and an in-
trasaccular torsion of the omentum is found with some serosan-
guinous fluid. The adhesions between the omentum and the sac
are taken down, and detorsion of the omentum is performed. At
this point, attention should be directed to the abdominal cavity to
rule out, or to rule in, an intra-abdominal torsion of the omen-
tum. This can be accomplished by laparoscopy through the open-
ing of the hernial sac, or through laparotomy. If an intra-
abdominal torsion of the omentum is found, wide resection of the
omentum is a definitive treatment, also taking care of the etio-
logical factors: cysts, adhesions, or tumors. The results are good,
and morbidity and mortality are nearly nil.
Inguinal Hernial Trauma

Inguinal hernia, just because it is protruding and exposed, espe-
FIGURE 24.1. Double torsion of the omentum: intra-abdominal and in- cially when it is large and irreducible, is prone to trauma in a form
trasaccular. Inset: torsion of the omentum in the inguinal hernia sac.
of a blow, of a fall, or a severe crash injury.
Any of these mechanisms of injury can produce a rupture of the
hernia sac and its covering (complete) (Fig. 24.2, right), or rup-
ment of the omentum can be caused by heavy exercise, cough, hy- ture only of the hernia sac (incomplete) (Fig. 24.2, left).
perperistalsis, change in body position, and hemodynamic forces.
The torsion may be either complete or incomplete. In the com-
plete type, there may be up to six full turns. The secondary omen- Complete Rupture
tal torsion is much more common, and is always bipolar between
two points of fixation: the normal attachment to the transverse In complete rupture, which is the most common type, the hernia
colon, and a secondary fixation that usually is due to hernia, ad- sac and its covering can rupture either spontaneously, following a
hesions, cysts, or tumors. violent blow, or through a prolonged and forceful taxis. l
Omental torsion occurs in association with irreducible or free In a long-standing inguinal hernia, the skin, ulcerated from ir-
inguinal hernia, most commonly with a right inguinal hernia re- ritation or bruising, cannot resist the strong impulse of the her-
lated to the greater size and mobility of the right side of the omen- niated viscera and ruptures, with extrusion of its contents. The
tum. It can be intra-abdominal or intrasaccular (intrahernial), or
both.
Intra-abdominal torsion can be divided into two types: the more
frequent subcolic, when the omentum twists just under its inser-
tion to the transverse colon; and the less frequent suprahernial
type, when the torsion takes place just above the neck of the in-
guinal hernia sac. In the intrasaccular or intrahernial variety, the
herniated omentum twists inside the hernia sac.
Double torsion of the omentum is a combination of both the
intra-abdominal and the intrasaccular type, and possesses a char-
acteristic physiopathology. The omentum enters the right inguinal
sac, adheres to it by inflammation, and forms a mass. Due to nu-
merous manual reductions of the hernia, the omentum tends to
twist along its own axis and ends up with an intrasaccular torsion.
At the same time, the abdominal omentum, through the combined
actions of intestinal peristalsis and abdominal muscle contraction,
can twist along its axis between two fixed points of insertion, the
transverse colon and the hernia sac. If the torsion is high and
acute, the patient presents with a steady, severe right lower quad-
rant abdominal pain, the onset of which may be gradual or sud- FIGURE 24.2. Left: incomplete rupture; rupture of the inguinal hernia sac
den, but with no nausea, no vomiting, and no signs of intestinal only. Right: complete rupture; rupture of all of the coverings of the in-
obstruction. On examination, the tenderness is usually in the mid- guinal hernia.
188 E. Nicolo
most common viscus to be extruded is the small intestine, followed

by the colon and omentum. This complication in reality is not as
serious as it seems. Following the complete rupture, the extruded
intestine can remain outside the sac and its covering for several
hours. It can also get dirty and contaminated. At the operation,
the intestine must be cleansed, washed, and irrigated with copi-
r
ous warm saline, and then repositioned back into the abdominal
cavity. The inguinal hernia is repaired, and the rent of the hernia
coverings is debrided and closed. Full recovery is usually expected.
Incomplete Rupture
In the incomplete rupture, the covering of the sac resists the blow
and remains intact. Only the hernia sac ruptures. A clear obser-
FIGURE 24.4. Perforation of the small bowel following blunt abdominal
vation by A. Cooper17 can best illustrate this clinical presentation:
trauma in patients with inguinal hernia.
A patient with inguinal hernia, after lifting a heavy object, experi-
enced an acute, violent pain in the groin, and the hernia bulge sud-
denly increased in size. Two weeks later, the patient presented with omentum can also be subject to contusions following taxis. The
incarceration of the hernia. At the operation, immediately under the omentum can be crushed, lacerated, or detached; bleeding from
incised skin, is exposed a fibrous envelope, like a sac, containing loops
the omental vessels can be substantial. Rupture of the coverings
of bowel. Behind these loops of bowel, a true serosal sac is identified.
of the inguinal hernia can be caused by forcible and prolonged
In the anterior wall of the sac, a circular opening is evident, repre-
senting the rupture of the sac through which the intestine protruded. taxis with extrusion of the herniated viscera (Fig. 24.2, right). The
The bowel was replaced back in the abdominal cavity, and the her- intestines can also rupture, and when reduced into the abdomi-
nia repaired. The patient fully recovered. nal cavity, can cause diffuse peritonitis. Perforation is a much more
common complication of taxis than hemorrhage.
Any abdominal trauma may be part of the etiology of hernia Another clinical entity to be mentioned is the small bowel per-
contusion, but the one to keep in mind because it must be avoided foration following blunt abdominal trauma in patients with in-
is the maneuver of taxis. 1 Taxis has been employed for centuries guinal hernia (E. Nicolo & E. Erickson, 1980, unpublished results).
to reduce an incarcerated inguinal hernia. Attempts to reduce an The presence of inguinal hernia may be the main factor suggest-
incarcerated hernia manually must be avoided. Numerous coming a small bowel perforation following severe, or even trivial,
plications, especially after forcible and prolonged taxis, have been blunt abdominal trauma.
reported. The most common complications are hemorrhage and A loop of bowel resting adjacent to the internal inguinal ring
perforation. bursts against the aperture when the intra-abdominal pressure in-
Attempts at taxis are nearly always followed by extravasation of creases suddenly during blunt abdominal trauma (Fig. 24.4). The
blood into the coverings of the inguinal hernia, especially in the onset of abdominal pain can be delayed, and diagnosis can be
wall of the sac where serous-hemorrhagic fluid can be found. He- missed at the beginning. Therefore, blunt abdominal trauma in
morrhagic infiltrates can be found in the subserosa of the bowel patients with inguinal hernia should be regarded with suspicion
and in the omentum. In some cases, taxis is followed by frank and of an acute perforation of the small bowel until proven otherwise.
brisk hemorrhage, due either to laceration of the mucosa with ev- Tenderness, rebound tenderness, and rigidity of the abdomen
idence of gastrointestinal bleeding, or to mesenteric detachment are the most revealing physical signs, as well as tenderness of the
and laceration (Fig. 24.3) with endoabdominal bleeding. The hernial bulge. At laparotomy, the perforation is usually small and
is located on the antimesenteric border of the small bowel. The
bowel wall adjacent to the perforation is normal. Debridement of
the perforation and the enterorrhaphy is usually sufficient. Bowel
resection may be necessary. The inguinal hernia is repaired at a
later date.
Benign Tumors of the Inguinal

Hernia Sac
In general, benign tumors of the wall of the inguinal hernia sac
are rare.
Cysts of the sac are usually connected with the hernia sac, and
are related to anomalies in the obliteration of the processus vagi-
nalis. They can be large enough to fill the scrotum and become
symptomatic when torsion occurs. 18
Nodular mesothelial hyperplasia, a benign, inactive condition
FIGURE 24.3. Detachment and laceration of the mesentery. of the hernia sac, is a true pathological entity that can mimic and
simulate a malignant process, including malignant meso the-

lioma. 19 Excision of the cyst and of the mesothelial hyperplasia of
the sac is curative.
Benign Tumors of the

Contents of the Sac
Benign tumors of the bowel, omentum, and mesentery can be
found unexpectedly in the inguinal hernia sac, and can be cystic
or solid. The most common solid benign tumor of the mesentery,
bowel, and omentum is lipoma. 2o
The appendices epiploicae are fat-laden pouches of peritoneum
of the large bowel arranged to the taenia libera medially, and to
the taenia omentalis laterally. These are the sites at which the
blood vessels penetrate the bowel wall, and where diverticula oc-
cur. Appendices epiploicae can be involved in a number of dis-
ease processes such as epiploic appendicitis due to torsion or
thrombosis, or acute and chronic inflammation secondary to di-
verticulitis. They initiate incarceration in an inguinal hernia. The
appendices epiploicae can also become hypertrophied and can
reach up to 10 cm in length, forming a pedunculated lipoma. FIGURE 24.5. Inferior pole of a mesenteric cyst contained in an inguinal
When found in the inguinal hernia sac, the appendices epiploicae hernia sac.
can appear normal, hypertrophied, inflamed with diverticulitis, or
strangulated, with necrosis.
The treatment consists of excision of the appendices epiploicae. hernia is repaired. The bowel resection is best performed through
Maximum attention should be exercised to avoid opening a di- laparotomy.
verticulum.
A lipoma the size of an egg located on the antimesenteric bor-
der of the small bowel, and a lipoma of the omentum, either cir- Malignant Inguinal Hernia Sac Neoplasm
cumscribed and encapsulated or enveloped between the two
serosal layers, have been found in the inguinal hernia sac. Tumors that arise from any of the fibrous, fatty, vascular, or retic-
ular tissues that lie beneath the peritoneal mesothelium of the sac
are best regarded as tumors of the parietes, or retroperitoneal,
Omental and Mesenteric Cysts and for this reason are not treated here. Tumors of the hernia sac
can be primary or metastatic. The primary derives from the peri-
Benign cystic tumors of the mesentery and omentum can be found toneal sac, and the metastatic from either an organ contained in
in the inguinal hernia sac, and may be embryonal, lymphatic, he- the sac or a primary tumor of a distant organ not contained in the
morrhagic, or hydatid. 21 ,22 hernia sac. There are sparse and scattered reports of neoplastic
Embryonal cysts include enterogenous cysts, congenital redu- complications of the hernia sac. The hernia sac tumor was first
plication, and dermoid cysts. reported by Arnaud24 250 years ago in 1749, and the first com-
Lymphatic cysts include lymphangioma and lymphangiectasis; prehensive review on the subject was published in 1933 by Gros-
they are retention cysts containing serous or chylous fluid due to Devaud. 25
disruption oflymphatic ducts. The less common chylous cysts con-
tain a milky fluid, creamy, rich in fat, and alkaline. 23 In one case
of lymphoma, the milky, free fluid within the peritoneal cavity was Primary Malignant Tumor of the Sac
aspirated and sent for identification of tumor cells. None were
present. Further investigation revealed a lesion on the liver and a The great majority of the hernia sac tumors are secondary or
diagnosis of non-Hodgkins lymphoma, which accounted for the metastatic. Primary tumors are extremely rare. Primary mesothe-
milky collection (R. Bendavid, personal communication, 1999). liomas of the hernia sac are recognizable pathological entities. 26
Hemorrhagic cysts are old lymphatic cysts in which bleeding oc- Two forms of the disease exist: a benign and, much more com-
curs following a trauma forming an encysted hematoma. mon, malignant form. 2 Malignant mesothelioma l ,2,27,28 can arise
Hydatid cysts co-exist with multiple small echinococcal cysts lo- not only from the mesothelial cells of the sac wall, but also from
cated in other organs, liver, omentum, and so on. the remnant mesothelial cells in the tunica vaginalis, epididymis,
All the cysts of the mesentery are located between the two serosal and spermatic cord, although they are more rare. Malignant
layers. In rare cases, a cyst can be found in the mesentery of a her- mesothelioma is more common in men, average age around 50,
niated bowel loop, or can send its inferior pole into the inguinal with a history of exposure to asbestos, and with demonstrable as-
hernia sac (Fig. 24.5). Most of the time, it is necessary to resect bestos bodies in the lungs. The usual clinical presentation of pa-
the bowel: the cyst wall is adherent to the blood supply of the tients with malignant mesothelioma of the hernia sac is abdominal
bowel, making its excision or shelling out nearly impossible. The pain, abdominal distension, ascites, and an incarcerated inguinal
190 E. Nicolo
hernia. The diagnosis may also be made during the operation for cystadenoma of the ovary, or by rupture of a mucocele of the ap-
the repair of inguinal hernia, and is an incidental finding. The vis- pendix. The irritant mucus produces chemical peritonitis, and the
cid ascites can cause obliteration of the sac with incarceration of mucus-producing cells become implanted on the peritoneum,
the hernia and intestinal obstruction. Histologically, the lesion causing 'jelly-belly.» The jelly-belly is characterized by increasing
should be differentiated from nodular mesothelial hyperplasia,19 abdominal girth as well as an increase in size of the hernia, and
which is a benign reactive condition that can simulate a malignant can be the most common presenting symptom. Another most fre-
process. The benign form, when localized, is treated effectively by quent finding in women is a palpable ovarian mass. The
surgical excision. In most instances, the diagnosis of malignant pseudomyxoma peritonei has a particular affinity for the ovary.
mesothelioma is usually made when the tumor is far advanced, Usually, the diagnosis is made during surgery and with a biopsy of
and the prognosis is generally poor. If the malignant mesothe- the sac. The treatment of pseudomyxoma peritonei, although still
lioma of the inguinal hernia sac has spread to the cord and/or to controversial, can be curative. 35,36 It consists of a cytoreductive
the surrounding tissue, wide resection, including the cord, should surgery combined with intraperitoneal chemotherapy to eradicate
be performed and the hernia repaired. In the early stage of the possible residual tumor left behind. Metastasis to the hernia sac
disease without ascites, good response to therapy can be achieved from distant organs not contained in the sac can arise from the
with intracavitary P-32 combined with external radiation, and pro- stomach, bladder, pericardium, tonsils, and skin as a metastatic
longed survival can be expected. 29 malignant melanoma. When the sac is examined accurately, the
diagnosis can come as a surprise. When the metastasis is not con-
fined to the hernia sac, but spread through the parietal and vis-
Metastatic or Secondary Tumor of the Sac ceral peritoneum, the disease is far advanced, and the clinical
presentation would be abdominal distension, cachexia pallor, and
Metastatic or secondary tumors of the sac may arise from primary ascites. The intraoperative management consists of excising the
tumor of a visceral organ contained in the sac. The inguinal her- sac for biopsy and sending the ascitic fluid for cytology. Laparo-
nia sac can contain any structures of the abdominal cavity as well scopic examination through the open sac is useful to determine
as any malignant lesion affecting them. Metastasis to the hernia the site of the primary tumor and to assess the extent of the
sac is due to the direct extension of the adjacent malignant process intraperitoneal metastatic spread. The hernia is repaired when
involving the herniated viscus. The most common primary tumor possible.
associated with the hernia sac metastasis is the carcinoma of the
colon, especially the cecum and the sigmoid. 30-32 Sarcoma of the
mesentery and the omentum, as well as carcinoma of the appen- References
dix and the bladder, are less common. In the majority of cases, in-
carceration is a diagnostic feature indicating the presence of a 1. Watson LF. Hernia. St Louis: C.V. Mosby; 1948:35-37.
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peutic measures. N Engl] Med. 1969;218:1091.
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4. Bhajekar MY. Strangulated inguinal hernia. Arch Surg. 1947;54:41-57.
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5. Zimmerman LM, Laufman H. Malignant tumors in hernial sacs. Arch
changes the usual characteristics of the hernia. A long-standing Surg. 1940;41:1215-1219.
hernia, previously reducible, can become hard for the presence 6. McGee GS, Williams LF, Potts J, et al. Gastrointestinal tuberculosis:
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more and more irreducible. Colicky pain can start, then nausea, 7. Post R Tuberculosis in the 1990s: resurgence, regimen, and resources.
vomiting, and abdominal distension with signs and symptoms of South MedJ 1992;85:584-593.
strangulation. Especially in elderly patients, the irreducibility of 8. Donati D. Tubercolosi del sacco erniario. Bull Sci Med (Bologna). 1937;
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di irriducibilita. Riv Chir. 1938;4:128-138.
Metastatic tumor of the sac may derive from a primary tumor
10. Binderow SR, Klapper AS, Bufalini F. Hernioscopy: laparoscopy via an
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can arise include ovaries, large bowel, stomach, pancreas, bladder, taining a foreign body (pin) in the sac of an inguinal hernia in a child.
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25
Soft Tissue Infection and Loss of
Abdominal Wall Substance
Ronald T. Lewis
Incisional hernias that follow the common abdominal wound in- grenell and extend freely to involve and destroy abdominal wall
fections result from loss of abdominal wall substance (LAWS). But muscle, subcutaneous tissue, and skin.
far more substantial LAWS is caused by the major necrotizing in- Loss of abdominal wall substance may also result from focal
fections of the abdominal wall discussed in this chapter. These in- necrotizing infection. Meleney's progressive synergistic gangrene
fections are quite uncommon, but they are devastating and is the best example.I 2 Another focal infection, idiopathic scrotal
dramatic. Indeed, when they occur, the immediate risk is to life. gangrene, described by Fournier, 13,14 is usually confined to the per-
Early diagnosis, prompt treatment by radical surgical debride- ineum, but may break through to the abdominal wall and then
ment, and broad systemic support are essential for survival. The simulate the diffuse polymicrobial infection commonly known to-
resulting loss of abdominal wall substance is then a major issue of day as Fournier's gangrene.
further management, but is in part the price of survival.
Clinical Presentation
Classification
Clostridial Myonecrosis
Most necrotizing infections of the abdominal wall are diffuse.
Many causative organisms and conditions occur that are not read- Clostridial myonecrosis (gas gangrene) is a highly lethal condi-
ily differentiated clinically when they present. The main distin- tion. Most gas gangrene occurs in the limbs and is associated with
guishing characteristic is the presence or absence of inflammatory trauma or with diabetes and peripheral vascular disease. Gas gan-
cells on Gram's stain of the wound discharge. 1 Inflammatory cells grene of the abdominal wall occurs rarely, but is all the more dev-
are absent in clostridial myonecrosis, commonly known as gas gan- astating as it follows gall bladder or colon surgery-surgery of
grene. The remaining nonclostridial conditions marked by an in- relatively low morbidity and mortality. Despite the name gas gan-
tense inflammatory response in the wound discharge are now grene, neither gas nor skin gangrene occurs early in the disease,
grouped conveniently under the generic title necrotizing fasciitis for the focus of infection is deep in the muscle. For the same rea-
because they require a common approach to diagnosis and initial son, effective treatment is often delayed and associated with mas-
treatment. 1,2 sive loss of abdominal wall substance.
The early descriptions of necrotizing fasciitis were of superficial The main characteristics are abrupt onset within 48 h of surgery
monomicrobial infections such as Meleney's "acute hemolytic or injury, severe wound pain, marked swelling of the abdominal
streptococcus gangrene" caused by group-A J3-hemolytic strepto- wall, toxicity manifested by tachycardia out of proportion with the
cocci. 3 We now know that these organisms are also responsible for rise in body temperature, and by mental confusion. A brownish
20% of the more deeply seated necrotizing fasciitis,4 and that they watery discharge with a mousy odor is typical. This presentation
may even penetrate the fascia and involve muscle. 5 In addition, differs significantly from that seen in clostridial cellulitis. The lat-
the past 15 years have seen an increasing incidence of necrotizing ter is an infection of skin and subcutaneous tissues of more grad-
fasciitis caused by group-A J3-hemolytic streptococci associated with ual onset characterized by a foul smelling purulent discharge, and
toxic shock syndrome. 6 Other monomicrobial infections caused lacking the severe pain and toxicity typical of gas gangrene. These
by zygomycoses 7 and halophic marine vibrios 8 have been described differences, pointed out by Qvist in 1941,15 are worth emphasiz-
that may destroy the abdominal wall. Today, most necrotizing fasci- ing, as they are often forgotten today.
itis is polymicrobial. The term coined by Wilson refers to necro-
tizing infection involving Scarpa's fascia, but sparing the deep
fascia and muscle. 9 These infections are caused by synergy between Necrotizing Fasciitis
gram positive cocci such as nongroup-A J3-hemolytic streptococci,
and gram negative bacilli. But deeper infections result from syn- As indicated previously, this is a conglomeration of inflammatory
ergy between aerobic and anaerobic gram negative bacilli.lo They conditions of the abdominal wall, perineum, or extremities that
are common in the perineum under the name of Fournier's gan- cannot be clearly differentiated early in their clinical course, but

25. Soft Tissue Infection 193
which require prompt generic diagnosis and aggressive treatment. dominant source of mortality in the Colombian volcanic cata-
The actual presentation varies with the primary location of the in- clysm. 7 The main causative organisms were Rhizopus arrhizus, Mu-
fection within the abdominal wall and with the organisms involved. cor species, and Absidia species. The clinical presentation was
The keys to early diagnosis are the recognition of edema out of insidious, like classic polymicrobial necrotizing fasciitis, but the in-
proportion to skin erythema, gas in the tissues, and skin vesicles. fection more frequently involved the muscle, and the zygomycetes
Later, local skin necrosis may be noted; fever may persist despite were readily seen on microscopic examination of the affected tis-
antibiotic treatment, and systemic hypotension and organ failure sue following radical debridement. The mortality was particularly
may develop. high, 80%, in patients with mucormycosis. Howard and cowork-
ers8 have described necrotizing fasciitis in patients with minor
wound contaminated with halophilic noncholera marine vibrios.
Hemolytic Streptococcus Gangrene The clinical presentation was acute, simulating the course of he-
molytic streptococcus gangrene. V. vulnijicus, V. parahaemolyticus,
Well described by Meleney,3 hemolytic streptococcus gangrene is and V. alginolyticus were the main bacteria.
characterized by dramatic onset and rapid progression.
"Usually within 24 hours after the appearance of the original lesion,
the affected member becomes greatly swollen, red-hot and tender ...
Gram Negative Synergistic Necrotizing Cellulitis
the patient has a rapidly developing fever which may be preceded by
a chill, and is almost always followed by profound prostration ... in The most insidious form of necrotizing fasciitis is Gram negative
a day or two certain areas turn darker, changing from red to purple synergistic necrotizing cellulitis. ll It is polymicrobial from the out-
and then to blue. About this time blisters and bullae begin to form, set, and, as suggested by its name, it results from synergy between
into which clear fluid collects ... usually on the fourth or fifth day aerobic and anaerobic Gram negative bacteria. Like classical
the purple areas of skin become frankly gangrenous." polymicrobial necrotizing fasciitis, it is found in older patients with
impaired host resistance, but abdominal wall infections are most
He goes on to say that less severe lesions mummify and granulate,
likely following colon surgery or i~ury and in neglected perineal
whereas in more severe cases the patient becomes toxic and deliri-
infections. Figure 25.1 illustrates the course of such an infection.
ous, and develops secondary pneumonia with metastatic abscesses.
The perineal form of this condition, now called Fournier's gan-
grene, is especially dangerous. It may readily extend onto and de-
stroy the abdominal wall. Figure 25.2, adapted by Rudolf and
Polymicrobial Necrotizing Fasciitis coworkers 17 from Tobin and Be~amin, 18 illustrates the ready path-
way for spread of infection along Colles fascia of the perineum
Polymicrobial necrotizing fasciitis constitutes 80% of patients with
and the dartos fascia of the scrotum and penis to Scarpa's fascia
the classical necrotizing fasciitis described by Wilson in 1952. Dis-
of the abdominal wall. This contrasts strongly with idiopathic scro-
tinct from hemolytic streptococcus gangrene, the onset is slower,
tal gangrene as described by Fournier,13,14 which probably arises
and systemic signs are more obvious than local findings. The three
in periurethral glands, and is at least temporarily contained by the
hallmark signs described above are the best guides to early diag-
tunica albuginea and Buck's fascia, so that it rarely extends to the
nosis. The infection occurs typically in patients with impaired host
abdominal wall.
defense mechanisms, particularly the elderly, patients receiving im-
munosuppressive treatment, and those with chronic visceral ill-
ness, cancer, or peripheral vascular disease. When the diagnosis is
suspected, Gram's stain of the wound discharge for bacteria and
Progressive Synergistic Gangrene
inflammatory cells and plain X-rays of the abdomen for gas in the
This is a soft tissue infection that primarily affects the skin and sub-
tissues may provide important additional clues to the diagnosis. 16
cutaneous fat. It usually starts around colostomies or retention su-
tures, but may extend and gradually erode muscle and fascia. It
was originally described by Luckett in 1909,19 but it was the care-
Streptococcal Necrotizing Fasciitis ful clinical and bacteriologic description of Brewer and Meleney
in 1926 that established the entity.12 Ten days after draining an ap-
Streptococcal necrotizing fasciitis is clinically indistinguishable pendiceal abscess, they noted an area of exquisitely painful gan-
from polymicrobial necrotizing fasciitis except for its occurrence grene around 2 retention sutures. This enlarged rapidly to produce
in younger and healthier patients. 4 A subset of these patients de- the now classic lesion of 3 concentric zones: an outer advancing
teriorates rapidly with progressive fever, shock, and organ failure- zone of erythema and swelling, merging with a purple mid-zone
the toxic shock syndrome. This represents increased virulence and and a central, ulcerated and necrotic zone. Micro-aerophilic non-
toxicity of the group-A hemolytic streptococci, the so-called "flesh hemolytic Streptococci were grown in pure culture from the outer
eating bacteria." It also accounts for the increased mortality ob- rim of the lesion, and hemolytic S. aureus from the central necrotic
served in these healthy patients. area. Fever and wasting are commonly associated. Figure 25.3 il-
lustrates the course of progressive synergistic gangrene.
Zygomycetic and Noncholera Vibrio

Necrotizing Fasciitis Idiopathic Scrotal Gangrene
Zygomycetic and noncholera vibrio necrotizing fasciitis have been In 1883, Fournier13 described 5 patients with fever and scrotal
described more recently. Zygomycetic necrotizing fasciitis was a edema that became gangrenous within 24 to 30 h. The necrotic
194 R.T. Lewis
A B
FIGURE 25.1. Necrotizing fasciitis. (A) Gram negative synergistic necrotiz- healing, protrusion of the abdominal wall caused by loss of abdominal wall
ing cellulitis arising around a cecostomy and producing necrosis of the en- substance (LAWS).
tire right flank requiring debridement. (B) Following skin graft and
slough separated from the testes rapidly, and the resulting wounds less often; and Ct. septicum, Ct. histotyticum, Ct. bifermentans, and Ct.
granulated. Fournier reviewed the local and general causes of scro- fallax are unusual. Exotoxins produced by the bacteria in an anaer-
tal gangrene, but could find none in the cases he described. Still, obic environment are responsible for the toxicity and tissue lysis
in seems likely that they originated in the periurethral glands. This typical of gas gangrene. A fall in redox potential in the contami-
condition is rarely seen today. As noted above, most cases of nated wound favors conversion of spores to the vegetative forms
"Fournier's gangrene" of the perineum today are more properly that produce exotoxins. Ct. perfringens produces 12 exotoxins, Cl.
cases of Gram negative synergistic cellulitis. novyi 8, and Ct. septicum 4. The most important toxins are lecithi-
nase, an a-toxin that lyses cell membranes and causes hemolysis,
and the 8-toxin, which causes skeletal muscle necrosis, cardiac tox-
Pathogenesis icity, and hemolysis.
Clostridial Myonecrosis
Necrotizing Fasciitis
Six species of Clostridia have been found to cause gas gangrene:
.
Ct. perfringens is the usual cause (70% of cases); Ct. novyi occurs The four main factors in pathogenesis of necrotizing infections
(an anaerobic wound environment, toxic lytic enzymes, bacterial
synergy, and thrombosis of subcutaneous nutrient blood vessels)
are less well understood in necrotizing fasciitis than in gas gan-
Skin ' ---
grene. An anaerobic wound environment favors bacterial synergy,
SCar pa's particularly between aerobic and anaerobic bacteria. Few lytic en-
fascia /
zymes have been found in polymicrobial necrotizing fasciitis, but
Meade and Mueller showed that a collagenase produced by the
Pseudomonas species promotes rapid fascial necrosis. 20 More re-
cently, Talkington and others 21 have associated necrotizing lesions
Tunica in streptococcal necrotizing fasciitis with a protease elaborated by
albuginea the bacteria. Seal and Kingston 22 examined the role of bacterial
synergy and lytic enzymes in local progression and systemic toxic-
ity of streptococcal necrotizing fasciitis. Group-A streptococci in-
jected intradermally produced spreading infection in 12% of
loscia experimental animals. But when S. aureus was injected along with
the streptococci, spreading infection occurred in 50% of animals.
fascia When the a-toxin of S. aureus was injected with the streptococci,
spreading infection occurred in 75% of animals. Thrombosis of
(usci(l nutrient blood vessels in the subcutaneous tissues accounts for the
Buck's fascia skin necrosis in necrotizing fasciitis. Barker and coworkers showed
that the incidence of thrombosis of nutrient blood vessels is higher
Tunica albugineo
in patients with acute skin necrosis than in those with delayed
FIGURE 25.2. Pathways of spread and fascial barriers in perineal infection. necrosis. 23
(Reprinted from Rudolf R, Soloway M, DePalma RG et al. Am] Surg. The role of exotoxins produced by group-A f3-hemolytic strep-
1975;129:591-596, with permission. Modified from Tobin CE and Ben- tococci in the pathogenesis of streptococcal necrotizing fasciitis
jaminJA (see ref. 18.» with toxic shock syndrome (StrepTSS) is particularly interesting.
c
A
FIGURE 25.3. (A) Progressive synergistic gangrene arising around a lower spreading infection. The wound is packed witb gauze. (C) The contracted
abdominal stoma. Typical concentric zones are readily visible. (B) Wide re- wound following skin graft and healing.
section of tbe abdominal wall was required to excise and arrest tbe rapidly
Specific strains of S. pyogenes produce potent pyogenic exotoxins to 20% of T cells, whereas conventional antigens can activate only
(SPEs) that cause the fever, shock, and tissue necrosis typical of 0.01 % of T cells. The result of this massive activation causes re-
StrepTSS, perhaps by causing monocytes to produce monokines, lease of an immense load of lymphokines, particularly interleukin-
especially tumor necrosis factor-a (TNF-a) , a prominent mediator 2, TNF-{3, and interferon-yo The magnitude of this response
of fever, shock, and tissue injury. It has also been proposed that parallels the increased virulence of group-A streptococci in
exotoxins can increase the virulence of group-A streptococci by StrepTSS and the severity of the systemic effects.
acting as superantigens which differ from conventional antigens A further mechanism of increased virulence of certain group-A
in their interactions with T cells 24 (Fig. 25.4). streptococci comes from the presence of M-proteins-especially
Conventional antigens interact with T cells in three phases- types 1 and 3-that decrease phagocytosis by polymorphonuclear
internalization and preprocessing; binding; and T-cell activation. lymphocytes. In this respect, it is interesting that streptococci car-
The antigens are first phagocytosed by monocytes and deposited rying M proteins types 1 and 3 have accounted for the majority
as small peptide antigen determinants in the lysosymes. They then of cases of StrepTSS studied. 25 Clindamycin impairs M-protein
pass into small vesicles and complex with major histocompatibil- synthesis and is particularly effective in treating experimental
ity class II molecules (MHC) in a special binding groove. Finally. S. pyogenes infections. Table 25.1 summarizes the changes in char-
the MHC-peptide complexes pass to the surface of the monocyte, acteristics and pathogenesis of diffuse nonclostridial necrotizing
where they are sampled by specific sequences of amino acids of soft tissue infections.
the variable regions (V) a- and {3-chains of the T-cell receptor
(TCR).
In contrast to this complex and limiting process, superantigens Progressive Synergistic Gangrene
need no preprocessing: binding occurs anywhere on the surface
of the MHC molecule and is not restricted to a binding groove, In 1931, Meleney confirmed the bacteriology of this condition and
and interaction with the TCR can occur with any V {3 element and demonstrated the role of synergy between the micro-aerophilic
does not require matching amino acid sequences. The result of streptococci and the hemolytic S. aureus in an experimental ani-
this far less limited process is that superantigens can interact with mal. 26 Neither organism injected separately produced the lesion,
and activate all T-Iymphocyte-expressing V {3 elements normally 5 but injection of both simultaneously led to gangrene of the skin
196 R.T. Lewis
Conventional Superantigen FIGURE 25.4. Activation of lymphocytes by superantigens
~o
compared with that by conventional antigens. (Reprinted
from Lewis T. Soft Tissue Infections. World ] Surg.
1998;22:146-151, with permission.)
\0 ~ 0
Internalization
'0'-0
Ag
Binding
and Superbinding
presentation
T cell activation
T cell activation
:,/ i
1- .. .- ................................................................................ -
(VP,)2S D~ (J~,)6 c~, Df3, (Jf3,)6 cf3,
-". ~ mmr.;]f,]r:I~£:'l[ljlm ~mm::llilm Ii/j

: -v : iii illWfjltlii:Jfll0l W1fj!I$J@b':!f}]!ii 101
: : '
I
p-Char gene organization
Teell
and subcutaneous tissue. Mter central ulceration occurs, over- surgical debridement and planned re-exploration and revision. A
growth of Gram negative bacilli often develops in the wound. Al- high index of suspicion, the clinical clues to early diagnosis pre-
though the initial lesion develops slowly, progressive expansion is viously outlined, and ancillary investigation, such as Gram stain-
rapid and relentless. This accounts for the name given to the le- ing of the discharge or tissue aspirate and imaging of the part, are
sion (Fig. 25.3). the only prerequisites. At operation, the abdominal wall is incised,
Scarpa's fascia is examined and explored for "undermining" of the
skin and subcutaneous fat typical of necrotizing fasciitis. Necrotic
Idiopathic Scrotal Gangrene tissue is excised, and the deep fascia is opened to inspect muscle
for involvement and viability. No attempt is made to refine the di-
By definition, the source of this lesion is obscure. Coenen and agnosis before exploration. This will come later, based on the find-
Przedborski found that anaerobic streptococci were the main ings at initial operation, the results of microbiologic studies,
causative organisms. 27 However, overgrowth of Gram negative or- biopsy, the response to broad spectrum antibiotic therapy, and
ganisms is common later. In recent times, fewer than one-third of supportive treatment.
cases reported as Fournier's gangrene are idiopathic. As noted Antibiotics are chosen empirically at first. Triple therapy with
above, the name has been appropriated by the perineal form of high dose intravenous penicillin, an aminoglycoside, and clin-
Gram negative synergistic cellulitis originating mainly from peri- damycin is advocated by some. Others prefer mono therapy with
anal infection, trauma, or disease of the urinary tract. imipenem-cilastatin, or the use of a third generation cephalo-
sporin or quinolone and clindamycin or metronidazole. Within
48 h, more specific therapy should be available: penicillin 6 to 12
Treatment million units per day is given for clostridial myonecrosis and mono-
microbial necrotizing cellulitis, and antifungals for zygomycetic
In treating necrotizing infections of the abdominal wall it is es- cases; broad spectrum therapy is continued for polymicrobial
sential to be aware that these conditions require prompt, radical, necrotizing fasciitis; and for streptococcal necrotizing fasciitis with
StrepTSS, intravenous penicillin, 18 million units per day, clin-
damycin, 2.7 g per day, and human immunoglobulin 400 mg/kg
TABLE 25.1. Classification of necrotizing soft tissue infections causing per day for 5 days are recommended. Planned surgical re-explo-
loss of abdominal wall substance (LAWS) ration of the wound is also advisable at this time. If massive ab-
dominal wall resection has occurred, temporary abdominal wall
Focal necrotizing infections
support with prosthetic materials may be required. Systemic sup-
Progressive synergistic gangrene
Idiopathic scrotal gangrene port of organ function (especially that of the kidneys), coagula-
Diffuse necrotizing infections tion, and nutritional status is often necessary. Later, reconstruction
Clostridial myonecrosis-gas gangrene by skin grafting or more complex measures is undertaken.
Nonc1ostridial infections-necrotizing fasciitis The use of hyperbaric oxygen therapy (HBO) remains contro-
Monomicrobial versial. It is most useful in clostridial myonecrosis, but has also
Hemolytic streptococcal gangrene been advocated for other necrotizing infections. 28 Production of
Streptococcal necrotizing fasciitis the a-toxin ceases at P02 240 mm/Hg,29 and in experimental an-
Streptococcal necrotizing fasciitis with toxic shock syndrome imals, survival improves. 3o In special centers, HBO clearly adds
Polymicrobial
benefit to therapy by surgical debridement and high dose antibi-
Classic polymicrobial necrotizing fasciitis
otics,31 but it cannot replace surgical debridement as the mainstay
Gram negative synergistic necrotizing cellulitis
of treatment.
References 18. Tobin CE, Benjamin ]A. Anatomical study and clinical consideration
of the fasciae limiting urinary extravasation from the penile urethra.
1. Dellinger EP. Severe necrotizing soft tissue infections: multiple disease Surg Gynecol Obstet. 1944;79:195.
entities requiring a common approach. ]AMA. 1991;246:1717-1721. 19. Luckett WH. Large phagedenic ulcer of the abdomen. Ann Surg.
2. Kaiser RE, Cerra FB. Progressive necrotizing surgical infections-a uni- 1909;50:605-608.
fied approach.] Trauma. 1981;21:349-355. 20. Meade jW, Mueller CB. Necrotizing infections of subcutaneous tissue
3. Meleney FL. Hemolytic streptococcus gangrene. Arch Surg. 1924;9: and fascia. Ann Surg. 1968;274-280.
317-364. 21. Talkington DF, Schwartz B, Black CM, et al. Association of phenotypic
4. Giuliano A, Lewis F, Hadley K, et al. Bacteriology of necrotizing fasci- and genotypic characteristics of invasive Streptococcus pyogenes isolates
itis. Am] Surg. 1977;134:52-57. with clinical components of streptococcal toxic shock syndrome. In-
5. Yoder EL, Mendez], Khatib R Spontaneous gangrenous myositis infect Immun. 1993;3:369.
duced by Streptococcus pyogenes: case report and review of the literature. 22. Seal DV, Kingston D. Streptococcal necrotizing fasciitis: development
R.tro Infect Dis. 1987;9:382-385. of an animal model to study its pathogenesis. Br] Exp Pathol. 1988;69:
6. Greenberg RN, Willoughby BG, Kennedy D], et al. Hypocalcemia and 813-831.
toxic shock syndrome associated with streptococcal fasciitis. South Med 23. Barker FG, Leppard B], Seal DV. Streptococcal necrotizing fasciitis:
] 1983;76:916-918. comparison between its histological and clinical features. ] Clin Pathol.
7. Patino ]F, Castro D, Valencia A, et al. Necrotizing soft-tissue lesions af- 1987;40:335-341.
ter a volcanic cataclysm. World] Surg. 1991;15:240-247. 24. Stevens DL, Tanner MH, Winship], et al. Severe group A streptococ-
8. Howard R], Pesa ME, Brennaman BH, et al. Necrotizing soft tissue in- cal infections associated with a toxic shock-like syndrome and scarlet
fections caused by marine vibrios. Surgery. 1985;98:126-130. fever toxin A. N Engl] Med. 1989;321:1.
9. Wilson B. Necrotizing fasciitis. Am Surg. 1985;18:416-431. 25. Schwartz B, Facklam RR, Brieman RF. Changing epidemiology of
10. Stone HH, Martin ]D, Jr. Synergistic necrotizing cellulitis. Ann Surg. group A streptococcal infection in the USA. Lancet. 1990;336:1167-
1975;129:702-711. 1171.
11. Rouse TM, Malangoni MA, Schultz ~. Necrotizing fasciitis: a pre- 26. Meleney FL. Bacterial synergism in disease processes with confirma-
ventable disaster. Surgery. 1982;92:765-770. tion of the synergistic bacterial etiology of a certain type of progres-
12. Brewer GE, Meleney FL. Progressive gangrenous infection of the skin sive gangrene of the abdominal wall. Ann Surg. 1931;94:961.
and subcutaneous tissues, following operation for acute appendicitis. 27. Coenen TE, przedborskiJ. Die gangran des penis und scrotums. Bietr
Ann Surg. 1926;84:438-450. Klin Chir. 1911;75:136-167.
13. Fournier ]A. Gangrene foudroyante de la verge. Sem Med. 1883;3: 28. Ledingham I, Tehrani MA. Diagnosis, clinical course and treatment of
345-346. acute dermal gangrene. Br] Surg. 1975;62:364-372.
14. Fournier ]A. Etude clinique de la gangrene foudroyante de la verge. 29. Brummelkamp WH. Considerations on hyperbaric oxygen therapy at
Sem Med. 1884;4:69-70. three atmospheres absolute for clostridial infections type welchii. Ann
15. Qvist G. Anaerobic cellulitis and gas gangrene. BM] 1941;2:217-221. NY Acad Sci. 1965;117:688.
16. Fisher]R, Conway M], Takeshita RT, et al. Necrotizing fasciitis: impor- 30. Demello Fj, Haglin lJ, Hitchcock CR Comparative study on experi-
tance of roentgenographic studies for soft tissue gas. ]AMA. 1979;241: mental Clostridium perfringens infection in dogs treated with antibiotics,
803-806. surgery, and hyperbaric oxygen. Surgery. 1965;73:936-941.
17. Rudolf R, Soloway M, DePalma RG, et al. Fournier's gangrene: syner- 31. Hitchcock CR, Demello Fj, Haglin lJ. Gangrene infection: new ap-
gistic gangrene of the scrotum. Am] Surg. 1975;129:591-596. proaches to an old disease. Surg Clin North Am. 1975;55:1403-1410.
Part V
Biomaterials
26
Biochemistry, Immunology, and Tissue
Response to Prosthetic Material
Susanne K. Woloson and Howard P. Greisler
Introduction Cellular Aspects of Wound Healing

with Prosthetic Material
The implantation of relatively biocompatible prosthetic materials
has gained wide acceptance in the past few decades. Additionally, The implantation of prosthetic material results in a unique wound
there has been an increasing number of indications for using pros- environment in that the normal components involved in healing
thetic material in the practice of surgery. The differential healing are intimately in contact with a foreign body. The sequence of
response of the surrounding tissue adjacent to the prostheses has events that normally occurs during wound healing involves coag-
been recognized but incompletely understood. Typically, there ulation, inflammation, angiogenesis, epithelialization, fibroplasia,
are three stereotypical responses to foreign material, character- matrix deposition, and contraction. 6 The cellular components in-
ized as (1) destruction or lysis; (2) incorporation and tolerance; clude mostly blood-borne elements such as platelets, monocytes,
and (3) rejection or extrusion'! A truly biocompatible prosthetic macrophages, and polymorphonuclear leukocytes. However, there
material, unlike all known implants to date, would not elicit a for- are also fibroblasts, endothelial cells, and smooth muscle cells that,
eign body reaction. together with the circulating inflammatory cells, elicit a complex
Much of our knowledge regarding the host response to pros- cascade of events resulting in the activation of these inflammatory
thetic material comes from the pioneering work by Voorhees et cells and the production of a variety of growth factors. These
aI., who developed the first successful prosthetic vascular graft. 2 growth factors and cytokines in turn stimulate the cells involved
The characteristics of the healing response at the tissue/prosthetic in the inflammatory response and augment wound healing (Fig.
interface are determined by the inherent properties of the pros- 26.1) .6
thetic material as well as by the nature of the host tissue. Factors Immediately after implantation and contact with the prosthetic
that can affect host tissue healing include the nutritional and im- material, plasma proteins are adsorbed to the graft. The amount
mune status of the patient as well as the existence of any chronic of adsorbed protein directly correlates with their plasma concen-
disease processes. The inherent properties of the prosthetic ma- trations. The more commonly adsorbed proteins include albumin,
terial that may affect healing involve, among other surface and immunoglobulin (Ig)G, and fibrinogen. 7 Mter a period of equili-
bulk properties, the porosity, electrical charge, surface chemistry, bration, there is a redistribution of these proteins depending on
compliance, and surface texture of the material. For example, it their electrical affinities and biochemical properties, known as the
is known that porous grafts allow transinterstitial ingrowth ofmes- Vroman effect. The Vroman effect also varies between prosthetic
enchymal cells, whereas prostheses with less porosity do not show materials. 8 For example, fibrinogen is differentially adsorbed de-
this phenomenon. 3 The interaction of the prosthetic material pending on the properties of the prosthetic material. 9 Because of
with blood-borne elements is also variable between materials. For the varying concentrations of these adsorbed proteins, depending
example, polyethylene terephthalate (Dacron®) activates com- on the type of prosthetic material, their interaction with circulat-
plement to a greater extent than expanded polytetrafluoroethyl- ing inflammatory cells is also differential. Laminin, fibronectin,
ene (ePTFE).4 Finally, the location of implantation of the and vitronectin all have an arg-gly-asp (RGD) sequence on their
prosthetic material results in a differential healing response. surface ligands, which bind to the glycoprotein IIb/IlIa receptor
Williams et al. has demonstrated that ePTFE implants placed in a complex on platelet membranes. Once this occurs, there are cy-
subcutaneous position in rats exhibited a limited formation of mi- toskeletal changes within the platelet that occur, leading to de-
crovascular elements, but an extensive fibrous capsule. In con- granulation and release of bioactive substances from alpha
trast, the same ePTFE implants placed in adipose tissue resulted granules and dense bodies. Investigators have attempted to alter
in marked neovascularization with virtually no fibrous capsule the level of bound RGD sequence proteins and activation of com-
formation. 5 plement that occur with prosthetic material by preferentially ap-
201
202 S.K. Woloson and H.P. Greisler
INJURY
A
and von Wille brand factor, leading to greater platelet deposition.
The conformational change that occurs with platelet activation
may expose additional surface receptors for activated clotting fac-
tors, resulting in greater thrombogenicity. Several cytokines are re-
leased from activated platelets that augment the acute phase of
healing. Platelet derived growth factor (PDGF), released from al-
pha granules, is a strong chemoattractant and a mitogen for fi-
RESISTANCe )-• • liliiii broblasts and smooth muscle cells. Platelet factor 4 (PF4) inhibits
TO INFECl1CN
circulating proteases and promotes further platelet aggregation.
Thromboxane A2 is a potent vasoconstrictor as well as a platelet
aggregator and promoter of neutrophil adhesion. Interestingly, it
ENCQTHEUAL eELS
EPITHELIAL IANG,OGENESIS) has been shown in canines that thromboxane B2, the stable
CELLS
metabolite of thromboxane A2, is chronically elevated after pros-
DE3RIDEMENT ~AOTEOGL YC)'N
thetic implantation and is associated with a decreased circulating
~
SYNTHESIS
platelet count even after 1 year. ll The function of these chroni-
cally adherent platelets is not understood, nor is their role in
wound healing in the face of a prosthetic implant.
COlL.4GEN CQlL.4GEN
'"~,J' Polymorphonuclear Leukocytes

The polymorphonuclear leukocyte is another key player in the
+
acute inflammatory response to healing. These cells are attracted
to the fibrin coagulum present along the prosthetic surface as well
as C5a, leukotriene B4 , and PF4. These chemoattractants all in-
------~ HEALED WOUND ....r - - - - - - - -
crease the adhesivity of neutrophils on endothelial cells by a di-
FIGURE 26.1. Schematic of the sequence of cellular events during response rect effect on the neutrophil. Macrophage-derived interleukin
to wound healing. (Reprinted from Hunt TK, Mueller RV. Current surgical (IL)-l and tumor necrosis factor increase endothelial cell affinity
diagnosis and treatment, 9th ed. Norwalk: Appleton and Lange; 1991:95-108, for neutrophils. It has been shown in other laboratories that neu-
with permission.) trophils preferentially adhere to endothelial cells. 12
Mter neutrophils adhere to endothelial cells, they become ac-
tivated and penetrate the endothelial layer through a complex
mechanism and enter the subendothelial connective tissues. There
plying albumin to the graft surface.I° This process, called surface they release both proteolytic enzymes that degrade the extra-
passivation, is aimed at attempting to decrease the activation of cellular matrix and oxygen free radicals, which may allow the neu-
platelets and thus decrease their release of biologically active sub- trophil to "cleanse" the wound of debris and dead tissue. In
stances. As yet, this process has not resulted in a more favorable addition, neutrophils are capable of attaching to foreign materi-
healing response with prosthetic materials. als through several processes, including using adhesion receptors
All known prosthetic surfaces activate both the classic and al- for activated complement factor 3b (C3b) and IgG. If they are un-
ternative complement pathways, leading to the generation of com- able to phagocytize the prosthetic material, they become activated
plement (C) 5a. The extent of complement activation depends on and secrete the same substances previously mentioned.
the prosthetic material, as mentioned previously. The generation
of C5a has many important ramifications, including its chemo-
tactic ability for inflammatory cells and alteration of the interfa- Monocytes and Macrophages
cial milieu. The blood-borne inflammatory cells include platelets,
monocytes, macrophages, and polymorphonuclear leukocytes. Circulating monocytes are critical performers in the cellular re-
Each of these cell types has distinct yet interrelated roles in the sponse of prosthetic wound healing. They are attracted to the bio-
cellular response of healing in the face of prosthetic material. material by a variety of mechanisms and in turn result in a cascade
of reactions leading to cellular recruitment and release of bioac-
tive substances. Through this process, monocytes differentiate into
Platelet Adhesion inflammatory monocytes, then into macrophages, and finally ac-
tivated macrophages. The degree of macrophage infiltration de-
Platelet adhesion to the prosthetic material occurs rapidly after pends on the characteristics of the biomaterial itself. Studies in
closure of the wound through interactions with adhered proteins our laboratory have shown differential activation of macrophages
as previously described. Once these platelets are "activated," they with various prosthetic materials. 13
release a number of biologically active substances that recruit Monocytes preferentially adhere to areas of injured vascular en-
additional platelets as well as other cellular elements. Serotonin, dothelium, resulting in monocyte activation and the concomitant
epinephrine, and adenosine diphosphate are released locally cascade of events it invokes.I 4 There are also many bioactive sub-
and lead to further platelet recruitment. Alpha granules released stances that are chemotactic for monocytes as well. C5a, which is
by platelets contain several adhesive glycoproteins, including adherent to the implanted prosthetic material itself, is chemotac-
fibrinogen, beta-thromboglobulin, thrombospondin, fibronectin, tic for monocytes, as is PDGF, which is released from endothelial
26. Response to Prosthetic Material 203
cells, smooth muscle cells, and platelets. Extracellular matrix pro- endothelial cells. The macrophages exposed to polyglactin 910 re-
teins, such as fragments of elastin, fibronectin, and collagen, are leased more mitogenic factors for all three cell lines than did
also chemotactic for monocytes. Activated macrophages in tum macrophages exposed to Dacron or to no prosthetic material.
release substances that perpetuate the cascade of responses. When the media were preincubated with a neutralizing anti-bFGF
Leukotriene B4 released from macrophages is chemotactic for neu- antibody, the level of cellular proliferation significantly decreased.
trophils and monocytes and results in increased adhesion of neu- Western blotting analysis demonstrated that the media exposed to
trophils to endothelial cells. Activated macrophages also release polyglactin 910 were immunoreactive to anti-bFGF antibody. Thus,
PDGF, acidic and basic fibroblast growth factor, transforming although PDGF plays a role in smooth muscle cell migration dur-
growth factor beta (TGFf3) and IL-l and IL-6. All of these sub- ing wound healing, bFGF appears to playa role in smooth mus-
stances modulate and perpetuate the cellular response at the pros- cle cell proliferation following explanation of at least some
thetic/blood/tissue interface. Additionally, oxygen free radicals prosthetic devices. Obviously, these cytokines are involved in many
and proteases released from macrophages modulate the healing other roles, some of which may overlap.
response. Thus, the complexity of the role monocytes and
macrophages have in the healing response of prosthetic implants
is profound. Transforming Growth Factor Beta
Transforming growth factor beta is actually a family of proteins
Bioactive Mediators of Wound Healing that has recently been characterized and its implications in wound
healing examined. It is released from platelets, smooth muscle
There are several biologically active mediators released from a va- cells, and activated macrophages. This growth factor has the
riety of cell types that affect the healing response in the face of unique ability to stimulate certain populations of cells while in-
prosthetic material. Among these are the growth factors, which hibiting others. Originally, it was found as a bioactive substance
can be subdivided into competence factors and progressive fac- that would induce fibroblasts to divide. Interestingly, nearly all cell
tors. Competence factors stimulate the cells they are affecting to types have receptors for TGFf3. TGFf3 has a strong homology to
enter the synthetic phase of the cell cycle, but only in the pres- epidermal growth factor (EGF), but, unlike EGF, it is an inhibitor
ence of other necessary proteins. Progressive factors indepen- of endothelial cell proliferation. The effect of TGFf3 on smooth
dently promote the passage of cells into the S-phase. There are muscle cell proliferation is bimodal, stimulating smooth muscle
five mllJor families of growth factors relevant to healing of pros- growth at low concentrations and inhibiting growth at higher con-
thetic materials that are differentiated on the basis of their se- centrations. TGFf3 is a strong inducer of extracellular matrix pro-
quence homology and their function.I 5 tein production and thus clearly has a role in modulating the
healing response. Previous animal studies have shown a synergis-
tic effect ofTGFf3 with EGF and PDGF in stimulating smooth mus-
Platelet Derived Growth Factor cle cell growth in normal rat kidney.19 Similar to the finding with
bFGF, when a recombinant form of TGFf3 was administered, a
Platelet derived growth factor is a competence factor that binds marked stimulation of smooth muscle cell proliferation was ob-
to high affinity receptors on both smooth muscle cells and fi- served.
broblasts, resulting in their proliferation. Endothelial cells do not One of the most profound roles for TGFf3 is that it is the most
contain PDGF receptors and thus are not stimulated by this cy- potent chemoattractant for monocytes that also result in their ac-
tokine. All cells involved in wound healing, with the exception of tivation. This generates a cascade of cellular migration and pro-
neutrophils, secrete PDGF, thus making it widely available to the liferation through the release of more growth factors. Prosthetic
receptors on fibroblasts and smooth muscle cells. PDGF is also material also differentially affects the level of TGFf3 production.
chemotactic for smooth muscle cells, neutrophils, and monocytes, For example, Dacron grafts induce a relatively greater level of
thus promoting the inflammatory response to wound healing. TGFf3 expression. 2o Although the precise role of TGFf3 during
While the half-life of PDGF is short, merely 2 minutes, only a brief wound healing in the face of prosthetic material has not been elu-
exposure is required to exert its effect on cells. 16 cidated, it appears as though it is clearly involved as an induction
signal for monocytes. Also, it appears to assist in modulating the
healing response through its effect on extracellular matrix pro-
Fibroblast Growth Factor teins and indirectly through its effect on other cell types involved
in the healing response. These roles suggest that TGFf3 is closely
Basic fibroblast growth factor (bFGF, FGF-2) is synthesized as part involved in modulating the healing response at the prosthetic/
of the healing response as well as in response to exposure to pros- tissue interface.
thetic material. It is produced by activated macrophages, smooth
muscle cells, and endothelial cells. Using immunochemical stud-
ies, Baird et al. have shown that bFGF is a potent mitogen for Insulin-Like Growth Factor
smooth muscle cells, endothelial cells, and fibroblasts. 17 Studies in
our laboratory have examined the role of macrophage produced Insulin-like growth factors (IGFs), which are progression factors,
bFGF after exposure to prosthetic material. IS Rabbit peritoneal were named because of their sequence homology to proinsulin.
macrophages were exposed to either Dacron or polyglactin 910 (a However, their functions do not directly involve glucose metab-
bioresorbable material) or to neither substance and then the con- olism. One of the isoforms of IGF, also referred to as somato-
ditioned media added to quiescent BALB c/3T3 fibroblasts, rab- medin C, stimulates skeletal cartilage and bone growth and
bit aortic smooth muscle cells, or mouse capillary lung LE-II increases organ size. IGF is thought to be involved in wound heal-
204 S.K. Woloson and H.P. Greisler
ing because it is released from platelets during the clotting cas- smooth muscle cells as a monomer. Within the extracellular space,
cade along with other known growth factors. IGF is also produced these monomers polymerize into a thick helical arrangement of
by fibroblasts and is a potent chemoattractant agent for vascular insoluble fibers. Collagen synthesis remains elevated for months
endothelial cells. 21 When IGF is present, it promotes migration in the wound area. Net accumulation of collagen ceases by the
of vascular endothelial cells into the wound area. IGF is also mi- 21st day after creation of the wound, and net loss occurs. From
togenic for fibroblasts. IGF is thought to act synergistically with this time, there is collagen remodeling forming an interlocking
PDGF, also released from activated platelets, to promote epithe- network of fibers. As a consequence of this remodeling, bursting
lial regeneration. strength increases up to 6 months after injury despite the de-
creased amount of collagen. Ultimately, however, the healed tis-
sue regains only 80% of the tensile strength of normal skin and
Epidermal Growth Factor fascia. Unfortunately, other mechanical properties such as elastic-
ity and energy absorption capacity are even less well restored. The
Epidermal growth factor, also a progression factor, is the last of final result is a weaker, brittle scar. A permanent prosthetic mate-
the five major growth factors contributing to the wound healing rial supplements wound strength, but a resorbable prosthesis pro-
response. Although plasma levels of EGF are undetectable, it is vides no long-term strength advantage.
found highly concentrated in platelets. 22 EGF appears to playa
role in migration and proliferation of endothelial cells, as well as
promoting chemotaxis of other cells through synthesis of fi-
bronectin. Animal studies have shown that topical application of
Differential Tissue Response to
EGF to wounds resulted in accelerated rates of epidermal regen- Prosthetic Materials
eration. 23 EGF has also been found to increase the tensile strength
of incisions, presumably through indirect effects by promoting cel- There are a variety of prosthetic materials used in the manage-
lular production of extracellular matrix proteins. 24 The exact role ment of abdominal wall hernias. Chemical differences in these ma-
for EGF in healing in the face of prosthetic material is incom- terials have been shown to differentially affect the healing
pletely understood, but it is likely involved in promoting en- response. As mentioned previously, much of our knowledge about
dothelialization and augmenting the migration of other cell types the biochemical and histological effects of different prosthetic ma-
through production of fibronectin by endothelial cells. terials comes from research in vascular surgery. Appropriate se-
lection of a specific prosthesis may serve to modify the healing
response in some desirable manner.
The Nature of Wound Repair
Within hours of creation of the wound, the prosthetic/ tissue in- Polypropylene Mesh
terface is heavily populated with inflammatory cells and bioactive
mediators previously mentioned. The activated polymorphonu- Bard® mesh (formerly Marlex®) (C.R. Bard, Inc., Billerica, MA) is
clear leukocytes adhere to the prosthetic material already coated the most commonly used prosthetic for abdominal and thoracic
with fibrin coagulum and release a variety of products capable of wall reconstruction as well as for reinforcement during hernia re-
causing tissue injury. These products include those of oxygen me- pair. Bard mesh is a knitted polypropylene with a filament diam-
tabolism such as superoxide anion, hydrogen peroxide, and hy- eter of 150 /.Lm and a pore size of 620 by 620 /.Lm. It is a permanent
droxyl radicals. In addition, there are neutral proteases that are and stiff prosthesis. Histological examination of the healed mesh
released, such as collagenases, elastases, gelatinases, and cathep- in both animals and humans generally demonstrates incorpora-
sin G. All of these agents allow cleansing and debridement of tion of the individual fibers with connective tissue. 26-28 All studies
wounded or dead tissue and/or organisms. It is thought that the report a marked and dense fibroblastic response along the mesh
presence of prosthetic material may prolong or accentuate this surface, forming whorls.
process and thus induce enhanced tissue destruction. Also, pros- Reports have suggested that Bard mesh generates more scar con-
thetic material may sequester slime-producing pathogenic organ- tracture and becomes folded and crumpled if not firmly sutured
isms or necrotic debris, thereby preventing the cellular and to the wound edge. 29 While some authors routinely secure the
metabolic defense mechanisms from accomplishing their goal. mesh to tissue, other authors do not experience problems with
This was postulated because of the demonstration that a much folded mesh and thus do not recommend stringent fixation.
smaller inoculum of bacteria was capable of causing a clinically The weave pattern of Bard mesh produces an uneven surface.
significant infection when prosthetic material was present. 24a,30 This may account for some of the dense fibroblastic response to
The cellular population 5 to 7 days following creation of the this prosthesis. There have been reports of fistula development
wound is largely composed of mononuclear phagocytes that dif- when bowel tissue is in direct contact with Bard mesh. The cause
ferentiate into resident macrophages. These cells secrete a large for this is not clear, but may be secondary to the dense adhesions
number of effector proteins that further modulate the healing re- the mesh induces or merely due to the inherent stiffness and
sponse. Macrophages eventually coalesce into foreign body giant roughness of the material.
cells in the presence of undigestible prosthetic material. 25 Their Experimental models of wound infection have shown that more
role is unclear, but they remain indefinitely in the presence of a bacteria adhere to Bard mesh than to expanded ePTFE.30,31 Be-
permanent prosthesis. cause of these findings, some authors have suggested that Bard
Connective tissue synthesis is the final stage of wound healing. mesh should not be used in contaminated fields. Others argue
Fibroblasts have an abundant capability to synthesize collagen and that the macroporous structure of Bard mesh may allow free egress
proteoglycans. Collagen is initially secreted from fibroblasts and of contaminated material, thus making it a beneficial prosthetic
choice. 32 Interestingly, the levels of adherent bacteria are similar was no healing advantage of any of the three different structures
in models of peritonitis when comparing Bard mesh to ePTFE. over the other.
Expanded Polytetrafluoroethylene Polyethylene Terephthalate

Expanded polytetrafluoroethylene, manufactured by W.L. Gore Mersilene® mesh (Ethicon, Inc., Somerville, NJ) consists of Dacron
and Associates, Inc. (flagstaff, AZ), is sold under the trade name (polyethylene terephthalate) fibers knitted into a mesh pattern. It
Gore-Tex® Soft Tissue Patch. It is a permanent prosthesis created is a permanent prosthesis that is pliable and macroporous. It has
by polymer extrusion, followed by mechanical stretching of a poly- been utilized for hernia repairs since the 1950s after favorable ex-
mer specifically designed to be chemically inert. Gore-Tex has a perience with it as a vascular prosthesis. Experimental work using
microporous structure consisting of solid nodes of PTFE inter- a rat model demonstrated superior abdominal wall bursting
connected by thin fibrils. The average internodal distance is 22 strength in animals closed with Mersilene mesh compared to those
/.Lm, with a range of 17 to 41 /.Lm. The internodal space creates an with primary suture closure or sham-operated animals. 35 Experi-
80% void volume for potential cellular penetration and collagen ments performed with Dacron vascular grafts demonstrated heal-
deposition. Macroscopically, the prosthetic material is smooth and ing with less collagen content than grafts made from bioresorbable
pliable. It was designed to elicit a minimal tissue response, yet al- material. 36 The reason for this finding may be due to the differ-
low mesenchymal ingrowth to prevent dense visceral adhesion for- ential effect of Dacron on macrophages releasing TGFI3. 2o TGFI3
mation. Its use in hernia repair has resulted in a less bulky and has the ability to induce the production of extracellular matrix
less painful repair compared to Bard mesh. 33 proteins, as mentioned earlier.
Histological analysis of tissue healing with ePTFE demonstrates Clinically, Mersilene mesh has had favorable results for repair
a minimal inflammatory reaction. Fibroblasts and macrophages in- of selected hernias with a low incidence of recurrence and com-
filtrate the void spaces, and collagen is deposited here. The tissue plication rates. 35 Despite this, the use of Mersilene mesh for the
layer that forms adjacent to the surface of the ePTFE consists of repair of hernias is not commonplace.
fibroblasts, macrophages, lymphocytes, and occasional multinu-
cleated foreign body giant cells. A thick "neofascia" develops along
the surface of the ePTFE, but little scar contraction or distortion Polyglycolic Acid
of the material develops.29 The density of the scar is less with
ePTFE than with Bard mesh, but the fibrous ingrowth into the Dexon® mesh (Davis and Geck, Inc., Danbury, CT), available in
void spaces of ePTFE anchors the prosthesis to the tissue. both woven and knitted forms, is constructed from a homopoly-
A 60 /.Lm internodal distance ePTFE has been used in animal mer of glycolic acid. The knitted form will not unravel when cut,
models of vascular graft healing. 3 This more expanded material but the woven form must be cut with a hot knife. It is a tempo-
allows transinterstitial ingrowth of mesenchymal tissue, allowing rary prosthetic and may favorably influence wound healing. It has
in animal models complete endothelialization of a prosthetic tube. been shown that mesenchymal tissue grows rapidly on resorbable
In vascular surgery, endothelialization is thought to deter early mesh. 37 Studies in our laboratory examined vascular graft im-
graft failure secondary to thrombosis. In hernia repair, this in- plantation into rabbit aortas using a polyglycolic acid prosthesis. 38
creased tissue incorporation may provide a thicker lining of con- Histologically, we observed a progressive replacement of the pros-
nective tissue. Another potential advantage of ePTFE involves the thetic with a dense fibrocollagenous tube containing myofibro-
formation of fewer adhesions in experimental animal models. Fi- blasts and lined with endothelial cells, creating a neointima as the
nally, bacteria seem to be less adherent to the surface of ePTFE polyglycolic acid was resorbed. Although mild aneurysmal dilata-
than Bard mesh in both the presence and absence of antibiotics. tion was observed in 11 % of the specimens, their bursting strength
However, no difference was noted in animal models of peritoni- was equivalent to that of normal aortas and exceeded three to five
tis, as was mentioned earlier. Whether these findings are clinically times that of normal systolic pressure. Further evaluation sug-
significant is unclear. Nonetheless, some authors have recom- gested that all dilatation occurred early before adequate tissue in-
mended the use of ePTFE in situations where prosthetic material growth. Modifications of the graft have improved these results.
is required not only because of the decreased bacterial adherence Other investigators have examined the use of Dexon mesh in
but also because of the relative ease with which it can be removed the repair of rabbit fascial defects. 39 Their results showed no acute
if need be. inflammatory response, a mild mononuclear cell infiltrate, and a
Three different structures of ePTFE have been developed to op- mild foreign body giant cell reaction. At 10 weeks, the material
timize the reparative process. Described above, the Soft Tissue was 50 to 70% resorbed. The surface of the mesh developed a
Patch is laminar in structure. There is also a MycroMesh® variety layer of collagen and fibroblasts and supported the growth of a
that is multilaminar with perforations, as well as a Dual Mesh® va- mesothelial lining. This connective tissue layer was denser that that
riety that has one surface of 22 /.Lm and a relatively nonporous 3 seen with Bard mesh, ePTFE, or Vicryl® mesh in the same model.
/.Lm surface. The healing characteristics of these different varieties There was no statistical difference between the amount of adhe-
were compared in abdominal wall defects in rabbits. 34 The find- sions between Dexon and Vicryl prostheses. This finding was sim-
ings demonstrated that the Soft Tissue Patch and the Dual Mesh ilar with Bard mesh. However, ePTFE resulted in significantly less
were progressively encapsulated by organized connective tissue on adhesion formation than the other three meshes. Unfortunately,
both the peritoneal and subcutaneous surfaces. MycroMesh im- Dexon mesh provided the least tensile strength at 10 weeks fol-
plants differed only in the formation of connective tissue bridges lowing the repair than any other prosthesis, resulting in hernia
in perforated areas. The amount of macrophage infiltration was formation in the rabbits.
similar for all three varieties. The authors concluded that there Polyglycolic acid mesh may be the ideal material for placement
206 S.K Woloson and H.P. Greisler
in selected contaminated fields. The rationale is that it does not prostheses. However, despite this improved tensile strength com-
require operative removal if infection develops, because it resorbs pared to Dexon, all animals still developed hernias by 10 weeks
more rapidly and it inhibits bacterial growth. 40 •41 Dexon mesh has postimplantation.
been successfully implanted in contaminated abdominal wall de-
fects and in healing compromised abdominal incisions in hu-
mans. 42 ,43 All wounds healed and no hernias developed when the Conclusion
mesh was used for support and the fascia was closed primarily. In
the group with contaminated abdominal wall defects, six of eight There are many different prosthetic materials, and more will be
patients developed hernias in follow-up ranging from 3 to 18 available as technology continues to advance. All elicit a unique
months. The authors believe that this complication balances fa- response with regard to the cellular elements and bioactive me-
vorably against the more serious complications seen when per- diators they stimulate. Choosing which prosthetic material to use
manent mesh is utilized. is akin to designing the "appropriate" wound healing response. At
present, there does not appear to be an ideal implantable foreign
material. Each situation should be evaluated individually and the
Polyglactin requirements for the prosthetic material determined. Then, based
on what information is available about the differential tissue re-
Vicryl mesh (Ethicon, Inc., Sumerville, NJ) is manufactured using sponse to prosthetic materials and the specific requirements of the
a knitting process with a pore size of 280 by 400 f..'m. There is con- individual patient, the proper substance can be chosen. Future ad-
siderable experience with this material as suture and experimen- vances in designing implantable material as well as an increased
tally as a partially bioresorbable vascular graft. The experimental understanding of the nature of wound healing will provide the
vascular experience suggests that this material would function well surgeon with the opportunity to modify the patient's healing
with respect to tissue incorporation, connective tissue formation, response.
and wound healing. Implantation of 69% polyglactin 910
(PG910)/31 % polypropylene vascular grafts in canines resulted in
a thicker connective tissue layer than Dacron or ePTFE.44 A simi-
lar study in rabbits demonstrated more extensive collagen depo-
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sion. Am Surg. 1967;33:715-716. cular grafts in dogs. Surgery. 1991;110:645-655.
29. Elliott MP,Juler GL. Comparison ofMarlex® and microporous Teflon® 45. Greisler HP, Henderson SC, Lam TM. Basic fibroblast growth factor
sheets when used for hernia repair in the experimental animal. Am] production in vitro by macrophages exposed to Dacron® and poly-
Surg. 1979;137:342-344. glactin 910.] Biomater Sci Polym Ed. 1993;4:415-430.
30. Brown GL, Richardson JD, Malangoni MA, Tobin GR, Ackerman D, 46. Greisler HP. Bioresorbable materials and macrophage interaction.
Polk HC Jr. Comparison of prosthetic materials for abdominal wall re- ] Vase Surg. 1991;13:748-750.
27
Biomaterials: Structural and Mechanical Aspects
of Prosthetic Herniorrhaphy
RJ. Minns and M.I.A. Selmia
Introduction mechanical properties were compared. The prototype woven car-

bon fiber patch had shown by tests in animals to lack sufficient in-
A major step in the treatment of groin hernia is the restoration of trinsic strength for human application. 3 A modified carbon fiber
the integrity of the abdominal wall. The tissues adjacent to the de- patch was therefore produced and tested for suture "pullout"
fect may be affected by the same pathological process that led to strength (or suture retention force) and tensile strength. This im-
the development of the hernia and thus be of little utility in the proved material compared favorably with a conventionally used
repair. In such cases, prosthetic mesh is used to both reinforce the material of polyester mesh. 3 Histology showed an abundant or-
repaired abdominal wall and provide a framework for the growth derly deposition of collagen fibers, highly vascularized with a min-
of the patient's own fibrous tissues. imal chronic inflammatory response of the carbon fiber patch. In
Many materials have been developed, tested, and used, and the contrast, the polyester mesh induced a flimsy collagenous capsule
degree of success of each has been reported. 1- 3 The literature gives with a marked inflammatory response. Mechanically, the carbon
the history not only of the development of these materials and fiber patch displayed a significant increase in breaking strength
their behavior in animal models and clinical trials, but also of the with implantation time over the polyester mesh. With its superior
development of laboratory tests and comparisons. biological and mechanical behavior over conventional polyester
and polypropylene meshes, it was clinically considered an ideal
material for a lasting repair of inguinal hernias. A prospective trial
of this new material, donated by the manufacturer, was com-
Studies menced in October 1984, resulting in a 13-year follow-up study of
108 patients repaired with the modified carbon fiber patches.
We studied, in uniaxial tension, the strength and stiffness of Mer-
silene® mesh and its extension properties compared to the exten-
sions obtained for transversalis fascia. 4 A collagen mesh prosthesis
has been used successfully in rabbits, and, unlike the nonab- Materials and Methods
sorbable metallic and plastic meshes, the absorbable collagen mesh
will not leave a foreign body permanently embedded in the tissues. 2 Mechanical Properties of Transversalis Fascia
A new lyophilized porcine skin preparation has been used in a clin-
ical trial, using the technique of Tinckler,5 for the support of the Transversalis fascia was obtained from 14 patients who underwent
prosthetic herniorrhaphy, 10 from direct or indirect inguinal her-
transversalis fascia in preperitoneal herniorrhaphy. We studied fur-
ther, in biaxial tension, the strength and stiffness of stainless steel nias and 4 from femoral hernias. Strips approximately 2 mm wide
and Mersilene meshes and porcine skin and their failure charac- and 20 mm long were cut parallel to the main fiber axis and
teristics as observed in the scanning electron microscope. 6 mounted and tested in 0.9% NaCI in an Instron™ (Welwyn Garden
The fibrous forms of polymeric carbon fiber have been used ex- City, Herts, UK) type TM IH2 table model tensile testing machine. 9
The samples were elongated at a constant rate (0.2 cm/min) and
perimentally in animals and clinically for the repair of ligaments
the load simultaneously recorded. The stress was calculated by di-
and tendons. 7 Carbon fiber has the properties of being well tol-
viding the load obtained (in grams) by the initial cross-sectional
erated by the body, presumably because of its inertness, and of ap-
area of the specimen (in mm2), determined gravimetrically.
pearing to induce a proliferation of ordered collagenous fibrous
tissue in the direction of the carbon fiber filaments. By means of
conventional textile processes, the carbon fibers in this study were
fabricated into a loose flexible sponge. The resulting carbon fiber Scanning Electron Microscopy
patch consisted of pure filamentous carbon fiber with no surface of Transversalis Fascia
treatment and could be cut to the desired size and shape.
These patches were inserted into the dorsolumbar aspect of rab- Cleaned strips of transversalis fascia were treated with crude bac-
bits along with similar sized discs of Mersilene mesh, and the bio- terial a-amylase to remove the noncollagenous components. IO A

27. Structure and Mechanics of Biomaterials 209
very careful dehydration procedure was employed using increas-

ing strengths of acetOne (50 to 100% in steps of 10%,20 minutes
at each step), followed by critical point drying using CO 2 as the
drying liquid. The dried specimens were mounted on marked alu-
minum stubs and coated with gold/ palladium to produce a uni-
form coating approximately 150 angstroms (A) thick. The coated
specimens were examined at tilt angles between 0 and 45° in a
Cambridge Stereoscan S10 scanning electron microscope oper-
ated at an accelerating voltage of 20 kilovolts (kV), and the results
were recorded with an Exacta VXSOO camera on Ilford FP4 135
roll film.
Uniaxial Tensile Properties of Mersilene Mesh

Strips of Mersilene mesh were cut in three directions: parallel (di-
rection 1 in Fig. 27.1), at 45 ° (direction 2), and perpendicular (di-
rection 3) to the mesh hole long axis for mechanical testing. The
strips were cut wide enough to include at least six "knots" in the
mesh weave at anyone section, perpendicular to the testing axis.
The strips were mounted identically to the transversalis fascia sam-
ples and tested under the same conditions at the same elongation FIGURE 27.2. Biaxial straining apparatus used for straining samples of steel
rate. Mersilene strips were also observed in the scanning electron and Mersilene® mesh and porcine skin. Clamping plates shown are for
microscope to determine mesh weave and fiber diameter. testing flat clamped specimens. Clamping plates were also made that could
accommodate the sutures around the periphery of the specimens at 3 mm
intervals.
Biaxial Tension Tests

The mesh prosthesis testing frame is shown in Fig. 27.2. It was de-
signed to be mounted horizontally in a Hounsfield "W"-type ten- find the load-extension characteristics of the prostheses alone, ad-
siometer. As the end plates, which are connected to the ditional plates were made to clamp the mesh around all four sides
tensiometer by pins, move apart relative to one another, they cause as shown in Fig. 27.2. The mesh was then sandwiched between two
the rolling element bearings to slide/ roll along the 45° slopes. strips of medium-grade carborundum paper on the clamping
This has the effect of pushing out the side arms by the same dis- plates to prevent slippage of the mesh. The experimental proto-
tance as the end plates. When the rig sits in the tensiometer, the col for both the biaxial and suture slippage tests are described by
thickness of the clamp base is such that the mesh lies in the same Minns et al. Il
horizontal plane over the testing area and the tensiometer pulling
axis lies within this plane. In the first series of tests designed to
Animal Implantation Experiments
Adult (over 9 months) male New Zealand white rabbits were used
for our study.12 The fur was removed from the lumbar region, and
each rabbit was anesthetized with intravenous pentobarbitone. A
longitudinal skin incision was then made in the mid-lumbar re-
gion and deepened to the plane beneath the subcutaneous mus-
cle layer. This displayed the spinous processes and lumbar fascia.
The lumbar fascia was then cleared of overlying tissue and a 2 .3
cm disc offascia excised on each side of the midline, exposing the
underlying erector spinae muscle layer. On the one side, a 2.5 cm
disc of sterilized carbon fiber patch was sutured into the defect,
and on the other, a similar aired disc of sterilized Mersilene mesh
was sutured in place. All the discs were sutured with interrupted
2-0 Mersilene sutures. The wound was then closed with interrupted
Dexon® 3-0 sutures and the skin sprayed with a plastic film. The
animals were returned to the cages and allowed standard diet and
freedom of movement until killed.
A further series of animal experiments was performed in which
2.5 cm diameter samples of carbon fiber were covered with a 2 .5
cm diameter sample of Mersilene (polyester) mesh and sutured
FIGURE 27.1. The three directions of uniaxial testing performed on the at the same site. These experiments were conducted to ascertain
Mersilene® mesh material. the biological responses of the two materials immediately apposed
210 RJ. Minns and M.I.A. Selmia
The strain was calculated by dividing the increase in lengths be-

tween the clamp ends by the length at no load. The stress was not
calculated, as it was considered too impractical to measure the
cross-sectional area. All specimens were extended to rupture and
complete division.
Description and Mechanical Testing of the

New Modified Carbon Fiber Material
The original patch material (SI), derived from polyacrylonitrile
acid (O-PAN), was modified by further developing the basic sup-
port felt. Using different combinations of needling and the sup-
port woven felt to improve the suture retention characteristics,
further intertwining of some of the carbon fibers within the ma-
FIGURE 27.3. Scanning electron micrograph of the structure within the
carbon fiber patch. The individual carbon fiber filaments are 9 /Lm in terial (S2) occurred (Fig. 27.4). The implanted material was made
diameter. into rectangular sheets 70 by 110 mm, with a slot and aperture of
10 mm in diameter for the spermatic cord.
Ten samples of right-angled triangular patches of the two types
to each other within the fascia. The carbon fiber implants were
of carbon fiber (SI and S2) and an identical size sample of Mer-
further strengthened by altering both the design and the struc-
silene were subjected to compression by a spherical-ended inden-
tural integrity. This was achieved by using a denser weave of the
tor while secured by interrupted sutures (PDS 2-0) to a base plate
central carbon fiber fabric, by further needling, and by an addi-
with an identical size triangular opening (Fig. 27.5) . The samples
tional heat treatment process to create the coalescing of individ-
were compressed at a speed of 1 mm/sec and the force response
ual carbon fibers and increase the density of the whole section.
recorded. The sutures were spaced at 10 mm intervals, 5 mm from
Repeat animal experiments using 2.5 cm 2 implants of the new car-
the edge. The force was noted on a chart recorder when the first
bon fiber material were performed in the lumbar region with two
suture was seen to pull out of the sample. Tensile tests were also
implants, one of Mersilene and one of the carbon fiber, on either
performed on dumbbell-shaped strips of the three materials, 10
side of the spine.
mm wide and 60 mm long; 20 samples of each material were tested.
Carbon Fiber Implants Patient Data of the Carbon

The patches of carbon fiber were constructed of woven bundles Fiber Hernia Trial
of carbon fiber containing approximately 500 filaments in each
bundle. The bundles were twisted and mechanically drawn into a One hundred eight patients, all male, aged between 33 and 81
woven layer approximately 1 mm thick (Fig. 27.3). Two layers of years, with a mean age of 57 years, underwent inguinal hernior-
nonwoven carbon fiber were placed on both surfaces on the wo- rhaphy in the period October 1984 to September 1985. Fifty-nine
ven sheet and joined by conventional textile needling techniques had right-sided hernias, and 49 had left-sided hernias; 58 were di-
to form a patch 3 mm thick and 10 cm in diameter. The experi- rect, 48 were indirect, and 1 had both. The duration of symptoms
mental patches, circles 2.5 cm in diameter, were cut with scissors ranged from 1 month to 4 years. All were primary elective surgi-
from the large patch, steam autoclaved, and sealed until ready for cal procedures. All the patients were assessed in the period March
use. Circles of standard Mersilene mesh were cut to the same size, 1991 to April 1992, and this 5-year follow-up study was reported. 13
autoclaved, and prepared in the same way as the carbon fiber
patch.
Uniaxial Testing of the Implants

Parallel sided strips approximately 3 mm wide and 20 mm long
were cut from both the carbon fiber and Mersilene implants, eight
strips being obtained from each implant. Fifty specimens of un-
used carbon fiber patch and Mersilene mesh of similar dimensions
were also tested in tension. Special clamps of stainless steel were
used to grip the ends of each specimen and introduced into the
jaws of the tensile testing machine. The specimens were kept moist,
and the distance between the clamp ends was recorded. The ma-
chine used was an Instron type 1195 tensile testing machine in
which the specimens were extended at a constant speed of 5
mm/min. The extension was recorded simultaneously with force,
the full-scale forces being switched between 5 and 25 Newtons (N). FIGURE 27.4. Scanning electron micrograph of surface of the implant.
SPHERICAL
INDENTOR
2·5cm dia.
RIGID BASE WITH

TRIANGULAR
APERTURE
FIGURE 27.5. Aschematic diagram of the mechanical testing rig.

FIGURE 27.6. Sample of the carbon fiber patch with the aperture for the
spermatic cord precut and before trimming to fit the template.
An up-to-date 13-year follow-up study of the same cohort of pa-
tients is now reported of the carbon fiber implants. 14 A pro forma
was used for pre-, peri-, and immediate postoperative assessments,
which included the patients' subjective grading on a visual ana- Results
logue scale of 0 to 10 for discomfort and pain. These subjective
scores were also used at the 6-month and 5-year follow-ups.15 In Mechanical Properties of Normal and
the 5-year follow-up, the initial assessments were done by mail. Herniated Transversalis Fascia
Those who did not respond to the postal survey were asked to at-
tend a follow-up clinic, as were the three patients who reported All the specimens tested mechanically displayed the stress-strain
discomfort on the postoperative follow-up forms. Of the 108 pa- curve characteristic of connective tissue. The curves consist of two
tients, 80 (74%) replied to the postal survey and questionnaire; regions: first, a "toe" region in which large extensions are recorded
16 patients had died. In the later study, the assessments were ini- for low loads usually associated with the straightening of the wavy
tiated by asking the patient to attent a follow-up clinic. Fifty pa- collagen bundles observed in the scanning electron microscope;
tients attended and were examined; 22 patients had died; 36 second, a stiffer region up to rupture usually associated with the
patients did not reply. This was despite repeated attempts to performance of straight collagen fibrils as in tendon. There was
contact them by telephone, sending letters on three occasions, no significant difference between the values of stress and strain
and contacting their general practitioner, who had no follow-up for transversalis fascia obtained from the femoral or inguinal ring
address. region. However, there was a drop in the ultimate tensile strength
(rupture load divided by the initial cross-sectional area) for the
transversalis fascia herniated tissue layer, as the strain at rupture
Surgical Procedure was similar to that of the normal tissue (Table 27.1).
All connective tissue is time dependent, and the load relaxation
A skin crease incision was made in the groin down to the exter- studies conducted on strips of transversalis fascia show this tissue
nal oblique aponeurosis, which was opened in the line of its fibers.
The spermatic cord was separated from the walls of the inguinal
canal to reveal the inguinal sac if direct; it was dissected off the
cord if indirect. The sac was either reduced and plicated (n = 54)
or resected (n = 54). A template made of "Lyofoam," 3 mm thick
and 110 by 70 mm with a 10 mm diameter hole split to the edge
for the spermatic cord, was cut to fit the posterior wall of the canal.
The carbon fiber implant (Fig. 27.6), which was the same size as
the template, was trimmed, irrigated with sterile saline, and lo-
cated before being sutured into position along the posterior wall
of the inguinal canal using a continuous monofilament absorbable
suture (polydioxanone). The straight edge of the implant was laid
along the reflected edge of the inguinal ligament with the patch
extending lateral to the deep inguinal ring, where the cord
emerged through the hole in the implant (Fig. 27.7). The exter-
nal oblique aponeurosis was closed in front of the cord. A drain
was used in the 49 procedures performed at Dryburn Hospital to
prevent hematoma formation over the operation site, and it was
removed by 48 hours. FIGURE 27.7. The carbon fiber implant in situ just before closure.
TABLE 27.1. Ultimate tensile strength and strain at rupture of transversalis fascia strips tested
mechanically
Source of fascia U.T.S. (km/cm2 ) Strain at rupture (%) Site of source
Hernia 26.1 58.5 4 femoral, 10 inguinal

Normal 32.1 57 Inguinal region P.M. 10
to be highly viscoelastic. A 5% drop in load at constant extension the contribution of this interbundle network must be small, since
was recorded after 40 seconds. The change in slope of the relax- the bundles will not have aligned in the direction of the loading
ation curve may very well be associated with the interfibrillar fluid axis until much higher strain and the wavy bundles of fibers would
flow during relaxation and the displacement of fluid from the in- have straightened at low extensions, accounting for the main stiff-
terstices between the bundles of collagen fibers. 9 There was no sig- ness in its stress-strain behavior.
nificant difference between the time-dependent properties of The Mersilene prosthesis is composed of fibers of approximately
normal and herniated transversalis fascia. 40 f-Lm diameter grouped into bundles that were knotted at 1 mm
intervals to give a mesh arrangement, the mesh holes shaped like
a rhombus, the long axis approximately 1.5 mm, and the short
Uniaxial Properties of Mersilene axis approximately 1 mm. The mesh threads appear to be con-
Mesh Material tinuous in the direction of the long axis, all these factors ac-
counting for the directional mechanical properties of the mesh.
Strips of Mersilene mesh tested parallel to the mesh long axis were The diameters in transversalis fascia fibers and Mersilene mesh
stiffer than when they were extended perpendicularly, but they fibers are compared in Table 27.3.
only elongated to 38% of their original dimension (Table 27.2).
The ultimate tensile strength fell when tested at 45° to the mesh
long axis, possibly due to shearing at the mesh knots rather than Biaxial Testing of Prosthetic Materials
tensile failure of the mesh fiber bundles, which occurred when
tested in the other two directions. The elastic modulus (slope of Load-strain curves of all the types of material tested are shown in
the linear region of the stress-strain curve) and strain at rupture Fig. 27.10. The clamped specimens all had higher ultimate tensile
were therefore a function of the loading direction, while the ulti- strengths than the stitched specimens. The steel mesh was by far
mate tensile strength depended on failure mode. the strongest, but when tested in the sutured condition it extended
five times more than the clamped case. The stitched Mersilene
mesh extended to twice the size of the clamped Mersilene meshes,
Scanning Electron Microscopy of Transversalis and the porcine skin extended by one-and-a-half times. A measure
and Mersilene Mesh of the ability to resist rupture is the storage energy of the speci-
men exhibited during loading and is proportional to the area un-
Transversalis fascia observed in the scanning electron microscopy der the load-extension curve. 3 The material with the highest
after treatment with a-amylase to remove the ground substance storage energy was the stitched steel mesh. However, this high
reveals very clearly fibers arranged in wavy bundles, and associated value of storage energy appears to be related to the sutures, as the
with these bundles is an interlacing network of fibrils (Fig. 27.8). clamped steel mesh has a low storage energy. All the mechanical
The wavy bundles of fibers contain smaller bundles of fibers, each testing results are summarized in Table 27.4. The ratios of the
of these bundles containing individual collagen fibrils. Some of clamped to stitched maximum loads for the three materials tested
these fibrils appear to anastomose and bifurcate, as can be seen are shown in Table 27.5 and are fairly similar in value. Conse-
in the lower bundle in Fig. 27.9. quently, the maximum loads recorded by simple biaxial straining
Surrounding the fiber bundles is a fine network of fibrils that clamping tests could give a representative measure of the stitched
is sparse, while in other areas it is very dense. During elongation, performance.
TABLE 27.2. The mechanical properties of Mersilene® reinforcing mesh tested in three directions
Direction of loading U.T.S. (km/cm 2) Elastic modulus (km/ cm2) Strain at rupture (%)
+
<>•
1.28 X 103 2.1 X 103 65
<::> 0.59 X 103 5.2 X 103 49.5
+-<>-.
¥
1.53 X 103 7.5 X 103 38
TABLE 27.3. Diameters involved in mesh prosthesis for hernia

reinforcement
Diameter (Mm)
Transversalis fascia fibers 0.07-0.12

Transversalis fascia bundles 2-4
Mersilene® mesh fibers 40
Mersilene® mesh spaces 1500
Carbon fiber 10
holes by tearing the fibrous material of the skin (Fig. 27.12). The
steel mesh, although it became distorted around the holes where
the sutures passed, did not show any broken steel fibers; the su-
tures snapped around the periphery (Fig. 27.13).
Carbon Fiber Versus Mersilene Mesh

FIGURE 27.8. Scanning electron micrograph of transversalis fascia, show-
ing wavy bundles and interlacing network of collagen fibrils (X500). The gross appearance of the implants in situ showed quite clearly
that even after only 2 weeks of implantation, the carbon fiber
patches were totally impregnated with a white, thick tissue. In com-
Scanning Electron Microscopy of Mechanically parison, the tissue associated with the Mersilene mesh was thin,
the mesh being clearly visible even up to 12 weeks of implanta-
Tested Materials tion. When the skin was reflected to reveal the implants in the 2-
and 3-week implantation animals, it was discovered that the un-
The scanning electron microscope shows quite clearly the mech-
dersurface of the skin had reddened over the carbon fiber patches.
anism of failure of the three materials. When the specimens were
This was possibly caused by the abrasive action of the carbon fibers
clamped along all the edges and tested to failure, the failure oc-
during the movement of the skin over the patch. In the scanning
curred at one corner and progressed diagonally across the speci-
electron microscope, all the specimens showed quite clearly that
men. This may be because the corners in a simple biaxial straining
condition represent areas of high strain concentration between
the ends of adjacent clamps. The most interesting aspect of the 260
Steel Mesh
failure analysis was for the sutured cases. The Mersilene mesh (clamped)
failed because the knots around the periphery of the specimen 240
between the edge and where one of the sutures passed unraveled
(Fig. 27.11). A similar failure mechanism was observed for the 220
porcine skin. The suture did not break, but pulled out from the
200
160
C/) 160
c
0
.,
j
140
z
"0 Steel Mesh
CIS
0 (stitched)
-.J 120
100
60
60
40
20 Single Suture
0 10 20 30 40 50 60
Strain %
FIGURE 27.9. Scanning electron microgra ph of a dense area of collagen
fibril bundles with a fine mesh of interconnecting fibrils overlying the main FIGURE 27.10. Load-strain curves of all the types of materials tested by both
wavy collagen fiber (X500). clamping and stiching (bars represent:': 1 SO).
TABLE 27.4. Maximum stiffness (slope of steepest portion of load extension curve), strain at
maximum load, and storage energy (area under local-extension curve) of the material tested
Maximum Strain at
Tests Maximum load stiffness maximum load Storage
Material tested conducted (N) (N/ mm) (%) energy
Mersilene® mesh Clamped 142.2 1.43 22.5 1400

Mersilene mesh Stitched 83.7 0.35 49.9 1800
Porcine skin Clamped 125.0 1.12 24.5 1200
Porcine skin Stitched 69.7 0.42 27.0 1320
Steel mesh Clamped 260.0 5.71 U .5 1450
Steel mesh Stitched 157.0 0.89 44.3 3370
16 sutures tensile 243.0 1.60 23.0 1200
the carbon fibers did not disintegrate even after 12 weeks of im- like collections of inflammatory cells seen in the Mersilene im-
plantation, and the original architecture of the patches was pre- plants are not seen. At the end of the experimental period, the
served. The carbon fiber bundles and the structural integrity of appearances are those of a latticework of carbon fibers surrounded
the original patches are clearly seen, with connective tissue clearly by orderly collagenous tissue only moderately cellular and with
invading the interfibrillar spaces in the implant. The knots of the a relatively low-grade nondestructive inflammatory mononuclear
Mersilene mesh are clearly seen, but the connective tissue sur- infiltrate.
rounding the mesh fibers is loosely connected to the individual In the case of the Mersilene grafts, the enclosure of the plaited
fibers and not as obviously integrated into the mesh spaces as with strands of the prosthesis in a thin layer of collagenous tissue is vir-
the carbon fiber. Histologically, there was no sign of deposited car- tually complete by about 4 weeks, and in the experimental period
bon within either the lymph nodes or any pleural or lung tissue. no thickening of the collagenous layer seems to occur.
Following the implantation of the carbon fiber pads, there oc- A feature is a florid foreign body granulomatous response with
curs a series of responses that varies considerably in its tempo from considerable inflammation. This invades each plaited strand so
one experimental animal to another. This series of responses has that each appears to be lying loosely in what amounts to an in-
as its end result the deposition of orderly bands of mature col- flammatory exudate. The individual fibers of the Mersilene do not
lagenous material. Elastin is not elaborated in response to the pres- become separated as the carbon fibers do; this is more likely a re-
ence of carbon fiber. flection of the physical properties of the plaited fibers than a re-
The earliest changes, which are seen in the most conspicuous sult of the tissue response. When the Mersilene was positioned
form at between 2 and 4 weeks after implantation, consist of a pro- over the carbon fiber patch, the reddening under the skin was not
found edema of the implant, with wide separation of the individ- evident, and excellent incorporation of the composite implant was
ual carbon fibers by a proteinaceous fluid. A variable number of seen (Fig. 27.16). Histologically, the combined materials inte-
inflammatory cells, particularly mononuclear, are seen within the grated well, and no biological adverse response was seen between
edematous implant, but sometimes these can be quite scanty. From the two materials (Fig. 27.17).
the periphery of the implant, there occurs an ingrowth of cells.
At first, histiocytes predominate, but later increasingly large num-
bers of cells with the morphology of fibroblasts are seen. As early
as 5 weeks after implantation, significant amounts of collagen are
being laid down, but inflammatory cells predominate in numbers
over cells of fibroblastic type up until about 8 weeks after im-
plantation. Thereafter, there is by and large a balance of cell type,
and the collagenous nature of the matrix that has formed between
all the individual carbon fibers, which were originally separated
by edemic fluid, becomes more striking. While cells of the
macrophage series are common, multinucleate giant cells are
rarely in evidence (Fig. 27.14), and this is a feature that contrasts
with the response elicited by Mersilene (Fig. 27.15). The abscess-
TABLE 27.5. Ratios of clamped to stitched maximum loads for three

tested materials
Max load (clamped)/

Material tested Max load (stitched)
Mersilene mesh 1.70

Porcine skin 1.79
FIGURE 27.11. Scanning electron micrograph of Mersilene® mesh that
Steel mesh 1.59
failed by unraveling at the sutures in the clamp.
FIGURE27.12. Scanning electron micrograph of porcine skin that failed

FIGURE 27.14. Histological response of the carbon fiber patch 8 weeks af-
between two adjacent sutures.
ter implantation (hematoxylin and eosin [H&El stain, X300).
Tissue-Engineered Synthetic Scaffolds for repair of the fascia in hernias. The concept has also been utilized
in the development of a cartilage support matrix that has 17 years
Tissue Repair: A Textile Approach of clinical experience in various joints in the body.
to Implant Design
Tissue engineering is an emerging interdisciplinary field that ap- Design Parameters
plies the principles of biology and engineering to the development
of viable substitutes that restore, maintain, or improve the func- The approach used by researchers has been to assume that cells
tion of human tissues. This form of therapy differs from standard and their accompanying matrix need a scaffold to enter, adhere
drug therapy in that the engineered ~issue becomes integrated to, and proliferate in, in an ordered manner. The three features
within the patient and has the potential to offer a permanent and of the tissue-engineered scaffold are the overall architecture and
specific cure for the disease state. Although cells have been cul- porosity, the fiber morphology, and the surface chemistry. Textile
tured outside the body for many years, it has recently been possi- mesh knitted monofilament or multifilament yarns made of per-
ble to grow complex three-dimensional tissue constructs in the manent or resorbable polymers have produced the most common
laboratory in vitro to meet clinical needs. Many textile designs have three-dimensional scaffolds used in tissue repair. Depending on
been produced to reproduce the fibrous architecture of tissues the applications, their characteristics can be altered to have, for
that need augmenting (supporting) or replacing (prosthesis) in example, high tensile strength (such as a ligament prosthesis), su-
the human body. Tissue engineering concepts of producing a lat- ture retention abilities (hernia reinforcement), or an architecture
tice for the ingrowth of cells in vivo to lay down the appropriate and porosity that is similar to the structure being replaced (artic-
matrix have been used very successfully for the skin and for the ular cartilage). There is a move to more "tension-free" surgery in
FIGURE 27.13. Scanning electron micrograph of steel mesh that failed by FIGURE 27.15. Histological response of the Mersilene® (polyester) mesh
breaking the sutures rather than the steel fibers. sectioned through a knot, 8 weeks after implantation (H&E, X200).
pair fiber producing cells (fibroblasts) appear to prefer their

processes to attach to a rough fiber surface rather than a smooth
one. These are seen on carbon fibers very clearly, as these fibers
develop longitudinal grooves during the production process of
spinning.
The fiber chemistry relating to the leaching out of substances
with time and the pH of the immediate environment around the
fiber will dictate the chemical response of the repair tissue. An
electronegative environment is conducive to repair, and a highly
hydrophilic matrix increases cell ingrowth. A highly hydrophobic
material such as PTFE, has poor cellular attachment. In our ex-
perience, carbon fiber has most of the three attractive features to
tissue regeneration described if produced to the optimum design
for the application.
Hernia Reinforcement
FIGURE 27.16. View of the 2.5 cm diameter carbon fiber/Mersilene® com-
posite on the lumbar aspect of the rabbit after 6 weeks' implantation. The specifications of the ideal implant were determined when the
surgical technique was established. The mechanical properties of
the implant depend on the method of implantation in the area of
the hernia. The surgical practice was to produce an implant that
would be sandwiched between two layers of fascia that could be
the repair of the inguinal wall, and, as a consequence, the tensile
apposed above and below the implant in a tension-free manner.
strength of the mesh is not the prime consideration, but the re-
The ideal characteristics were that the implant should be able to
tention of securing sutures is important. The porosity of the scaf-
be held in situ by peripheral sutures, resist the possibility of load-
fold determines the "flow" of the repair matrix material and the
ing under biaxial tension without breaking up during the very
laying down of the initial scar material leading to a fibrous repair.
early postoperative period due to coughing or lifting, and to pro-
Animal experiments using a textile mesh knitted multifilament
duce an organized fibrous tissue response quickly with minimal
yarn of polyester (Mersilene) clearly show that a highly porous
inflammation.
mesh with holes at least 1 mm wide is undesirable for integration
A densely knitted mesh of carbon fibers in a woven continuous
of the repair. Much smaller and uniform holes, still with a
multifilament yarn was produced, the yarn bundles containing as
high porosity (more than 80%), are preferable conditions for a
many as 1000 carbon fibers. Although the carbon fibers are two
proliferative repair. Fiber surface morphology is another repair-
orders of magnitude in diameter larger than the collagen fibers
inducing factor that is relevant to the repair process. The main re-
that constitute the fibrous element of the repair matrix, the poros-
ity of the implant, especially at the first interface with the repair
matrix, allows the fibrous structure to invade the implant with ease.
The top and bottom surfaces of the woven mesh are covered with
a nonwoven layer of carbon fibers, and the three layers are at-
tached by a double-acting needling process that allows interdigi-
tation of the nonwoven layers with the central woven mesh. The
two outer surfaces then present an interface of a highly porous
scaffold with the repairing matrix for the ingrowth of cells and
vascular and fibrous structures for total integration at the wound
site. The strong central woven mesh allows the passage and re-
tention of sutures and has the biaxial tensile strength to resist sud-
den tensile loads that may occur before the full integration of the
repair material.
Mechanical Testing of the

Implanted Materials
The load-strain curves were constructed for each specimen, and
the breaking force and area under each curve were calculated.
The areas under the curves were considered a measure of the en-
ergy absorbed by the specimens and gave an indication of the work
FIGURE 27.17. Histology of the carbon fiber / Mersilene®composite. A Mer- to rupture. For both materials, the mean breaking force and range
silene "knot" is clearly seen center top and the carbon fiber matrix below of rupture force were plotted against implantation time and com-
(H&E stain) . pared to the intact non implanted materials (Fig. 27.18). For the
30 35
T
T T _---- .. Carbon fibre
30
Breaking 20 ,.. ______ ..- - - . L 25
Force .../ " L Mersllene@ 20
(Newtons) 10-F-~;""'':'-'--''':-' '.'_.._._._.. _._._._.. _._._._. ·onty .~ ..•._. _. Failure Force (N)
15
-------- --- ---
----
::··.::.·,·:·.C~rbon·.tltir~ >:Q~l{:.: .:-: ':.' ~.'.,
10
o0 2 4 6 8 10 12 14 5
Weeks Implantation 04----,----,----.----,
FIGURE 27.18. The force to rupture (Newtons) of the implants plotted
o 258 12
Weeks post implantation
against implantation time (weeks). The values for carbon fiber (dashed
line) and Mersilene® mesh (solid line) at each time interval are shown,
together with the range of values (vertical bar). The upper shaded por- Carbon fibre
tion is the range of the force to rupture for strips of Mersilene mesh and Mersilene
the lower shaded portion for carbon fiber strips. Carbon fibre/Mersilene
FIGURE 27.20. The force at failure of the 3 implant constructs shown against
implantation time.
carbon fiber strips, the force to rupture increased as the implan-

tation time increased, although the intact carbon fiber was very
weak in tension. This was in contrast to the force to rupture of the
Mechanical Test Results of the Clinical
implanted Mersilene strips, which remained nearly constant and Carbon Fiber Material
similar to the intact Mersilene material. The carbon fiber implants
were stronger than the Mersilene implants after 8 weeks' implan- Although the tensile properties of the modified carbon fiber sam-
tation and continued to increase in rupture strength. The energy ples showed no significant improvement over the original mater-
absorbed by both implanted materials was similar up to 6 weeks' ial (Fig. 27.22), an unpaired "S" test on the data suggested that
implantation. Mter this, the carbon fiber implants showed a far there was a highly significant (p < .001) improvement in the su-
greater increase in energy absorption than did the Mersilene (Fig. ture retention properties. There was no significant difference be-
27.19). When combined as a composite implant, the failure force tween the suture retention properties of the modified material and
is always greater than the Mersilene or carbon fiber individually the Mersilene (Fig. 27.23).
(Fig. 27.20), as is the work to failure (area under the stress-strain
curve) after 6 weeks' implantation (Fig. 27.21).
Clinical Results of the Modified
Carbon Fiber Material
H"--
Immediately postoperatively, and at 6 months, there was no evi-
dence of the sinus formation or infection that had been associ-
ated with previous prosthetic materials. One failure occurred 16
months postoperatively. At reoperation, a defect was found at the
T Til ~
I V Work to failure
n
160,---------------------
Jm~-
140~------------------~~-
120~--------------~~·~···~···----
........
40
~l-
100i-----------------------~~~==~===
80~----------------------------~·~····~···~,,~---------
T 60~-----------------.. ~~
...7.~
...r·~·~
~-----------
~~-
~- ~ -~
20
~g~:::::::-:-:-:-:-=-=-=-==.~~
. .~.~:. ::===::::::::~~~===
O~--------,r--------,.--------.,---------r-I------~I
- - - - - --- - :- - - - -- carbenflOreonly
- - - - - - - - - -,1 - - - - I- - - - - I- -----mersiienemeshonlv 2 4 6 8 10 12
I ! •
o Weeks post implantation

2 4 6 8 10 12
WEEKS POST IMPLANTATION
Carbon fibre
FIGURE 27.19. The variation of energy absorbed by the strips in tension Mersilene
with implantation time. The values for carbon fiber strips and Mersilene® Carbon fibre/Mersilene
mesh strips are shown with the range of values at each time (vertical bar).
The dashed horizontal lines show the energy to rupture for intact carbon FIGURE 27.21. The work to failure (area under the stress-strain curve) for
fiber and Mersilene strips before implantation. the three constructs examined.
Tensile Tests clinical results, as assessed by all the patients, were regarded as
(dumbbell-shaped specimens) excellent.
20 Discussion
50
It appears that the strength of the transversalis fascia is related to
51 • original C.F.
52 • modified C.F. the occurrence of inguinal hernias, the defective tissue having a
Mars • Mersilene I- lower rupture stress than normal fascia. However, what is of more
38.7 interest is the area under the stress-strain curve, as this is related
Force
(N) to the work done in breaking the specimen. Normal transversalis
T 1.9 fascia has a greater curve area than herniated fascia and is conse-
1.8 rr 24.8 quently less easily ruptured. The resistance to rupture relates to
r±-18.2 the ability of the collagen fibers to withstand the repeated high
loads that would be encountered physiologically. Any defect in the
collagen framework reduces its resistance to rupture. Another fac-
OL-__ ~~ ______ ~-L ______ L-~ _____
tor that may be related to the failure of the transversalis fascia is
its time dependence properties, which were low, according to the
S1 S2 Mers
load relaxation tests conducted. This would mean that the trans-
FIGURE 27.22. Tensile properties of modified carbon fiber sample show no versalis fascia would have a low ability to absorb shock in the case
significant improvement over original material. of sudden loading, and local areas of high strain may consequently
rupture weak. points in the collagen framework. The pliability of
a synthetic mesh for hernia reinforcement allows for adaptation
medial part of the repair between the patch and the inguinallig- to the directional extensibility and loadings that are encountered
ament where the suture appeared to have pulled through. The in the body, especially in the area where the transversalis fascia
carbon fiber implant appeared extremely well infiltrated by fibrous has failed. However, excessive extension of the mesh in one di-
tissue and was firm and supportive to probing. rection or the other would tend to have a twofold effect on the
The mean preoperative visual analogue score for discomfort was integrity of repair. First, on loading, the mesh holes and interstices
4.0, with a standard deviation of 2.7, and for pain the score was would be closed from the open weave of the mesh at rest. Second,
1.8 with a standard deviation of 2.58. The scores at 5 years after and perhaps more important, when the mesh is positioned under
operation were significantly reduced (paired Hest); for discom- load caused by the tension of the sutures, the load-extension prop-
fort: mean 0.25, standard deviation 0.65, p < .001; and for pain: erties in situ are dramatically modified. The mesh would appear
mean 0.11, standard deviation 0.53, p < .001. The clinical result very stiff and restrict the natural movement of the wound area if
as assessed by the patient was excellent in all but one case, in which applied under tension or very lax if the mesh was applied loosely,
it appeared that preoperative testicular pain was unaffected by her- allowing large relative movements between tissue and the rein-
nia repair, but there was no evidence of recurrence in the clini- forcement, thus having little value as a supportive prosthesis.
cally examined group. With the information obtained from this study, it should be pos-
At the 13-year follow-up, there was no pain or discomfort, no sible to design a suitable prosthesis that would be mechanically
evidence of recurrence, and no lymph node enlargement. The strong, with a stiffness and extension in all directions comparable
to the surrounding fascia and with mesh pores or interstices that
would allow tissue ingrowth.l1 The mesh fiber arrangement de-
Suture Retention pends on weave and average fiber angle to give the desired me-
(triangular samples, first sutures' pull-out force) chanical properties. It appears that a knitted weave with
interlocked fiber junctures is desirable in that slippage and un-
raveling of the mesh fibers will not occur, 2 and it has the required
9.6 T5.6 load-extension properties to evenly support the defective tissue at
50- .-- T54.0 all stages of extension.
49.8 In the area of the defective transversalis fascia, there is a me-
Force 51 . original C.F.
(N) 52· modified C.F.
chanical weakness in patients who have undergone prosthetic
Mars • MersDene herniorrhaphy. To reinforce this weakened area, three types of
X· 3 prosthetic material have been used clinically with various degrees
rr~O.2 of success: skin, woven meshes, and nonwoven sheets. However,
on loading the prostheses, the interstices presented to and in con-
tact with the fibrovascular tissue would alter, as would the amount
of load and movement taken by the prosthesis and that taken by
the sutures. How much the mesh or the sutures or both deform
in situ would be related to the mechanical properties of the ma-
terials and sutures used. A stiff mesh and relatively elastic sutures
81 82 Mers
applied tightly would mean that the prosthesis would restrict move-
FIGURE 27.23. Suture retention properties of modified carbon fiber sam- ment of the surrounding tissue and possibly allow a better chance
ples versus Mersilene®. of tissue ingrowth at the interface. What would be sacrificed would
be the natural movement of the wound area. Any excessive pres- we saw no evidence of fragmentation or migration of carbon fibers
sure would transfer load to the rather elastic sutures, and this either into the surrounding tissues or into the regional lymph nodes,
would be the weak point of the prosthesis. This appears to be the this might be revealed in long-term experiments.
case of the stainless steel mesh. Skin wounds, although apparently Certain mineral fibers are known to cause carcinoma of the lung
well healed, remain weak and brittle structures through 150 days or mesotheliomas of the pleura and peritoneum when ingested,
and have at that time only half the ability of uninjured tissue to re- but fibers greater than 3 #-tm diameter have difficulty penetrating
sist rupture. 15 Therefore, for transversalis fascia, which is similar in the respiratory bronchioles. If carbon fibers and Mersilene fibers
structure to skin, mechanical support for at least 150 days would are ingested, their diameters diminish the possibility of initiating
appear to be one requirement for a supportive prosthesis design. fibrosis and reaching the pleural surfaces. However, long-term
If it were possible to control the structural organization of col- studies of malignant changes induced by carbon fiber have not
lagen during healing, and thus improve scar performance,12 a been carried out, and further investigations are obviously needed.
prosthesis that had the ability to do this and provide mechanical The carbon fiber patches implanted in the experimental animal
support in the first 150 days after operation would appear ideal. show a successful mechanical and structural repair after 8 weeks'
Porcine skin certainly has the extension and load properties that implantation. Although mechanically weak in the early stages of
are required at operation if employed correctly. That is, if the su- implantation, carbon fiber may, combined with a clinically ac-
tures are applied with little tension at rest, the scar tissue will then ceptable material such as Mersilene mesh as a composite, offer the
be evenly supported, as shown by the extension properties deter- exciting possibility of being a superior reinforcing prosthesis for
mined compared with transversalis fascia. However, one cannot abdominal defects and incisional hernias.
depend on scar tissue to take over support of the prosthesis that In the clinical study of the new strengthened carbon fiber patch,
fragments or disintegrates. Porcine skin is not absorbed before 150 there was a very low recurrence rate with a high patient satisfac-
days, and, as it would appear that the scar tissue, which has be- tion rate 13 years after the implantation.1 2 In the one case of re-
come incorporated within the prosthesis, would be subjected to currence after 4 years, suture pullout seems to have been the cause
low loads, no recurrence has occurred clinically. rather than a mechanical failure of the carbon fiber patch itself.
We recommend that a prosthesis used as a supportive material The previous exprimental findings were borne out at the time of
not under tension should be inert, have elasticity comparable to repair of the recurrence when excellent ingrowth of fibrous tissue
the scar tissue formed, be easily manageable at operation, provide into the carbon patch was observed.
an interface allowing chemically and structurally the incorpora- It may be argued that the recurrence rate after a standard elec-
tion of repair tissue within the interstices, and provide supportive tive hernia repair should be low without the need to use prosthetic
strength for up to 1 year after operation. Stainless steel appears materials. With good tissue available and good technique, this
too stiff on its own, and its elasticity as a prosthesis depends on should certainly be the case. However, there are cases, especially
suture elasticity. Also, the interstices are extremely large for in the elderly, where poor tissue quality may contribute to a re-
organized tissue ingrowth. Mersilene mesh has adequate two- currence. The availability of a good biocompatible material such
dimensional supportive strength and extension properties but suf- as carbon fiber with improved qualities compared to previous pros-
fers from large pore size, and the possibility of complete tissue in- thetic materials should prove to be of benefit in such circum-
corporation is small. Porcine skin, when properly applied, appears stances. Long-term effects of carbon fiber on soft tissues appear
to have adequate elasticity and extension properties in two di- not to present a problem. I6
mensions when sutured in position and provides an ideal inter- Recurrence rates after repair of recurrent inguinal hernias vary:
face for tissue incorporation. It is clear from the mechanical testing in one series by one surgeon, it was 9%.4 George and Ellis6 re-
that the Mersilene mesh is stronger in the initial stages of repair ported a recurrence rate after repair of incisional hernias of 46%
than the carbon fiber patch in the experimental animal. However, and observed in their literature search that recurrence rates after
that strength is overtaken by the incorporated tissue within the the use of Marlex mesh varied between 0 and 11.3%.8,17,18
carbon fiber patches after 8 weeks of implantation. This suggests Johnson-Nurse and Jenkins I9 demonstrated the benefit of fi-
that an appropriate design of prosthesis should incorporate the brous tissue ingrowth into the carbon fiber patch repairs of sheep
advantageous features of both materials. Not only would the Mer- incisional hernias and the very low subsequent recurrence rate.
silene mesh supply initial strength to the prosthesis immediately We suggest that the use of carbon fiber may have beneficial and
after implantation, but it would also allow fixation by virtue of eas- wider applications not only in elective hernia repair, but also in
ier suturing. Mersilene fails because knots within the mesh unravel recurrent inguinal hernia, and in the surgical management of the
at the suture fixing locations, thus leaving the strength of the pros- difficult abdominal incisional hernia, as an alternative to Mersi-
thesis dependent on the strength of the mesh rather than of the lene or Bard® mesh. 5
sutures. However, this failure strength appears quite adequate for
the type of physiological loads likely to be encountered. Mersilene
mesh positioned over the carbon fiber patch may decrease the
likelihood of abrasion of the overlying skin.
Although both materials produce a connective tissue response, the
References
carbon fiber patches produce a response of organized noninflam-
1. Adler RH, Pelecanos NT, Geil RG, Rosenzweig SE, Thorsell HG. A col-
matory fibrous tissue that becomes quickly incorporated with the ma-
lagen mesh prosthesis for wound repair and hernia reinforcement.
terial. No viscoelastic studies were performed. However, within the Surg FIlTUm. 1962;13:29-33.
matrix of the tissue is a ground substance, which gives rise to the re- 2. Matheson AJM, James JH. A review of inguinal hernia repair using
pair tissue having highly time-dependent properties. This may be a stainless steel mesh. J R GoU Surg Edinb. 1975;20:59-62.
good thing for the distribution of load through the fibrous matrix 3. Forrester Je. Mechanical, biochemical and architectural features of
during high rates ofloading that may occur physiologically. Although surgical repair. Adv Biol Med Phys. 1973;14:1-34.
4. Forrester jC, Zederfelot BH, Hayes TL, Hunt TK. Tape-closed and su- 12. Ward R, Minns RJ. Woven carbon fiber patch versus Dacron® mesh in
tured wounds: a comparison by tensiometry and scanning electron mi- the repair of experimental defects in the lumbar fascia of rabbits. Bio-
croscopy. Br J Surg. 1970;57:729-737. materials. 1990:1.
5. Tinckler LF. Preperitoneal prosthetic herniorrhaphy. Postgrad Med J 13. Minns Rj, Claque MB, Ward R, Cullen Pj, Dunstone GH. The repair
1969;45:665-667. of inguinal hernias using carbon fiber patches. A five-year follow-up.
6. George CD, Ellis H. The results of incisional hernia repair: a 52-year Clin Mat. 1993;14:139-144.
review. Ann R Coil Surg Edinb 1996;68:185-187. 14. Selmia MIA, Minns Rj, Cullen PJ. The repair of inguinal hernia using
7. Minns Rj, Soden PD,jackson DS. The role of the fibrous components carbon fiber patches. A thirteen-year follow-up. Cleve Med J 1999;3:
and ground substance in the mechanical properties of biological tis- 103-106.
sues: a preliminary investigation. I J Biomech. 1973;6:5S3-165. 15. Minns Rj, Denton~, Dunstone GH, SunterjP. An experimental study
8. Liakakos T, Karanikas I, Panayiotidid H, Dendrinos S. Use of Marlex® of the use of a carbon fiber patch as a hernia prosthesis material. Bio-
mesh in the repair of recurrent incisional hernia. Br J Surg. 1994;81: materials. 1982;3: 199-203.
248-249. 16. Tayton K, Phillips G, Ralis Z. Long-term effects of carbon fiber on soft
9. Edwards LC, Pernokas LN, Dunphy]E. The use of a plastic sponge to tissues. J Bone Joint Surg. 1982;64B: 112-114.
sample regenerating tissue in healing wounds. Surg Gynecol Obstet. 17. Usher RC. Hernia repair with Marlex® mesh. Arch Surg. 1962;84:73-
1957;105:303-309. 78.
10. jenkins DHR, McKibbin B. The role of flexible carbon-fiber implants 18. Molloy RG, Moran KT, Waldron RP, Brady MP, Kirwan WOo Massive
as tension and ligament substitute in clinical practice. A preliminary incisional hernia, abdominal wall replacement with Marlex® mesh. Br
report. J Bone Joint Surg. 1980;62B:497-499. J Surg. 1991;78:242-244.
11. Minns Rj, Stevens DC, Gore GM, Tinckler LF. The mechanical and 19. johnson-Nurse C, jenkins DHR. The use of flexible carbon fiber in
structural properties of reinforcing materials used in prosthetic the repair of experimental large abdominal incisional hernias. Br J
herniorrhaphy. Eng Med. 199;8:15-19. Surg. 1990;67:135-137.
28
Biomaterials Pathology
Nir Kossovsky, Charles]. Freiman, and David Howarth
Introduction In contrast, bulk properties are the features of a material that

arise from the composition and microstructure of everything be-
The modem era of biomaterials was born with the discovery of an- low the few molecules at its surface. These properties include op-
tibiotics in the mid-twentieth century. Antibiotics enabled surgeons erationally defined attributes such as elastic modulus, fatigue
to control the bacteria that invariably settled on a medical device strength, tensile strength, ductility, fracture toughness, and hard-
from the operating room atmosphere immediately before im- ness. Because degradation phenomena are closely related to a ma-
plantation. Once bacteria were under control, differences among terial's bulk properties, they are addressed in the bulk properties
various materials and the biological responses they provoked be- section although they are technically surface events.
came apparent, and the need to develop materials that exhibited
improved "biocompatibility" emerged. In this chapter, we present
a brief but comprehensive review of the essential factors con-
tributing to biomaterials and their induced biological response, Surface Properties
which we term bi(JTeactivity.
Surface chemistry is the science of phase boundaries. In mathe-
matics, the term surface refers to the geometric concept of area
without thickness. However, in surface chemistry, it refers to the
General Principles chemical concept of a phase boundary, a region where the physi-
cal properties vary from those of one phase to those of the ad-
Materials Principles joining phase. Because this transition occurs over distances of
molecular dimensions, a "chemical surface" has a thickness.
It is useful to divide the physical properties of a medically im- The boundary between phases, the interface, is a thin layer of
planted device into two broad categories: surface properties and material whose properties differ profoundly from those of the bulk
bulk properties. Although there is some overlap, this division is phases it separates. For example, the state of (mechanical) energy
useful in understanding the pathological phenomena associated of the surface is different from that of the underlying bulk so that,
with an implanted device, as well as the mechanisms underlying in a fluid interface, the difference manifests itself as a contractile
the pathophysiological responses of the body to that device. tendency, which makes the interface act like an elastic membrane
The science of biomaterials and medical device pathology ex- seeking the configuration of minimum area, a sphere.
ists because the materials from which medical devices are fabri- The chemical composition of the interface layer is generally dif-
cated differ from the materials from which our bodies are ferent from that of the bulk phase. For example, the interface be-
fabricated. These differences in chemistry between biomaterials tween a piece of metal such as iron and the air is extremely
and our natural materials lead to both different surface proper- complex and bears little resemblance to either iron or air. The
ties and different bulk properties. metal is likely to be covered with an oxide layer (rust), and the
Everything we touch, see, taste, or smell is matter. Generally, our top layer of the oxide is probably hydroxylated from prolonged
experience with matter is superficial, with only the top few layers contact with water vapor in the air. The next layer may consist of
of molecules. It is these surface molecules that give materials many tightly bound water, followed by a layer ofloosely bound water de-
of their physical and chemical properties. Therefore, all of the pending on the relative humidity. Finally, there is usually a layer
principal chemical and biophysical interactions between im- of environmental "scum" consisting of airborne organic waste.
planted materials and the biological environment occur at sur- The interface may also exhibit electrical charge separation, and
faces. Surfaces are physically unique environments with special consequently the interface between two neutrally charged bulk
mechanical, chemical, and electrical properties. These properties phases may appear to bear a charge. The unique energetic (me-
are derived from the electron clouds of the atoms comprising the chanical), chemical, and electrical properties of interfaces often
surface and are influenced significantly by the electrons of atoms exert great and highly varied effects on the behavior of material
comprising an opposing surface. systems. These may appear bizarre and contradictory if one at-
221
222 N. Kossovsky et aI.
tempts to describe or explain them in terms of bulk phase be- Ductility is the degree of plastic deformability. Brittle materials
havior alone. (nonductile) usually fail within the elastic range. In contrast, duc-
At the molecular level of life, the chemical properties are de- tile materials exhibit plastic deformation within the elastic range.
termined by the shapes of molecules, as well as the sequence of Tensile strength is the force that must be applied in opposing
atoms comprising those molecules. This phenomenon is demon- directions to cause the material to break completely. This is typi-
strated to all of us daily. For example, the egg white protein oval- cally measured by placing clamps at opposing ends of a strip of
bumin changes from a globular shape to a much more linear shape material and using a tensiometer to gradually increase the force
through the addition of energy by mechanical beating. Mter heat applied until there is complete separation of the material into two
is added, the result of this changed shape (from beating) is a souf- pieces. The tensile strength of an abdominal mesh prosthesis can
fle in contrast to an omelet. be tested either simply with the material itself or after the mater-
When a device is implanted in the body, it is immersed in an ial has been implanted. The tensile strength in the latter case in-
aqueous solution with a high concentration of proteins, as well as cludes the strength of any products of the bioreactive process, such
other macromolecules. These proteins are highly surface active as collagen deposition.
and tend to be drawn to the interface. The concentration of these In contrast, bursting strength is the degree of force that must
proteins can be significantly higher at the interface than in the be applied uniformly to cause a rupture. With an abdominal mesh
aqueous solution. In addition, the proteins at the interface can ex- prosthesis, this is typically measured by implanting the material
perience shape changes. and infusing the area of implantation with a fluid until an ema-
The nature of the surfaces of materials from which the bioma- nation of that fluid occurs.
terials are fabricated determines the type of interaction those The study of wear and resistance to it is known as tribology and
surfaces are likely to have with the protein-rich aqueous environ- is formally defined as the study of the effects of friction on mov-
ment. The interactions involving surface protein shape change ing parts and the methods, such as lubrication, of obviating them.
may lead to the initiation of any of the four m.yor pathophysio- Wear is defined as the removal of material from a solid surface by
logical phenomena (inflammation, thrombosis, infection, and another material as a result of relative motion between the two.
neoplasia). Finally, the sequelae of initiation of these pathophysi- This removed mass can be poorly adherent to the new surface and
ological phenomena range from clinical insignificance to major may be released. Thus, such wear causes two types of failure. The
medical complications and device failure. first is a "wear-out" mode occurring after long periods of wear,
when significant amounts of material are ultimately removed. The
second is a "seizure" mode, which occurs in systems where parti-
Bulk Properties cles whose diameters are larger than the clearing space between
the sliding surfaces are produced and ultimately jam the system.
Bulk properties are operationally defined attributes. One of the
most critical properties of a material is its response to mechanical
forces, such as tension, compression, shear, torsion, and bending. Bioreactivi ty
Materials tend to form in a manner that is both proportionally
and directionally related to the magnitude of the applied forces; In discussing the potential pathological responses to an implanted
when the force is removed, materials may tend to return to their medical device, perhaps the best way of viewing the body is as a col-
original shape. The relationship between the applied force and lection of homeostatic systems. The implantation and presence of
the resulting deformation can be quite complex. a given implanted medical device has the potential to introduce
When the force to which a material is subjected is removed, a stress into these homeostatic systems. If this stress exceeds the adap-
number of different events may occur. First, a deformed material tive capacity of the system, the system experiences irreversible in-
may return to its original configuration, in which case the defor- jury, causing cells to die. The precise moment when reversible injury
mation will have been of the elastic type. Second, a deformed ma- progresses to irreversible injury cannot at present be identified.
terial may not return to its original configuration, and there will A system exposed to persistent sublethal stress will show one of
remain a permanent change in dimensions, or form, in the ab- several adaptive responses. These responses may be identified ei-
sence of an applied load. In this instance, the deformation will ther clinically or pathologically as evidence of cell injury. Gener-
have been of the plastic type. Generally, materials will exhibit elas- ally, cells adapt to injury by conservation of resources. This may
tic deformations at lower forces and plastic deformations at greater be accomplished by decreasing or ceasing their differentiated
forces. The ratio of the force to deformation, for the force range functions and reverting to ancestral unicellular characteristics, fo-
where a material exhibits elastic behavior, is known as the elastic cusing solely on survival functions.
modulus. A medical device (or the material that it is composed of) should
As the force is increased, the deformation of a material pro- not induce undue stress on the adjacent cells once implanted.
gresses from elastic behavior to plastic behavior to catastrophic However, meeting this requirement alone does not ensure a fa-
failure. The transition from elastic to plastic behavior is marked vorable clinical course. Various homeostatic mechanisms in the
by the loss of the linear relationship between force and deforma- body may induce stress by initiating a "preemptive" reaction to the
tion. This transition is known as the yield strength and is expressed device. This is the reason that both cellular and organized systemic
in units of force. The transition from plastic behavior to the be- responses to stress are seen following device implantation. These
ginning of the failure mode is marked by the point at which a ma- responses constitute the elements of pathophysiology.
terial continues to undergo progressive strain in the absence of Four major pathophysiological phenomena are examined. They
any additional force. This point is known as the material's ultimate are inflammation, thrombosis, infection, and neoplasia. These
strength. processes are not completely independent, and for any given de-
28. Biomaterials Pathology 223
vice they may not all be relevant. However, they represent the ma- mune activation. Macrophages are endowed with a broad spec-
jor biological responses that may greatly affect the clinical per- trum of inflammatory and degradative biochemical systems, and
formance of a medical device. their level of activity is clearly related to the chemistry of the bio-
material to which they are responding (Table 28.2).
The third arm of inflammation, the immune response, is only slowly
Inflammation and Wound Healing being recognized as a bioreaction associated with medical devices
and biomaterials. The immune response is a specific and acquired
In the pathology of abdominal mesh, perhaps the greatest con- reaction by the immune system to foreign material entering or com-
cern, and hence the area that most research focuses on, is in- ing into contact with the body. It is a very complex and sophisti-
flammation and wound healing. Inflammation is the reaction of cated defense reaction involving antibodies, a variety of cells, and
vascularized living tissue to injury. It is the primary biological re- blood vessels. These are usually the same elements that mediate
action to implanted medical devices. In addition, it is probably a chronic inflammation, but the duration and intensity of the bio-
component of the other three major pathophysiological responses: logical reaction in an immune response tend to be much more pro-
thrombosis, infection, and neoplasia. The inflammatory system has nounced than in nonimmune chronic inflammation.
four arms that are related both temporally and hierarchically. The fourth arm of inflammation consists of the wound healing
The first arm of inflammation is usually the initial component phase and characteristically follows any of the first three arms
to respond to injury, and thus it is known as the acute phase of in- chronologically. This phase consists of the replacement of dam-
flammation. It involves primarily blood vessels. The hallmarks of aged tissues by various cells that specialize in secreting extracel-
acute inflammation include the accumulation of fluid and plasma lular matrix materials to form scar.
components in the affected tissue. This is due to the dilation and Especially with implanted medical devices, the terms acute and
increased permeability of blood vessels and intravascular stimula- chronicinflammation usually are misnomers. Many materials evoke,
tion of platelets in the presence of polymorphonuclear leukocytes. at the onset, an inflammatory reaction characterized by the infil-
Polymorphonuclear leukocytes are the principal cellular media- tration of macrophages. With certain materials polymorphonu-
tors of the nonvascular element of the acute inflammatory reac- clear leukocytes may appear at the site of implantation months
tion through engulfment of foreign agents or iJtiured cell material. after macrophages have been actively engaging an implant. Wound
In contrast to the polymorphonuclear leukocytes, the platelets, in healing and scar formation follow the initiation of inflammation,
conjunction with mast cells and basophils, mediate the vascular el- but their progression and the magnitude of scarring may be af-
ement by the liberation of the vasoactive substances and other infected by the degree of persistent inflammatory activity as well as
flammatory intermediates (Table 28.1). by the severity of primary injury.
The second arm of inflammation is known as the chronic phase
of inflammation. This arm is most active with persistent injury.
When the acute inflammatory response is unable to eliminate Thrombosis
the iJtiurious agent or restore injured tissue to its normal physio-
logical state, there may be a progression to a state of chronic in- Of the four major pathophysiological phenomena, thrombosis is
flammation. The primary cellular components of the chronic probably the least relevant to abdominal mesh. This is due to the
inflammatory response are macrophages, plasma cells, lympho- traditionally extravascular location of these devices. However, it is
cytes, and, in certain conditions, eosinophils. possible, although perhaps not probable, that the device could,
Macrophages are the most important cells to consider in the due to poor anatomical conformation or by contributing to the
chronic inflammatory reaction to an implanted material, for they formation of fistulas, seromas, and so forth, have a thrombogenic
play a pivotal role in material degradation and in potential im- effect. Poor anatomical conformation or the formation of seromas
TABLE 28.1. Inflammatory mediators

Origin Action
Cell derived
Histamine Vascular leakage
Serotonin Vascular leakage
Lysosomal enzymes Immobilization of neutrophils, vascular leakage, and chemotaxis
Prostaglandins Vasodilation, pain, fever, potentiation of other mediators
Leukotrienes Leukocyte adhesion, bronchoconstriction, vasoconstriction,
vascular permeability, and chemotaxis
Platelet-activating factor Bronchoconstriction, vascular leakage, and chemotaxis
Cytokines Acute phase reactions, leukocyte adhesions, and chemotaxis
Plasma derived
Complementary system Opsonization and lysis of microbial organisms, vascular
leakage, and chemotaxis
Kinin system Dilation of blood vessels, contraction of smooth muscle,
aggregation of polymorphonuclear leukocytes, and
vascular leakage
Clotting/fibrinolytic system Converts fibrinogen to fibrin, vascular leakage, and chemotaxis
224 N. Kossovsky et al.
TABLE 28.2. Macrophage products
Group Specific products Action
Neutral proteases Collagenase Degrades connective tissue components

Elastase Degrades connective tissue components
Plasminogen activator Activates plasmin (fibrinolytic agent)
Chemotactic factors Attraction of other leukocytes
Arachidonic acid metabolites Prostaglandins and Vasodilation, vasoconstriction, vascular permeability, and chemotaxis
leukotrienes
Reactive oxygen metabolites O 2; HOCI, H 20 2 and OH- Endothelial damage, tissue damage, inactivation of antiproteases,
and vascular leakage
Complement components Parenchymal damage, opsonization, vascular permeability, and chemotaxis
Coagulation factors Factor V and Local conversion of fibrinogen to fibrin
thromboplastin
Growth promoting factors Fibroblasts, blood vessels, and myeloid progenitor cells
Cytokines Interleukin-l, interleukin-6, Acute phase reactions, fever, leukocyte adhesion, chemotaxis, B cell
and tumor necrosis differentiation, endothelial cell activation, and fibroblast stimulation
factor
Other agents Platelet activating Invokes inflammation, bronchoconstriction, vascular leakage, and chemotaxis
Interferon Antiviral activity
could cause pressure on blood vessels, thereby affecting the flow mental and immune defense factors that interact with biomater-
of blood and possibly giving rise to thrombi. Fistulization could ial properties in what has been termed by Gristina as the "race for
expose the vasculature to infectious agents, against which an in- the surface" of the interface. 6 Prosthesis design and prevention of
flammatory reaction could promote thrombosis. Although some implant-associated infection must include consideration for the in-
of the materials from which abdominal meshes are fabricated are teraction of the biomaterial with the host tissue and the contri-
used for vascular prostheses, there is a lack of research on the bution of each to the microenvironment.
thrombogenic activities of the various abdominal meshes, and
hence thrombosis is not reviewed for each type of mesh.
Neoplasia
Infection Over the years, medical researchers have discovered what appears
to be an ever-increasing number of substances that possess car-
Infection is the second greatest concern with abdominal mesh, cinogenic potentials. It is curious, therefore, that little research
and, not surprisingly, in the available literature on abdominal has been done on the possible carcinogenic effects of abdominal
mesh, infection is the second most studied of the four major patho- mesh. This lack of research prevents us from reviewing the car-
physiological phenomena. Infection is a pathological reaction to cinogenic effects for each specific type of mesh.
implanted medical devices because it is potentiated by the process A neoplasm, or cancer, is an uncontrolled proliferation of cells
of device implantation. This simple phenomenon was appreciated that express varying degrees of fidelity to their precursors. The
back in the fourteenth century when the French surgeon Guy de neoplasm is an abnormal mass of cells that persists after cessation
Chauliac noted that wound infections were easier to control if as- of the stimulus that produced it, and, in general, it is irreversible.
sociated foreign bodies were extracted. 1 Elek and Cohen, in the Its growth is, for the most part, autonomous. The structural re-
1950s, showed that 106 Staphylococcus pyogenes were required to pro- semblance of the neoplasm to its putative cell of origin makes spe-
duce a pus-forming clinical infection in human volunteers but that cific diagnoses possible as to the source and potential behavior of
the addition of a foreign body reduced the necessary bacteria in- the neoplasm. Although the causes of most cancers are not iden-
oculum to 102.1a tified and the mechanisms of carcinogenesis remain obscure, con-
Several mechanisms have been postulated to play a role in siderable data on the biological attributes of neoplasia are
prosthesis-associated infections. An implanted foreign body may available. A wide variety of human and experimental data suggest
produce tissue liquefaction and sterile abscess formation by incit- that the neoplastic process entails not only cellular proliferation
ing an acute inflammatory reaction when reactive materials, such but also a modification of the differentiation of the involved cell
as cobalt or copper, are implanted into soft tissue. 2 Tissue dam- types.
age can be exacerbated by the release of enzymes and oxygen free Several observations are important at this point. First, neoplasms
radicals and other inflammatory mediators. Tissue reactivity can are usually derived from cells that normally retain a proliferative
also be greatly increased by the production of particulate wear de- capacity. Thus, mature neurons and cardiac myocytes do not of-
bris.3-5 Implants may alter local host immune defenses through ten give rise to tumors. Second, a tumor may express varying de-
the reduction of granulocyte and bactericidal capacity. Infection grees of differentiation, from relatively mature structures that
may also be enhanced due to sequestration of bacteria from phago- mimic normal tissues to a collection of cells so primitive that the
cytes in the early postoperative period. cell of origin cannot be identified. Third, the stimulus responsi-
The establishment of tissue integration of the implant or the ble for the uncontrolled proliferation may not be identifiable; in
development of bacterial colonization and subsequent device- fact, it is not known for most human neoplasms.
associated infection is influenced by a number of host environ- The experimental production of cancer by a chemical occurred
in 1915, when Japanese investigators, using coal tar, produced skin tics are polycarbonate, a tough flexible plastic (used in drinking
cancers in rabbits. Since that time, the list of organic and inor- straws), and polyvinyl chloride (PVC).
ganic carcinogens has grown exponentially. Yet, a curious paradox Polypropylene, a thermoplastic polyolefin, can vary widely in me-
existed for many years. Many compounds known to be potent car- chanical properties, depending on its degree of crystallinity, as re-
cinogens are relatively inert in terms of chemical reactivity. The flected in its density. The repeating monomer of the polypropylene
solution to that riddle became apparent in the early 1960s, when polymer consists of two carbon atoms, one of which is saturated
it was shown that most, although not all, chemical carcinogens re- with two hydrogen atoms and the other of which is saturated with
quire metabolic activation before they can react with cell con- one hydrogen atom and one methyl group. The polymer is formed
stituents. For biomaterials, a process analogous to metabolic by free radical addition, and, because of its asymmetry, may exist
activation may be the free radical, oxidative, and hydrolytic reac- in one of three forms depending on the spatial position of the
tions associated with inflammation. methyl group. The name given to the polypropylene chain struc-
A number of different sarcomas have been induced in rodents ture depends on whether the methyl groups are all in the same
by the implantation of materials such as plastic and metal films, plane (isotactic), uniformly alternating planes (syndiotactic), or
various fibers, plastic sponges, glass spheres, and dextran polymers. randomly distributed (atactic). The strength of the material cor-
In addition to the chemical nature of these implants, the critical relates strongly with the degree of crystallinity and is maximal in
features include size, smoothness, and durability of the implanted the isotactic form and minimal in the atactic form.
surfaces. Biomaterial-induced cancers appear to be highly species Polypropylene is extremely resistant to biological degradation.
specific. With "physical" carcinogens, common factors of this class It has excellent environmental stress-cracking resistance and is rel-
seem to be the need for the development of chronic fibrosis or, atively impermeable to water vapor. Polypropylene is not weakened
at least, an inflammatory response. 7 Foreign bodies once consid- significantly by the action of tissue enzymes. 10 In addition to the
ered prototypic examples of "physical carcinogens" are being fabrication of surgical meshes for abdominal wall and hernia re-
reevaluated as chemical carcinogensB as new data on the chemi- pairs, sutures are a major medical application of this material. Cur-
cal properties of asbestos come to light. 7 In addition, there are nu- rently, there are several polypropylene meshes available, Marlex,
merous synthetic polymers that may release monomers or additives Prolene, Trelex®, and Surgipro®. The latter is made of braided
that might induce a chemical carcinogenic response at the site of strands of polypropylene, while the other three are monofilament
implantation or in other parts of the body.9 However, an associa- strands. Marlex and Prolene have been the subjects of most re-
tion between implanted devices and neoplasia has yet to be demon- search and publications.
strated in humans.
Marlex
Specific Materials
Marlex is currently the most widely used abdominal mesh. 11 Pio-
Having examined general principles applicable to all types of ab- neered by Francis C. Usher in 1958,l2 it was originally fabricated
dominal mesh, we turn our attention to specific types of clinically from polyethylene,13,14 but it was later formulated in 1962 as a
available abdominal mesh. When discussing specific devices, we polypropylene mesh to overcome shrinking, stiffening, and dis-
have limited our research to data acquired solely through ab- tortion in autoclaving.I 5 Both the polyethylene mesh and poly-
dominal applications. In addition, we have confined our discus- propylene mesh are referred to as Marlex. However, because the
sion to meshes that are clinically available. polyethylene-formulated Marlex is no longer in use, we will con-
fine our discussion to the current polypropylene formulation of
Marlex and the term Marlexwill refer exclusively to the polypropyl-
Permanent Meshes ene mesh.I 2- 14,16-26
Marlex has enjoyed a favorable reputation. 15,22,25,27-31 It is known
Permanent meshes, also called nonabsorbable meshes, are devices for being resistant to infection,15,IB,22,24,27,32-34 well toler-
that, barring a catastrophic event or surgical removal, remain es- ated,15,25,2B,30 and strong enough to allow a woman to have an un-
sentially intact throughout the life of a patient. In contrast, the ab- complicated, successful pregnancy and vaginal delivery.35 However,
sorbable meshes that we examine are degraded by the body over the mesh has been noted to cause bowel complications,10,25 sero-
time. The permanent meshes that we examine are Marlex® (C.R. mas,23,33 sinus formation,ll,33 mesh migration ,11 buckling,36,37 and
Bard, Inc., Billerica, MA), Prolene® (Ethicon, Inc., Somerville, NJ), adhesions11 ,31,3B,39 that can make the device difficult or impossible
Gore-Tex® ePTFE Soft Tissue Patch (W.L. Gore & Associates, Inc., to remove when necessary.38,39
Flagstaff, AZ), and Mersilene® (Ethicon, Inc.).
Physical Characteristics Marlex is a monofllament mesh in which
each filament has a diameter of 0.017 cm. The mesh is 0.065 cm
Polypropylene thick, weighs 0.1522 g/10 cm2, and has a density of 0.23 g/cm3.
The bursting strength is 68.9 ::!: 1.9 kg and 4.5 ::!: 0.12 kg/cm2. As
In 1954 Italian scientist Giulio Natta, using Karl Ziegler's metal- to tensile properties, its breaking strength is 34.6 ::!: 1.1 kg (wale)
organic catalyst technique, developed propylene, an ethylene with and 16.5 ::!: 1.4 kg (course), and its breaking elongation is 74.3 ::!:
one small carbon methyl group attached. Propylene was unique 2.3% (wale) and 203.2 ::!: 3.9 (course). The pores of the mesh vary
in that, when polymerized, all the methyl groups faced in the same from 68 to 23 p,m X 23 p,m. 4O
direction rather than the usual random fashion. Such "isotactic Marlex is radiolucent and does not compromise radiological di-
polymers" (the name was proposed by his wife) possess useful prop- agnostic techniques. 34 It does not readily oxidize with age, either
erties and can now be manufactured. Other isotactic polymer plas- on the shelf or when implanted.
Tyrell et al.,n using New Zealand white rabbits, found the ten- New Zealand white rabbits. Polypropylene's structure allows for its
sile strength to be 2.66 kg 10 weeks after implantation (Fig. 28.1). total integration with reparative tissue. 46
In addition, they found that the tensile strength increased over Hydrophobic polypropylene meshes were found to repel mi-
50% from weeks 2 to 10, but they note that the data were not nor- grating connective tissue cells, which invaded the interstices of
mally distributed. Murphy et al.,41 using CD rats, recorded a ten- polyethylene terephthalate mesh in a unique three-dimensional
sile strength of 3.02 kg/em 15 to 20 weeks after implantation of organ culture matrix designed by Dasdia et al. 47
the device. Adhesions and inflammation around the graft were found to be
Jenkins et al.,42 using Sprague-Dawley rats, examined bursting greater with polypropylene than with polytetrafluoroethylene in
strength and found that it increased by over 100% from the first rats with abdominal wall defects. 48
week of implantation to the fourth week. Although there is wide Brown et al.,49 using Hartley guinea pigs, studied adhesion for-
variation in the data, at 1 week all ruptures were at the prosthe- mation with five separate sets of conditions. They found that in-
sis/muscle interface, whereas at week 4 all ruptures occurred at fection had little effect in slowing the formation of tenacious scar.
the inguinal canal.
Inflammation-Clinical Studies The pores of Marlex enable the
Law and Ellis,19 using Sprague-Dawley rats, found that the ab-
penetration of fibrous tissue. 15,26,27,32 Wound seromas have also oc-
dominal wall breaking strength did not weaken over a 4-week in-
curred,23,33 as have wound sinuses. 33
terval after implantation in the presence of infection (S. aureus).
Molloy et al. 33 reported that in 50 patients seromas occurred in
2 (4%) and wound sinuses in 6 (12%). One of these had wound
Inflammation and Wound Healing-Lahoratory Studies Murphy et
infection at the time of repair. Sinuses appeared during an inter-
al. 41 graded mean adhesion formation after 15 to 20 weeks as mod-
val of 6 to 18 months after surgery. The mesh was not removed in
erate, requiring gentle dissection augmented with limited sharp
any of these cases. Patient follow-up ranged from 6 months to 10
dissection. Law and Ellis 17 found on average moderate adhesions
years (mean = 3.75 years).
freed by aggressive blunt dissection at both weeks 1 and 22. Jen-
Stone et al. 50 reported that in 23 patients studied over 20 years
kins et al. 42 characterized the average adhesion formation at week
wound sepsis occurred in 12 patients (52%), intestinal fistulas in
1 as maximal, changing to moderate at week 4.
12 patients (17%), and erosion into bowel/skin in 3 patients
The adhesion formation of the polypropylene mesh and the
(13%). When a skin graft was attempted (15 patients), successful
polytetrafluoroethylene patch was judged in a study by Hengirmen
results (more than 80% take) occurred in 3 patients (20%).
et al. 43 as moderate in abdominal wall defects in rats. Macrophage
Difficult removal of the device was reported with 16 patients
response to experimental implantation of polypropylene prosthe-
(Fig. 28.2).
ses in New Zealand white rabbits diminished after the first 90 days,
although foreign body granulomas increased. 44 Infection-Clinical Studies Marlex has acquired a reputation for
Law and Ellis 19 conducted tensiometric studies of healing in ab- being resistant to infection,15,18,22,24-27,32-34 and, if infection does
dominal wall defects created in Sprague-Dawley rats. At up to 22 occur, it can be resolved without removal of the mesh. 22 ,25,27,33,39
weeks, Marlex mesh and Gore-Text Soft Tissue Patch provided a However, chronic infection 18 and extrusion in the presence of in-
strong repair, but the fibrous response induced by Dexon® mesh fection 26 have been reported. The mesh itself can become infected
was insufficient to produce a strong support. Bellon et al. 45 found if necrotic fascia and soft tissue are sewn into the mesh or if it is
no significant differences in degree of adhesion formation or in- covered prematurely with grafts or flaps when large concentrations
tegration between Marlex and Prolene in abdominal defects in of bacteria have colonized the mesh surface. 37
M Marlax G Gore-Tax D Dexon v Vicryl

3
2.5
~
Kg 1.5 .'" G
0.5
t 'f
a
a 2 4 6 8 10 12
Weeks FIGURE 28.1. Tensile strengths of four prostheses.
FIGURE 28.2. Clinical data for Marlex and Prolene.

\_ Marlex 0 Prolene \
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Wound Sepsis Intestinal Erosion into Difficult Acceptable
Fistula Bowel/Skin Removal Skin Graft
Take (>80%)
Molloy et al. 33 reported that in 50 patients the wound infection of preparing a nontoxic refrigerant. Much to the surprise of Dr.
rate was 8% (4 patients). S. aureus occurred in 2, Staphylococcus al- Plunkett and his assistant, Jack Rebok, no gas emerged. When
bus in one, and a J3-hemolytic Streptococcus in one. All the infec- Plunkett placed the tank on a scale, he found that it weighed what
tions responded to appropriate antibiotic therapy, and device it should when full. Intrigued, Plunkett was determined to get to
removal was not required. the bottom of this mystery. Instead of immediately discarding the
tank, Plunkett and Rebok got a saw and hacked the tank in two.
Inside, they found a white powdery wax that neither of them had
Prolene ever seen before. It was (poly)tetrafluoroethylene or, as it is com-
monly known today, Teflon®.
Physical Characteristics Prolene is also a polypropylene mesh. Pro- On taking a sample home for further analysis, Plunkett learned
lene was first made clinically available in 1970, and the formula- that it had some very remarkable properties. It was more inert
tion has not changed since that time. 51 Among surgeons, it has a than sand (not affected by strong acids, bases, or heat, and no sol-
reputation for being easier to use than Marlex, being not as vent would dissolve it), but, unlike sand, it was extremely "slip-
stifP°,52,53 and easier to remove. 50 Unlike Marlex, Prolene will not pery." Finally, finding it to be similar to polyethylene, Plunkett
unravel when cut. 53 Prolene is reportedly 0.027 in thick and has wrote up his notes and left a sample with DuPont's Plastics Group.
a burst strength of 250 Ib/in 2.53 Although Plunkett tried for several years to interest various fac-
tions at DuPont in his discovery, the patented formula, along with
Inflammation and Wound-Heating-Clinical Studies Stone et al. 47 re- a half-pound of the expensive prototype, sat unused on a shelf for
ported that in 101 patients studied over 20 years wound sepsis oc- nearly 5 years before someone could think of a use for it. At that
curred in 25 patients (24%), intestinal fistulas in 3 (3%), and point, Teflon was valueless because (like the mythical universal sol-
erosion into bowel/skin in 1 (1%). When a skin graft was at- vent that would dissolve its own container) it could not be applied
tempted (29 patients), successful results (more than 80% take) oc- to any product without slipping right off.
curred in 21 patients (72%). Difficult removal of the device was Today, polytetrafluoroethylene is the most commonly used flu-
reported with seven patients (Fig. 28.2). orocarbon polymer in medical application. The monomer tetra-
Capozzi et al. 53 reported that in 485 patients (encompassing 651 fluoroethylene is structurally similar to ethylene. The polymer,
repairs) 4 patients (0.8%) developed seromas that resolved with formed by free radical addition, tends to be highly crystalline, with
simple aspiration. The average follow-up period was 5.06 years. a density more than twice that of water at 2.2 g/ml. It has low ten-
Infection-Clinical Studies Capozzi et al. 53 reported that in 485 pa- sile strength, low shear strength, low elastic modulus, low surface
tients (651 repairs) 7 patients (91.4%) developed subcutaneous tension, and a low coefficient of friction. Because it is highly vis-
wound infections. In two instances, the infection extended to the cous even when melted, it is difficult to use industrially in appli-
mesh layer. The removal of the device was not required, and cations other than medical textiles.
the infections were resolved with simple drainage, packing, and As a textile, polytetrafluoroethylene, along with polyethylene
other conservative measures. Prophylactic antibiotics were not terephthalate and polypropylene, dominate the medical textile
used unless the hernia operation was done in addition to another field. Polytetrafluoroethylene is fabricated into filaments by mixing
procedure. the melted polymer with cellulose-type fillers. Mter the thread fila-
ments are spun, the fillers are oxidized. The now dark chocolate-
colored fibers are cleansed of oxidized filler with strong acids or
Polytetrafluoroethylene heat soaks. 54
Although polytetrafluoroethylene appears to adsorb oxygen
On April 6, 1938, young Roy Plunkett (born in New Carlisle, Ohio, fairly well, as do the fluorocarbons currently used as blood sub-
in 1910) opened a tank of gaseous tetrafluoroethylene in hopes stitutes, it does not seem to bind the sterilizing agent ethylene ox-
ide. Thus, little aeration appears to be necessary for this material low rate of adhesion formation. 62 ,63,65 There have been reports
following gas sterilization. 55 that polytetrafluoroethylene exhibits incomplete host tissue fixa-
Polytetrafluoroethylene is not known to be susceptible to any tion 15,63 and fibrous tissue ingrowth.63 In addition, there have been
degradative biological process and is highly resistant to almost any reports of ePTFE "wrinkling and curling on itself."15 There is con-
form of corrosive oxidative attack. However, when abraded, poly- cern that ePTFE can provide a nidus for bacteria, given the small
tetrafluoroethylene tends to flake, due to its low shear strength size of its pores. 15,32 It has been reported that infection can ne-
and despite its low friction coefficient and low surface tension. cessitate removal of the device. 69 Evidence suggests that ePTFE
The earliest studies of the biological reaction to polytetrafluo- can act as a physical barrier to neoplasia. 70
roethylene arose from the clinical problems associated with the
polytetrafluoroethylene acetabular cups. As Charnley noted in a Physical Characteristics Tyrell et al. 11 found the tensile strength to
controlled study in which he injected polytetrafluoroethylene par- be 1.565 kg 10 weeks after implantation (Fig. 28.1). In addition,
ticulates into his thigh, the polytetrafluoroethylene hurt much they found that the tensile strength increased less than 4% from
more than the ultrahigh-molecular-weight polyethylene. 56,57 The weeks 2 to 10. However, they note that the data were not normally
abrasive wear of polytetrafluoroethylene produced large numbers distributed. Murphy et al. 41 recorded a tensile strength of 2.67
of particles that evoked an aggressive granulomatous inflamma- kg/ cm 15 to 20 weeks after implantation of the device.
tory reaction. In addition to the typical chronic inflammatory cell Law and Ellis19 found the abdominal wall breaking strength sig-
infiltrate, which was judged to be relatively greater than the infil- nificantly weaker in the presence of bacterial contamination (S.
trate evoked by any other common orthopedic material, both aumus) 4 weeks after implantation.
necrosis and a lymphoplasmacytic infiltrate were noted. 58,59 Simi-
larly, when abraded materials from the early polytetrafluoroethyl- Inflammation and Wound-Healing-Laboratory Studies Murphy et
ene DeBakey disc in cage mitral valve prostheses embolized to the al. 41 graded mean adhesion formation after 15 to 20 weeks as min-
heart and kidney, the inflammatory cellular reaction has been de- imal, requiring only gentle gauze dissection. Law and Ellis 17 found,
scribed as strikingly intense. 6o Even when used as a composite, con- on average, minimum adhesions freed by gentle blunt dissection
tinuous phase polytetrafluoroethylene has induced significant at both week 1 and week 22.
inflammation when the application has yielded particulates. Both Brown et al. 49 studied adhesion formation with five separate sets
the mica composite Fluorosint® and the alumina or carbon com- of conditions and found that, on average, infection or peritonitis
posite Proplast® have initiated aggressive and often destructive had little effect in promoting the formation of adhesions. Pre-
inflammatory reactions. 61 Unlike any other material used for bio- operative or postoperative antibiotics seemed to have a very minor
medical application that we have seen, polytetrafluoroethylene effect on the formation of adhesions where infection was present.
particulates evoke both a late neutrophilic infiltrate and the for-
mation of dense lymphoid aggregates. Curiously, the material is
nevertheless used today in particulate form by injection for both Polyethylene Terephthalate
vocal cord augmentation and ureteral orifice procedures.
The principal uses of this material today are for meshes in ab- In 1941, two English fiber chemists, Whinfield and Dickson,
dominal hernia repair (Teflon mesh) and for vascular prostheses. patented the combination of terephthalic acid and ethylene gly-
Polytetrafluoroethylene (PTFE) is currently available in modified col, "Terylene®." It was the first successful synthetic fiber to replace
form as Gore-Tex Expanded Polytetrafluoroethylene (ePTFE) Soft cotton and wool. Resistant to stain and impervious to destruction
Tissue Patch. by moths or beetles, Terylene was an immediate hit in the textile
industry.
DuPont's version ofTerylene came to be known as Dacron® and,
The Gore-Tex ePTFE Soft Tissue Patch as the first waterproof, crease-resistant synthetic fiber, became
DuPont's biggest selling product. In 1952, DuPont took a film ver-
The Gore-Tex ePTFE Soft Tissue Patch is not a mesh but rather a sion of Terylene (Mylar®) and produced magnetic tape from it,
microporous sheet that appears to the unaided eye as a smooth, and it is used today in microfilm, magnetic audiofilm, and com-
solid, nonporous sheet. ePTFE was first made clinically available pact disks. Later in 1952, DuPont scientists came up with an arti-
in December 1981, and the formulation has not been changed. ficial blood vessel made of Dacron polyester. The vessels were
Some studies 21 ,26 have used experimental formulations that have improved throughout the 1950s and 1960s with a coating of al-
never been available clinically. The research done by Lamb et al., 21 bumin, a protein found in especially high concentration in egg
which has been widely cited,ll,18,33,62-M utilized a knitted polytet- whites. Albumin was thought to reduce clot formation under cer-
rafluoroethylene mesh that, while provided by the manufacturer tain conditions in certain prostheses.
of the clinically available ePTFE, has never been available for clin- Polyethylene terephthalate is the most widely used polymer in
ical use as an abdominal device. It is also worth noting that the the fabrication of textile components for medical devices. It is the
widely cited41 ,65,66 research done by Sher et al. 67 also utilized an predominant member of the textile family of medical device ma-
experimental formulation of ePFTE that has never been available terials, which also includes polypropylene and polytetrafluoroeth-
clinically.68 Although this formulation was also provided to Sher ylene. Polyethylene terephthalate may be reinforced with fillers
et al. by the manufacturer of the clinical product, the formulation such as titanium dioxide and carbon or may be copolymerized. As
was an industrial membrane with a different pore size that was not in polypropylene, the raw material is melt extruded to produce
designed for clinical use. 68 We will confine our discussion to the fibers that may then be woven or bonded to produce threads or
only polytetrafluoroethylene formulation that has been available assembled sheets of material.
for clinical use, the ePTFE Soft Tissue Patch. Polyethylene terephthalate is the only material currently used
Satisfactory results have been obtained with ePTFE.62,65 It has a to fabricate textile vascular graft prostheses. The material is also
used to create cardiovascular patches and wound repair meshes utation and opposition are based on unverified information. 76
and as an anchoring component for many percutaneous devices. Mersilene is widely used in France, Italy, and Belgium.
It is also used to fabricate the sewing rings for cardiovascular de-
vices and for blood filters in extracorporeal circulation devices. Its Physical Characteristics Mersilene is a multifilament mesh. Each fil-
brief use as an articulating component in hip prostheses was ended ament has a diameter of 0.0014 cm. The mesh is 0.023 cm thick,
owing to its poor tribological properties and the consequent os- weighs 0.0432 gl10 cm2, and has a density of 0.19 g/cm3• The
teolytic inflammatory reactions induced by the wear debris.57 bursting strength is 19.9 ± 0.3 kg and 1.3 ± 0.02 kg/cm 2• As to
Some in vivo studies of suture material show little or no loss of tensile properties, its breaking strength is 12.2 ± 1.3 kg (wale) and
strength of the textile in vivo. 71 Other studies show an early loss 6.9 ± 0.9 kg (course), and its breaking elongation is 45.2 ± 3.0%
of 10 to 20% of the fiber strength following implantation.54 Stud- (wale) and 103.9 ± 3.1 % (course). The pores of the mesh mea-
ies of vascular grafts recovered from humans in the late 1970s show sure 120 X 85 /Lm, taking the two longest perpendicular axes of
fairly convincing evidence of in vivo degradation. The measure- the pore. 40
ment of diameter and cross-sectional area of filaments removed Mersilene mesh is constructed of interlocked fiber junctions,
from explanted polyethylene terephthalate vascular prostheses which allow it to be cut to any shape without raveling. 78 Although
showed swelling on the order of 5% during the first 30 months of it has been reported that Mersilene is "readily sterilized by stan-
implantation. Among the explanations for this observation were dard steam pressure, "78 the manufacturer warns that "unused Mer-
absorption of water and blood proteins or, alternatively, chain scis- silene which has been removed from the package may be
sion and molecular weight loss associated with the introduction of resterilized not more than one time by a conventional steam au-
hydroxy and carboxy groups into the surface layers of the fibers. toclaving process at conditions of 250°F (121°C) for 20 minutes.
Devices recovered 30 months after implantation showed a fiber Mersilene mesh may also be flash autoclaved not more than one time
size decrease, which has been explained as complete dissolution at conditions of 270°F (132°C) for 10 minutes. Resterilization un-
of the degraded surface layers of the polymer.72 Reductions in der any other conditions or by any other means is neither rec-
bursting strength of 10 to 15% were associated with these physi- ommended nor endorsed by Ethicon, Inc."79 (emphasis added).
cal changes.
Chemical changes have also been reported. Polyethylene tereph- Inflammation and Wound Healing-Clinical Studies Advocates of
thalate fibers, as present in recovered arterial prostheses follow- Mersilene warn that contact with the stomach and bowel should
ing human implantation, show loss in molecular weight and be avoided due to possible fistulization, transmigration, and in-
increases in carboxyl group concentration. The kinetics of chain ternal obstruction. 76 Its ability to produce adequate fibroblastic re-
scission approximate a logarithmic decay model, with 25% response is controversial among surgeons. There have been reports
duction in the initial average molecular weight at 10 years. 73 A that it is "reactive enough to induce a rapid fibroblastic response
25% reduction in bursting strength was projected for 162 months. to ensure fixation,"76 but it has also been reported that it "does
Working independently from in vitro simulations and extrapolated not stimulate a marked fibroblastic infiltration."32
data, Guidon et al. 72 suggested a 4 to 7% annual loss of fiber ten- Pans and Pierard,8o in a study of the repair of abdominal mus-
sile strength associated with fiber crazing, splitting, and cleavage. cular wall defects in rats, found the least amount of adhesions to
As noted earlier, polyethylene terephthalate does not wear well. omentum and gut with Mersilene compared with Gore-Tex and
Abrasive forces present in hip joints generate large numbers of par- an experimental Vicryl®-Mersilene prosthesis.
ticulates, which then lead to unacceptable levels ofinflammationP
Polyethylene terephthalate has complement-activating proper-
ties. The material also has the propensity to swell and trap small Absorbable Meshes
molecules, which may result in the transfer of industrial process-
ing solutions into the final anatomical site, where they may leach Absorbable meshes, in contrast to permanent meshes, are devices
out over time and produce local injury.74 that the body dissolves over time. Although these meshes have
In fiber form, and especially in particulate form, the material been used for abdominal organ wrapping, the authors have ex-
evokes an aggressive macrophage mediated inflammatory reac- cluded these data on the basis that they are outside the scope of
tion, coupled with a significant infiltrate of fibroblasts and neo- this chapter. The absorbable meshes we will examine are Dexon
vascular tissues. (American Cyanamid Company) and Vicryl (Ethicon, Inc.)
In a study by Mori et al.,8I 3-week-old Wistar KY strain male rats
underwent a full-thickness abdominal wall excision with repair
Mersilene with nonabsorbable meshes (Prolene, Marlex, and Gore-Tex) and
absorbable mesh (Vicryl). Vicryl mesh, although it has less strength,
Polyethylene terephthalate is currently available in the form of resulted in the fewest adhesions.
Mersilene mesh and has been clinically available since at least
1960. 75 The formulation has remained the same since its intro-
duction. Contrary to general conception, this would make it the Polyglycolide
oldest abdominal mesh formulation that is still in use as the cur-
rent polypropylene formulation of Marlex was not made clinically Polyglycolic acid, either alone or copolymerized with lactic acid,
available until 1962. is an extremely popular synthetic material for the fabrication of
Satisfactory results have been obtained with Mersilene. 20 ,76,77 absorbable sutures. The homopolymer polyglycolic acid material
However, even proponents of Mersilene conceded that it has a has a repeating ester backbone consisting of two carbons and an
poor reputation in the United States, and some American surgeons oxygen, whereas the side chains of nonesterified carbon are two
oppose its use. 76 It is thought by its proponents that the poor rep- hydrogen atoms. The material is highly ordered and therefore
highly crystalline, with a high melting point. It is melt extruded Similarly, Jenkins et al. 42 examined bursting strength and found
into sutures. The copolymer, on the other hand, consists of nine an increase of approximately 50% from weeks 1 to 4. At week 1,
parts glycolide with one part L-lactic acid. The copolymer induces all ruptures occurred at the prosthetic/muscle interface, whereas
a respectable amount of disorder to the polymer, thereby reduc- at week 4 ruptures occurred at both the prosthetic/muscle inter-
ing both crystallinity and melting temperature. face and the inguinal canal.
As degradable sutures, the copolymer seems to be absorbed
more rapidly.82 The degradation mechanism seems to be hydrol- Inflammation and Wound Healing-Laburatury Studies There is evi-
ysis of the ester linkages; both heat and alkaline conditions has- dence to suggest that granulation and fibrosis can form on the de-
ten the loss of strength of the sutures. vice, acting as a permanent reinforcement. 93 However, it has been
reported that Vicryl invokes less collagen ingrowth than does
Dexon.l l
Dexon Jenkins et al. 42 studied adhesion formation and found that, on
average, from weeks 1 to 4 there was a minor change in adhesions,
Polyglycolic acid is available in the form of Dexon mesh. Dexon with minimal adhesions at both week 1 and week 4.
was first made available in 1983, and that formulation is the only
one that has been available in the United States. d3 However, other
formulations, introduced after 1983, have been clinically available Summary
outside the United States. 83 Satisfactory results have been obtained
with the device. 84.85 Bioreactivity
Physical Properties Dexon can be cut to any size without fraying.86 In reviewing the experimental data on the various abdominal mesh
The device has been reported to be completely absorbed within prostheses, we have encountered two recurrent problems. First,
90 to 180 days.84.86-88 many papers fail to identify specifically the device being examined.
Tyrell et al. 11 found that the mean tensile strength decreased Second, many papers report properties for one formulation of a
approximately 50% from weeks 2 to 10 of implantation. They note device based on experiments with a completely different formu-
that the data were not normally distributed (Fig. 28.1). lation. For example, in the case of Marlex, we have reviewed pa-
pers that justifY conclusions on the polypropylene formulation
Inflammation and Wound Healing-Laburatury Studies Although the using data obtained from the polyethylene formulation, with no
device is reported to cause adhesions, there is evidence to suggest mention of this difference. The research on the ePFTE Soft Tis-
that the adhesions fade as the mesh is absorbed. 85 It is controver- sue Patch often justifies conclusions by utilizing research of ex-
sial whether the fibrous ingrowth into the device is sufficient to perimental formulations that were constructed differently from
accomplish a permanent repair. Although it has been reported the clinically available device, once again without noting the dis-
that the ingrowth is sufficient to provide a permanent repair, other crepancy. Many papers on Dexon simply do not specifY which of
reports indicate otherwise. 87.89 the many clinically available formulations were investigated. Like-
Law and Ellis l7 found that, on average, adhesion formation wise with Vicryl, many papers do not give any indication whether
changes from minimum adhesions freed by gentle blunt dissec- the data had been obtained from the knitted or woven formula-
tion at week 1 to moderate adhesions freed by aggressive blunt tion of the device.
dissection at week 22. We have attempted to clarifY these incongruities in the sections
on each device and have summarized our impressions in Table
28.3. However, we believe that it is incumbent on future re-
Vicryl searchers to take the following steps before disseminating their
findings. First, contact the manufacturer of the device and obtain
Polyglactin 910 mesh is polyglycolic acid copolymerized with lac- a clear understanding of the various formulations of the device
tic acid and is available as Vicryl. Vicryl is clinically available in two and which of those formulations are or have been available clini-
formulations, a knitted mesh and a woven mesh. Vicryl woven cally and when. Second, specifY the exact formulation that is be-
mesh was first made clinically available in 1985, and the formula- ing investigated and indicate whether it is an experimental or
tion has not been changed. 90 Vicryl knitted mesh was first made clinically available formulation, as well as whether there are other
clinically available in 1983 and then later recalled and re-released formulations available clinically. When reviewing other research
in 1985. 91 The reason for the recall is unclear. When possible, we on the device, note the date of the research and compare it with
will differentiate between the knitted and woven formulations. Sat- the date when the clinical formulation was made available, as this
isfactory results have been obtained with Vicryl,92-94 and infections could indicate that the research was not based on the clinically
have been resolved without the removal of the device. 93 available formulation.
Physical Properties The Mullen burst strength of knitted Vicryl is

in excess of 60 psi.93 Knitted Vicryl appears to be completely ab- Histology
sorbed within 90 days.93 However, there is evidence to suggest that
Vicryl's rate of absorption is more variable than Dexon's.ll The We compared the various histological parameters, in particular
variable rate of degradation may explain why Tyrell et al. ll found wound strength and collagen ingrowth, for the various materials
that the tensile strength increased approximately 75% from week as reported by individual investigators (Fig. 28.3). It appears that
2 to week 10. However, they noted that the data were not normally there is no direct relationship between the rate of collagen in-
distributed (Fig. 28.1). growth and wound strength.
TABLE 28.3. Relative bioreactivity comparison*

Fibrogenicity Resistance
(collagen-rich to degradation Extent of
Anatomical chronic Resistance (hygroscopic available
confonnatioan inflammation) to infection and mechanical) data
Marlex 1 5 5 5
Prolene 2 5 5 3
ePTFE 3 4 4 4
Mersilene 4 3 3 2
Dexon and 5 1 1
Vicryl
*5 = greatest; 1 = least.
tChronic inflammation, but generally macrophages with late fibrosis.
Marlex With long-tenn placement, Marlex consistently evokes a By almost all admissions, ePTFE's ability to encourage fibrous
chronic inflammatory reaction characterized by a relative paucity tissue proliferation in the setting of gross wound infection is sig-
of macrophages and giant cells, aggressive and rapid fibroblast in- nificantly impaired.
filtration through the pores of the mesh, in addition to dense col-
lagen deposition. With regard to mesothelial cell growth over the
mesh, evidence suggests that it largely regenerates and is mor- Mersilene Histological studies of Mersilene as an abdominal mesh
phologically unimpressive. This has not been demonstrated con- prosthesis are few. 64 In our experience, polyethylene terephtha-
clusively, however. late evokes an aggressive macrophage and giant cell rich inflam-
In some wound infection models,19 the chronic inflammatory matory reaction that is followed by a dense fibrous ingrowth. The
process with fibroblast proliferation and collagen deposition was fibrous tissue matures over time and can become hyalinized after
not significantly altered in the presence of Marlex. In other ex- many years.
periments modeling acute peritonitis,49 the fibrinopurulent reac-
tion in the short tenn was so severe that no significant wound Dexon With long-tenn use, the fibrils of the Dexon mesh are es-
healing occurred. sentially fully absorbed by macrophages and the vacated volume
is replaced by a moderately cellular fibrous ingrowth. The cellu-
Gore- Tex ePTFE Soft Tissue Patch With long-term placement, ePTFE larity of the fibrous proliferation is greater than that associated
evokes a chronic inflammatory reaction that is different in many with Marlex.
ways from the more extensively studied Marlex. First, fibrous tis- Wound infection data with this material in the abdominal mesh
sue does not penetrate through the pores and thus the binding setting are not available.
of ePTFE to the wound bed is substantially less intense. Second,
the giant cell component of the inflammatory reaction is signifi-
cantly greater. Third, in several reports, polytetrafluoroethylene Vicryl With long-tenn use, the fibrils of the Vicryl mesh are es-
has been shown to evoke a neutrophilic reaction in the absence sentially fully absorbed by macrophages and the vacated volume
of culturable bacteria. The mechanism for this late "acute" type is replaced by a moderately cellular fibrous ingrowth. The cellu-
of reaction is not clear, but in our own work we have suggested larity of the fibrous proliferation is greater than that associated
that macrophage-derived interleukin-8 may be the responsible with Marlex. Wound infection data with this material in the ab-
chemotactic factor. 95 dominal mesh setting are not available.
3.5 90%
80%
3
,c_ 70%
i III 2.5
e:S
0):;) 2
60% ~
..5~
C I! 40%
...
50% ~
'5l.
CD .. 1.5
30% g'
0).-
1II,c
=.( 1
8- 0.5 20%
10%
o +-.l...---<_ _ ~ __ ~!-----+--L _ _ _--L-+--L..._ _ _-L-....j. 0%
Marlex Gore-Tex Vicryl Oexon
FIGURE 28.3. Histological data for four prostheses.

Ic::::J Collagen Ingrowth - % Absorbed at 10 Weeks I
Conclusion 17. Law NW, Ellis H. Adhesion formation and peritoneal healing on pros-
thetic materials. Clin Mater. 1988;3:95-101.
It is important to consider abdominal mesh materials when eval- 18. Dayton MT, Buchele BA, Shirazi SS, et al. Use of an absorbable mesh
uating the overall safety and effectiveness of prosthetic hernia re- to repair contaminated abdominal wall defects. An:h Surg. 1986;121:
954-960.
pair procedures. An understanding of the general principles of
19. Law NW, Ellis H. A comparison of polypropylene mesh and expanded
biomaterials and the specific properties of the various prosthetic polytetrafluoroethylene patch for the repair of contaminated abdom-
mesh materials is of great use to the operating surgeon. inal wall defects-an experimental study. Surgery. 1991;109(5):652-
It is apparent from the data reviewed in this chapter that the 655.
basic biophysical and mechanical properties of the principal ma- 20. Adloff M, ArnaudJP. Surgical management oflarge incisional hernias
terials in clinical use today vary widely. The great debate over which by an intraperitoneal Mersilene mesh and an aponeurotic graft. Surg
prosthesis is "better" cannot be answered in a single sentence be- GynecolObstet. 1987;165(3):204-206.
cause the relative advantages and disadvantages of the character- 21. Lamb JP, Vitale T, Kaminski DL. Comparative evaluation of synthetic
istic bioreactivities are contextual. meshes used for abdominal wall replacement. Surgery. 1983;93:643-648.
As biomaterial investigators, it is our hope that we have con- 22. Walker PM, Langer B. Marlex mesh for repair of abdominal wall de-
fects. Can] Surg. 1976;19:211-213.
tributed substantively to the clinical assessment of these biomate-
23. Gilbert AI. Overnight hernia repair: updated considerations. South
rials, and we appreciate being a part of the medical search for the MedJ 1987;80(2):19:211-213.
ideal prosthetic material for hernia repair. 24. Johnson PC, Persons ML, Schulak JA. A technique for early wound
management using polypropylene mesh reconstruction of the ab-
dominal wall. Surg Gynecol Obstet. 1988;167(5):435-436.
25. Kambouris A. Full-thickness abdominal wall resection for recurrent
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1981:269-998. orrhaphy and pelvic peritoneum reconstruction. Contemp Surg. 1985;
61. Semlitsch M. Technical progress in artificial hip joints. Sulzer Tech Rev. 27(6):11-15.
1974;4:1-11. 86. Kavanah MT, Feldman MI, Devereux DF, et al. New surgical approach
62. Bauer jJ, Salky BA, Gelernt 1M, et al. Repair of large abdominal wall to minimize radiation-associated small bowel injury in patients with
defects with expanded polytetrafluoroethylene (PTFE). Ann Surg. pelvic malignancies requiring surgery and high-dose irradiation. Can-
1987;206(6):765-769. cer 1985;56(6):1300-1304.
63. van der Lei B, Bleichrodt RP, Simmennacher RJK. Expanded polytet- 87. Mannon LM, Vinocur CD, Standiford SB, et al. Evaluation of ab-
rafluoroethylene patch for the repair of large abdominal wall defects. sorbable polyglycolic acid mesh as a wound support. ] Pediatr Surg.
Br] Surg. 1989;76(8):803-805. 1985;20(6):737-742.
88. Devereux DF, Thompson D, Sandhaus L, et al. Protection from radi- 94. Gainant A, Boudinet F, Cubertafond P. Prevention of postoperative
ation enteritis by an absorbable polyglycolic acid mesh sling. Surgery. wound dehiscence in high risk patients. A randomized comparison of
1987;101 (2):123-129. internally applied resorbable polyglactin 910 mesh and externally ap-
89. Law NW. A comparison of polypropylene mesh, expanded polytetra- plied polyamide fiber mesh. Int Surg. 1989;74(1):55-57.
fluoroethylene patch and polyglycolic acid mesh for the repair of ex- 95. Kossovsky N, Millet D, Juma S, et al. In vivo characterization of the in-
perimental abdominal wall defects. Acta ChiT Scand. 1990;156:759-762. flammatory properties of poly( tetrafluoroethylene) particulates. J Bio-
90. Ethicon, Inc. (manufacturers ofVicryl). Personal communication. med Mater &s. 1991;25:1287-1301.
91. Ethicon, Inc. (manufacturers ofVicryl). Personal communication. 96. Berliner SD. Clinical experience with an inlay expanded polytetraflu-
92. Hallock GG, Altobelli JA. Polyglactin 910 mesh for support of the oroethylene soft tissue patch as an adjunct in inguinal hernia repair.
donor defect of the double-pedicled rectus abdominis musculocuta- Surg Gynecol Obstet. 1993; 176:323-326.
neous flap. Ann Plast Surg. 1989;22 ( 4):358-364. 97. Simmermacher RKJ, van der Lei B, Schakenraad JM, et al. Improved
93. Clarke-Pearson DL, Soper ]T, Creasman WT. Absorbable synthetic tissue ingrowth and anchorage of expanded polytetrafluoroethylene
mesh (polyglactin 910) for the formation of a pelvic "lid" after radi- by perforation: an experimental study in the rat. Biomaterials. 1991;
cal pelvic resection. AmJObstet GynecoL 1988;158(1):158-161. 12:22-24.
29
Carcinogenicity of Implantable Biomaterials
B. Klosterhalfen, U. Klinge, and V. Schumpelick
Foreign-Body Carcinogenesis Tumorigenesis of Biomaterials

in Rodent Animal Models in Patient Follow-Up Studies
Tumor development in response to the subcutaneous implanta- The ability of implantable devices to induce malignancy locally or
tion of plastics and other inert materials, known as foreign-body systemically is a matter of concern, especially when they are placed
(FB) carcinogenesis, was first observed over 40 years ago. It is a in young patients with a long life expectancy. It is estimated that
classic model of multistage endogenous tumorigenesis that re- 88,200 hip replacements were performed in 1975 and that 11 mil-
quires one-half or two-thirds of the rodent lifespan for sarcoma lion people currently carry implanted metallic fixation devices.
or tumor development. However, unlike chemical rodent car- With such a large number of implants in place and a 20-year la-
cinogenesis, FB carcinogenesis is generally dismissed as a phe- tency period exceeded, one might expect a gradually increasing
nomenon unique to the rodent. The early experimental studies number of implant-related cancers to emerge if the risk of malig-
demonstrated unequivocally that certain physical characteristics of nancy is significant. Fortunately, clinical observations support the
the implant, such as size, shape, and surface morphology, but not hypothesis that the risk of cancer with metal implant devices is ex-
chemical composition, were essential for FB carcinogenesis. Fur- tremely low. Only 20 cases of malignancy in association with metal
thermore, a dose/response relationship was found between the fixation devices have been reported in the literature, with laten-
implant size and tumor frequency. Materials that will induce FB cies ranging between 1 and 30 years. 3
tumors include films of Dacron®, nylon, polyethylene, polystyrene, Although the risk of local cancer with metal implants appears
polyvinyl chloride, saran, cellophane, polydimethylsiloxane, and to be very low, there is still a question of increased risk for cancer
Teflon®. It was concluded that tumor formation was directly re- systemically. Gillespie et al. 4 found a significant increase in the risk
lated to cellular events during the FB reaction and formation of of lymphatic and hemopoietic tumors in 1358 patients after total
the fibrotic capsule surrounding the implant. hip replacement. The authors of that study are quick to caution
Subsequent studies have extended these observations and against assuming a causal relationship, for many other factors
demonstrated that subcutaneously implanted materials of any associated with arthritis may have contributed to the increased
chemical composition can cause tumors in several animal species cancer rate.
provided that it possesses a smooth and impermeable surface. In Cancers in association with polymers also appear to be rare. In
powdered, perforated, or porous form, these materials lose their one series, Deapen and Brody' studied the incidence of breast can-
tumorigenicity, confirming a primary role for the physical char- cer in 3112 patients in the Los Angeles area after esthetic breast
acteristic of the implant rather than its chemical composition. For aUgnIentation, with average follow-up at both 6.2 and lO.6 years
example, subcutaneously implanted cellulose millipore filters with after implantation. In another series, Berkel et a1. 6 studied a co-
a pore size less than 0.02 /Lm have been shown to induce a high hort of 11,676 women, with an average follow-up of 10.2 years. In
percentage of tumors in rats, whereas the same filters with a pore this study, no increased risk of breast cancer was documented af-
size of more than 0.65 /Lm are not tumorigenic. Of partial inter- ter aUgnIentation mammoplasty.
est, several investigators have shown that if the implant and the
surrounding fibrotic capsule are removed within 6 months, no tu-
mors develop. Other studies have shown that the frequency of FB The Risk of Foreign-Body Carcinogenesis
tumors varies directly with the capsule thickness.
Taken together, these results suggest that FB tumor initiation
Mter Surgical Mesh Implantation in
and progression occur in cells within the fibrotic capsule. Tumors Hernia Repair
observed have been mainly fibrosarcomas or histiocytomas.} A re-
cent study in rats 2 indicated that biodegradable materials (copoly- In 1997, James et al. 7 reported that the cellular response in the
mer of e-carprolactone and L-Iactide) show a higher incidence of case of FB carcinogenesis is characterized by an accumulation of
sarcoma formation than nonabsorbable materials, such as sheets proliferating and damaged cells in the interface. Silicone foils and,
made of Marlex® (now Bard® mesh). as positive control, impermeable cellulose acetate filters indicated
235
236 B. Klosterhalfen et al.
TABLE 29.1. Sarcomas induced by biomaterials In 1980, Brand and BrandS identified nearly 100 sarcomas in-
duced by scars. A total of 50% of these appeared within 25 years.
Year of
In 1988,Jennings et al. 9 reported 40 sarcomas induced by foreign
Author publication Latency (years) Material
bodies. They appeared after a mean of 17.6 ± 24.9 years, seeming
Dargent 1997 Dacron to have two peaks within 5 years or after 15 years (Table 29.2). In
Caralps-Riera 1996 2.3 Dacron the 1970s, on the basis of his experimental results in animals,
Fyfe 1994 4 Dacron Brand et al.I° postulated a multiphasic appearance of induced
Raso 1993 Femoral vascular graft sarcomas.
Weiss 1991 Dacron Judging from the results of the animal models of tumor devel-
Weinberg 1980 1.2 Dacron
opment after polymer implantation, sarcomas should be observed
Fehrenbacher 1981 12 Dacron
in humans after 30 to 50 years, a period of time correlating to one-
Moncure 1987 Dacron
Wallnofer 1977 3 Graft half or two-thirds of the rodent lifespan. Taking into account that
O'Connell 1976 1 Dacron scientific retrospective or prospective investigations on the long-
Burns 1972 10 Dacron term effects of meshes in hernia surgery, or of other implants, are
Ott 1970 19 Sutures not available, FB carcinogenesis cannot be safely ruled out with-
jennings 1988 20 Swab out continued investigation and appropriate patient follow-up.
Leinhardt 1988 20 Sutures, polyethylene
Levis 1980 Silicon injections
Data are compiled from several sources. 1l- 14 References

1. Brand KG, Buoen LC, johnson KH et al. Etiological factors, stages,
significantly elevated TUNEL (in situ apoptosis detection method) and the role of the foreign body in the foreign-body tumorigenesis: a
and peNA (proliferating cell nuclear antigen) positive cells com- review. Cancer &so 1975;35:279-286.
pared with the negative control (porous cellulose acetate filters). 2. Nakamura T, Shimizu Y, Takimoto Y et al. Biodegradation and tu-
morigenicity of implanted plates made from a copolymer of E-capro-
The results of this group show direct parallels to our findings on
lactone and L-lactide in rat. J Biomed Mater &so 1998;42:475-484.
the heavyweight (Marlex, Prolene®, Parietex®) and lightweight
3. RubinjP, Yaremchuk MJ. Complications and toxicities of implantable
(Vypro®, Mersilene®) meshes, which also reveal a "dose-dependent" biomaterials used in facial reconstructive and aesthetic surgery: a com-
irritation of the recipient tissues, with significantly increased cell prehensive review of the literature. Plast Reconstr Surg. 1997;100:
damage and proliferation rates in the heavyweight mesh groups 1336-1353.
compared with the lightweight mesh groups. 4. Gillespie W, Frampton C, Henderson R et al. The incidence of cancer
Whether FB carcinogenesis is a serious cause for concern in the following total hip replacement. J Bone Joint Surg Br. 1988;70:539.
case of surgical meshes is a legitimate question. Fortunately, up to 5. Deapen DM, Brody GS. Augmentation mammoplasty and breast can-
now no example of tumor development after mesh implantation cer: a 5-year update of the Los Angeles study. Plast Reconstr Surg.
has been documented. However, there are an increasing number 1992;89:660.
6. Berkel H, Birdsell DC, jenkins H. Breast augmentation: a risk factor
of case reports of FB carcinogenesis after implantation of other
for breast cancer. N EnglJ Med. 1992;326:1649.
biomaterials, in particular vascular prosthetic devices, although
7. James Sj, Progribna M, Miller Bj et al. Characterization of cellular re-
the mean survival time of these patients is usually less than 10 years sponse to silicone implants in rats: implications for foreign-body car-
(Table 29.1). A striking finding is the fact that most sarcomas were cinogens. Biomateriols. 1997;18:667-675.
reported after the implantation of Dacron, which is a hosiery-like 8. Brand KG, Brand I. Risk assessment of carcinogenesis at implantation
surgical mesh; until now sarcomas were associated with experi- sites. Plast Reconstr Surg. 1980;66:591-595.
mentally implanted non textile plates or foils. 9. jennings T, Peterson L, Axiotis C et al. Angiosarcoma associated with
foreign body material. A report of three cases. Cancer. 1988;62:2436-
2444.
TABLE 29.2. Latency of foreign-body induced sarcomas 10. Brand KG, Buoen LC, Brand I. Multiphasic incidence offoreign body-
Latency (years) Number induced sarcomas. Cancer &so 1976;36:3681-3683.
11. Ott G. FremdkiiTpersarkome, 1st ed. New York: Springer-Verlag, 1970.
:55 14 12. Weiss WM, Riles TS, Gouge TH et aI. Angiosarcoma at the site of a
:510 3 Dacron vascular prosthesis: a case report and literature review. J Vasc
:520 14 Surg. 1991;14:87-91.
:530 5 13. Weinberg DS, Maini BS. Primary sarcoma of the aorta associated with
:540 3 a vascular prosthesis: a case report. Cancer. 1980;46:398-402.
>40 14. O'Connell TX, Free lij, Golding A. Sarcoma associated with Dacron
prosthetic material: case report and review of the literature. J Thomc
Data are from jennings et al. 9 Cardiovasc Surg. 1976;72:94-96.
30
Suture Selection for Hernia Repair
Philip B. Dobrin
Sutures are used to maintain tissues in apposition until sufficient to about 90% of original strength after 1 year. When absorbable
healing occurs to provide endogenous wound strength. The heal- sutures are inserted into tissue they rapidly degrade, losing
ing process begins soon after tissue is wounded or incised and pro- strength at the same time as the healing tissue is getting stronger.
gresses through the phases of inflammation, proliferation, and The degradation of absorbable sutures has been studied by sev-
maturation/remodeling. Wound strength is negligible immedi- eral authors.6-10 Postlethwait6,7 demonstrated that polyglycolic acid
ately after surgery, increasing rapidly with the deposition of colla- sutures lose 30% of their initial strength in 7 days and about 80%
gen types III and 1. 1 Sutures must hold the wound together during of their strength after 14 days. Carlson and Condon9 summarized
these reparative processes. the strength half-lives given by the suture manufacturers on the
In inguinal hernias, there are well-defined structural landmarks package inserts: chromic catgut, 1 week; poliglecaprone (Mono-
that are stronger than sutures2 and that permit assessment of the cryl®) , 1 week; polyglactin (Vicryl®), 2 to 3 weeks; polyglycolic acid
tension that might be imposed by repair. A McVay repair imposes (Dexon®), 2 to 3 weeks; polyglyconate (Maxon®), 3 to 4 weeks;
the greatest tension. A Bassini repair imposes somewhat less ten- and polydioxanone (PDS®), 4 to 5 weeks. Polypropylene (Pro-
sion, and the tension imposed is reduced by a generous relaxing lene®) and polyamide (nylon) retain most of their strength in-
incision. 3 A Shouldice repair is under less tension than either a definitely. Greenwald and co-workerslO demonstrated that many
McVay or a Bassini repair.4 The tension in a repair is reduced to absorbable sutures retain little, if any, strength after 6 weeks in
zero when a section of slack prosthetic material such as polypropyl- vivo; in contrast, nonabsorbable sutures retain various degrees of
ene mesh or polytetrafluoroethylene (PTFE) is interposed be- stiffness, tensile stress, and toughness (Figs. 30.1 to 30.3). The de-
tween structural fascial elements. Similar considerations apply to cline in mechanical properties exhibited by absorbable sutures
umbilical, epigastric, and incisional hernias, where the tension also raises concerns about the ability of these sutures to provide suffi-
can be reduced by insertion of a slack segment of mesh or PTFE; cient strength for the early healing wound.
a tight prosthesis will simply transmit the tension, putting the re- Several prospective clinical studies have been undertaken to
pair at risk. All abdominal wall hernias are subject to tension that compare absorbable with nonabsorbable sutures used in hernia
results from intraabdominal pressure; this is amplified by the ra- repair. Baltazar andJohnston ll compared polyglycolic acid sutures
dius of the abdomen, as dictated by the law of Laplace. in 46 patients versus Dacron, cotton, or silk sutures in 41 patients
The present chapter examines the issue of suture selection for when performing inguinal herniorrhaphies. The study was ran-
hernia repairs. Absorbable versus nonabsorbable sutures are con- domized and prospective. Follow-up was possible in 91 % of the
sidered, as are continuous versus interrupted suture techniques. patients over a 9 to 37 month period. Six recurrences occurred in
Some special mechanical properties of polypropylene sutures are the polyglycolic acid group (14.6%) compared with three (7.7%)
reviewed. Finally, complications of surgical sutures, such as sus- in the nonabsorbable group. This difference was not significant.
ceptibility to infection, suture granulomas of the bladder, and the The postoperative complication rate also was similar, with five
formation of "buttonhole hernias," are discussed. Throughout this hematomas, ecchymoses, and minor subcutaneous abscesses oc-
review, conclusions and recommendations are based on clinical curring in each group (p = not significant). The authors con-
and scientific evidence. cluded that there was no advantage to using polyglycolic acid over
nonabsorbable Dacron, cotton, or silk.
Anderson and co-workers 12 performed a randomized prospec-
tive study in 235 consecutive patients to compare polyglycolic acid
Absorbable Versus with silk sutures used in herniorrhaphies. Topical ampicillin was
Nonabsorbable Sutures applied to all of the wounds at the time of surgery. There were 11
wound infections, no suture sinuses, and 3 recurrent hernias, with
Fascial wound strength after incision has been studied in experi- no statistically significant difference between groups.
mental animals. 5 There is no measurable strength immediately af- Burcharth and co-workers 13 prospectively compared absorbable
ter surgery. After 2 weeks, about 20% of strength is restored. This polyglycolic acid sutures with nonabsorbable silk sutures in 302
increases to 50% after 1 month, to about 70% after 2 months, and patients. Polyglycolic acid was used in 150 cases and silk sutures
237
238 P.B. Dobrin
3.5E+8 FIGURE 30.1. Elastic modulus, a measure of stiffness, of su-
1
tures before and after 6 weeks of incubation in vivo. Poly-
3.OE+8 ,.f glycolic acid (Dexon), polyglactin (Vicryl), and gut did not
Dtimeo
... survive the 6 weeks' incubation. (Reprinted from Green-
~2.5E+8
...... rt rt W1I after 6 weeks in vivo
wald et al.,IO with permission.)
l2.oE+8
~
rl 1.5E+8 r+
:g ~
~ 1.0E+8
·il
r+ ;eo - r-
~ 5.0E+7
O.OE+O - '- -o '-
'" 0
'" '"
i
0 0 0
u
~ ~ ~ ~
~
~ ~
~ ~ ~
~
p..
U
Suture Material
in 152 cases. Follow-up at 5 years showed that the recurrence rates study of 111 patients who underwent herniorrhaphy without mesh
were identical, with 9.3% recurrences in each group (p = not sig- using absorbable polydioxanone. Two-year follow-up data were ob-
nificant). tained from 81 of the 111 patients. There was one wound infec-
Dorflinger and Kiil14 used a double-blind randomized study to tion, three hematomas, and two recurrences. Although there were
compare absorbable polyglycolic acid sutures with nonabsorbable no patients treated with nonabsorbable sutures with which to com-
Dacron sutures in the repair of 61 hernias in 58 patients. Bassini pare these findings, the outcome data are very acceptable and do
repairs were used for all the inguinal hernias, and McVay repairs not suggest that the absorbable suture degraded before the wound
were used for all the femoral hernias. There were 29 patients in had acquired sufficient strength.
each group. The patients were reexamined 6 months after surgery. Although they are not reviewed in detail here, at least five ran-
There were no wound infections and no suture granulomas, but domized prospective studies have been carried out to compare ab-
there was one recurrence in each of the two suture groups (p = sorbable with nonabsorbable sutures for closing abdominal
not significant). wounds (not hernias)P-21 Continuous or interrupted suture tech-
Solhaug15 compared the use of polyglycolic acid with polyester niques were used for both absorbable and nonabsorbable arms of
(Mersilene) to repair inguinal hernias. A total of 520 patients were the studies. These studies included 1814 abdominal closures. Re-
randomized to each of the two treatment arms. Recurrence rates view of the data demonstrated no significant differences between
were 5.1 % in the polyglycolic acid group and 4.9% in the poly- absorbable and nonabsorbable sutures with respect to outcomes.
ester group (p = not significant). Neuralgia requiring excision of Thus, there appears to be no clear advantage on the side of ei-
the ilioinguinal nerve occurred in two patients, and a suture fis- ther absorbable or nonabsorbable materials with respect to effi-
tula occurred in one patient. Both of these complications occurred cacy and complications such as wound infections and recurrences.
in the polyester group (p = not significant). Lichtenstein 22 argued that, because of their rapid loss of strength,
Dick and co-workers 16 performed a noncomparative prospective absorbable polyglycolic acid sutures should not be used for
8.0B+14,--------------------------,
7.0E+14 Dtlmeo
6.0B+14 ~ after 6 weeks in vivo
l!
a5.0E+14
i'
..... 4.0E+14
2
i
Z
3.0E+14
2.0E+14
1.0E+14
O.OE+O+'---'-1r-'-"-r...........,...
I
'" '"
iI
0 0 0 0 0 0 0
'" '"
0 0
'" 0
'" FIGURE 30.2. Tensile sress, a measure of resistance to break-
S
III
~ ~ ~
(I) ~
~ ~ ~
~
~
~ ~ ~
6
~ age, before and after 6 weeks of incubation in vivo. Poly-
!> c
~
glycolic acid, polyglactin, and gut did not survive the 6 weeks'
~
)1
ffi f incubation. (Reprinted from Greenwald et aI.,lO with per-
Suture Material mission.)
30. Suture Selection for Hernia Repair 239
FIGURE 30.3. Toughness, a measure of the energy absorbed 1.2E+8

by the suture (area under the stress-strain curve), before
and after 6 weeks' incubation in vivo. Polyglycolic acid,
1.0E+8
o time 0
polyglactin, and gut did not survive the 6 weeks' incubation.
(Reprinted from Greenwald et al.,IO with permission.) ~ after 6 weeks in virIo
18.0E+7
+ r+
a6.0E+7 rt
.......
II ~ rt
14.oE+7
:+
~Ul
2.0E+7
J '--
-- --
Ii II~ ~
Q -0 Q -0 0 0 0 -0 0 -0 0 -0 0 -0
\II
~ ~ ~ ~ ~ :2~
~
Po.
~
Po.
~ Suture Material
tension-free mesh repairs. He preferred polypropylene. For many incidence of wound infection was 8.6%, and the incidence of
years, Devlin and co-workers used stainless steel wire for Shouldice wound dehiscence was 2.3%. Incisional hernias occurred in 16.9%
repairs. In 1986, they reported that they also had changed to us- of those closed with interrupted polyglactin 910 and in 20.6% of
ing polypropylene for the same operation. 23 Recently, Nyhus et those with continuous polyglactin 910. These differences were
al. 24 stated that they "learned very early on that silk or cotton not statistically significant. However, these rates of incisional
should never be used to sew polypropylene mesh. The suture and hernia are unacceptably high and suggest problems with surgical
mesh must be made of the same material." This suggests that technique.
polypropylene sutures may be an ideal nonabsorbable suture for Trimbos and co-workers28 performed a rarIdomized trial to com-
herniorrhaphy and virtually requisite for polypropylene mesh re- pare interrupted absorbable polyglactin 910 sutures with contin-
pairs, whereas a PTFE suure may be preferable with expanded uous absorbable polyglyconate sutures for closing the midline
PTFE patches. On the other hand, Robbins and Rutkow described fascia following laparotomy. The polyglyconate sutures were be-
the use of interrupted polyglactin sutures to secure their plug in gun at the two ends of the incision and advanced to be tied at the
mesh plug repairs. A 4-year follow-up study demonstrated a 0.7% center. There were 172 patients assigned to the interrupted suture
recurrence rate in 2861 patients after primary repair and a 3.4% closures and 168 assigned to the continuous suture closures. The
re-recurrence rate in 207 patients who had a previous repair. These patients were evaluated 2 weeks after surgery and again after 1
data strongly support the use of absorbable sutures when the re- year. Results were suture fistula: interrupted, 0%, continuous, 2%;
pair is not under tension. wound pain: interrupted, 1%, continuous, 2%; incisional hernia:
interrupted, 3%, interrupted, 4%. None of these paired differ-
ences were statistically significant. The authors recommended us-
Continuous Versus Interrupted Sutures ing continuous sutures to speed the surgery and leave less foreign
material in the wound.
Although there are no systematic prospective studies comparing Finally, Gislason and co-workers29 investigated the incidence of
continuous suture repairs with interrupted suture repairs of her- dehiscence and incisional hernia in 599 patients after closure of
nias, such data are available for midline and transverse abdomi- the abdominal aponeuroses. Patients were randomized to closure
nal closures. Absorbable sutures were used in each of the studies with one of three suture techniques: continuous mass closure with
discussed here. Fagniez et al. 26 compared continuous absorbable polyglyconate, continuous mass closure with polyglactin 910, or
polyglycolic acid suture closures with polyglycolic acid sutures interrupted mass closure with polyglactin 910. The latter com-
placed in an interrupted fashion. The study randomized 3135 pa- parisons are of particular interest here. The overall rate of dehis-
tients undergoing laparotomy. The patients were well matched cence was 2%, 4% occurring after continuous polyglyconate
for medical conditions, oncologic drugs, corticosteroid therapy, closure as compared with 2% after both continuous and inter-
radiation, anemia, ventilator support, obesity, ascites, age, and rupted polyglactin 910 closures. These differences were not sta-
male/female ratio. The dehiscence rate was 1.4% with continuous tistically significant. The rate of incisional hernias depended on
closures and 2.0% with interrupted ones (p = not significant). the presence of infection. In the absence of a wound infection,
These are truly remarkable results, and they are highly reliable however, there were nine incisional hernias in the polyglyconate
considering the large number of patients under study. group, seven hernias in the continuous polyglactin 910 group, and
Wissing and co-workers 27 compared four techniques for closing six hernias in the interrupted polyglactin 910 groups. These were
the midline fascia after laparotomy in a randomized prospective not significantly different from one another.
multicenter trial. The study included 1491 patients using the Thus, none of the studies described above demonstrate a sig-
following methods: interrupted closure with polyglactin 910, con- nificant advantage to continuous or interrupted suture techniques
tinuous closure with polyglactin 910, continuous closure with poly- for abdominal closure. This justified the use of a continuous su-
dioxanone-s, and continuous closure with nylon. The overall ture technique that distributes the tension and reduces the
240 P.B. Dobrin
amount of foreign body in the wound. However, interrupted su- light. 33,38,41-47 They pass through tissue with little friction,34,37,47
ture techniques may be preferable in the case of circular hernias are not thrombogenic,48 and are relatively resistant to infection. 49
such as umbilical and some epigastric defects. In this case, inter- Examination of the mechanical characteristics of various sized
rupted sutures may give greater security as the sutures lie in line polypropylene sutures demonstrates some remarkable features.
with the radially applied forces about the circle. The elastic modulus (a measure of stiffness) and tensile stress (a
Unfortunately, there are no data comparing matched continu- measure of resistance to breakage) correlate inversely with the
ous and interrupted nonabsorbable sutures of the modem type cross-sectional area of the filaments but directly and linearly with
currently used for herniorrhaphy or abdominal closures. There the circumference of the filaments (Figs. 30.4, 30.5).50 This sur-
are, however, a number of nonrandomized, noncomparative stud- prising finding suggests that the strength of the suture may lie in
ies using continuous polypropylene to close midline abdominal its shiny outer surface rather than in its core. Similar relationships
incisions. The results obtained are most encouraging. Shephard were found for nylon, another monofilament suture, but not for
and co-workers3o evaluated the outcomes of 200 unselected silk, a braided suture. X-ray birefringence studies of melt-spun
patients who underwent midline incisions or laparotomy for gy- polypropylene and polyethylene fibers suggest that the crystalline
necologic malignancy. Twenty-two percent had undergone pre- elements of the skin are more highly oriented than those of the
operative radiation therapy, 18% were obese, and 15% had core. Although this orientation was found in melt-spun fibers, it
undergone prior bowel surgery. Thus, these patients were at in- was not observed in un extruded bulk material. 51 During manu-
creased risk for wound healing problems. Number two polypropyl- facture, melt-spinning consists of extruding the material in a
ene was used in all cases. There was an 8.5% postoperative wound molten state and then extending the filaments longitudinally un-
infection rate and, over a 2-year period, a 5% rate of postopera- der load while they are waml and still extensible. 52 In this man-
tive incisional hernia. These numbers are satisfactory. ner, the crystalline materials may be oriented in the direction in
Knight and Griffen31 reported the results of 1000 consecutive which the filaments are being pulled. The filaments usually are
patients whose abdominal incisions were closed with continuous passed through a water bath filled with cool or room temperature
monofilament polypropylene suture. Wound dehiscence occurred water to harden them. Under these conditions, the skin must so-
in just 0.4%, and incisional hernias occurred in only 0.7%. These lidity first, orienting the crystals in the outer surface. As a result,
are remarkably low values, leading one to wonder how closely the the skin of the filament may bear most of the load, protecting the
patients were studied in the postoperative period. Although they crystals in the core from being oriented.
did not compare polypropylene with any other suture, the authors These observations have practical implications with respect to
suggested that polypropylene may be especially useful in contam- intraoperative handling of the suture. 53 Laboratory studies demon-
inated wounds. Thus, although these are not comparative studies, strate that abrasion of the suture by the tom foil envelope in which
they certainly argue that polypropylene is an effective and useful it is packed, kinking or axially twisting the suture, and tugging on
monofilament nonabsorbable suture. the suture to remove the accordion-like pleats, as often done by
the scrub nurse, have no effect on suture strength. A stray knot,
however, which tends to crease the suture skin, and pinching with
Polypropylene Sutures surgical forceps both decrease suture strength. The latter pertur-
bation causes injury in a graded fashion comparable with a phar-
Polypropylene sutures have certain properties that are particularly macological dose/response curve. 50 These observations emphasize
relevant to their use in surgery. They are strong when used in sizes the crtical importance of discarding sutures that have acquired a
that are appropriate for the load to which they are subjected. 32- 38 stray knot during surgery and the absolute prohibition against
They are also resistant to oscillatory loads. 39 They resist deterio- grasping the suture with any instrument. Handling with fingers
ration in vivo,9,33,38,40 although they may be degraded by oxida- seems the most prudent course. Of course, portions of the suture
tion, certain chemicals, high energy radiation, and ultraviolet that are not to be incorporated in the repair, such as those near
24.0
7-0
20.0
..
GO
2
N 16.0
E
....uc
......
(I) 12.0
::;)
....I
::;)
c
0
2; 8.0 '00.99 '00.99
u
,0.11.-.05 + 5.5 ,'.0;'1+5.5
j::
(I)
C FIGURE 30.4. Elastic modulus, a measure of stiffness, for a
....I 4.0
L&I
wide range of sizes of polypropylene sutures. Modulus is in-
versely and curvilinearly related to cross-sectional area (left)
but is directly and linearly related to suture circumference
o 1.0 2.0 3.0 4.0 o 200 400 600 800 (right). This suggests that stiffness is in the outer surface of
CROSS-SECTIONAL AREA X leT" ~ ClRCUMFEREHCE/CROSS-sECTIONAL AREA em-I the suture. (Reprinted from Dobrin,5o with permission.)
FIGURE 30.5. Tensile stress, a measure

of resistance to breakage, for three
sizes of polypropylene sutures. Tensile 6.0 6.0
stress is inversely related to cross-
sectional area (left) but is directly re-
lated to suture circumference (right).
This suggests that strength is in the ...~ 5.5 5.5
outer surface of the suture. (Re-
printed from Dobrin,5o with permis- N~"
7-0
sion.)
i
m 5.0 5.0
e:
C/l
r-O.99
i
r.Q.94
y = -7.68 x 101~ + 5.5 x 109 y-3.18x 106 x+3.47x 109
~ 4.5 4.5
4.0 4.0
I I I I I I I I , I I , I I
0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 100 200 300 400 500 800 700 800 900
CROSS-SECTIONAL AREA X 10 'an2 CIRCUMFERENCE ICROSS-SECTIONAL AREA anlal
the needle, may be handled in any way that is convenient, as they nylon in 61 patients, polybutester in 61 patients, and PTFE in 69
will be discarded. patients. Polybutester is a unique, remarkably extensible suture.
Another way in which a suture may be made to break is by over- Ten percent of the patients had infectious complications, and four
loading it. Consider construction of a continuous suture line. If a had deep infections, all of these occurring in the patients who had
suture line is constructed with a loose loop, the slack will be dis- been closed with PTFE. Therefore, the authors concluded that
tributed among several loops on either side of the loose one. IT a PTFE sutures carried an increased risk of infection.
suture line is constructed with one or more tight loops, however, Jones57 reviewed 256 consecutive Shouldice (77%) and Bassini
suture-tissue friction will not permit redistribution of the excessive (32%) herniorrhaphies performed without mesh at one hospital
tension. 39 Excessive tension can easily be applied inadvertently as over a 15-month period. Sutures used included braided (linen,
the surgical assistant "follows" the surgeon, pulling up on each silk, polyester) or monofilament (nylon, polypropylene) materi-
loop. als. All were nonabsorbable sutures. Braided sutures were used in
Finally, as a suture line is being constructed, continuous or in- 68% of the repairs and monofilament sutures in the remaining
terrupted, it is subjected to tension. This is probably greatest as cases. Wound infections occurred in 12 of the 175 operations in
the surgeon pulls up on the two strands and ties the knot. 36 This
now remains as chronic tension on which additional acute loads
may be applied, such as those resulting from coughing, from ab- CONTROL
dominal distention, or from a Valsalva maneuver associated with
heavy lifting. Experimental studies of chronically loaded poly-
propylene sutures demonstrate that the filaments undergo grad- 400
ual viscoplastic creep to greater length. Sutures subjected to heavy y = 0.6296 x + 255.33
chronic loads tend to break at lower than usual acute loads within E 375
r = 0.9565
~
48 hours of loading. 54 IT they do not break in the first 48 hours
ILl
after chronic loading, they actually increase in strength, breaking lE 350
at higher than normal acute loads (Fig. 30.6).55 This suggests that e
CI
slow, gradual viscoplastic extension (creep) causes increased ori- ~ 325
entation of the crystals in the core of the suture. Whatever the ~II::
mechanism, this increased resistance to breaking after chronic III 300
loading suggests that, if a polypropylene suture does not break 5 275
soon after surgery, it will remain intact and actually will gain in ~
strength during the postoperative period.
250
0 50 75 100 125 150 175
Sutures and Wound Infections CHRONIC LOAD (gm)
FIGURE 30.6. Acute force required to break polypropylene sutures after

Certain sutures seem to be associated with increased risk of in- they have been loaded chronically. Chronic loading increases the strength
fection. Cahill and co-workers56 compared two monofilament su- of the suture in response to subsequently applied acute forces. (Redrawn
tures with PTFE in performing hernia repairs. These included from Dobrin and Mrkvicka. 55 )
242 P.B. Dobrin
which braided sutures were used (6.8%) but in only 1 of the 81 wound infections (16% versus 7%) when the fascia had been
operations in which monofilament sutures were used (1.2%). This closed with multifilament sutures. This difference was statistically
difference was highly significant (p < .01). These findings are sup- significant (p < .05). Figure 30.7 illustrates the surface structure
ported by experimental work by Bucknall,58 who compared of various monofilament and multifilament sutures.
monofilament sutures with multifilament nonabsorbable sutures It should be emphasized that the presence of any suture, a for-
in infected wounds in rats. Electron microscopy detected bacteria eign body, compromises the host's ability to cope with infection.
in the interstices of the infected multifilament sutures. These find- Patterson-Brown and co-workers 64 compared the incidences of in-
ings are supported by several clinical and experimental studies that fection in inoculated pouches in guinea pigs in the presence of
show that braided and naturally occurring material such as silk, as different suture materials. The pouches were inoculated with Es-
well as nonbraided catgut, have higher rates of infection than cherichia coli and Bacteroides fragilis. The following proportions of
monofilament sutures. 59-62 pouches were infected: polypropylene, 52%; polyglactin 910, 53%;
Osther and co-workers63 studied fascial closures in 204 consec- polyglycolic acid, 41 %; PTFE, 51 %; polydioxanone, 52%; no su-
utive patients with suspected wound healing problems with ture present, 26%. It is evident that the presence of suture mate-
monofilament polyglyconate or multifilament polyglycolic acid su- rial doubled the risk of infection. Following his experimental
tures. These investigators found more than twice the incidence of studies, Bucknell58 recommended using a synthetic monofilament
A B c
o E F
G H
FIGURE 30.7. Different suture materials. Absorbable: (A) Chronic catgut ester (2/0 Mersilene) . (Reprinted from Chu CC, von Fraunhofer JA,
(2/0 surgical gut). (B) Dexon. (C) Monocryl®. Nonabsorbable monofila- Greisler HP. Wound closure biomaterials and devices. Boca Raton: CRC Press;
ment: (D) ePTFE (Gore-Tex®). (E) 2/0 Prolene. (F) Nylon (2/0 Ethilon®). 1997;67-68, with permission.)
Nonabsorbable multifilament: (G) Silk. (H) Nylar (2/0 Nurolon). (I) Poly-
nonabsorbable suture for operating in an infected field. Poly- nylon sutures. When the suture/incision length ratio was greater
propylene wound be such a candidate. Often one can use a poly- than 4:1, there was a 9.0% incidence of incisional hernia. When
glycolic acid or polyglactin mesh with absorbable sutures for the suture/incision ratio was less than 4:1, however, there was a
infected fields that must be closed to retain abdominal contents. 65 21.5% incidence of incisional hernia. Thus, using a sufficient su-
Most patients will develop new incisional hernias as the mesh de- ture length avoids the need for excessive tightening of the suture
grades, but, once the infection is controlled and the field is clean, and should prevent the "cheese knife" effect of the suture on the
the fascia may be closed with polypropylene mesh and polypropyl- native materials. With prosthetic repairs, the bilaminar prosthesis
ene sutures. described by Bendavid77 should avoid cutting of the ePTFE. Of
course, another way to avoid this complication is to use an ab-
sorbable suture, but this makes little sense in the presence of a
patch composed of foreign material.
Suture Granulomas of
the Urinary Bladder
An unusual delayed complication of sutures for herniorrhaphy is Conclusions
the development of a paravesical suture granuloma66-68 or a su-
ture granuloma of the bladder. 69 •7o These present clinically and Review of published evidence suggests that surgeons may use ab-
histologically as a chronically inflamed pseudo tumor. Most often sorbable as well as nonabsorbable sutures, the use of one having
suture granulomas develop around a nonabsorbable suture, usu- little advantage over the other. Similarly, surgeons may use con-
ally silk. Surgical excision reveals a mass with chronic inflamma- tinuous as well as interrupted sutures, again with little demonstra-
tion and giant cells. In some cases, the mass may be mistaken for ble advantage on either side. Monofilament sutures are preferable
a rhabdomyosarcoma because it is covered with normal urothe- to braided or multifilament sutures to reduce the risk of infection.
Hum. 67 In one case, a boy had undergone herniorrhaphy at 8 Based on the rate of wound healing and the rate of degradation
months of age. At 2 years of age, he presented with an umbilical of absorbable sutures, it would seem wise to use a nonabsorbable
fistula running between the umbilicus and the herniorrhaphy site. suture, especially if the repair will be under continued tension.
Excision of the fistula revealed inflammation surrounding the silk With all of these considerations, it seems that polypropylene ful-
suture. 71 Silk, a braided, naturally occurring protein, seems to be fills most or all of these requirements. The foreign body repre-
especially predisposed to the formation of suture granulomas. In sented by the suture may be considered negligible in light of the
a study of abdominal incisions, Kronborg72 found suture granu- large amount of foreign material present in mesh and ePTFE
lomas 12 times more frequently with silk sutures (12/163) than patches. The suture material used should match the mesh or patch,
with polyglycolic acid sutures (1/163). This difference was statis- so polypropylene should be used for polypropylene meshes, but
tically significant. Clearly, suture granulomas of the bladder and PTFE suture should be used for ePTFE patches. All sutures, espe-
paravesical area would be less likely if one avoided silk sutures and cially polypropylene, should be handled with care to avoid injuries
used an absorbable or synthetic monofilament suture instead. to suture surfaces.
Buttonhole Incisional Hernia References

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244 P.B. Dobrin
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granuloma resembling bladder carcinoma on CT scanning. Br] Ra- 77. Bendavid R Composite mesh (polypropylene-e-PTFE) in the intra-
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609-611. Surg. 1944;81:1606-1608.
31
Use of Fibrin Glues in the Surgical
Treatment of Incisional Hernias
J.P. Chevrel and A.M. Rath
In the 1900s the advantages of the adhesive properties of fibrin Fibrin Glue Composition
were investigated in the form of a blood clot applied to a wound
for hemostasis and adhesion. l An autologous plasma glue, rich in
Fibrin sealant has been used clinically in many surgical applica-
fibrinogen and thrombin, was used in 1940 for nerve anastomo-
tions, although a Food and Drug Administration approved com-
sis. 2 The fibrinogen was not sufficiently concentrated, however,
mercially available product does not yet exist in the United States. 9
and normal fibrinolysis destroyed the glue. It was only in 1972, in
Two fibrin glues commercially available in France (Tissucol®, Im-
Vienna, that Matras et al. 3 used a very concentrated cryoprecipi-
muno; and Biocol®, Laboratoire Franc;:ais de Fractionnement et
tated fibrin glue for nerve anastomosis in an animal model and in
Technologie) are bi-compound biological products. The first com-
humans. Its safety and effectiveness made it attractive for a wide
pound consists of a solution of highly concentrated fibrinogen, fi-
variety of surgical indications, and new generations of fibrin
bronectin, and Factor XIII. The second compound is composed
sealants quickly developed in response to these demands.
of thrombin and, for Biocol, calcium chloride. To reconstitute the
lyophilized compound 1, a protease inhibitor, aprotinin, is used.
Compound 2 reconstitution is achieved by the use of water for
Biocol and a solution of calcium chloride for Tissucol. All the con-
Why Does Fibrin Glue Improve stituents are of human origin except aprotinin, which is bovine
Wound Healing? (Table 31.1).
To obtain the fibrin glue, the two compounds must be mixed
In normal wound healing, fibrin formation is important during together. Several reactions then occur (Fig. 31.1): The thrombin
the first hours after injury and in the first stage of wound healing, transforms fibrinogen into monomers of fibrin, which make a gel-
for it constitutes the matrix into which collagen fibers will grow like aggregate; it also activates the Factor XIII to Factor XIIIa, as
to enhance wound strength. The two mechanisms that contribute calcium is present. Factor XIIIa then polymerizes the monomers
to the generation of the wound extracellular matrix are leakage of fibrin and the fibronectin. lO It has been shown that Factor
of plasma proteins, such as plasma fibronectin and fibrinogen, and XnIa catalyzes covalent link formation between the fibronectin of
synthesis of variants of fibronectin by cells in the wound vicinity. 4 the glue and the host collagen; this would explain the good ad-
It was proved that defibrinogenation delays collagen accumulation hesion of fibrin glue. l1
and strengthening in skin wounds. 5 Fibrin deposition also pre- Time for reconstitution (solubility) depends mainly on the tem-
cedes new blood vessel formation. It was demonstrated that fibrin perature. For Tissucol it was found to be 19 minutes at 37°C, but
gels themselves can induce an angiogenic response, even in the it can be shortened by the use of a heating mixer to 7 minutes.
absence of platelets, which normally produce a growth factor in- Addition of electrolytes, NaCI for example, can significantly
ducing angiogenesis. 6 shorten this reconstitution time, but at the cost of seriously com-
Fibrin acts as a scaffold for migrating fibroblasts. Fibrin and its promising fibrin polymerization and cellular vitality. In fact, the
degradation products are chemotactic for leukocytes, macro- strong ionization of such a product suppresses fibroblast prolifer-
phages, and circulating monocytes. Platelets and fibrin initiate the ation. 12,13
healing process and ensure its continuity by attracting cells that Time to coagulation depends on the thrombin concentration.
produce angiogenic growth factors. 7 The fibrinogen concentra- Tissucol and Biocol have comparable thrombin concentrations, 500
tion in fibrin glues seems to playa role in fibroblast migration and and 670 IU/ml, respectively. Adhesion occurs within 20 seconds.
angiogenesis. Pandit et al. s showed that a fibrinogen concentra- Fibrin glue is resorbed completely, mainly by proteolysis, but fi-
tion of 60 mg/ml significantly increases the volume fraction offi- brinolytic activity depends on the type of tissue glued and is highly
broblasts and the number of blood vessels in fibrin glue-treated variable. Aprotinin inhibits such degradation and one can prolong
rabbit ear ulcers. the action of the glue by increasing its aprotinin content. Optimal

31. Fibrin Glues in the Surgical Treatment of Incisional Hernias 247
TABLE 31.1. Composition of biological glues for 1 ml of fibrin glue whereas 3000 KIU /ml is a sufficient concentration for current uses
of fibrin glues. The persistence of fibrin aggregates may lead to
Biocol® Tissucol®
local inflammatory reactions.
Lyophilisate 1 As far as cytocompatibility is concerned, these physiological fi-
Fibrinogen 127 mg 75/115 mg brin sealants are well tolerated and do not impair the healing
Fibronectin 11 mg 2/9mg process. The addition of salts to speed reconstitution is cytotoxic,
Factor XIII 19 IV 10/50 IV for it increases osmolarity and conductivity, avoiding fibroblast pro-
Lyophilisate 2 liferation.
Thrombin 670 IV/ml 500 IV/ml Biocol and Tissucol are human plasma and bovine serum de-
CaCl2 Bmg
rivatives. Safety controls must handle two different problems: vi-
Reconstitution solution of
ral disease transmission and bovine spongiform encephalopathy
lyophilisate 1
Aprotinin 10,000 KID/ml 3000 KID/ml (BSE) transmission. Biocol is manufactured from plasma derived
Reconstitution solution of from French blood transfusion centers, whereas Tissucol uses
lyophilisate 2 plasma coming exclusively from officially licensed plasmaphoresis
Water CaCl2 40 mmol centers in central Europe. Both products are carefully screened at
different stages in their preparation.I 5
KID, kallidogenose inactivation units. Biocol is tested for hepatitis B surface antigen, anti-hepatitis B
core antibody for hepatitis B, antivirus antibody for hepatitis C,
anti-human immunodeficiency virus (HIV)-1 and HIV-2 antibod-
aprotinin concentration is difficult to estimate for a particular tis- ies for HIV, anti-human T-celllymphotropic virus (HTLV)-1 and
sue. Ideally, the fibrinolysis resistance of the glue should last long HTLV-2 antibodies, alanine aminotransferase level, and syphilis.
enough to prevent early separation but wear off by the time the Furthermore, during the manufacturing process, a specific viral
wound healing process has taken over that task. In practice, it is inactivation stage is introduced in which a solvent detergent
considered that 3000 kallidogenose inactivation units (KIU)/ml procedure destroys the envelope of the viruses (HIV, canine her-
of aprotinin is correct. lO Tissucol has this concentration, whereas pes virus, HBV, cytomegalovirus, and EBV); the product is pas-
Biocol has 10,000 KIU /1. teurized at 60°C for 10 hours and then incubated at 37°C for 22
hours at pH 4 in the presence of pepsin, which accelerates the
process of viral inactivation.
Quality Criteria Purification procedures and testing for the absence of viral
markers in the finished products complete this battery of precau-
A biological glue must satisfy the criteria of efficacy, biocompati- tions. The manufacture of Biocol has received approval from the
bility, safety, and ease of utilization. Efficacy is evaluated by mea- Institut Pasteur and from the New York Blood Center.
suring fibrin clot tensile strength and adhesive power after For Tissucol, the selection of donors is equally strict. The search
coagulation of the compounds. Ten minutes after application, the for viral contamination uses the same tests and, in addition, since
fibrin glue clot reaches the tensile strength of 1200 g/cm 2. Its ad- January 1996, the polymerase chain reaction (PCR) , which is a ge-
hesive power is 214 g/cm2.I 4 Time to coagulation is 20 seconds. netic amplification technique allowing early screening of the
Tissucol also exists as a "slow glue," which sets in 1.5 to 2 minutes, viruses for hepatitides B, C, and D, HIV, papilloma virus, herpes-
at a thrombin level of 4 IU/ml. virus, and HTVL, particularly during the incubation period. These
Stability of the fibrin clot depends on aprotinin concentration. tests are carried out at the time the sample is obtained and then
Biocol has three times more aprotinin than Tissucol: 10,000 repeated on the donor on the 90th day. During manufacture, vi-
KIU/ml, which is only necessary in a urokinase-rich milieu, ral thermoinactivation is carried out by steam heat for 10 hours.
component 2
Component 1 I Thrombin Ca++
Fibrinogen Aggregated Fibrin Soluble

fibrin r-----: reticulated degradation
monomers + products
fibronectin
Factor XlII FXIII'- Factor XIIIa
Fibronectin r
Aprotinin
Plasminogen Plasmin
i
FIGURE 31.1. Reactions and mechanisms after fibrin Tissular plasminogen
glue application. (Modified from Seelich.I°) activators
248 J.P. Chevrel and A.M. Rath
A new problem may have arisen with the recognition of the risk
of transmission of BSE to humans. The aprotinin in these fibrin
glues is of bovine origin. It is at present made in Germany (Hoechst-
Behring for Biocol, Bayer and Pentapharm for Tissucol) from
bovine lungs from countries deemed free of BSE (Argentina,
Uruguay). In the absence of any known case of BSE in these coun-
tries, the risk seems to be nil. Bovine lungs are considered by the
World Health Organization to be only weakly infectious, and the
methods of obtaining aprotinin are in agreement with the princi-
ples laid down by the European Drug Agency. The two laborato-
ries manufacturing aprotinin are at present working simultaneously
toward development of a synthetic product.
Finally, some rare cases of anaphylactic reactions to fibrin glues
have been published,I6-18 most of them due to an antibovine
thrombin reaction or to an undetected immunity problem in the
donor, in the case of a fibrin glue made from homologous fresh
FIGURE 31.2. Glue application.
frozen plasma from a patient. Manufactured glues such as Biocol
and Tissucol should not provoke such problems. Medically treated
allergy due to the aprotinin has been described 19 and is a caution
rectus sheath (Gibson, Clotteau-Premont). These incisions allow
listed in Biocol inserts.
plasty of the linea alba (Welti-Eudel, Chevrel) at the cost of weak-
Fibrin glue utilization is easy. Solubility must be achieved ther-
ening the abdominal wall at the site of the relaxing incisions over
momechanically and not by the addition of salts in the composi-
the rectus abdominis muscles. A prosthetic reinforcement is nec-
tion, as it was stated earlier. Biocol, which is cryodehydrated,
essary: An onlay mesh may be sutured in front of the abdominal
reconstitutes in 5 to 10 minutes at room temperature, whereas Tis-
wall, fixed laterally to the external oblique fascia with a nonalr
sucol needs to be heated at 37°C and is soluble in 7 to 15 min-
sorbable running suture. Spraying of fibrin glue (Fig. 31.2) over
utes. Both compounds are mixed in a mixing device before
the mesh attaches it immediately to the musculofascial surface,
spraying. One milliliter of glue covers 25 to 100 cm 2 with the
creating a new tendon of insertion of the flat muscles into the re-
adapted spraying device. The glued surfaces must be held in con-
constructed linea alba. At the end of the operation a physiologi-
tact for 2 minutes after fibrin glue application.
cally reinforced abdominal wall is thus restored.
Fibrin glues can be used to eliminate dead space that may lead
Why Use Fibrin Glues in to seroma formation and/or infection. Fibrin glue is also a he-
mostatic agent. Its properties as a wound healing accelerator make
Incisional Hernia Repair? it suitable for complete prosthesis fixation in the repair of lateral
or parastomal hernias.
The main principle of incisional hernia repair is to re-establish a
physiological abdominal wall in order to restore its respiratory and
postural functions. In other words, it is mandatory to reconstruct Results of Fibrin Glue Fixation of a
the linea alba into which the flat muscles insert through the rec-
tus sheath. When this insertion is lost, as is the case in midline in-
Reinforcement Prosthesis for
cisional hernias, flat muscles retract, become sagittate, and tend Incisional Hernia Repair
to enlarge the hernial orifice. A vicious circle is created, modify-
ing the physiological mechanisms in which abdominal wall is in- From June 1979 to June 1998, 422 incisional hernias were oper-
volved: respiratory mechanics (paradoxical respiration, studied by ated on in the Department of General Surgery of the Avicenne
Rives et al.20 ), posture (lumbar lordosis), abdominal cavity in- Hospital, Bobigny, France. At the beginning of the experience,
tegrity (abdominal organ protrusion), and skin integrity (trophic 153 patients underwent rhaphy or plasty without a prosthesis, and
alterations of the skin over the hernia). 273 patients had a plasty reinforced by an onlay mesh. In 143 of
In the case of large incisional hernias, closure of the defect can these, a spray of fibrin glue completed prosthesis fixation. Tissu-
be difficult or made only under tension. To achieve a tension-free col was employed in 72 cases and Biocol in 71. At first, 4 to 5 ml
suture, it is necessary to perform relaxing incisions in the anterior of glue was sprayed, but it was seen that this could lead to seroma
TABLE 31.2. Comparative results
Rhaphy or plasty plus Rhaphy or plasty plus

Rhaphy or plasty onlay prosthesis prosthesis and fibrin glue
(n = 153) (n = 130) (n = 143)
Morbidity 26 (16.9%) 30 (23%) 15 (10.48%)

Hematomas 8 (5.2%) 3 (2.3%) 2 (1.39%)
Seromas 5 (3.26%) 9 (6.92%) 9 (6.29%)
Sepsis 13 (8.49%) 18 (13.84%) 4 (2.79%)
Recurrence rate 42 (27.40%) 17 (13.07%) 7 (4.89%)
31. Fibrin Glues in the Surgical Treatment of Incisional Hernias 249
50 2. Seddon ~, Medawar PB. Fibrin suture of human nerves. Lancet.

1942;2:87-92.
~40
S
3. Matras H, Dinges HP, Mamoli B, Lassmann H. Non-sutured nerve
I! 30 transplantation. ] Maxillofac Surg. 1973;1:37.
:l
! 20 4. Van der Water L. Mechanisms by which fibrin and fibronectin appear
in healing wounds: implications for Peyronie's disease. ] UrnL 1997;
~ 10 157(1):306-310.
5. Brandstedt S, Olson PS. Effect of defibrinogenation on wound strength
o
rhaphy or plasty rhaphy or plasty + rhaphy or plasty +
and collagen formation. A study in the rabbit. Acta ChiT Scand. 1980;
prosthesis prosthesis + fibrin glue 146(7):483-486.
6. Dvorak HF, Harvey VS, Estrella P, Brown LF, McDonagh J, Dvorak AM.
FIGURE 31.3. Recurrence rate: comparative results. Fibrin containing gels induce angiogenesis. Implications for tumor
stroma generation and wound healing. Lab Invest. 1987;57 (6) :67~86.
7. Schlag G, Redl H, Turnher M, et al. The importance of fibrin in wound
repair. In Schlag G, Redl H (eds): Fibrin sealant in operative medicine, vol
2. Berlin: Springer; 1986;3-12.
formation. We reduced the volume to 2 ml, which is enough to 8. Pandit AS, Feldman DS, Caulfield J. In vivo wound healing response
achieve good results with significantly fewer seromas. to a modified degradable fibrin scaffold. ] Biomater AppL 1998;12(3):
It was found that patients with fibrin glue had fewer hematomas 222-236.
than the other two groups, the sepsis rate was impressively de- 9. Spotnitz WD, Falstrom JK, Rodeheaver GT. The role of sutures and
creased, and seroma formation increased with the use of a pros- fibrin sealant in wound healing. Surg Clin North Am. 1997;77(3):
thesis regardless of whether fibrin glue was used or not (Table 651-659.
10. Seelich T. Tissucol® (Immuno, Vienna): biochemistry and methods of
31.2). In the group in which fibrin glue was used, seroma forma-
application. ] Head Neck PathoL 1982;3:65-69.
tion was statistically related with the absence of suction drains: In
11. Duckert F, Nyman D, Gastpar H. Factor XIII, jilrtin and collagen. Colla-
fact, 15.8% of the patients without suction drains developed a gen platelet interaction. Stuttgart: Schattauer; 1978:391-396.
seroma, whereas only 3% of the 100 patients drained had this com- 12. Seelich T. A propos des criteres de qualite d'une colle biologique. Lyon
plication. There was no difference in morbidity between Biocol ChiT. 1988;84:259-260.
and Tissucol. 13. Schlag G, Redl H. Fibrin sealant: efficacy, quality and safety. In Wa-
Recurrence rates closely depend on the technique used. It is un- clawiczek HW (ed): Progress in fibrin sealant. Heidelberg: Springer;
acceptably high when a simple herniorrhaphy or a hernioplasty 1989:3-17.
without mesh reinforcement is used: 27% in our series. When an 14. Bagot d'Arc M. Colle de fibrine: efficacite, qualite, securite. Symposium
onlay mesh is used, recurrence rate falls to 13%. The use offibrin International "Actualitis en chirurgie des nerft pmphiriques. "Nancy, France,
November 1990.
glue dramatically improves this figure: 4.8% recurrence rate (Fig.
15. Chevrel JP, Rath AM. The use of fibrin glues in the surgical treatment
31.3). Here again, no relationship was found between recurrence
ofincisional hernias. Hernia. 1997;1(1):9-14.
rate and type of fibrin glue used. Mter reoperation, we obtained 16. Mitsuhata H, Horiguchi Y, SaitohJ. An anaphylactic reaction of topi-
good results in 98.6% of cases. cal fibrin glue. Anesthesiology. 1994;81:1074-1077.
Fibrin glue spraying seems to be a safe, easy to perform, and 17. Berguer R, Staerkel RL, Moore EE, et al. Warning: fatal reaction to
effective method to complete an onlay mesh incisional hernia the use of fibrin glue in deep hepatic wounds. Case reports. ] Trauma.
repair. 1991;31:408-411.
18. Milde LN. An anaphylactic reaction to fibrin glue. Anesth Analg.
1989;69:648-686.
19. Gandon P, RatJP, Larregue M. Allergie au Tissucol. La lettre du GERDA.
References 1988;5:1.
20. Rives], Lardennois B, Pire]C, et al. Les grandes eventrations. Impor-
1. Bergel S. Uber Wirkungen des Fibrins. Dtschr Med Wochenschr. 1909; tance du volet abdominal et des troubles respiratoires qui lui sont sec-
35:63~65. ondaires. Chirurgie. 1073;99:547-563.
32
Collagen-Based Prostheses for Hernia Repair
P.B. van Wachem, T.M. van Gulik, MJ.A. van Luyn, and Robert P. Bleichrodt
Introduction Autologous and Homologous Implants

Closure of abdominal wall defects is still a major surgical problem. Dermal Implants
The usual methods have significant disadvantages.! If the defect
is bridged by prosthetic material, nonabsorbable prostheses have In 1913, Otto Loewe was the first to report the use of autoder-
produced the best results. However, the presence of prosthetic ma- moplasty for hernia repair.5 With good results, he implanted der-
terial may lead to eventual complications due to foreign body re- mal grafts in nine patients with abdominal wall defects. Both
action, lack of fixation to the surrounding host tissues, or erosion Loewe 5 and Rehn 6 advised removal of the epidermal layer and
of the viscera and overlying skin. Moreover, synthetic meshes re- the subcutaneous fat to prevent infection and cyst formation.
quire skin cover, are prone to infection, and cannot be used in a However, the method was not widely accepted because removal
contaminated environment. 2 of the epidermal layer was difficult and time consuming. In
Reconstructions with autologous material such as free dermal, Russia, the method became popular after Janov7 perfected a
fascial, or musculofascial flaps are also unsatisfactory. Transplant method of removing the epidermal layer while sparing the pap-
harvesting is time consuming and frequently followed by func- illary layer. His method involved submersion of the skin graft
tional deficits at the donor site. The results of such reconstruc- in boiling normal saline. 7,8 Whether the epidermis needs to be
tions are often disappointing because of bulging of denervated removed remains controversial because good results have also
muscles and reherniation rates of up to 20%.! been reported from implantation of unprocessed skin under
Ideally, prosthetic material acts as a scaffold for the ingrowth of tension. 9- 11
fibrocollagenous tissue and supports the abdominal wall or di- Mter implantation, the dermis is incorporated in the fibrocol-
aphragm until the newly formed host tissue can resist intraab- lagenous tissue of the host, as shown in experimental studies.!2-14
dominal pressure. The use of a collagen prosthetic mesh for hernia In the first days after implantation, fibrin is deposited on the skin
repair is based on this concept. graft, followed by infiltration by granulocytes and macrophages.
Collagen is the m.yor supportive component of connective tis- With the formation of granulation tissue, capillaries infiltrate the
sue and constitutes about 30% of the total body protein in mam- graft within 3 to 4 days. Mter 14 days, the graft is fully vascular-
mals. Existing as stress-resisting fibers with a characteristic ized. The new vessels are the center of tissue repair, with outgrowth
structural organization, collagen imparts strength to skin, fascia, of fibroblasts and formation of collagen. Within 2 months, the
dura, bone, tendon, ligaments, and the gut wal1. 3 For application graft is transformed into a cell-rich fibrocollagenous tissue. If the
as prosthetic devices, collagen is available as a reconstituted prod- graft is implanted under tension, hair follicles and sebaceous
uct or, in its naturally occurring form, as a fibrous collagen ma- glands disappear within 6 days.!3
trix. Reconstituted collagen is manufactured from solubilized In clinical practice, several techniques of autodermoplasty have
collagen, usually from animal skins, reconstituted into filaments, been applied in hernia repair. The graft can be a strip that is
sheets, tapes, sponges, or tubing. 4 The advantage of reconstituted threaded through the fascia like a shoelace, supporting its primary
collagen is that it consists of highly purified collagen that can be closure. 6,9,15 The material may be implanted as an underlay, inlay,
molded into any shape, but major disadvantages are its low phys- or onlay graft. Encouraging results of autodermoplasty were found
ical strength and its relatively poor resistance to biodegradation. in observational studies. Korenkov et al.I 4 reviewed three studies
Fibrous collagen is available as fascia, dura mater, and dermis, pro- involving 160 patients in whom hernias were repaired with autol-
viding a naturally woven, biological fabric. Because fibrous colla- ogous full-thickness skin grafts and three studies involving 458 pa-
gen retains its structural integrity, it maintains its original tients in whom corium grafts were used. The reherniation rates
stress-resisting mechanical properties. Clearly, as a prosthetic were 3.2 to 12% and 0 to 7.6%, respectively, after a follow-up of 2
device for the repair of hernia, fibrous collagen is the preferable to 5 years. However, bulging of the abdominal wall was a common
material. finding.

32. Collagen-Based Prostheses for Hernia Repair 251
Fascial Implants Human Dura Mater

The theoretical advantages of autologous fascial grafts com- Human dura mater has been used in surgery since 195529 and for
pared with nonbiological substitutes are that they are easily ac- hernia repair since 1958. 30 Since then, human dura mater has
cepted by the host and incorporated into the fibrocollagenous been used with success in the reconstruction of abdominal wall
tissue without eliciting a foreign body response and that fascia hernias, congenital abdominal wall defects, and diaphragmatic
induces collagen synthesis and remodeling of fibrocollagenous hernias.
tissue. The dura mater is a strong structure that contains several layers
The most frequently used graft is fascia lata. This is a strong and of dense fibrocollagenous tissue. In each layer the collagen fibers
versatile graft of dense fibrocollagenous tissue, strong enough to run parallel, but the collagen fibers in the different layers cross
resist intraabdominal pressure. The collagen fibers are ideally ori- each other, forming a strong and elastic structure with an average
ented and woven to resist longitudinal slipping of fibers and fi- breaking strength of 4.2 N/m2.30
brils and are molecularly organized to ensure maximum inter- and Freeze drying (lyophilization) and chemical dehydration are the
intramolecular cross-linking. 16 Initially, fascia lata strips were used most frequently used methods to process dura mater. Preparation
as living sutures. 17,18 Kirschner introduced the use of fascia lata as of freeze-dried dura mater allografts has been described in detail
a sheet to bridge fascial defects.I 9 by Jarrel et al. 31 In brief, dura mater is removed within 24 hours
From experimental and clinical studies it is known that fascial from selected human cadavers. Mter being tailored, washed, and
grafts remain viable after implantation. The grafts are revascular- sterilized in ethylene oxide, the grafts are freeze dried, sealed in
ized, as shown angiographically in experimental studies. 20 ,21 More- sterile glass containers under vacuum, and stored at room tem-
over, Gallie and Le Mesurier18 found that the fascial implants were perature. Dehydration by organic solvents followed by gamma-ir-
enveloped in newly formed vascular tissue within 3 weeks. Several radiation is another frequently used method to preserve dura
case reports and experimental studies confirmed these observa- mater. Processing destroys and removes all cells and noncollagen
tions. 21 - 24 proteins, thus diminishing immunogenicity. Both methods pre-
In contrast to scar tissue, which responds to physical stress by serve the collagen fibers in their natural multidirectional pattern,
becoming thin and elongated, fascia lata retains its shape, with although gamma-irradiation is known to interact with cross-links.
parallel orientation of fibrils as seen on electron micrography.16 Concern exists about the transmission of human immunodefi-
The anchorage of fascia lata to the adjacent myoaponeurotic tis- ciency virus and viral hepatitis. A review of 664 dura mater allo-
sues around the edges of the defect has proved to be better than graft implantations by surgeons throughout the United States
that of synthetic prostheses, while the tensile strength of the grafts found no documented cases of infection among implant recipi-
remains constant for 1 year after implantation. 25 Stimulation of ents. 32 Since then, four cases have been documented of iatrogenic
synthesis and net deposition of collagen is another advantage of Creutzfeldt:Jakob disease acquired after implantation of lyoph-
fascial grafts. 16 ilized dura mater grafts, all of which originated in one German
In clinical practice, free fascia lata grafts are used for the repair firm.33-36 No cases ofCreutzfeldt:Jakob disease have been reported
of abdominal hernias and abdominal wall defects. In many re- from grafts from authorized banks in the United States, probably
ported series, the grafts were used for reconstruction in a contam- as a result of strict selection criteria and screening of donors, sero-
inated or infected environment. logical testing, postmortem examinations, bacteriological surveil-
In earlier reports, reherniation rates of 6 to 15% were found af- lance, and specialized treatment to inactivate viruses and the
ter hernia repair with fascia lata. 26,27 Peacock16 used free fascia lata Creutzfeldt:Jakob disease agent. 37,38
as onlay grafts after primary closure of ventral hernias to reinforce Pesch and Stoss39 implanted solvent dehydrated, gamma-irradi-
the myoaponeurotic wall and to stimulate the synthesis of colla- ated human dura grafts in abdominal wall defects in rats. In the
gen. He found reherniation in only 1 of the 17 patients after a fol- first week after implantation, an inflammatory response was found.
low-up of 2 to 5 years. Recently, two larger series of patients with Within 3 hours the graft was infiltrated by granulocytes, which dis-
ventral hernias repaired with free fascia lata grafts were re- appeared within 1 week. Macrophages started to infiltrate the graft
ported. 21 ,28 Williams et al. 28 reconstructed 12 ventral hernias, of after 36 hours, and their number increased tremendously in the
which 7 were done in a contaminated field. Postoperative com- following days, accompanied by degradation of collagen fibers.
plications included two cases of soft tissue dehiscence (intact fas- Granulation tissue was formed around the patch, and capillaries
cia), two patients with graft breakdown, and one patient with a and fibroblasts infiltrated it from the outside to the center, slowly
recurrent bowel fistula. Reherniation occurred in 1 of the 12 pa- replacing the graft with fibrocollagenous tissue. Mter 1 year a layer
tients. The fate of the patients with graft breakdown and recur- of fibrocollagenous tissue replaced the graft. Similar observations
rent fistula is not mentioned. were made by Wojtyczka. 40 Mechanical investigations demon-
Disa et al. 21 performed abdominal wall reconstructions with strated a 75% reduction of the tensile strength until the 12th week
autologous fascia lata in 32 patients of which 30 were performed and a slight increase afterward. Mter 30 weeks, bulging of the ab-
in a contaminated field. Postoperative local abdominal wall com- dominal wall was a common finding.
plications included cellulitis in three, seroma in two, and skin Dura mater has been successfully used for repair of abdominal
dehiscence with exposed fascia grafts in seven patients. In five wall defects and diaphragmatic hernias in children. The short-term
of the seven patients with a wound dehiscence, the wound results of repair of congenital abdominal wall defects are remark-
healed by secondary intention; in two patients the graft was cov- ably good.4l-44 However, in corroboration of experimental stud-
ered with a split skin graft. Donor site complications occurred ies, reherniation and bulging of the abdominal wall are frequently
in 12 to 18% of the reported series; no cases of knee instability mentioned complications in the long term. In a series of Klein et
were found. al.,43 secondary abdominal wall reconstructions were required in
252 P.B. van Wachem et al.
56% of the patients after reconstruction of a congenital defect Klopper.54 Sheepskin was used because it has a remarkable struc-
with dura mater. ture, featuring a loose and essentially porous dermal architecture.
Several reports have been published about the usefulness of hu- The dermal fiber bundles (Fig. 32.1A) interweave at a low angle,
man dura mater for the repair of abdominal hernias in adults un- combining flexibility and extensibility with high tensile strength. 50
der clean and contaminated circumstances. During pre tanning processes, all the cellular and nonfibrous com-
ponents of the skin are removed by treatment with a lime-sodium
sulfide solution and proteolytic enzymes. The skin is subsequently
Heterologous Implants split in a horizontal plane to separate the papillary layer, contain-
ing most appendages, from the regularly woven dermal layer. The
To overcome the drawbacks of autologous grafts, interest has fo- latter layer is then tanned, that is, cross-linked with a glutaralde-
cused on the modification of allogeneic and xenogeneic fibrous hyde (G) solution, after which the collagen mesh, now referred
collagenous tissues as potential commercially available devices. to as GDSC, is allowed to dry. The resulting GDSC patches are
Commercially available examples of these devices are the above- eventually sterilized by gamma-irradiation (2.5 Mrad). The degree
mentioned allografts and dermal and skin xenografts. 45 ,46 In many of cross-linking can be gauged by determination of the shrinkage
of these devices, the cellular components have been eliminated to temperature. 55,56
reduce the immunogenic potential of the collagen bioimplant. In a series of experiments in the rat, the host tissue response
Collagen by itself has low immunogenicity, and this is further re- and the fate of GDSC grafts were studied. GDSC patches were im-
duced during the modification processes to which it is subjected. 47 planted subcutaneously as an onlay graft in rats with ventral her-
nia. 54 The patches elicited a foreign body type of tissue reaction,
Dermal Grafts which gradually decreased over time. Although subject to absorp-
tion, the GDSC grafts persisted for more than 36 weeks after im-
Approximately 40% of the total collagen content of the body re- plantation. By that time, newly formed host collagen had been
sides in the dermis of the skin. 48 The dermis combines optimal deposited as layers of fibrous tissue associated with the graft. Clin-
flexibility with high physical strength in all directions due to its ical application of the GDSC grafts as a dressing for split skin graft
unique three-dimensional, fibrous architecture. A certain hierar- donor sites resulted in sound healing with no untoward effects. 57
chy in the collagen fibrous system in the dermis can be distin- In a feasibility study in humans in whom abdominal incisional
guished. Under the light microscope, dermal fiber bundles (10 to hernias too large for primary closure were repaired with GDSC
50 #Lm) can be observed that are composed of collagen fibers (2
grafts, absorption of the grafts was apparently too rapid and re-
#Lm). These fibers are formed by bundles of still thinner units, the
sulted in recurrences. Thus, although the xenogeneic GDSC grafts
fibrils (0.1 to 0.2 #Lm). The fibrils in turn are made up of bundles had theoretically provided an attractive biological material for the
of polypeptide chains termed filaments (0.01 to 0.02 #Lm).49,50 repair of hernia, the degradation and absorption rate after im-
As a device to bridge defects, as in the closure of abdominal wall
plantation were far too high to allow permanent repair. Further
defects or in hernia repair, dermal tissue would seem to provide research was focused on the cause of failure and on the develop-
an ideal biological mesh prosthesis. For use as a surgical device, ment of methods to improve collagen cross-linking techniques to
the collagen substance needs to be purified and preserved, a produce a more persistent type of dermal collagen.
process rendering the collagen protein resistant to decay. Several
methods can be applied to preserve proteinaceous substances. The
most commonly used techniques to stabilize collagen are tanning
Cytotoxicity and Biocompatibility
and lyophilization. Tanning is a time-honored process in which
To test the cytotoxicity of GDSC, a sensitive test system with hu-
animal skin, that is, animal dermal collagen, is transformed into
man fibroblasts, called the methy1cellulose (MC) cell culture,58,59
leather. The mechanism underlying the tanning process is the ar-
was developed. The test can be used as an indirect system for ma-
tificial introduction of intermolecular cross-links within the colla-
terials testing for up to 7 days without the culture medium need-
gen matrix. 51 For implantation purposes, collagen is usually
ing to be refreshed, thus without running the risk of removing
cross-linked by treatment with aldehydes, such as formaldehyde or
possible toxic leachables or compounds. With this method, GDSC
glutaraldehyde.52
was found to induce a cell growth inhibition of approximately 77%
A common feature of collagenous implants is that they are
(Fig. 32.1B). Both primary (leachables) and secondary (enzymat-
liable to degradation and absorption by the host. This process in-
ically released) cytotoxic compounds originating from the graft
volves an inflammatory response, subsequent enzymatic degrada-
were found to be responsible for cell growth inhibition. 60 ,61
tion, and gradual absorption by phagocytosing macrophages. The
Biocompatibility was studied in a subcutaneous rat model. The
sequence of events leading to absorption of a collagen device is
results confirmed the in vitro results. GDSC showed increased in-
quite similar to the chronic inflammatory reaction observed in re-
filtration of polymorphonuclear neutrophils with extensive intra-
lation with foreign bodies. 53 Collagen can be to some extent ren-
cellular lipid formation, cell degeneration, and death. 62 The grafts
dered resistant to degradation and absorption by cross-linking the
were degraded by giant cells within 15 weeks.
collagen molecules. The higher the degree of cross-linking, the
more persistent the collagen device will be after implantation. 54
Cross-Link Modifications
Cross-Linked Dermal Sheep Collagen and Tissue Engineering
The application of a purified dermal sheep collagen (DSC) graft To reduce cytotoxicity and improve biocompatibility, processing of
as an abdominal wall substitute was examined by Van Gulik and GDSC was modified in three ways. First, cross-linking procedures
A B
c D
FIGURE 32.1. (A) Scanning electron micrograph (X 140), showing that DSC distribution in between DSC collagen (C) bundles at 4 hours after seed-
matrices consist of thinner and thicker collagen bundles. (B) Light mi- ing. (D) Light micrograph (XI000), showing one myotube (M) with two
crographs (X625). (Top) Cell proliferation of the control at day 7 in MC nuclei adhering to a collagen (C) bundle at day 7 after seeding. (C and
cell culture. Spread cells are present in mono and double layer. (Bottom) D reprinted from van Wachem et al. 68 ©1996 John Wiley & Sons, Inc., with
Cell growth inhibition and deviant cell morphologies during culture in permission.)
the presence ofGDSC. (C) Light micrograph (X400), showing a good cell
with glutaraldehyde were modified63 to bring about a significant trinsic cross-links (that is, within collagen fibrils). Ethyleneoxide
increase in shrinkage temperature. Second, a switch was made to sterilization further increased the resistance of the grafts.
sterilization with ethylene oxide because gamma-irradiation was These modifications dramatically reduced cytotoxicity. The in
known to interact with cross-links. Third, new cross-linking agents vitro growth inhibitions of modified GDSC, HDSC, and CDSC were
such as hexamethylenediisocyanate (H) and carbodiimide (C) 15%, 10%, and 0%, respectively.68
were examined. 65 ,56 The resulting DSCs are further referred to as In vivo, only modified GDSC showed a slight tissue incompati-
HDSC and CDSC. Mechanical properties of modified GDSC, bility. In contrast to HDSC and CDSC, modified GDSC showed ex-
HDSC, and CDSC were examined during in vitro degradation. 67 tensive calcifications, accompanied by less ingrowth of giant cells
Carbodiimide cross-linking resulted in the highest shrinkage tem- and fibroblasts and poor formation of rat collagen in between the
perature when used in combination with an activator of carboxyl modified GDSC bundles. 68 ,69 HDSC was found to induce forma-
groups.65 Probably this is related to an increased formation of in- tion of rat collagen in between the DSC bundles. Both modified
A B
FIGURE 32.2. (A) Macrograph of a large defect of oval form (2 by 4 cm) implant (i = CDSC), muscle cells (arrows) are sprouting in the fibrous tis-
in the abdominal wall of a rat. It was repaired with RDSC and sutured with sue, which also contains many blood vessels (V) . The sprouting is limited
Maxon®. (8) Macrograph of a herniation as observed by bulging of the to a first rim. Muscle cells were never found to grow spontaneously into
belly (arrow) at 5 weeks after implantation ofRDSC. (C) One of the CDSC- the implant, which had induced a foreign body reaction with giant cells
implanted rats at week 20 after implantation. The shaved belly of the anes- and fibrous tissue. (See color insert). (Reprinted from van Wachem e t al.71
thetized rat (arrow) showed no herniation. (D) Light micrograph (X63) ©1994 Wichtig Editore, with permission.)
showing growth of muscle tissue at week 5. At the anchorage site with the
A B
FIGURE 32.3. (A) Micrograph (XlOO), showing the seeded CDSC disc at one is longitudinally (L) sectioned; the latter shows the typical striation,
week 3. Locally, at the edge of the implant (i), a specific immune reaction which was not found inside the implant even myoblast seeded. (See color
with lymphocyte (L) accumulation is observed. (8) Micrograph (XIOO), insert). (Reprinted from van Wachem e t al. 73 ©1999 Elsevier Science Ltd.,
showing the nonseeded control disc with an overview of the implant (i) with permission.)
and overlapping muscle. Most muscle fibers are cross sectioned (M), and
CDSC and HDSC degraded within 15 weeks. CDSC degraded at a about long-term results is lacking, it is impossible to draw conclu-
much slower rate and showed formation of rat collagen and vas- sions about the ultimate usefulness of dura mater for abdominal
cular sprouting, which made it the optimal rat collagen scaffold wall repair.
compared with modified CDSC and HDSC.68 Degradation of the Cross-linked dermal sheep collagen has been tested only in ex-
patches resulted in reherniation 70 ,71 (Fig. 32.2A). In addition, experimental animals. With tissue engineering, the material seems
tensive adhesion formation between the patch and bowel was promising.
found. At present, the application of autologous, homologous, and het-
To prevent adhesion formation, we modified the HDSC patch erologous collagen-based prosthetic devices in hernia repair is not
by plasma polymerization with polytetrafluoroethylene. This re- recommended. In the long term, degradation of the patches may
sulted in a patch with a hydrophobic (TFE) and a hdyrophilic result in reherniation. The feasibility of collagen-based prostheses
side. The patches were used to repair full-thickness abdominal for induction and stimulation of collagen synthesis and muscle re-
wall defects in rats, with the TFE-plasma polymerized side of the pair to reduce reherniation rate in primary repair depends on fur-
patch facing the intraabdominal viscera. During a follow-up of ther research.
6 weeks, the TFE-HDSC ~showed fewer bowel adhesions, fewer
herniations, and delayed degradation than the control HDSC.70
However, degradation proceeded rapidly. Mter 4 and 6 weeks, References
HDSC implants were about half their original thickness, which
resulted in reherniation or bulging of the abdominal wall (Fig. 1. Simmermacher RKj, Bleichrodt RP, Schakenraad JM. Review: bio-
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With CDSC, the degradation time could be increased to at least 290.
20 weeks (Fig. 32.2C). CDSC promoted new collagen formation 2. Bleichrodt RP, Simmermacher RK, van der Lei B, et al. Expanded poly-
and functioned as guidance for a small rim of muscle overgrowth. tetrafluoroethylene patch versus polypropylene mesh for the repair of
However, muscle cells did not grow into the DSC matrix (Fig. contaminated defects of the abdominal wall. Surg Gynecol Obstet. 1993;
32.2D; see color insert). 176(1):18-24.
3. Nimni ME, Harkness RD. Molecular structure and functions of colla-
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8. Kranich H. Behandlung grosser Narben- und Bauchwandhernien mit
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bulging of the abdominal wall. 722-727.
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18. Gallie WE, Le Mesurier AB. Living sutures in the treatment of hernia.
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Can Med Assoc) 1923;13:469.
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strong, which makes them a good substitute for the myoaponeu- 20. Pau HW. Revascularization offascia after tympano-plastic grafts: a study
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256 P.B. van Wachem et al.
21. Disa jJ, Klein MH, Goldberg NH. Advantages of autologous fascia ver- the use of lyophilized dura mater for abdominal wall closure in chil-
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Plast Reconstr Surg. 1984;74:465-475. Exp Patho! 1972;53:540--549.
23. Orlando F, Weiss JS, Beyer-Machule CK, et al. Histopathological con- 46. ShuckJM. The use of heteroplastic grafts. Burns. 1975;2:47.
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26. HamiltonJE. Free mattressed fascia lata patches in the repair oflarge skin splits, as viewed in conjunction with various histological and mi-
abdominal incisional hernias. Am Surg. 1956;22:217-221. croscopic techniques.] Soc Leather Technologists Chemists. 1987;71:7-9.
27. Hamilton JE. The repair of large or difficult hernias with mattressed 51. Heidemann E. The current state of collagen chemistry in relation to
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85-90. proteins: scientific, industrial and medical aspects. London: Academic Press;
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101(3):713-718. sorption: effect of glutaraldehyde concentration. Artif Organs. 1990;
29. Sewell WH, Koth DR, Pate jW, et al. The present status of our exper- 14:443-448.
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30. Noort R van, Black MM, Martin TRP, et al. A study of the uniaxial me- 54. Van Gulik TM, Klopper PJ. The processing of sheepskin for use as a
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31. Jarrel MA, Malinin n, Averette HE, Girtanneer RE, et al. Human dura splits as determined by an experimental method. ] Soc Leather Tech-
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32. Prolo DJ. Use of transplantable tissue in neurosurgery. Clin Neurosurg. mechanical properties of gamma-irradiated sheepskin splits. ] Soc
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33. Miyashita K, Inuzuka T, Kondo H, et al. Creutzfeldt:Jakob disease in a 57. Van Gulik TM, Christiano RA, Broekhuizen AH, et al. A tanned sheep
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37. Marx RE, Carlson ER: Creutzfeldt:Jakob disease from allogeneic dura: 61. Van Luyn MJA, van Wachem PB, Olde Damink PJ, et al. Secondary
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33
Clinical Applications of Stainless Steel Mesh
Jean Jacques Duron
Introduction (0.02%). The weight of the prosthesis is 150 g/m2. The weave con-
sists of 20 squares per sqUare centimeter. Surgical handling of this
Incisional hernias and adult inguinal hernias imply the loss of ab- mesh is relatively easy; it tan be cut with ordinary scissors and fash-
dominal wall substance. 1,2 For incisional hernias, the use of pros- ioned to any desired shape. Our experience shows that folding the
theses would therefore seem desirable whenever the edges of a edges over to form a "hem" 0.5 cm wide eliminates the unpleas-
fascial defect or myoaponeurotic layer cannot be approximated antly prickly borders of the mesh.
without tension. 3 Today, the "Lichtenstein tension-free mesh pro- In case of reoperation, the incorporation of the steel mesh
cedure" can be proposed as a primary approach to the repair of within fibrous tissue is complete, hiding the prosthesis. In these
inguinal hernias with a low recurrence rate. 4,5 Convinced of the conditions, the abdominal cavity can be opened with ordinary scis-
efficacy of the tension-free procedure, we have used stainless steel sors and closed by simple approximation of the edges of the open-
mesh (Toilinox®) 6 for more than 30 years, even though during re- ing in the prosthesis.
cent years this type of prosthesis has been used less and less. The cost of steel mesh is remarkably low. We have never de-
tected any deterioration or alteration of the metal.
History of Metal Prostheses

Techniques
The use of metal prostheses to reinforce the abdominal wall dur-
ing the repair of hernias is of relatively long standing. In 1900, the Incisional Hernia
German surgeons Goepel 7 and Witzel8 reported the use of silver
wire filigrees for the repair of hernias. Over time, because of sil- Our technique is close to that described by Chevrel, with a plasty
ver's reactivity, the use of silver filigrees disappeared from surgi- of the anterior rectus sheaths as described by Welti.I 5- 17 The dif-
cal practice. ferent steps of the operation are as follows:
Between 1940 and 1950, the use of a tantalum gauze was re- The skin scar is resected, and the hernial sac is identified and
ported for incisional and inguinal hernia repair. 9- 11 However, sev- opened. All adhesions are lysed, the sac is resected, and the peri-
eral drawbacks, such as infection and fragmentation, appeared on toneum is closed with a running absorbable suture. The anterior
follow-up. As new plastic meshes appeared, the use of tantalum rectus sheaths are incised longitudinally, giving rise to a medial
gauze quickly diminished and finally ceased. and lateral border along each incision. The medial borders are
In 1952, Babcock12 reported experimental studies of a metal brought together at the midline with a continuous absorbable su-
prosthesis made from a fine stainless mesh and began to apply this ture. The stainless steel mesh is positioned and anchored to the
material especially in hernia repair. Several authors noted good rectus sheaths (lateral borders of the incision) with nonabsorbable
results with this procedure. 13- 15 In 1986, Validire and colleagues6 sutures. To prevent the formation of seromas, two suction drains
reported on 150 large abdominal incisional hernias. The follow- are left in place for 10 days (Fig. 33.1).
up of these patients showed a low rate of recurrence, but also some If the incisional hernia is large, two sheets of stainless steel mesh
mild discomfort. are used. These must tie sutured together with nonabsorbable
sutures.
The Prosthesis
Inguinal Hernias
The stainless steel prosthesis (Toilinox) is a wire mesh measuring
30 X 15 cm that is sterilized with ethylene oxide. The metal (steel The dissection of the inguinal area is classic and complete.
3020) is composed of chrome (18%), nickel (10%), carbon (3%), Through an anterior inguinal approach, the spermatic cord is
silica (l %), phosphorus (0.04%), sulfur (0.03%), and manganese carefully freed, and the transversalis fascia is incised. Hernial sacs

33. Clinical Applications of Stainless Steel Mesh 259
tients. Necrotizing fasciitis was seen in 3%, but removal of the mesh
was not necessary. The perioperative mortality rate was 2% and oc-
curred only in emergency patients. The follow-up of 92% of the
patients was documented for 5 years or longer. The recurrence
rate was 10%. Mild pain at the site of insertion of the steel mesh
occurred in 6% of the patients.
Inguinal Hernias
FIGURE 33.1. Positioning of the mesh in incisional herniorrhaphy: (1) stain- The surgical procedure described above was performed from 1981
less steel wire mesh and (2) rectus muscle. to 1999 on 207 patients in two different teaching hospitals. This
technique, although not completely abandoned, has been less fre-
quently performed since 1992 due to the rise of competing pro-
are identified, dissected, and resected whenever necessary. The cedures for inguinal hernia repair. The mean age of the patients
stainless steel mesh is fashioned into a lozenge shape. The small- was 71 years (198 males, 9 females). Elective operations numbered
est edge is sutured to the ligament of Cooper with three or four 149, and emergencies numbered 58. Perioperative morbidity was
nonabsorbable sutures, as in the McVay operation. IS More later- mainly local infectious complications (3%), and the steel mesh
ally, the stainless steel prosthesis is sutured to the ligament of was never removed.
Poupart. Near the deep inguinal ring, the mesh is incised to allow Long-term follow-up was more difficult than for incisional her-
passage of the spermatic cord. Medially, the mesh is sutured to the nias, probably because of the advanced ages of the patients and
conjoined tendon and the anterior aspect of the internal oblique. the "banal" nature of the operation, which did not always moti-
The mesh will be entirely covered by the external oblique aponeu- vate patients to return for examination. One hundred eleven pa-
rosis. Two suction drains are left in place for 3 days (Fig. 33.2). tients were followed up for more than 5 years, with a recurrence
rate of 6%. One percent of patients experienced slight pain.
Results
Comments
Incisional Hernias
The use of stainless steel mesh as a prosthesis is not new; the first
The reported results include the patients from a previous series6 report in the literature will soon be 50 years 01d. 12 For our part,
and our personal series of patients operated on in two different we have used it for more than 20 years, although its use is cur-
teaching hospitals. Two hundred fourteen patients were operated rently declining. Over time, we have tested the solidity of this pros-
on according to the surgical procedure described (65 males, 149 thesis, and we have never observed a "fracture" of the mesh. 19 •20
females, mean age 61 years). Emergency operations account for On x-ray the image of stainless steel mesh is characteristic and dif-
19% of all cases. Sixteen percent of the patients underwent an- ferent from the image offorgotten foreign bodies (gauze). In our
other surgical procedure during the same operation (colon re- practice, the stainless steel mesh does not disturb computed to-
section, hysterectomy, appendectomy, and so on). mographic scan images, particularly during the workup of a peri-
Early postoperative complications were seen in 8% of the pa- or postoperative sepsis (Fig. 33.3).
FIGURE 33.2. Positioning of the mesh inguinal herniorrhaphy: (I) stainless FIGURE 33.3. Computed tomographic scan showing a large abscess in con-
steel wire mesh, (2) spermatic cord, and (3) conjoined tendon. tact with the mesh.
260 JJ. Duron
As for the results of our technique of incisional hernia repair, 12. Babcock WW. The range of usefulness of commercial stainless steel
we want to stress the frequency (16%) of concurrent intraab- cloth in general and special form of surgical practice. Ann Western Med
dominal procedures (sometimes septic). Whatever the circum- Surg. 1952;6:15-23.
stances, in no instance was the stainless steel mesh removed. Other 13. Preston DJ, Richards CF. Use of wire mesh protheses in the treatment
of hernias. 24 years experience. Surg Clin Nurth Am. 1973;53:549-554.
authors, pointing out the resistance of the steel mesh to infection,
14. Mathieson AJM, James JH. A review of inguinal hernia repair using
have proposed this material in the treatment of septic incisional
steel mesh.] R Coil Surg Edinb. 1975;20:58-62.
hernia. 21 In the long term, our recurrence rate (10%) compared 15. Thomeret G, Dubost L, Pillot G. L'utilisation de la toile d'acier in-
favorably with those of other large series of operated incisional oxydable dans la cure des eventrations et des hernies. Mem Acad Chir.
hernias. 22 1960;36:500-507.
We have never observed any migration of the steel mesh with 16. Welti H, Eudel F. Un procede de cure radicale des eventrations post-
visceral complications, as published in the literature,23 probably operatoires par auto-etalement des muscles grands droits apres inci-
because of its superficial placement. Postoperative infections are sion du feuillet anterieur de leurs gaines. Mem Acad Chir. 1941;28:
not associated with a higher recurrence rate or with pain at the 791-798.
edges of the mesh. 17. ChevrelJP. Traitement des grandes eventrations medianes par plastie
en paletot et prothese. Nouv Presse Med. 1979;8:695-696.
Follow-up of patients operated on for inguinal hernias is diffi-
18. McVay CB. The anatomic basis for inguinal and femoral hernioplasty.
cult. The recurrence rate (6%) is higher than in a series with a
Surg Gynecol Obstet. 1974;139:931-945.
high rate of elective procedures. 24 A recurrence rate of 3% was as- 19. Arnaud JD, Eloy R, AdlofI M, et al. Critical evaluation of prosthetic
sociated with detachment of the mesh in earlier cases; this led us materials in repair of abdominal wall hernias. New criteria of toler-
to use the ligament of Cooper. ance and resistance. Am] Surg. 1977;133:338-345.
20. Petit J, Stoppa REvaluation experimentale des reactions tissulaires
autour de la prothese de la paroi en tulle de Dacron.] Chir. 1974;
Conclusion 107:667-672.
21. Galeano F, Gonzalez Aguiar 0, Lado A, et al. EI problema del injerto
At the dawn of the third millennium, regardless of the existence supurado en las eventraciones recidivantes. Su solucion con la malla
of newer prostheses,25 we are encouraged by our long and favor- de acero inocydabile. Pren Med Argent. 1968;55:437-443.
able experience to continue the use of stainless steel mesh. Nev- 22. Mudge M, Hughes LE. Incisional hernia: a 10 years prospective study
of incidence and attitudes. Br] Surg. 1985;79:70-71.
ertheless, although stainless steel mesh remains our usual
23. Darmaillacq F, Churet JP. Lesion intestinale tardive causee par une
prosthesis in the repair oflarge incisional hernias, particularly with
prothese metallique de la paroi abdominale. Mem Acad Chir. 1966;92:
associated septic procedures, the use of this material has dramat- 547-548.
ically decreased for the repair of inguinal hernias. However, be- 24. Bendavid R The Shouldice technique: a canon in hernia repair. Can
cause of its very low cost, the stainless steel mesh remains a ] Surg. 1997;40:199-205.
favorable alternative to other prostheses that may be unavailable 25. Bauer.IT, Salky BA, Celernt 1M, et al. Repair of large abdominal wall
or too expensive. 26 defect with expanded polytetrafluoroethylene (ePTFE). Ann Surg.
1987;206:765-769.
26. Bapat RD, Patel RA. Stainless steel mesh. A neglected implant for in-
References guinal hernia repair.] Postgrad Med. 1974;20:94-98.
1. RivesJ, PireJC, FlamentjB, et al. Les grandes eventrations. In Chevrel

JP (ed): Chirurgie des paTOis de l'abdomen. Berlin: Springer-Verlag; 1985:
118-145.
2. Fruchaud H. Anatomie chirurgicale des hernies de l'aine. Paris: Doin; 1957. Commentary
3. Molloy RG, Morau KT, Waldron RP, et al. Massive incisional hernia:
abdominal wall replacement with Marlex mesh. Br] Surg. 1991;78: Robert Bendavid
242-244.
4. Lichtenstein IL, Shulman AG, Amid PK, et al. The tension-free hernio- The earliest use of stainless steel dates back to 1929 when Babcock
plasty. Am]Surg. 1989;157:188-190. introduced it and presented his experience in 1947 and again in
5. McGillicuddyJE. Prospective randomized comparison of the Shouldice
1951 to the American Therapeutic Society. I Babcock's publications
and Lichtenstein repair procedures. Arch Surg. 1998;133:974-978.
6. Validire J, Imbaud P, Dutet D, et al. Large abdominal incisional her-
covered hepatobiliary, pancreatic, and colorectal disciplines but
nias: repair by fascial approximation reinforced with stainless steel also inguinal and incisional hernias for which two eponymic re-
mesh. Br] Surg. 1986;73:8-10. pairs were prevalent in the 1950s. 2 Whereas silver and tantalum
7. Goepel T. Ueber die verschliessung von bruchpforten durch ein- wires tend to fragment within a year, stainless steel appears to be
heilung geflocuhtener, fertiger silberdrahtnetze (silberdrahtpelotten). relatively impervious to metal fatigue. I In a test reported by Bab-
Verh Dtsch Ges Chir. 1900;19:174-179. cock 165 strips of stainless steel mesh were subjected to flexion
8. Witzel o. Ueber den verschluss von bauchwunden und bruchpforten through 180 degress over 1.5 inch (3.75 cm) rollers 18,000,000
durch versenkte silberdrahtnetze (einheilung von filigranpelotten). times "without any of the wires breaking." The major advantages
Centralhl F Chir LeiPz. 1900;27:257-259. of stainless steel are its cost and its behavior in the presence of in-
9. Douglas DM. Repair oflarge hernia with tantalum gauze. Lancet. 1948;
fection. The inert nature of stainless steel is most reassuring when
1:936-937.
10. Throckmorton TD. Tantalum gauze in the repair of hernias compli-
superficial and deep wound infections complicate a postoperative
cated by tissue deficiency. Surgery. 1948;23:32-35. course or when bowel resection becomes a necessity in emergency
11. Koontz AR. Tantalum and Marlex mesh (with a note on Marlex hernia surgery. Management is carried out as if no prosthesis had
thread). An experimental and clinical comparison. Preliminary report. been used. These features were underlined by Mathieson and
Ann Surg. 1960;151:796-904. ]ames3 and Preston and Richards. 4
34
Repair of Abdominal Wall Defects by
Intraperitoneal Implantation of
Polytetrafluoroethylene (Teflon®) Mesh
M.L. Druart, R. Chamlou, A. Mehdi, andJ.M. Limbosch
Introduction have reported similar complication rates up to 10%7,S and hernia

recurrence rates of 6 to 10%.5,9,10
The surgical management of me:gor abdominal wall defects or in-
cisional hernias remains controversial. Although primary mus-
culofascial repair is sufficient for many patients, moderate or large Expanded Polytetrafluoroethylene
hernias and refractory cases may require the use of a prosthesis.
Various prosthetic materials have been described and tested over
(ePTFE, Gore-Tex®)
the years. In theory, the ideal material must be strong, biologically
In 1963, ePTFE was developed. This was initially used by vascular
inert, noncarcinogenic, and resistant to infection. Many materials
surgeons in 1975, before being adopted by other surgical special-
have been developed, but there is no agreement on which is best.
ists, and it was first used in the repair of abdominal wall defects
Importantly, the most effective positioning of the prosthesis is also
in 1983. ePTFE is an inert material and causes little host inflam-
a subject of debate, with some preferring intraabdominal place-
matory reaction. Monaghan and Mebanll reported one recur-
ment and others opting for the extraperitoneal position. Many
rence and no complications in a series of 37 patients and noted
studies have been performed with various materials and tech-
that the recurrence was due to poor collagen ingrowth into the
niques but provide no clear answers as to the optimal manage-
patch and subsequent herniation between two sutures. In a larger
ment of abdominal hernias. In this chapter, we first discuss two of
case series of 121 patients, Kennedy and MatyasI2 reported a 4%
the commonly used prosthetic materials, polypropylene (Marlex®)
complication rate and a 2% recurrence rate. In a recent report
and expanded polytetrafluoroethylene (ePTFE Gore-Tex®) and
on 12 years of ePTFE use in 98 patients, Bauer et al.I 3 noted five
then report our experience with polytetrafluoroethylene (PTFE)
seromas, three fistulas, and nine infections. Ten patients devel-
mesh (Teflon®), a prosthesis that we use routinely in the man-
oped recurrent hernias. OthersI4-I7 have also reported similarly
agement of incisional hernias and abdominal wall defects and that
low incidences of recurrence and complications. Recently Gonza-
we believe has the best profile in terms of ease of use and low com-
lez et al. IS published the results of a study of 84 patients in whom
plication and recurrence rates.
intraperitoneal placement of ePTFE was used and concluded that
intraperitoneal placement of ePTFE has several advantages over
other techniques, including minimal dissection and possibly a de-
Polypropylene (Marlex®, Prolene®, creased risk of infection.
and Trelex®) Studies comparing the various prosthetic materials available
have yielded conflicting results. In rats, Simmermacher and Schak-
Developed in the late 1950s by Usher and co-workers,I-3 polypropyl- enraad I9 reported that Marlex was associated with a significantly
ene (Marlex) was reported to have flexibility and infection resis- lower incidence of recurrent herniation than ePTFE. In 200 pa-
tant properties superior to those of other materials available at the tients undergoing open repair of abdominal incisional hernias,
time and has become the most widely used prosthetic material for polyester mesh was associated with a much higher rate of infec-
incisional hernia repair. Although early studies4 reported compli- tion and recurrence than Marlex or ePTFE.20
cation rates as high as 45%, later groups documented the safety
and efficacy of Marlex with much lower complication rates. 5 Mol-
loy et al. 6 reported a wound infection rate of 8%, a wound sinus Intraabdominal Versus Extraperitoneal?
rate of 12%, a hematoma rate of 4%, and a wound seroma rate of
2% in a series of 50 patients. No complication was severe enough The optimal placement of a prosthesis is not well defined. In-
to necessitate removal of the Marlex prosthesis. They also reported traabdominal placement involves direct contact between the pros-
an 8% rate of hernia recurrence but suggested that this was due thesis and the abdominal viscera, which has raised fears about the
to inadequate peripheral attachment of the prosthesis. Others possibility of adhesion formation and intestinal obstruction. How-

34. Intraperitoneal Implantation of Polytetrafluoroethylene (Teflon®) Mesh 263
ever, a prosthesis placed in the intraabdominal position is rapidly TABLE 34.1. Risk factors influencing the outcome
enveloped by a neoperitoneum, offering a good defense against Parietal
Incisional
infection. Several authors describe an increased complication rate hernia defect
with the use of intraperitoneal prosthetic material as compared (n = 100) (n = 29)
with preperitoneal placement,21,22 but others, using polyester and
ePTFE, have reported no increased risk of complications,23-25 n % n %
and, in particular, Deysine,26 using ePTFE, noted no clinical evi- Multiple laparotomy 51 51% 6 21%
dence of adhesions or intestinal obstruction in their series of 89 Simple laparotomy 49 49% 9 31%
patients. Obesity 28 28% 18 62%
Respiratory insufficiency 19 19% 8 28%
History of
OUf Experience with Teflon (PTFE) Intraabdominal infections 11 11% 3%
Diabetes 10 10% 4 14%
Teflon®, produced by DuPont, is classed as a plastic. It is composed Multiparity 5 5% 3 10%
Cirrhosis 3 3% 3 10%
of carbon and fluorine, and the extremely strong bond between
these two elements accounts for the unequalled inertness of
Teflon. The mesh is made from pure PTFE fibers, 60 spun into a
yam. The yam is then knitted with knots approximately every 2.1 space for 3 or 4 days. An elastic Dale® abdominal binder (Dale
mm in both directions. The thickness of the knitted mesh is 0.026 Medical Products, Inc., Plainville, MA) was worn by all patients for
inches (0.66 mm). The diameter of the interstices is approximately 4 to 6 weeks.
1.2 mm. Teflon is an inert plastic with low tissue reactivity and The mean patient age was 59 years (range 35 to 92), with 56
moderate tensile strength, yet good flexibility and handling qual- males and 73 females. Twenty-seven patients (21 %) had had at
ities. It was first used as a prosthesis in the repair of abdominal least one previous repair of the hernia either in our institution or
wall defects by Ludington and Woodward in 1959 with good rein another hospital. Eleven patients (8.5%) had had a previous
sults. 27 However, a subsequent study by Gibson and StafIord28 re- prosthesis inserted. Risk factors potentially influencing outcome
ported a high incidence of complications such as persistent are listed in Table 34.1.
sinuses, abscesses, seromas, and wound infections, and the use of Among the 129 patients, 100 (77.5%) had an incisional hernia
Teflon fell into disrepute. More recently, Ambrosiani et a1. 29 re- and 29 (22.5%) a parietal defect. The mean follow-up period was
ported a 42.2% recurrence rate using PTFE for incisional hernia 40 months (range from 5 to 96 months). Early complications re-
repair. lated to the prosthesis (Table 34.2) occurred in four patients: two
We have continued to use Teflon, a supple, flexible, and com- (1.6%) m.yor (one bowel obstruction and one intestinal fistula)
paratively cheap prosthetic material, in our patients with incisional and two (1.6%) minor (seromas that resolved spontaneously). Late
hernias. As shown below, we have had low rates of complications complications occurred in two patients: One patient (0.8%) had
and recurrence. In a previous study by our group,30 in 23 patients a bowel obstruction 2 years after surgery, and one patient (0.8%)
with abdominal incisional hernias, we noted that Teflon was well had a recurrence of his hernia 5 years later. He was treated in an-
tolerated, with only 1 recurrence and 1 case of wound infection. other institution. None of the patients had any wound pain, wound
A prolonged case series of 86 patients also revealed only 1 recur- dehiscence, erythema, or induration.
rence (1.2%) and 4 wound infections (4.6%). Others 31- 35 have also
reported Teflon to be effective and to have a low incidence of side
effects and hernia recurrence. Complications
Recently, we conducted a retrospective study of 129 patients who
had undergone abdominal wall hernia repair in our institution. Bowel Obstruction
All the patients were operated on by the same surgical staff using
a PTFE mesh (Teflon, C.R. Bard Inc., Billerica, MA) prosthesis. Case I: A 56-year-old man, who had undergone multiple abdomi-
The same surgical protocol was used for all patients: cutaneous in- nal operations, with a past history of cirrhosis, obesity, and severe
cision over the hernia, dissection and resection of the sac, peri- respiratory insufficiency had had two previous primary repairs of
toneal incision to release adhesions from previous operations, and his incisional hernia. Six weeks after the implantation of the pros-
dissection 5 to 6 cm beyond the edges of the defect. The Teflon thesis the patient presented with a bowel obstruction. At surgery,
implant was placed intraperitoneally directly on the abdominal vis- the prosthesis was removed and an intestinal resection was per-
cera and anchored to the full-thickness muscular wall, under mod- formed. The hernia was repaired by primary suture. The patient
erate tension, with a series of interrupted nonabsorbable "U" is well after a further 4-years follow-up.
stitches every 1.5 cm. The edges of the prosthesis overlapped the
edges of the parietal defect by at least 4 cm on the visceral aspect
TABLE 34.2. Complications
of the peritoneum and the overlying abdominal muscles. In most
cases, the edges of the defect were approximated over the Teflon Early (n) Late (n) Total (n)
mesh with a continuous absorbable suture to prevent contact with
subcutaneous or cutaneous layers. Prophylactic antibiotic (first- Bowel obstruction 1 1 2
Fistula 1 1
generation cephalosporins) was used on induction of anesthesia
Seroma 2 2
and prolonged for 24 hours in all the patients. In all cases, the Recurrence
surgeon placed one or two suction drains in the subcutaneous
264 M.L. Druart et al.
Case II: A 61-year-old man who had undergone multiple ab- 6. Molloy RG, Moran Kf, Waldron RP, et al. Massive incisional hernia:
dominal operations presented with a mechanical bowel obstruc- abdominal wall replacement with Marlex mesh. Br] Surg. 1991;78:242.
tion 2 years after the implantation of the prosthesis. At operation, 7. Akman PC. A study of 500 incisional hernias. ] Int Colt Surg. 1962;
the proximal jejunum was fIxed to the prosthesis and to the an- 37:125.
8. Simchen E, Rozin R, Yohanan W. The Israeli study of surgical infec-
terior abdominal wall. Removal of the prosthesis and an intesti-
tion of drains and the risk of wound infection in operations for her-
nal resection were performed, and the incisional hernia was
nias. Surg Gynecol Obstet. 1990; 170:331.
repaired by primary suture. The patient is well after a further 9. Larson GM, Harrower HW. Plastic mesh repair of incisional hernias.
2-year follow-up. Am] Surg. 1978;135:559.
10. Lewis RT. Knitted polypropylene (Marlex mesh) in the repair of inci-
sional hernias. Can] Surg. 1984;27:155.
Intestinal Fistula 11. Monaghan RA, Meban S. Expanded polytetrafluoroethylene patch in
hernia repair: a review of clinical experience. Can] Surg. 1991;34:502.
Case III: A 61-year-old woman, who had undergone multiple ab- 12. Kennedy GM, Matyas JA. Use of expanded polytetrafluoroethylene in
dominal operations and who had had radiation therapy for a gen- the repair of the difficult hernia. Am] Surg. 1994;168:304.
13. Bauer lJ, Harris MT, Kreel I, et al. Twelve-year experience with ex-
eralized neoplasm of the uterus, presented 3 weeks after the repair
panded polytetrafluoroethylene in the repair of abdominal wall de-
of the hernia with an intestinal fIstula and abdominal abscess that
fects. Mt Sinai] Med. 1999;66:20.
required surgery for removal of the prosthesis, drainage, and hy- 14. Koller R, MiholicJ,Jakl RJ. Repair ofincisional hernias with expanded
peralimentation. There was no need for intestinal resection. polytetrafluoroethylene. Eur] Surg. 1997;163:261.
15. Balen EM, Diez-Caballero A, Hernandez-Lizoain JL, et al. Repair of
ventral hernias with expanded polytetrafluoroethylene patch. Br] Surg.
Hernia Recurrence 1998;85:1415.
16. Gillion JF, Begin GF, Marecos C, et al. Expanded polytetrafluoroeth-
Case IV: A 51-year-old woman with a large median supra- and in- ylene patches used in the intraperitoneal or extraperitoneal position
fra-umbilical incisional hernia and a past history of multiple ab- for repair of incisional hernias of the anterolateral abdominal wall.
Am] Surg. 1997;174:16.
dominal operations presented with a recurrence of her hernia 5
17. Bellon JM, Contreras LA, Sabater C, et al. Pathologic and clinical as-
years after operation. She was operated on at another institution.
pects of repair of large incisional hernias after implant of a polytetra-
The prosthesis had become detached; it was removed, and the de- fluoroethylene prosthesis. World] Surg. 1997;21:402.
fect was closed by primary suture. 18. Gonzalez AU, de Juan F, Albarran GC. Large incisional hernia repair
using intraperitoneal placement of expanded polytetrafluoroethylene.
Am] Surg. 1999;177:291.
Summary 19. Simmermacher RIg, SchakenraadJM. Reherniation after repair of the
abdominal wall with expanded polytetrafluoroethylene.J Am Coli Surg
In our institution, we routinely implant Teflon mesh, intraperi- 1994;178:613.
toneally, to repair abdominal incisional hernias. Many surgeons 20. Leber GE, Garb JL, Alexander AI, et al. Long-term complications as-
sociated with prosthetic repair of incisional hernias. Arch Surg 1998;
are reluctant to implant prosthetic material intraperitoneally for
133:378.
fear of bowel adhesions to the prosthesis leading to bowel ob-
21. Soler M, Stoppa R, Verhaeghe P. Polyester (Dacron) mesh. In Ben-
struction or perforation. Our experience with intraperitoneal im- david R (ed): Prostheses and abdominal wall hernias. Austin: RG. Landes
plantation of Teflon mesh in a large series of patients followed Company; 1994;268.
over a long period of time demonstrates that this technique allows 22. Mathonnet M, Antarieu S, Gainant A, et al. Postoperative incisional
a very low rate of hernia recurrence (0.8%) with a low and ac- hernias: intra- or extraperitoneal prosthesis implantation? Chirurgie.
ceptable risk of bowel obstruction or perforation (2.3%). We there- 1998;123:154.
fore recommend, and will continue to use, intraperitoneal Teflon 23. Oussoultzoglou E, BaulieuxJ, de la Roche E, et al. Long-term results
mesh to treat recurring parietal defects or to treat primary pari- of 186 patients with large incisional abdominal wall hernia treated by
etal defects even in patients presenting with risk factors for re- intraperitoneal mesh. Ann Chir. 1999;53:33.
24. Becouarn G, Szmil E, Leroux C, et al. Cure chirugicale des eventra-
currence such as those reported in Table 34.1.
tions postoperatoires par implantation intraperitoneale de tulle de
In conclusion, Teflon is a supple, flexible, easy to use, and com-
Dacron. A propos de 160 cas operes.] Chir (Paris). 1996;133:229.
paratively inexpensive prosthetic material that is effective and well 25. Bendavid R Composite mesh (polypropylene mesh-ePTFE) in the in-
tolerated in the repair of incisional abdominal hernias. traperitoneal position. A report of 30 cases. Hernia. 1997;1:5.
26. Deysine M. Hernia repair with expanded polytetrafluoroethylene. Am
] Surg. 1992;163:422.
References 27. Ludington LG, Woodward ER Use of Teflon mesh in repair of mus-
culofascial defects. Surgery. 1959;46:364.
1. Usher FC, Ochsner J, Tuttle LLD Jr. Use of Marlex mesh in the repair 28. Gibson LD, Stafford CEo Synthetic mesh repair of abdominal wall de-
of incisional hernias. Am Surgeon. 1958;24:969. fects. Am Surgeon. 1964;30:481.
2. Usher FC, Wallace SA. Tissue reaction to plastics; comparison of 29. Ambrosiani N, Harb J, Gavelli A. Echec de la cure des eventrations et
nylon, Orlon, Dacron and Teflon. Arch Surg. 1958;76:997. des hernies par plaque de PTFE (111 cas). Ann Chir. 1994;48:917.
3. Usher FC, GannonJP. Marlex mesh: a new plastic mesh for replacing 30. Druart ML, Limbosch JM. Traitement des eventrations par implanta-
tissue defects; experimental studies. Arch Surg. 1959;78:131. tion intraperitoneale de voile en Teflon. Ann Chir. 1988;42:39.
4. Jacobs E, Blaisdell FW, Hall AD. Use of knitted Marlex mesh in the re- 31. Copello AJ. Technique and results of Teflon mesh repair of compli-
pair of ventral hernias. Am] Surg. 1965;110:897. cated re-recurrent groin hernias. Rev Surg. 1968;25:95.
5. Usher FC. Hernia repair with knitted polypropylene mesh. Surg Gy- 32. Snijders H. The use of Teflon gauze in the treatment of medial and
necoIObstet.1963;117:239. recurrent inguinal hernias. Arch Chir NeerL 1969;21:199.
Commentary 265
33. Kalsbeek HL. Experience with the use of Teflon mesh in the repair of justified and supported its use. Copello's classic paper of 19683
incisional hernias. Arch ChiT NeerI1974;26:71. also noted the use of Teflon, without complication. On the other
34. Blondiau]V, Verheyen V, Coland M. Cure des hernies inguinocrurales hand, Gibson and Stafford, 4 quoted by Druart, followed 25 cases
par voie mediane preperitoneale et prothese en Teflon. Acta Chir Bel for a minimum of 3 years and found 1 recurrence, 1 persistent si-
1979;78:317.
nus, 1 case of multiple abscesses and draining sinuses, 5 seromas
35. Azagra JS, Aile JL, Esselen M, et al. Nonante-quatre hernies de l'aine
(20%), 8 wound infections (32%), and 5 removals of the Teflon
traitees par prothese interposee par voie mediane et preperitoneal.
Acta Chir Bel 1987;87:15. mesh (20%)!
Druart's own experience is arresting. She has reported on a se-
ries of 129 cases with 3 gastrointestinal complications (2.3%). One
recurrence (0.78%). No mortality. No infection. These statistics
Commentary reflect meticulous operating room technique and the most atten-
tive postoperative care.
Robert Bendavid Druart undertook a 15-year follow-up of her cases expressly for
this chapter, and we are indebted to her for this generous contri-
The use of prosthetic materials has increased remarkably in the bution from the "plat pays" of Belgium.
past decade. All tension-free repairs require them, plug repairs de- The trivia collector may be aware that Teflon was interposed be-
mand them, laparoscopic repairs rely on them. Whatever the una- tween the steel framework and the copper skin of the restored
nimity of this surge of consumerism in surgical practice, there has Statue of Liberty to prevent corrosion, proving that even the rule
been little agreement on the safety of these synthetic adjuncts for against the subcutaneous placement of mesh can admit of an ex-
use within the peritoneal cavity. The common materials, polytet- ception!
rafluoroethylene, polyester, polypropylene, and expanded poly-
tetrafluoroethylene, have all been examined to determine the de-
grees of cellular and inflammatory responses each evokes. Results References
have been paradoxical. Each material has been reported by some
investigators to provoke the least inflammatory and cellular re- 1. LeVeen H. Barberia JR. Tissue reaction to plastics used in surgery with
special reference to Teflon. Ann Surg. 1949;129(1):75-84.
sponse, while the same material has been declared by others to
2. Ludington LG, Woodward ER. Use of Teflon mesh in repair of mus-
cause the most! culofascial defects. Surgery. 1959;46:364.
An excellent review by LeVeen and Barberia in 1949 1 showed 3. Copello AJ. Technique and results of Teflon mesh repair of complicated
Teflon® to be inert; it evoked no inflammatory or fibroblastic re- hernias. Rev Surg. 1968;25(2):95.
sponse, and the thin capsule surrounding it did not thicken even 4. Gibson DL, Stafford CE. Synthetic mesh repair of abdominal wall de-
after 6 months. A report of Ludington and Woodward in 19582 fects; follow-up and reappraisal. Am Surg. 1964;30(8):481-486.
35
Polyester (Dacron®) Mesh
Marc Soler, Pierre]. Verhaeghe, and Rene Stoppa
Introduction of incorporation of the mesh7 and the strength of the reinforced

abdominal wal1. 5,6 More recently, Rath et al. B verified that Dacron
Prosthetic materials have been used in the repair of abdominal mesh displayed the best biocompatibility during the first month
wall hernias for nearly a century. First, metallic materials were de- after implantation when compared with Dacron/polyglactin com-
signed. Because of their rigidity, fragmentation, disintegration, posite and polypropylene mesh. Abdominal walls reinforced with
and particularly their dangerous migration, metallic prostheses polypropylene are, however, stronger than those with Dacron
have been abandoned. This transition was timely as the polymer mesh.
industry was coming of age and offered a number of products According to our own comparative study, the biocompatibility
called (somewhat improperly) "plastics." The saturated polyesters of Dacron mesh is better than that of composite mesh (Figs. 35.1
we now use are synthesized from paraxylene and terephthalic acid. to 35.3; see color insert). No statistically significant difference in
This synthesis was achieved in 1939, and polyester threads ap- biocompatibility was found when comparing Dacron, polypropyl-
peared in 1946. Mersilene® (Dacron®) mesh was created during ene, and expanded polytetrafluoroethylene (ePTFE). Dacron
the 1950s and has been used in the United States since 1954. In- mesh remains our point of reference in experimental work.
troduced in France by Rives, this material has been widely used
there since 1965, through the work of Rives and Stoppa in the re-
pair of hernias. In the English-speakingworld, Mersilene (Dacron) Intraperitoneal Placement of Polyester Mesh
has not enjoyed the same popularity, with a few exceptions. l -4 Poly-
ester (Dacron) mesh is a "close" mesh, 0.2 mm thick, light (40 Our study9 on the long-term effects (3 and 9 months) confirmed
g/m2), and interlock-process woven, which makes laddering im- the relatively poor biocompatibility of the composite prosthesis of
possible and cutting with scissors possible. It has lozenge-shaped, polyester and polyglactin compared with polyester mesh. We ob-
1 mm 2 pores. served that the combination ofpolyglactin 910 and polyester mesh
provoked and maintained an intense inflammatory reaction, sug-
gesting less compatibility than that with polyester mesh alone; fur-
Experimental Studies with Dacron Mesh thermore, the composite prosthesis forms as many adhesions with
in Abdominal Wall Surgery intraperitoneal viscera as polyester does. For these reasons, surgi-
cal interest in using a composite prosthesis in an intraperitoneal
In 1956, early animal experiments revealed the qualities of this position has waned.
material when placed in contact with living tissues. Because of the
layered nature of the abdominal wall, polyester mesh could be in-
serted in different areas, both intraperitoneal and extraperitoneal, Dacron Mesh, Some Clinical Aspects
although intraperitoneal placement raises the risk of serosal ad-
hesions. We discuss the main characteristics of the intraperitoneal Recently, Munshi and Wantz2 presented the technique of unilat-
and extraperitoneal uses of Dacron mesh and report on our ex- eral giant prosthetic reinforcement of the visceral sac (GPRVS)
perience of a compound prosthesis (combining polyglactin 910 performed through an infrainguinal approach to manage recur-
and polyester meshes) in the intraperitoneal position, which led rent and perivascular femoral hernias. For this technique, the au-
us to abandon the use of nonabsorbable meshes in this situation. thors require that the prosthesis be very flexible. For them, Dacron
mesh is at the present time the only appropriate material avail-
able; polypropylene is too rigid, and ePTFE does not allow ade-
Extraperitoneal Placement of Polyester Mesh quate fibroblast infiltration (incorporation).
Two series recently reported the use of polyester mesh in the
Adler et al.,5 Cerise et al.,6 and Harrison et al. 7 investigated poly- intraperitoneal position,lO,l1 but, although reported results were
ester mesh. The material gave good results in terms of the degree good, we never use this technique because it is often impossible

35. Polyester (Dacron®) Mesh 267
FIGURE 35.1. Photomicrograph of transverse cross section of polyester pros-

thesis at the sixth postoperative month in the extraperitoneal position FIGURE 35.3. Photomicrograph of transverse cross section of prosthesis at
(XIO). (See color insert.) the sixth postoperative month in the extra peritoneal position. Note the fi-
brous tissue reaction in black, significantly more conspicuous than the in-
flammatory granuloma in Fig. 35.2 (XIO). (See color insert.)
to use the greater omentum to separate the viscera from the pros-
thesis. In this situation, the viscera are involved in the incorpora-
tion of the mesh, with the attendant risk of peritonitis, obstruction, ant polyester mesh prosthesis and by the reports of Stoppa and
fistula, and so forth. We have observed one mesh migration in the Warlaumont,16 and Warlaumont,17 who catalogued 257 incisional
stomach, three in the small bowel, and one in the bladder; many hernias with a mean follow-up of 5.5 years, as well as 1438 groin
other cases are reported (Table 35.1). As it happens, even in dif- hernias treated with mesh. Dufilho,18 in a doctoral thesis (1981),
ficult cases, it is very often possible to separate the mesh and the analyzed 230 groin hernias and 150 incisional hernias. At the As-
intraabdominal viscera, using, for example, the Chevrel proce- sociation of French Surgeons (A.F.C.) at the 92nd French Con-
dure. 12 We sometimes use the Goiii-Moreno procedure 13 for giant gress of Surgery (1990), Chevrel and Flament12 reported on a
hernias that have lost their right of domain. This technique per- review of 1825 incisional herniorrhaphies out of which 1085 had
mits closure of the abdominal wall without tension and placement mesh implants. We refer also to the experience of Bouillot and
of the prosthesis in the extraperitoneal space. Alexandre 19 with 1017 hernia repairs (971 patients, 83% of which
were reviewed at 1 year, with a mean follow-up of 3.5 years) and
that of Mathonnet et ai.,l1 who recently presented 99 incisional
Complications Following Use of Dacron hernias treated with Dacron mesh.
Mesh in Groin and Ventral Hernias
The following discussion of complications has been inspired by Local Complications
the personal observations of D. Louis 14,15 on a series of 153 pa-
tients who had undergone incisional herniorrhaphies using a gi- Hematomas
Mter operating on 1438 groin hernias using polyester mesh,
Stoppa and Warlaumont l6 ,17 reported 72 hematomas (4.86%) in
comparison with 2.97% for McVay and 3% for Bassini repairs. Du-
filho I8 reported 9 hematomas out of 230 patients treated with
mesh (3.9%). Treating incisional hernias with polyester mesh,
Louis and co-workers counted 5 hematomas out of 153 operations
(3.2%)14,15; Dufilho 18 counted 3 in 150 (2%). The recent A.F.C.
inquiry12 reported 45 hematomas out of 1005 operations (4.8%)
following prosthetic repairs versus 37 of 733 (4%) following non-
prosthetic repairs. Bouillot and Alexandre 19 reported 35 superfi-
cial benign hematomas and sepsis (3.44%) and 7 deep hematomas
(0.68%) due to use of anticoagulant, in 2 cases the prosthesis
had to be removed. Mathonnet et al. 11 reported 18 (18.1 %)
hematomas, seromas, or excessive superficial scarring.
These figures, regrouped in Table 35.2, show a similar incidence
of hematomas with or without the use of prosthetic mesh. This
complication seems to correlate with the extent of dissection as-
FIGURE 35.2. Photomicrograph of transverse cross section of polyester pros- sociated with large prostheses, inadequate drainage, and preco-
thesis at the sixth postoperative month in the extraperitoneal position. cious heparin therapy. To avoid hematomas when dealing with
Note the inflammatory granuloma in red (XIO). (See color insert.) wide dissections, fibrin sprays have been suggested.
268 M. Soler et al.
TABLE 35.1. Intravisceral migration of prosthetic materials: Review of literature
Date Study Type of hernia Material Site Complication
1966 Darmaillacq and Churet29 Incisional Steel net Intraperitoneal Gut fistula
1971 Smith30 Incisional Tantalum Intraperitoneal Gut fistula
1973 Bothra31 Incisional Tantalum Preperitoneal Gut fistula
1974 Griffe and Crespy32 Incisional Nylon Intraperitoneal Gut fistula
1976 Herrera et al. 33 Incisional PTFE Preperitoneal Colonic fistula
1981 Dufilho 18 Incisional Polyester Intraperitoneal Gut fistula (X3)
Colonic (Xl)
1982 Warlaumont17 Groin Polyester Preperitoneal Bladder fistula
1983 Bedouret34 Groin Polyester Preperitoneal Bladder fistula
1989 Stoppa and Warlaumont16 Incisional Compound mesh Intraperitoneal Gut fistula
1990 Chevrel and Flament12 Incisional Polyester Intraperitoneal Gut fistula (X 1)
Gastric fistula (X 1)
PTFE, polytetrafluoroethylene.
Infectious Complications promote sepsis are intraoperative contamination and superficial

placement of a mesh; diabetes mellitus as a factor in sepsis has not
In hernia repairs, the incidence of sepsis is not related to the use been substantiated.
of mesh. Stoppa and Warlaumont16 reported the following rates Our own clinical experience is at variance with the supposed
of sepsis: 4.58% following Bassini operations, 2.3% following Mc- potential for infection induced by prosthetic meshes, suggested in
Vay repairs, and 2.15% following Stoppa operations (26/1223). isolated reports of infected prostheses or experimental studies un-
Dufilho,18 in a follow-up of 230 prosthetic repairs, reported 4.3% der conditions far removed from the reality of surgery.22,23 We are
superficial wound infections and 3.47% deep wound infections, in agreement with Usher and Gannon,24 who consistently found
for an overall rate of 7.8%. On surgery of incisional hernias, the that polypropylene mesh did not contribute to chronic sepsis,
A.F.C. inquiry12 revealed an incidence of superficial sepsis of 6.3% while multifilament silk sutures were responsible for infections and
(46 of 733) ofrepairs without prostheses and 4.63% (47 of 1005) sinuses. The surgical treatment of infectious complications is of
in prosthetic repairs. For deep sepsis, the rates were 0.3% (2 of paramount importance, and the removal of the mesh is almost
733) in nonprosthetic repairs and 1.09% (11 of 1005) for mesh never necessary or useful.
repairs, the overall rate of sepsis being 5.7%. Louis 14,15 reported Surgeons should realize that despite the theoretical implications
a global incidence of 11.8% and Stoppa and Warlaumont,16 a 5% of monofilament versus braided multifilament meshes, both types
incidence without prostheses and 6.1 % with prostheses. Dufilho 18 have demonstrated good clinical biocompatibility through long-
reported a global incidence of 13.3% out of 150 operations. Bouil- term experiences. The treatment of a superficial abscess is
lot and Alexandre 19 reported only one case of deep sepsis that ne- drainage and, when necessary, generous opening of the wound.
cessitated removal of the prosthesis. Mathonnet et al.!1 reported Deep sepsis requires the exposure of the mesh and, in some cases,
six cases (2%) of superficial sepsis. saline irrigation and suction drainage. When treatment is early
The more significant observations about sepsis are that a higher and aggressive, healing occurs consistently. Connective tissue will
incidence of sepsis is noted in incisional hernia repairs (Table grow through the mesh to create a solid abdominal wall, albeit at
35.3), that a similar incidence is evident with or without the use the cost of a longer hospital stay. Exceptionally, a subclinical in-
of prostheses, and that the size of mesh used is not a factor. Sep- fection may eventually manifest itself as a fistula. Here again, the
sis is favored, in our experience, by associated septic operations lesion must be treated aggressively, without removal of the pros-
(intestinal resections, biliary surgery); by certain circumstances thesis. Fistulography must be carried out, followed by complete
such as strangulation, cutaneous ulcerations, and abscess; and by excision of the sinus. In prevention, it is important to select pa-
a history of septic complication in a previous primary laparotomy.
As Rives et al. 20 ,21 insisted, the transfixing sutures ligated on a cu- TABLE 35.3. Incidence of sepsis in groin and incisional hernias repairs,
taneous pledget must be abandoned. Louis l4,15 correlated the in- with and without polyester mesh (compilation from references cited in
cidence of sepsis with the number of suction drains, but it is not the text)
clear that the patient groups studied were strictly comparable. Du- Groin hernias Incisional hernias
filho 18 found that obesity, age over 70 years, and cardiopulmonary
insufficiency were risk factors for sepsis. Other factors that may Superficial sepsis,
71/1394 = 5.1 %
Polyester mesh 36/1453 = 2.4%
TABLE 35.2. Incidence of hematomas in groin and incisional hernia Sepsis total number,
repairs, with and without polyester mesh (compilation from references 103/1544 = 6.6%
cited in the text)
Superficial sepsis,
Groin hernias Incisional hernias 66/1122 = 5.9%
No mesh 17/673 = 2.5%
Mesh 79/1668 = 4.73% 50/1158 = 4.3% Sepsis total number,
No mesh 20/673 = 3% 37/733 = 5.04% 68/1122 = 6%
tients with no known current infections. Rigorous aseptic tech- hernias. The cause may have been improper closure of the peri-
nique is imperative when handling mesh, and, while this is rela- toneum following resection of the hernial sac.
tively easy in groin surgery, it may be more difficult in large
incisional hernias for which surgery can be lengthy and complex,
and antibiotics may be indicated. In patently or potentially septic Wound Dehiscence
conditions, the use of absorbable mesh may be indicated; as
demonstrated by Levasseur et al. 25-27 and Rignier,2B sepsis does not Wound dehiscence is an exceptional occurrence that happened
complicate the use of such materials. once in the series of 1085 patients reported to the A.F.C.12 Again,
this is a mechanical complication unrelated to the nature of the
prosthesis.
Intravisceral Migration of Mesh
The rare complication of intravisceral migration of mesh is usu- Neurological Complications
ally encountered following incisional hernia repairs with nonab-
sorbable meshes. Table 35.1 shows the various fabrics: steel mesh Neurological complications are rare and result from the blind fix-
(Darmaillacq and Churet29 ), tantalum (Smith 3o and Bothra31 ), ny- ation of a prosthetic mesh in the vicinity of the femoral nerve; this
lon (Griffe and Crespy32) Teflon (Herrera et al. 33 ), and Dacron is one of the reasons we do not suture our giant bilateral pros-
(Chevrel and Flament12 ). The prosthetic material migration re- thesis in groin hernia repairs. We have had to reoperate on two
sults usually in fistulas of the small intestine and occasionally in referred patients to remove the offending sutures, and Dufilho 1B
fistuls of the colon or stomach. Following groin hernia repair, the also reported one case. The technique, not the type of mesh, was
urinary bladder may be involved. We have observed this compli- at fault.
cation in five instances: three following the use of a large in-
traperitoneal mesh (two polyester and one compound mesh) and
two following a giant preperitoneal prosthetic repair of bilateral Breakage of the Mesh
groin hernias. Bedouret34 reported one intraintestinal migration.
Dufilho 1B observed four external gastrointestinal fistulas in a group Dufilho 1B reported two cases of wound dehiscence on postopera-
of 16 intraperitoneal prostheses with two deaths and two recur- tive days 7 and 11, secondary to a break in the mesh, in obese pa-
rences of the hernia. In the A.F.C. report, Chevrel and Flament12 tients with severe respiratory insufficiency. Rives 37 reported a
reported two cases of migration (one stomach, one gut). Suhler similar case. Rath et al. B reported three cases, and they strongly
and Masson 35 and Dongaonkar36 also reported one case each of advise the use of polypropylene when the abdominal wall is very
migration by intraperitoneal mesh following sling operations for fragile. Where the clinical setting suggests it, a double layer of
gynecological prolapses. mesh is recommended.
In conclusion, visceral migration and fistula formation are rare
but dangerous complications of the intraperitoneal placement of
polyester (as well as polypropylene) mesh. The mechanism of mi- Morbidity and Mortality
gration is not clear. Is it due to inadequate fixation and loosening
followed by migration into a hollow viscus? Can adhesions between Table 35.4 presents morbidity and mortality data.
mesh and viscus by implicated? Whatever the mechanism, we def
initely condemn the intraperitoneal placement of a nonabsorbable mesh.
What is more, our own experiments have not shown that the place- Groin Hernias
ment of an absorbable prosthesis (P910M) between a polyester
mesh and a viscus is a safe answer to the problem. 9 Stoppa and Warlaumont16 reported 21 complications in a series
of 1223 cases: 16 bronchopneumonia, 3 thrombophlebitis, 2 pul-
monary embolism. Mortality rate was 0.57%; seven elderly patients
Intestinal Occlusions with strangulated hernias underwent emergency surgery. In the
same report, 215 patients received an inguinal polyester mesh
Intestinal occlusions are mechanical complications unrelated to patch with a general morbidity rate of 0.93% (two pulmonary in-
the nature of the mesh; they occur mostly after the intraperitoneal fections); 2 patients who underwent emergency surgery died; and
placement of a prosthesis, P910M included. They are infrequent. nonprosthetic repairs accounted for a 2% rate of complications
We have documented two cases due to adhesions following the ex- (10 pulmonary, 3 phlebitis, 1 pulmonary embolism) and 2.5% mor-
traperitoneal placement of a giant bilateral prosthesis for inguinal tality. Dufilho 18 reported 2.6% mortality (five patients with stran-
TABLE35.4. General morbidity and mortality in hernia surgery as a function of the use of mesh
(compilation from the reference cited in the text)
Groin hernias Groin hernias Incisional hernias Incisional hernias
with mesh without mesh with mesh without mesh
General 23/1437 = 1.6% 14/673 = 2% 17/247 = 5.9% 6/62 = 9.8%
complications
Mortality 15/1669 = 0.9% 17/673 = 2.5% 17/397 = 4.28% 8/212 = 3.77%
270 M. Soler et aI.
gulated hernias and one large scrotal hernia). Dufilho 18 also lists TABLE 35.5. Incidence of recurrences in hernia surgery as a function of
three major risk factors, namely, cachexia, respiratory impairment, the use of mesh (compilation from the references cited in the text)
and cardiac insufficiency. Bouillot and Alexandre 19 reported 27
Mesh No mesh
cases of benign general or cardiac complications in 971 patients,
or 2.78%; one patient with ischemic cardiopathy died (mortality, Groin hernias 43/1668 = 2.57% 80/673 = 11.88%
0.1%). Incisional hernias 86/1023 = 8.40% 118/453 = 26.04%
Incisional Hernias
0.56% in primary hernias. This compares favorably with an inci-
Louis 14,15 reported an 8% rate of postoperative complications, dence of 11.5% for 215 inguinal Dacron patches, 16.5% for 109
identified as phlebitis (5), pulmonary embolism (3), bronchopul- Bassini repairs, and 11.1 % for 654 McVay repairs. Dulfilho 18 re-
monary (6), temporary renal insufficiency (1), asthmatic crisis (1), ported only 2 recurrences (0.9%) in 230 patients after the of-
hematemesis (1), jaundice (1), and staphylococcal septicemia (1). fending septic mesh was removed. Stoppa and Warlaumont16
Mortality was 2.6%, identified as secondary to pulmonary em- reported a series of 257 incisional hernia repairs, with a mean
bolism (2), cardiorespiratory insufficiency (6), digestive tract fis- follow-up of 5.5% years. The success rate was 91 %, and failure was
tulas secondary to intraperitoneal prostheses (2), pulmonary most often due to insufficiently large dimensions of a mesh, dis-
embolism (1), and septic shock secondary to sepsis at operation lodgment of the mesh, or sepsis. The recurrence rate in non-
(1). The AF.C. inquiry12 listed 22 deaths (1.2%) out of 1085 pa- prosthetic repairs in this group was 45%. In the report of Louis
tient prosthetic repairs, including 18 respiratory failures after et al.,15 9 of 18 recurrences occured without septic complications,
emergency surgery. and the causative factors for recurrence were multiparity and pul-
Mathonnet et al. ll reported four (4%) general complications monary pathology.
without mortality. These statistics show higher morbidity and mor- Dufilho 18 reported 10 recurrences out of 150 prosthetic repairs
tality rates for incisional hernias than for groin hernias but lower (6.7% ); these failures were associated with sepsis (4 cases), in-
morbidity and mortality rates when mesh is used in hernia surgery testinal fistulas (3 cases), and mesh breakage (2 cases). The main
than when it is not used. The implications are that repairs with etiological risk factors were obesity and pulmonary pathology. The
polyester mesh are not risky and that Dacron material is well tol- AF.C. report12 revealed 53 recurrences out of 616 prosthetic re-
erated provided that it is avoided in septic situations. pairs (8.6%) and 100 recurrences following nonprosthetic repairs
(24%). Bouillot and Alexandre 19 reported 3 recurrences (0.3%);
83% of the 971 patients were reviewed at 1 year. Mathonnet et al,u
Delayed Complications reported four recurrences (4%). Table 35.5 summarizes the re-
currence rates.
Pain
Pain was a complication in 9% of incisional hernia repairs in the Conclusions
publications of Louis14,15 and resulted from the extensive retro-
peritoneal dissection; in no way does it reflect intolerance of the Abdominal wall prosthetic repairs have become commonplace in
mesh material. Exquisite pain may be due to fixation with non- the treatment of hernias, yielding far better long-term results than
absorbable sutures, and we therefore strongly recommend the use nonprosthetic repairs. Surgery using polyester mesh nevertheless
of slowly absorbable sutures. Dufilho 18 reported 16 cases of pain requires certain precautions: Do not use mesh in septic conditions;
syndrome (3.9%), incriminating sutures in 3, obesity and in- adhere to no-touch techbiques; do not place mesh within the peri-
creased tension in 1, and residual deep sepsis in 1. It is often dif- toneal cavity; select the patients who are at reasonable risk, and
ficult to differentiate accurately between pain of postoperative treat their associated pathophysiological disorders. We have tried
origin and that from degenerative spinal and pelvic origins. Nerve to establish experimental and clinical evidence of the good bio-
entrapment and other surgical nerve lesions are no more frequent compatibility of polyester, even under septic conditions where it
with than without the use of foreign material. will favorably compare with all the current prosthetic materials.
This quality of biocompatibility allows for the use of very large
pieces, widely overlapping a wall defect, a principle of repair we
Bulg;ing consider essential. The physical qualities of polyester mesh,
namely, suppleness and "stickiness," in addition to its low cost, have
Bulging was noted in 4% of our series of incisional herniorrha- led us to prefer it to other, more rigid and expensive materials,
phies and is a result of failure to approximate the muscular or fas- particularly in groin hernia repairs, where giant bilateral pieces of
cial edges of a defect, whether of necessity or on principle. The polyester mesh can widely envelop the visceral sac, rendering it in-
elastic quality of polyester mesh is a contributory factor and is all extensible, so that herniation cannot recur. The contribution of
the more regrettable when the anatomical and functional results Dacron mesh is of prime importance in unilateral giant prosthetic
are good. reinforcement of the visceral sac, a technique that has gained wide
acceptance. Polyester mesh, as we use it, is considered a good sub-
stitute for the endoabdominal fascia. This substitution is needed
Recurrences in difficult repairs of groin or ventral hernias. Research aimed at
improving prosthetic materials must seek higher mechanical
In a series of 1223 giant bilateral Dacron prosthetic repairs, Stoppa strength without sacrificing suppleness, lightness, and porousness,
and Warlaumont16 reported a global recurrence rate of 1.4%, or the qualities we look for with the greatest of interest in the surgi-
cal repair of the abdominal wall. Polyester (Dacron) mesh has de la mise en place par voie inguinale d'un tulle de Dacron non fendu
made an important and fruitful contribution to our surgical re- avec parietalisation des elements du cordon. Ann ChiT. 1996;50(9):
pair of hernia. 803-807.
20. Rives J, Pire JC, Flament JB, et al. Le traitement des grandes eventra-
tions. Nouvelles indications therapeutiques a propos de 322 cas.
Chirurgie. 1985;11:215-225.
References 21. RivesJ, PireJC, F1amentJB, et al. Major incisional hernia in surgery of
the abdominal wan. Berlin: Springer-Verlag; 1985:116.
1. Haskey RS, Gibler FC. Difficult hernias: Mersilene mesh in the repair 22. Brown GL, Richardson JD, Malangoni MA, et al. Comparison of pros-
of hernias.] Kans Med Soc. 1975;76:239. thetic materials for abdominal wall reconstruction in the presence of
2. Munshi IA, Wantz GE. Traitement des hernies femorales recidivees et contamination and infection. Am Surg. 1985;201:705-711.
pre-vasculaires par renforcement du sac visceral a l'aide d'une pro- 23. Law NW, Ellis H. A comparison of polypropylene mesh and expanded
these geante (GPRVS). Chirurgie. 1996;121:321-325. polytetrafluoroethylene patch for the repair of contaminated abdom-
3. Wantz GE. Giant prosthetic reinforcement of the visceral sac. Surg Gy- inal wall defects. An experimental study. Surgery. 1991;109:652-655.
necolObstet. 1989;169:408-417. 24. Usher FC, GannonJP. Marlex mesh, a new plastic mesh for repairing
4. Wantz GE. The technique of giant prosthetic reinforcement of the vis- tissue defects (I). Experimental studies. Arch Surg. 1959;78:131-137.
ceral sac performed through an anterior groin incision. Surg Gynecol 25. Levasseur JC, Lehn E, Rignie P. Etude experimentale et utilisation clin-
Obstet. 1993;176:497-500. ique d'un nouveau materiel dans les eviscerations graves post-opera-
5. Adler R, Mendez M, Darby C. Effects of implanted mesh on the toires. Chirurgie. 1979;105(7):577-581.
strength of healing wounds. Dis Colon Rectum. 1962;52:898-904. 26. Levasseur JC, Lehn E, Rignier P. La contention interne par prothese
6. Cerise E, Busuttil R, Graighead C, et al. The use of Mersilene® mesh resorbable dans Ie traitement des grandes eviscerations. ] ChiT. 1979;
in repair of abdominal wall hernias. Ann Surg. 1975;181:728-734. 116:737-740.
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plastic materials. Arch Surg. 1957;74:139-144. resorbable de polyglactine 910 dans Ie traitement des hernies et des
8. Rath AM, Zhang J, Amouroux J, et al. Les protheses parietales ab- eventrations.] Chir. 1980;117:563-564.
dominales. Etude biomecanique et histologique. Chirugie. 1996;121: 28. Rignier P. Etude experimentale d'une prothese a resorption lente. Son
253-265. interet dans Ie traitement des eviscerations post-operatoires. These
9. Soler M, Verhaeghe P, Essomba A. Le traitement des eventrations post- med, Reims, 1979.
operatoires par prothese composee (polyester-polyglactine 910), etude 29. Darmaillacq R, Churet JP. Lesion intestinale tardive causee par une
clinique et experimentale. Ann ChiT. 1993;47(7):598-608. prothese metallique de la paroi abdominale. Mem Acad Chir. 1966;
10. Becouann G, Szmil E, Leroux C, et al. Cure chirugicale des eventra- 92:547-548.
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de Dacron.] Chir. 1996;133(5):229-232. Clin North Am. 1971;51:1387-1389.
11. Mathonnet M, Antarieu S, Gainant A, et al. Eventrations post-opera- 31. Bothra R Late onset small bowel fistula due to tantalum mesh. Am]
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de Chirurigie. Paris: Masson; 1990:149-168. placee lors d'une cure d'eventration ala fa<;on d'un corps etranger
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] Chir. 1985;122:523-527. 34. Bedouret B. La migration des protheses utilisees dans les cures de
16. Stoppa R, Warlaumont C. The midline preperitoneal approach to and hernie ou d'eventration de la paroi abdominale. These med. Greno-
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36
Polypropylene Prostheses
Parviz K Amid
Pioneered by Francis Usher, the first generation of Marlex® mesh Permanence

made of polyethylene (a Phillips petroleum product) was intro-
duced in 1958. It provided the strength and inertness lacking in A suitable mesh for hernia repair should be nonabsorbable and
other prostheses but could not be easily sterilized and thus proved permanent. Absorbable biomaterials are recommended only for
unsatisfactory. In 1962, a polypropylene version of Marlex was de- temporary abdominal closure in cases of contamination or trauma.
veloped. This material not only provided the advantages of poly- They are unsatisfactory materials for use in permanent abdominal
ethylene but also permitted sterilization by autoclaving. [Editor's wall reconstruction. 9 A rat model study suggested possible benefit
note: To avoid confusion, references to experiments with this ma- from implantation of polyglactin mesh in the groin for repair of
terial that predate the name change from Marlex to Bard® mesh inguinal hernias. 10 According to this study, the mesh is replaced
will refer to "Marlex," the name that appears in the literature on by polarized collagen bundles oriented along the lines of stress.
the experimental results.] Morphologically, this implies that the newly formed collagen bun-
The necessary qualities of synthetic biomaterials have been well dles should be as strong as normal connective tissue. However, it
described by Cumberland1 and Scales. 2 The ideal synthetic mesh is doubtful that the resulting fibrous tissue can escape the in-
should be chemically inert, nonallergenic, noncarcinogenic, ca- evitable collagen metabolic disorder with the passage of time. Fur-
pable of resisting mechanical strains and withstanding sterilization, thermore, our animal experimentation, as well as the experiments
and should not produce foreign body reactions or be physically of other investigators,S have shown that such fibrous tissue can-
altered by tissue fluids. Polypropylene is produced by closely con- not resist intraabdominal pressure or prevent hernia formation
trolled polymerization of propylene, a derivative of propane gas. (Fig. 36.2).
It displays the excellent chemical resistance of hydrocarbon poly-
mers and has an outstanding hinge life,3 excellent stress crack re-
sistance, burst strength (psi) of more than 25 pounds, suture
retention of 10.7 pounds (warp) and 6.9 pounds (course), and
stretchability of 60% (warp) and 20% (course). Long-term stud- Resistance to Infection
ies have shown that the tensile strength of polypropylene im-
planted in tissue remains unchanged.3-5 Decades ago, surgeons learned that the use of multifilament
Monofilament polypropylene meshes, referred to as type I bio- braided sutures, which excluded macrophages but not bacteria,
material,6 an example of which is shown in Fig. 36.1, are the only frequently resulted in infection, foreign body granuloma, and si-
biomaterials available today that fulfill all the requirements, par- nus tract formation.I 1 Figure 36.3 shows a microscopic photo-
ticularly the following critical characteristics. graph of tissue with embedded Marlex mesh removed from a
patient who had developed a chronic draining sinus tract after
an inguinal hernia repair with Marlex mesh. The presence of for-
eign body reaction and granuloma at first glance can easily be
Inertness blamed on the use of the mesh. However, when examined under
higher magnification and polarized light, it becomes apparent
All available biomaterials, such as polypropylene meshes, ex- that the foreign body granuloma was caused by the multifilament
panded polytetrafluoroethylene (ePTFE) soft tissue patch, poly- suture material used in the fixation of the mesh (Fig. 36.4). Bio-
ester mesh, and Teflon® mesh, are well tolerated, without evidence materials that contain pores or spaces of less than 10 /-Lm in any
of rejection, polypropylene meshes being the least reactive of the of their two surface dimensions may increase the chance of in-
synthetic materials used under test conditions. 7,s Assumed infection and sinus tract formation. 12 Bacteria averaging 1 /-Lm in
stances of rejections are usually a misinterpreted infectious process size can hide in such small spaces and proliferate while being
or histiocytic reaction due to the micro porosity of the materials protected from neutrophilic granulocytes averaging lO to 15 /-Lm
used. in size.

36. Polypropylene Prostheses 273
FIGURE 36.3. Foreign body reaction to multifilament suture material (low

FIGURE 36.1. Scanning electron micrograph of Marlex mesh. power) .
Macroporous biomaterials with pore sizes larger than 10 /Lm, Rapid Fibrinous Fixation
such as type I biomaterials, do not promote or harbor infection.
Furthermore, when the surgical field becomes infected, a type I Rapid fibrinous fixation of biomaterials by the host's endogenous
biomaterial does not have to be removed. In these situations, fibrin is desired if seroma formation is to be minimized. This char-
drainage of the wound is all that is needed for the management acteristic, which is a function of the molecular permeability of
of the infection. Microporous biomaterials (type II biomaterials) macroporous biomaterials, decreases the chance of seroma col-
and prostheses containing a microporous component (type III bio- lection l 3 by elimination of potential dead space between the mesh
materials) can promote or harbor infection. Figure 36.5 shows a and the host tissue. Furthermore, sufficient molecular permeabil-
computed tomographic scan sinograph from a patient who de- ity provides proper scaffolding for the future fibrocytic infiltration
veloped a draining sinus tract 3 months after a bilateral inguinal into the substance of the mesh. 14 Figure 36.6A (from our animal
hernia repair with ePTFE soft tissue patch. The patch was spon- research laboratory) shows a 4 by 6 cm piece of Marlex mesh im-
taneously extruded 8 months later in spite of long-term massive planted between two layers of abdominal muscle of a rabbit. The
antibiotic therapy. In cases of infection, the biomaterials with mi- patch was fixed in place with plain catgut, and the rabbit was sac-
croporous components, such as types II and III, must be removed, rificed after 8 weeks. The polypropylene patch retained its origi-
as in the case of infected vascular grafts. nal square shape because of its rapid fibrinous fixation to the host
FIGURE 36.4. Foreign body reaction to multifilament suture material (high

FIGURE 36.2. Herniation after polyglactin mesh implant. power and polarized light).
274 P.Il Amid
a mesh with adequate pore size occurs in approximately 1 month. 14

Proper incorporation requires a pore size of 75 to 100 Mm. The
variety of monofilament polypropylene meshes (type I biomateri-
als) with pore sizes larger than 100 Mm produce complete infil-
tration of the host tissue into the entire thickness of the mesh (Fig.
36.7). Biomaterials that contain pores or spaces smaller than 75
Mm in size attract more histiocytic than fibrocytic infiltration from
the host tissue. IS The abundance of histiocytes instead of fibro-
cytes causes formation of immature, loose granulation tissue in
and around such materials. Figure 36.7 shows an example of host
tissue infiltration into the thickness of a piece of Marlex mesh re-
moved from a patient 3 years after its implantation. Figure 36.8
shows an example of inadequate host tissue incorporation of mi-
croporous ePTFE soft tissue patch removed from the same patient
4 years after its implantation.
36.5. Computed tomographic scan sinograph of sinus tract for-

FIGURE
mation in the right groin after bilateral hernia repair with ePTFE patch.
Surface Texture
A greater degree of fibrous tissue reaction and infiltration is as-
tissue during the short lifetime of the plain catgut. Figure 36.6B sociated with a textured surface prosthesis.1 6 Slight roughness of
shows a 4 by 6 cm piece of ePTFE patch that was similarly im- the surface of the individual fibers of polypropylene meshes (Fig.
planted on the opposite side of the same rabbit. Incomplete fi- 36.9) as well as the texture of its weave stimulates fibroplasia and
brinous fixation of this biomaterial during the same period of time promotes incorporation.
is apparent from its wrinkling and distortion.
A natomical Location
Host Tissue Incorporation
Experimental studies have shown that the best incorporation re-
Complete incorporation of the mesh within the host tissue is an sults from placement of the mesh between two abdominal muscle
important requirement if a solid repair is expected. The degree layersP Less ingrowth was noted after placement of mesh in the
of host tissue infiltration into the biomaterial depends on pore preperitoneal space. The least infiltration was achieved by mesh
size, surface texture, and anatomical location. between the abdominal aponeurotic tissue and the subcutaneous
fat (onlay graft)P
Based on the results obtained from animal experiments and hu-
Pore Size man clinical experience, it appears that type I biomaterials (the
variety of monofilament polypropylene meshes) are superior to
Tissue incorporation of synthetic prostheses is proportional to other available synthetic materials. They are completely inert, re-
their pore size. I4 Fibrocytic infiltration and collagen formation in sist infection and sinus tract formation, have rapid fibrinous fixa-
A B
FIGURE36.6. (A) Marlex mesh (black spots are ink marks showing the margin of the graph). (B) Gore-Tex patch (black spots are ink marks showing
the margin of the graph).
FIGURE 36.7. Complete host tissue incorporation of Marlex mesh.
FIGURE 36.9. Slight roughness of polypropylene fibres stimulate fibroplasia.
tion, become completely incorporated into the host tissue, and in Our animal studies support the experimental results of other
case of infection do not have to be removed. investigators, showing that currently available absorbable and non-
Frequently used biomaterials today are monofilament poly- absorbable biomaterials do adhere to the adjacent viscera. 20,21 Fig-
propylene meshes such as Atrium®, Bard mesh (previously Mar- ures 36.14 to 36.18 show intestinal adhesions to Marlex, Mersilene,
lex), Prolene®, and Trilex®. Examples of multifilament poly- Gore-Tex, Marlex/Vicryl, and Mersilene/Vicryl. It has been sug-
propylene mesh are multifilament Surgipro® (Fig. 36.10), gested by some authors 22 that covering the intestinal side of a non-
multifilament polyester mesh (Mersilene®) (Fig. 36.11), multifila- absorbable mesh with a layer of absorbable mesh would prevent
ment polytetrafluoroethylene mesh (Teflon) (Fig. 36.12), and adhesions and biomaterial-related intestinal fistula formation. It is
ePTFE soft tissue patch (Gore-Tex®) (Fig. 36.13). Except for the reasoned that a mesothelial lining would occur and prevent fistula
monofilament polypropylene meshes (type I biomaterials), the formation before absorption is complete. In 1994, we pointed out
biomaterials are either purely micro porous (contain pore sizes of that the intended purpose of a combination of absorbable/non-
less than 10 to 75 p..m in at least one of their two surface dimen- absorbable composites could not be substantiated by our rabbit
sions), such as ePTFE soft tissue patch, or contain microporous model experimentation. 23 Meanwhile, a report by Soler et al. 24
components such as multifilament biomaterials (Teflon, polyester, based on animal experimentations and clinical observation indi-
and Surgipro). These meshes, because of their microporosity, can cated that such combinations resulted in bowel adhesion and in-
result in histiocytic reaction and promote or harbor infection. testinal fistula in both the rat model and human subjects. More
The use of mesh for the repair of ventral hernias has come un- recently, different absorbable materials such as fibrin glue, colla-
der special scrutiny because of its propensity to generate adhe- gen, polyglycolic acid, polyglactin, Seprafilm®, and carboxymethyl-
sions when in direct contact with the intestines, which may lead
to biomaterial-related intestinal fistula formation. 18,19
FIGURE 36.8. Incomplete host tissue incorporation of ePTFE patch . FIGURE 36.10. Scanning electron micrograph of multifilament Surgipro.
FIGURE 36.14. Small bowel adhesion to polypropylene Marlex (Bard mesh) .
FIGURE 36.11. Scanning electron micrograph of Mersilene.
FIGURE 36.15. Small bowel adhesion to polyester mesh (Mersilene).

FIGURE 36.12. Scanning electron micrograph of Teflon.
FIGURE 36.13. Ten micron-scale scanning electron micrograph of Gore-Tex

Soft Tissue Patch. FIGURE 36.16. Small bowel adhesion to ePTFE (Gore-Tex) .
276
cellulose, used in combination with polypropylene mesh, have

been experimented with by other investigators. All of these stud-
ies demonstrated that absorbable/nonabsorbable composites can
only reduce the quantity and grade of adhesions. None were re-
ported to completely eliminate adhesion formation.
In 1994, we suggested covering the visceral side of the mesh with
a layer of nonabsorbable and tissue-impervious biomateria1. 23 Our
experimental animal study proved these refinements to be success-
ful for complete elimination of adhesion formation. A variety of
tissue-impervious biomaterials such as polypropylene film and sub-
micronic pore size ePTFE (Preclude® pericardial membrane and
Preclude dura substitute, manufactured by W.B. Gore Company,
Flagstaff, AZ) are available for this purpose. A commercially avail-
able version of such combinations (Composix®, manufactured by
Davol Company) is made of polypropylene mesh on the parietal
side and a layer of tissue-impervious ePTFE on the visceral side (Fig.
36.19). This product offers an excellent parietal surface for tissue
FIGURE 36.17. Small bowel adhesion to polypropylene/polyglactin 910 ingrowth while avoiding intestinal adhesion on the visceral side.
(Marlex/Vicryl) .
Conclusion
The importance of biomaterials in abdominal wall hernia surgery
is increasingly appreciated. Improvements in the recurrence rate
of in cisionaI hernias from 46% and inguinal hernias from 10% to
under l.0% for both have been reported following use of bioma-
terials. 25,26 Although decreasing, there exists an unjustified fear of
routine use of mesh in the repair of inguinal and incisional her-
nias. This is due to the negative experiences in the past when
an adequate biomaterial was not available. Mter Francis Usher
introduced Marlex mesh over three decades ago, safe suture ma-
terial for fixation of the mesh in place was not available. Compli-
cations related to braided and multifilament suture materials used
for the fixation of the mesh compounded the fear of using mesh
for the repair of abdominal wall hernias.
For the past 25 years, we have utilized Marlex mesh for the re-
pair of more than 10,000 adult groin hernias. Its utilization, to-
gether with employment of tension-free technique, has been
shown to be safe and effective. 27 More importantly, based on our
FIGURE 36.18. Small bowel adhesion to polyester/ polyglactin 910 (Mersi-
experience, as well as the experiences of more than 100 other au-
lene/Vicryl) .
thors, it reduces the postoperative pain, disability, and the recur-
rence rate, thus making the management of abdominal wall
hernias more cost effective.
References
1. Cumberland O. Uber die Verschliessung von Bauchwunden und
Brustpforten durch Versenkte Siberdrahtnetze. Cent Chir. 1900;27:257.
2. Scales JT. Discussion on metals and synthetic materials in relation to
soft tissues; tissue reaction to synthetic materials. Proc R Soc Med. 1953;
46:647.
3. Smith OS. The use of prosthetic materials in the repair of hernias. Surg
Clin North Am. 1971;51:1387.
4. Postlethwait RW. Long-term comparative study of nonabsorbable su-
tures. Ann Surg. 1970;171:892.
5. Usher CF. Hernia repair with Marlex mesh. In Nyhus LM, Harkins HN
(eds) : Hernia. Philadelphia:JB Lippincott; 1964:752.
6. Amid PK. Classification ofbiomaterials and their related complications
in abdominal wall hernia surgery. Hernia. 1997;1:15-21.
FIGURE 36.19. Composix mesh, new composite prosthesis, ePTFE on one 7. Wagner MW. Evaluation of diverse plastic and cutis prostheses in a
side, polypropylene on the other. growing host. Surg Gynecol Obstet. 1970;130:1077.
278 P.K Amid
8. Usher FC, Allen JE, Crosthwait RW, et al. Polypropylene monofilament. 18. Schneider R, HerringtonJLJr, Granada AM. The mesh repair of a di-
A new, biologically inert suture for closing contaminated wounds. aphragmatic defect later on into the distal esophagus and stomach.
]AMA.1962;179:780. Am Surg. 1970;45:339.
9. Lamb JP, Vitale T, Kaminski DL. Comparative evaluation of synthetic 19. Kaufman Z, Engelberg M, Zager M. Fecal fistula: a late complication
meshes used for abdominal wall replacement. Surgery 1983;93(5): of Marlex mesh repair. Dis Colon Rectum. 1981;24:543.
643-648. 20. Law NW, Ellis H. Adhesion formation and peritoneal healing on pros-
10. Brenner J. Implantation ofVicryl patch for inguinal hernia. Presented thetic materials. Clin Mater. 1988;3:95-101.
at the International Frascia Congress, Hamburg, Germany, May 1991. 21. Reisfeld D, Schechner R, Wetzel W. Traumatic lumbar hernia. Surg
11. Elek SD, Conen PE. The virulence of Staphylococcus pyogenes for man. Rounds. 1989;12:69-72.
Study of the problems of wound infection. Br]Exp PathoL 1957;38:573. 22. LouryIN, ChevrelJP. Traitement des eventrations. Utilization simulate
12. NeellII HB. Implants of Gore-Tex. Arch OtolaryngoL 1983;109:427-433. du treillis de polyglactine 910 et de Dacron. Presse Med. 1983;34:
13. Arnaud JP, Eloy R, Adloff M, Grenier ]F. Critical evaluation of pros- 2116.
thetic materials in repair of abdominal wall hernias. New criteria of 23. Amid PK, Shulman AG, Lichtenstein IL, et al. An experimental eval-
tolerance and resistance. Am] Surg. 1977;133:338-345. uation of a new composite mesh with the selective property of incor-
14. White RA. The effect of porosity and biomaterial on the healing and poration to the abdominal wall without adhering to the intestines.
long-term mechanical properties of vascular prostheses. ASAIO. 1988; ] Biomed Mater Res. 1997;28:373-375.
11(2):95-100. 24. Soler M, Verhaeghe P, Essomba A, et al. Treatment of postoperative
15. White RA, Hirose FM, Sproat RW, et al. Histopathologic observations incisional hernias by a composite prosthetic (polyester-polyglactin
after short-term implantation of two porous elastomers in dogs. Bio- 910). Clinical and experimental study. Ann Chir. 1993;47:598-608.
materials. 1981;2:171-176. 25. George CD, Ellis H. The results of incisional hernia repair: a 12-year
16. Taylor SR, Gibbons DF. Effectof surface texture on soft tissue response review. Ann R Coll Surg EngL 1986;68:185-193.
to polymer implants.] Biomed Mater Res. 1983;17:205-227. 26. Amid PK, Shulman AG, Lichtenstein IL. Critical scrutiny of the open
17. Dabrowiecki S, Svanes K, LevkenJ, et al. Tissue reaction to polypropyl- "tension-free" hernioplasty. Am] Surg. 1992;58:255-257.
ene mesh: a study of oedema, blood flow, and inflammation in the ab- 27. Amid PK, Lichtenstein IL. Long-term result and current status of the
dominal wall. Eur Surg Res. 1991;23:240-249. Lichtenstein open tension-free hernioplasty. Hernia. 1998;2:89-94.
37
Expanded Polytetrafluoroethylene
Nicholas Law
History cellular migration and collagen ingrowth into the macroporous

and microporous elements of the material, providing more rapid
Polytetrafluoroethylene (PTFE) has been used as a prosthetic ma- tissue fixation and incorporation. The same manufacturers have
terial for hernia repair since the 1950s, but the experimental re- also introduced DuaIMesh®, a material with different internode
sults of tissue incorporation have been rather conflicting because distances on each surface. On one side is the conventional in-
of surface and shape effects.! An abraded surface induced a ternode distance of greater than 17 /-Lm, but on the second side
greater cellular response than a smooth surface that was encap- the ePTFE is smooth, with micropores less than 3 /-Lm in size. This
sulated by a thin band of fibrous tissue. 2 A PTFE sheet, implanted small pore size resists cellular penetration and was developed to
subcutaneously in a rat, induced minimal foreign body tissue re- reduce the adhesion formation on the peritoneal surface of the
action, but, when the same material was implanted as a woven material.
cloth or felt, there was a marked ingrowth of collagen with the A more recent development by Vascutec is Fluorosoft® (Fluo-
surrounding capsule. 3 ropassiV®), a macroporous fluoropolymer tissue patch. This is a
Expanded polytetrafluoroethylene (ePTFE) was first introduced polyester material that has a fluoropolymer bonded to the poly-
into clinical practice in 1972 as a prosthetic vascular bypass mate- ester fibers to improve biocompatibility. The macro porous con-
rial. With extensive use in vascular surgery, it demonstrated ex- struction of the material allows better collagen ingrowth between
cellent biocompatibility, with collagen ingrowth into the material. the fibers of the mesh. 4 This material also has excellent suture re-
It was therefore further developed as a prosthesis for the repair tention qualities, which are similar to 2 mm ePTFE. Fluorosoft is
of soft tissue defects. available impregnated with hydrolyzable gelatine as Fluorosoft gel.
The gelatine is able to act as a reservoir for antibiotic bonding,
which may provide protection against infection in a contaminated
environment. 5
Mechanical Characteristics
Expanded PTFE is a soft, smooth material that has a porous mi- Tissue Incorporation
crostructure composed of nodes of solid ePTFE interconnected
with thin fibrils of the material. The standard patches used for soft Observations from experimental work and clinical specimens have
tissue reconstruction have an internode distance of between 17 shown that ePTFE implanted into the abdominal wall produced a
and 41 /-Lm, with a multidirectional fibrillary arrangement that pro- mild inflammatory reaction adjacent to the patch, which resolved
vides equal strength in all planes (Fig. 37.1). Expanded PTFE is a after 8 weeks. Mter implantation, collagen infiltration gradually
strong material that exceeds requirements for the repair of most reaches greater depths, up to 25 /-Lm at 1 week, increasing to 75
soft tissue defects and is available in sheets of 1 or 2 mm thick- /-Lm at 4 weeks. By 8 weeks collagen infiltration is between lOO and
ness, depending on the strength of the material required. During 150 /-Lm, with extensions to 300 /-Lm in localized areas (Fig. 37.2).6
the early phase of healing, it is important for any prosthetic ma- Greater collagen infiltration was observed throughout the perfo-
terial to retain the sutures that anchor it to the fascia. Expanded rated Mycro-Mesh material. Collagen bridges linking the newly
PTFE is designed not to fray and therefore has excellent suture formed tissues on either side of the mesh were established at the
retention strength, as documented in Table 37.1. sites of the Mycro-Mesh perforations. 7 In contrast, polypropylene
To improve the tissue ingrowth characteristics of the smooth mesh (PPM), an open-weave material, is incorporated by dense
patch, W.L. Gore has developed Mycro-Mesh®. One surface of My- whorled fibrils of collagen that invest the individual fibers of the
cro-Mesh is smooth, while the other side has shallow geometric material. 6 The Fluorosoft tissue patch is encapsulated by thick col-
depressions, with a macroscopic pore at each apex, approximately lagenous tissue by 2 weeks, and by this time the gelatine of the
2 mm in diameter. This change in material format increases the Fluorosoft gel has been completely absorbed. s
279
280 N. Law
FIGURE 37.1. The scanning electron micrograph shows the node and fibril
structure of ePTFE (Gore-Tex Soft Tissue Patch). The homogeneous black
regions are the solid nodes of the material; between these the expanded
fibrils can be seen (X250).
Abdominal Wall Strength

Mter Implantation
Recurrent herniation after repair with prosthetic materials most
commonly occurred at the interface between the abdominal wall
muscle and the prosthetic material. 9 This important region must,
therefore, be studied to measure the strength of the repair at the
FIGURE 37.2. Scanning electron micrograph showing two fibroblasts and
interface. Tensiometric studies should be performed with dumb- collagen deposition (X2400).
bell-shaped specimens of uniform dimensions, as used in engi-
neering practice, and taken from the same site in each animal.
An experimental comparison of ePTFE and PPM was performed
using these criteria. A 4 mm interface for PPM was stronger t~an
that of ePTFE at all time intervals from 1 to 22 weeks after Im-
Peritoneal Healing
plantation, although this difference never reached statis.tical sig-
There are significant differences in peritoneal healing when
nificance. The interface of ePTFE gains strength more rapidly than
ePTFE is compared with PPM.1° Scanning electron microscopy
that of PPM as the overlap between the fascia and the prosthetic
confirmed the regenerated mesothelial cells on the peritoneal sur-
material increases. The histological appearance of the incorpo-
face of the ePTFE 4 weeks after implantation at 17 days and 2 years
rated materials explains the variation in the strength of the inter-
(Figs. 37.3 and 37.4). In contrast, mesothelial cells were seen in
face. The PPM is invested by irregular whorled collagen fibers
an irregular pattern on the peritoneal surface of the PPM and
compared with the finer collagen infiltration of ePTFE. The finer
were found only in association with fatty omental adhesions.
collagen fibers require a wider interface to achieve the same
Assessment of the adhesions to each material showed that they
strength, as the more dense investment of collagen around PPM
were significantly less dense with ePTFE than with PPM, although
or other mesh materials. Thus the interface for PPM is stronger
there is no difference in the frequency with which either bowel or
for a small area, but, when implanted, ePTFE is a more supple ma-
omentum was adherent. lO •1l There was no difference in adhesion
terial because of the finer collagen infiltration. When ePTFE is
formation with ePTFE and with DualMesh, suggesting that the
used clinically for abdominal wall reconstruction, a large interface
lower porosity of the DualMesh is less important in view of its re-
should be created to give a wide area for collagen infiltration that
sistance to adhesion formation. Mycro-Mesh had more adhesions
will produce a strong abdominal wall repair.
than either DualMesh or ePTFE.12 Adhesion formation to Mycro-
Mesh implants appeared to start at the site of the perforations,
suggesting that the material's porosity may be an important factor
in adhesion genesis (Fig. 37.5).7
TABLE 37.1. Material and suture retention strength of 1 and 2 mm
expanded PTFE patches
1 mm patch 2 mm patch Infection
Material strength (kg/cm) 11 + 1.7 22 + 1.5 Evidence from ePTFE vascular grafts inserted for hemodialysis ac-
Suture retention 0.89 + 1.5 1.6 + 0.34
cess suggests that local sepsis around the graft may be treated by
37. Expanded Polytetrafluoroethylene 281
FIGURE 37.3. Fibroblasts, macrophages, and occasional foreign body giant FIGURE 37.5. Histological slide of Mycro-Mesh biomaterial 7 days after im-
cells were present in the tissue layer directly adjacent to the soft tissue plantation in a New Zealand white rabbit. The macropore is filled with
patch surface. A few macrophages and fibroblasts were noted within the early granulation tissue (H&E; X25) .
soft tissue patch interstices (hematoxylin and eosin stain [H&El; X50) .
drainage of the abscess and intravenous antibiotics, without re- contaminated wounds. Histological assessment of contaminated
moval of the prosthetic material. 13 The initial promising results wounds showed that PPM was invested by the same whorled col-
from infected vascular prosthesis stimulated investigation of the lagen fibers seen in the noncontaminated wound. However, col-
effects of contamination on ePTFE implanted into the abdominal lagen infiltration into ePTFE was scanty and irregular at 4 weeks,
wall. reaching a maximum depth of only 50 /-Lm. The protein matrix
Brown et al. 14 demonstrated that in wounds contaminated with and fibrous tissue around the patch were loose and not adherent
Staphylococcus aureus there were significantly fewer organisms ad- to the material, as collagen fibers had failed to penetrate the in-
herent to ePTFE than to PPM after surgery, which may be a prop- terstices of the ePTFE (Fig. 37.6).1 5
erty of bacterial adherence to the individual materials. In the The physical characteristics of these two materials may explain
presence of a mixed fecal peritonitis, the bacterial numbers on the different response . PPM allows organisms access through the
ePTFE and PPM were similar, but there were fewer complications mesh to the peritoneal cavity but is able to clear the bacteria from
associated with the ePTFE. There was, however, a marked differ- an infected focus. In contrast, ePTFE acts as a physical barrier be-
ence in the healing of experimental wounds repaired with ePTFE tween the peritoneum and the wound and may thus prevent this
and PPM and contaminated with S. aureus.15 Analysis of wound process. Arnaud et al. 16 have demonstrated that, in infected ab-
strength demonstrated that the interface of ePTFE was signifi- dominal wounds, porous mesh materials are more tolerant of sep-
cantly weaker than that of PPM up to 4 weeks postimplantation sis than nonporous woven materials, which act as a physical barrier
and significantly weaker than that of ePTFE implanted in non- to the clearance of infection by the peritoneal cavity.
In contaminated wounds, the peritoneal surface of ePTFE did
not show a continuous layer of mesothelial cells. Scanning elec-
FIGURE 37.4. An ePTFE (Gore-Text Soft Tissue Patch) implanted to repair

a ventral hernia and retrieved at 2 years. The implant is firmly incorpo-
rated with the host tissue. The external peri-implant membrane appears
bland and is continuous into the interstices with collagen deposition (Mil- FIGURE. 37.6. Incomplete host tissue incorporation of ePTFE patch 4 weeks
ligan's trichrome stain; X25). after implantation and contamination with Staphylococcus aureus.
282 N. Law
tron microscopy demonstrated scattered individual mesothelial ducing excessive fibrosis. PPM mesh, when studied histologically,
cells, which were not in continuity.IO In the presence of a staphy- is infiltrated by irregular whorled collagen fibers, creating a dis-
lococcal wound infection, the grade of adhesions to ePTFE was organized repair. In comparison, ePTFE is infiltrated by fine col-
not different from that of PPM at 2 and 4 weeks after implanta- lagen fibers that run in a more ordered fashion both parallel with
tion; this contrasts with the fewer adhesions seen with ePTFE in and perpendicular to the nodal microstructure. Mechanical mis-
noncontaminated wounds. This evidence adds support to the be- match between the material and the tissues may playa part in the
lief that generation of a mesothelial layer on the peritoneal sur- failure of this interface, and the more supple repair of ePTFE gives
face of ePTFE helps to prevent the development of high-grade a closer mechanical approximation to the abdominal wall, which
adhesions to the material. lO may reduce the incidence of failure at this interface. However, the
A major problem of the use of prosthetic materials is the de- size of overlap between the tissue and the material is by far the
velopment of wound infection and the need for prosthetic mate- most important factor in the security of any repair. If sufficient
rials in the repair of a contaminated wound. This has stimulated overlap cannot be achieved, Mycro-Mesh should be implanted for
the development of antibiotic impregnated materials to reduce the stronger interface ensured by its macroporous structure.
this complication. Expanded PTFE impregnated with silver
chlorhexidine was able to resist infection with S. aureus. 17 Similarly,
Mycro-Mesh impregnated with silver chlorhexidine (Mycro-Mesh
Plus) showed only an 11 % rate of infection by S. aureus compared
Onlay Repair for Inguinal
with an 80% infection rate with ePTFE in discs placed in the sub- Hernia with ePTFE
cutaneous tissues. Scanning electron microscopy showed the de-
velopment of a bacterial biofilm on the surface of ePTFE, but Although a local anesthetic may be used, general anesthetic is pre-
impregnation with silver chlorhexidine provided resistance to the ferred, as extensive dissection is sometimes required particularly
bacterial biofilm formation. 18 for recurrent hernias. The groin is prepared and draped and the
Fluorosoft gel can be impregnated with antibiotic before im- skin covered by an occlusive skin drape. Antibiotic prophylaxis is
plantation, and soaking with rifampicin, vancomycin, or genta- given routinely. A standard dissection is performed to expose the
micin prevented mesh infection compared with nonimpregnated cord structures and the deep inguinal ring. The hernial sac or sacs
material in the presence of S. aureus infection. All the nonim- are identified and excised, and the femoral canal is inspected to
pregnated material developed a bacterial biofilm, but this was in- rule out a hernia at this site. The floor of the inguinal canal is dis-
hibited by the impregnation of the antibiotics. 5 With the further sected, along with the reflected part of the inguinal ligament and
development of antibiotic impregnation and bonding to these ma- the muscle lateral to the deep ring so that all areas can be rein-
terials, it is hoped that their use can be widened into the field of forced with the ePTFE patch.
contaminated wounds. Most commonly a 1 mm thick ePTFE patch is used for the re-
pair. This is shaped to fit the floor of the inguinal canal following
the line of the inguinal ligament, with the apex sutured medial to
the pubic tubercle. A keyhole is then cut into either the lateral or
Clinical Uses of ePTFE the superior edge of the patch to accommodate the cord struc-
tures. The ePTFE is anchored medial to the pubic tubercle and
The repair of mcyor abdominal wall defects and large incisional
sutured with 2-0 Prolene® to the inguinal ligament. The patch is
hernias remains a complex surgical problem. Many prosthetic ma-
sutured superiorly to the conjoined tendon and continues later-
terials have been used for abdominal wall replacement, but none
ally to the deep ring to support this region. The two limbs of the
of these currently available materials is entirely satisfactory. The
keyhole are sutured together to provide a snug fit around the sper-
ideal prosthetic material should be biologically inert, yet it must
matic cord with the ilioinguinal nerve protected. The wound is
provide a strong and permanent repair of the defect with a min-
closed in layers.
imal reaction from the host tissues. It should allow ingrowth of
LeBlanc and Booth 19 reported the use of ePTFE for primary re-
connective tissue to provide wound strength yet stay pliable and
pair of inguinal hernias using this technique. None of the 94 her-
maintain its form long after implantation. However, it should not
nias repaired showed any signs of recurrence in the short mean
induce the formation of adhesions on the peritoneal surface. With
follow-up period of 2.6 years. Expanded ePTFE has been used suc-
the wider use of these materials in the presence of abdominal
cessfully in the repair of inguinal hernias using the preperitoneal
trauma or for abdominal decompression in the presence of sep- approach.20
sis, the behavior of the materials in adverse conditions is impor-
Recurrent inguinal hernias present a more difficult challenge.
tant. The reaction of the material to the underlying peritoneal
Early in our experience with ePTFE, 52 selected patients under-
contents is of vital importance, as is the response of the material
went recurrent inguinal hernia repair following previous surgery
to contamination or sepsis.
using either a nylon dam or the Shouldice technique. 21 The num-
ber of previous hernia repairs performed in each patient of this
group ranged from one to seven, with a median of two previous
Inguinal Hernias repairs. Mter a follow-up period of just under 2 years, there were
five re-recurrent hernias (10%). The two femoral recurrences and
For primary inguinal hernia repair using a conventional open ap- one prevascular recurrence were successfully repaired by suturing
proach, the prosthetic material is placed in a clean environment a second ePTFE patch across the defect. The remaining two re-
and not in contact with the peritoneal surface. In these circum- recurrences were early in the series and occurred medial to the
stances the best material is one that is easily incorporated into the ePTFE patch, due to insufficient overlap adjacent to the pubic
surrounding tissues but remains supple and flexible without pro- tubercle.
Expanded PTFE Repair of ical experience with the laparoscopic intraperitoneal placement
of DualMesh has not included any problems of intestinal ob-
Abdominal Wall Defects struction after inguinal hernia repair26 and only one instance af-
ter ventral hernia repair.27
An abdominal wall defect, caused by an incisional hernia or pro-
Expanded ePTFE patches have been used for the successful re-
duced as a result of tissue excision for a tumor, should be repaired
pair oflumbar hernias 28 and diaphragmatic hernias. 29 Abdominal
with a prosthetic material if there is insufficient tissue for primary
wall defects secondary to tumor excision have been successfully re-
repair.
paired with ePTFE,22,3o using the technique described above. Ex-
perimental evidence suggests that ePTFE acts as a physical barrier
to recurrent tumor and may limit the extent of invasion into the
Repair of Abdominal Wall Defects peritoneal cavity for tumor recurrence in the skin and wound. 31
Seroma is a well-recognized complication of the repair of soft
The use of materials for repair of abdominal wall defects needs tissue defects using prosthetic materials. Experimental evidence
much careful consideration. The interaction between the mesh, suggests that this is more commonly seen with ePTFE than PPM
the peritoneal surface, and the underlying peritoneal contents is and may be a consequence of ePTFE acting as a physical barrier
of paramount importance. Similarly, the reaction of the mesh to to fluid resorption through the peritoneal cavity.15 The incidence
contamination or infection will influence healing in the final out- of seroma ranges between 0 and 15%21-24 and is probably related
come for the repair. to the size of material inserted. It usually responds to repeated as-
piration.
Clinical experience with polypropylene mesh within the peri-
Surgical Technique toneal cavity has shown serious complications, including erosion
into abdominal organs, bowel fistulas, and extrusion of the
The technique used to repair large abdominal wall defects must mesh. 32- 36 In many reports of ventral hernia repair using ePTFE,
allow patch-to-fascia suturing of the ePTFE. If ePTFE is sutured to the mesh has been placed within the peritoneal cavity. There are
the edge of the defect without overlap, then a high incidence of no reports of intestinal obstruction secondary to adhesions to this
recurrence is seen through potentially weak areas. 22- 25 This clini- material or of intestinal fistulas developing as a result of erosion
cal finding is explained by the experimental study described above into the bowel. Once again, these clinical findings bear out the
that relates the strength of the interface to its size. experimental data described above.
The operation should be performed under a general anesthetic If ePTFE becomes infected, in most circumstances the patch
and antibiotic prophylaxis. The skin is covered with an occlusive should be removed. However, intensive local wound care to help
drape to reduce contamination of the wound. The hernia sac is infection to drain has resulted in wound healing. 22 ,24 Expanded
dissected free and the fascial margins debrided to expose healthy PTFE patches are most frequently infected when implanted in
fascia over the abdominal wall muscles. The peritoneal cavity is wounds that have been previously contaminated or are close to an
entered, and any loops of bowel or omentum adherent to the edge intestinal stoma or in multiple recurrent hernias where previously
of the defect are dissected free to prevent injury during recon- infected materials have been removed. Although a wound may not
struction. The sheet of ePTFE, either 1 mm for small defects or 2 appear infected at the time of surgery, up to 50% will develop in-
mm for larger defects, is cut to the contour of the wound. The fection in the postoperative period. 25 With the development of sil-
peritoneum is closed, using a DualMesh prosthesis if there is in- ver sulfasalazine bonding to ePTFE and the ability of Fluorosoft
sufficient tissue for closure; the 3 JLm surface lies on the peritoneal
contents to reduce adhesion formation. The patch is sutured to
the fascial margin with interrupted 2-0 polypropylene sutures (Pro-
lene) placed several centimeters from the edge of the patch. The
ePTFE is then tailored so that the normal abdominal contour is
restored by placing very slight tension on the repair to keep the
material flat. A second continuous 2-0 polypropylene suture is
placed around the edge of the material and sutured to the fascia,
with a 2 cm overlap of ePTFE and abdominal wall fascia. The ab-
dominal wall fat and skin are closed over a suction drain, which
is removed when the drainage fluid reduces.
The incidence of recurrent hernias is between 10 to 13%,22,24
but this is often a result of edge-to-edge suture to the fascia that
fails to allow sufficient overlap.23 If a recurrence does occur around
the edge of the ePTFE material, then a further patch may be su-
tured over the defect to complete the repair. 21 ,23
The choice of material for laparoscopic inguinal or ventral her-
nia repair rests on the position of the material for the recon-
struction. An extraperitoneal approach for groin hernias can
FIGURE 37.7. Scanning electron micrograph of a newly modified DualMesh
be treated in the same way as an open operation with ePTFE or biomaterial revealing the surface with the open microstructure. This sur-
Mycro-Mesh if the overlap with normal tissues is poor. However, if face appears irregular and ruilled to allow for cellular infiltration of the
the repair is intraperitoneal, DualMesh should be implanted to re- microstructure of the material as well as provide for vascularization around
duce the risk of adhesion and possible intestinal obstruction. Clin- and within the material (X200).
284 N. Law
8. Guidoin R, Marois Y, King M, Martin L, Laroche G, AwadJ. The ben-

efits of fluoropassivation of polyester arterial prostheses as observed in
a canine model. ASAIO J 1994;40:870-879.
9. Larson GM, Harrower HW. Plastic mesh repair of incisional hernias.
Am] Surg. 1978;135:559-563.
10. Law NW, Ellis H. Adhesion formation and peritoneal healing on pros-
thetic materials. Clin Mater. 1988;3:95-101.
11. Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex and Gore-
Tex to repair abdominal wall defects in the rat. Can] Surg. 1989;
39:244-247.
12. Bujan J, Contreras L, Carrera-San Martin A, Bellon J. The behaviour
of different types of polytetrafluoroethylene (PTFE) prostheses in the
reparative scarring of abdominal wall defects. Histol Histopathol. 1997;
12:683-690.
13. Bhat DJ, Tellis VA, Kohlberg WI, Driscoll B, Veith FJ. Management of
sepsis involving expanded polytetrafluoroethylene grafts for haemo-
dialysis access. Surgery. 1980;87:445-450.
14. Brown GL, RichardsonJD, Malangoni MA, Tobin GR, Ackerman D,
FIGURE 37.8. At 30 days, a higher magnification of the surface with the ruf- Polk HC. Comparison of prosthetic materials for abdominal wall re-
fles shows firm incorporation of the material into the host tissue. construction in the presence of contamination and infection. Ann Surg.
1985;201:705-711.
15. Law NW, Ellis H. A comparison of polypropylene mesh and expanded
polytetrafluoroethylene patch for the repair of contaminated abdom-
inal wall defects: an experimental study. Surgery. 1991;109:652-655.
to bond with rifampicin and other antibiotics, these materials will 16. Arnaud JP, Eloy R, Aprahamian M, Adloff M, Grenier JF. The use of
playa more important role in potentially infected wounds. mesh materials in the repair of infected wounds: experimental study.
Patients who require a prosthetic material to close a traumatic In Winter GFD, Leray JL, Degroot K (eds); Evaluation of biomaterials.
Chichester, England: John Wiley & Sons, 1980:453-457.
abdominal wall defect, or to support the wound after abdominal
17. Dent L, Modak S, Sampath L, Oluwole S, Hardy M. Evaluation of an
decompression for conditions such as acute pancreatitis, present infection resistant silver-chlorhexidine impregnated PTFE soft tissue
a difficult clinical problem. Expanded PTFE has a much lower in- patch. Surg Forum. 1992;18:70-72.
cidence of fistula formation,36 although fluid produced in the peri- 18. Malaisrie S, Malekzadeh S, Biedlingmaier J. In vivo analysis of bacter-
toneal cavity will not drain satisfactorily through Mycro-Mesh ial biofilm formation on facial plastic bioimplants. Laryngoscope. 1998;
pores. The PTFE bonded Fluorosoft patch with an impregnated 108:1733-1738.
antibiotic may resist infection and reduce fistula formation while 19. LeBlanc KA, Booth WV. Repair of primary and secondary inguinal her-
allowing fluid to drain, although as yet there is no clinical evidence nias using an expanded polytetrafluoroethylene patch. Contemp Surg.
to support this. 1992;41:29-32.
20. Pailler JL, Baranger B, Darrieus H, Schill H, Neveux Y. Clinical analy-
A newer DualMesh with a parietal side that appears ruffled to
sis of expanded PTFE in the treatment of recurrent and complex groin
allow for greater cellular infiltration is presently being introduced.
hernias. Postgrad Gen Surg. 1992;4:168-170.
Reports of its use are sure to follow (Figs. 37.7 and 37.8). 21. Law NW, Ellis H. Preliminary results for the repair of difficult recur-
rent inguinal hernias using expanded PTFE patch. Acta Chir Scand.
1990;156:609-612.
22. Bauer lJ, Slaky BA, Gelernt 1M, Kreel 1. Repair oflarge abdominal wall
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10:391-397. dominal wall defects. Br] Surg. 1989;76:803-805.
2. Salthouse TN, Matlaga BF. Effects of implant surface on cellular ac- 24. DeBordJR, Wyffels PL, Marshall S, Miller G, Marshall WH. Repair of
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Degroot K (eds) : Evaluation of biomaterials. Chichester, England. prosthetic patches. Postgrad Gen Surg. 1992;4:156-160.
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5. Goeau-Brissoniere 0, Leflon V, Letort M, Nicolas M. Resistance of an- 1998; 12:955-959.
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in a rabbit subcutaneous pouch model. Biomaterials. 1999;20:229-232. cal Rounds. March 1989.
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31. Law NW. The influence of prosthetic materials on the growth of Walker 34. Kaufman Z, Engleberg M, Zager M. Fecal fistula: a late complication
256 tumour in the rat. EurJ Surg OncoL 1990;16:237-239. of Marlex mesh repair. Dis Colon Rectum. 1981;24:543-544.
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38
Vypro®: A New Generation of Polypropylene Mesh
U. Klinge, B. Klosterhalfen, and V. Schumpelick
Introduction formed, building a three-dimensional framework around and

through the mesh. The number of fibroblasts and the degree of
vascularization correlate inversely with the overall extent of in-
The use of prostheses has become essential in the repair of re- flammation, although an initial phase of intense acute inflamma-
current abdominal wall hernias. Sutured pure tissue techniques, tion encourages the development of fibrous tissue.
reapplied after failure of the primary repair, are characterized by Whereas the strengthening of the abdominal wall to prevent the
recurrence rates of over 50%, while the reinforcement of the ab- recurrence is the main task of meshes, functional restrictions can
dominal wall with surgical meshes has significantly decreased these impair the quality of life. According to recent reports,12,13 about
rates to less than 10% .1,2 For some years, the failure of pure tissue half of the patients with a large mesh prosthesis within the ab-
re-repairs has been linked to a disorder of connective tissue im- dominal wall express complaints, such as paresthesia at the pal-
plicated in hernia formation. 3,4 Generally, the task of the pros- pable stiff edges of the mesh and the physical restriction of
thesis is to effect the mechanical sealing of the fascial defect and abdominal mobility. The removal of a mesh because of pain is rare,
to encourage wound healing processes. yet even minor complaints can affect the quality of life consider-
The first task of the mesh is to provide sufficient mechanical ably.
strength to meet physiological requirements in order to effect a In 1996, we suggested that the mechanical data of the abdomi-
permanent seal of the defect. The tensile strength of a fascia clo- nal wall after mesh implantation should correspond with physio-
sure is a function of the intraabdominal pressure, which ranges logical values both to reduce the amount of implanted material
up to 20 kPa in normal adults. 5,6 The tensile strength of the nor- and to diminish the inflammatory tissue response. In cooperation
mal abdominal wall is calculated as the product of the tensile with Ethicon, in Germany, we constructed a new mesh with a me-
strength according to the formula of Laplace and the area of the chanical strength of 16 N/cm, adapted to physiological require-
cross section. With a maximum intraabdominal pressure of20 kPa, ments (Table 38.1). This permitted a 70% reduction of the amount
the maximum required tensile strength is 16 N/cm. By this crite- of polypropylene compared with heavyweight meshes. To improve
rion, common meshes are revealed to be considerably oversized. initial intraoperative handling, the mesh is supplemented with ab-
For Prolene® mesh, an intraabdominal pressure of more than 131 sorbable polyglactin. The resulting large pores of about 5 mm pre-
kPa would be needed to cause mesh rupture. This strength is serve a high level of elasticity even when incorporated into scar
achieved by the use of unnecessary amounts of material, which tissue, as proved by animal experiments. ll ,14 It was also found that
contribute to the stiffness, the excessive foreign body reaction, and the extent of inflammation evoked by this first lightweight, large
the abdominal wall restriction associated with this and similar pore size mesh was significantly decreased. 9
"heavyweight" materials.
Although the details of the formation of a stable scar are un-
known, it is clear that a relatively long-lasting and highly active in-
flammation in the interface ultimately produces a firm scar plate Studies
around the mesh. Amid7 has clearly demonstrated the importance
of mesh structure to the clinical outcome as regards both the Materials
amount of material and the pore size. The implantation of pros-
thetic material always causes a foreign body reaction, whose in- Beginning in March 1991, all patients treated with a mesh for in-
tensity and duration depend largely on the type and amount of cisional hernia were prospectively identified. In the beginning of
the material.8-11 The acute granulocyte inflammatory reaction, ac- the prospective study, only the "heavyweight" monofilament
companied by a moderate seroma formation, is seen for about 2 polypropylene mesh Marlex® (Bard) was implanted, but in April
to 3 weeks,u The climax occurs after 14 to 21 days, after which a 1997, a change was made in favor of a monofilament polypropyl-
more or less chronic inflammation seals the foreign body into an ene mesh of intermediate (or relatively heavy) weight, Atrium®
epithelioid granuloma. Simultaneously, collagen-rich scar tissue is (Braun-Dexon), with a pore size increased by about 30%. Finally,

38. Vypro® Polypropylene Mesh 287
TABLE 38.1. Textile and material properties of the surgical mesh used in this study
Marlex Atrium Polypropylene part of Vypro Vypro
Material Polypropylene Polypropylene Polypropylene Polypropylene,

Polyglactin
Type of filaments Monofilament Monofilament Multifilament Both multifilament
Weight (g/m2) 95.1 90.2 26.8 54.6
Pore size (JIm) 600 800 5000 5000
Maximum tensile strength (N/5 cm)
Vertical 432 245 132 387
Horizontal 567 616 55 63
Subsequent tearing force (N)
Vertical 0.7 3.7 0.9 1.1
Horizontal 4.0 4.1 1.2 1.2
Forces tearing out the seam (N)
Vertical 57.2 55.8 17.5 29.6
Horizontal 55.8 56.2 22.7 29.0
Test pressing through the stamp
Maximum bursting force (N) 1656 1920 408 718
Tensile strength related to 58.8 56.2 16.1 31.9
the radius (N/cm)
Deformation at 16 N/cm (%) 14 17 31 16
in December 1997, a comparative, prospective, and randomized ter with a sample width of 50 mm at a distance of 100 mm from
clinical trial of the newly developed multifilament "lightweight" the margin of the mesh.
Vypro (Ethicon) and the intennediate weight Atrium mesh was
begun (Fig. 38.1). The results with each mesh were compared in
the areas of postoperative complications, the functional parame- Functional Examination
ters of the reinforced abdominal wall, and the material properties
listed in Table 38.1. All patients were physically re-examined by ultrasound and by
three-dimensional stereography at least 6 weeks after implantation.
The physical examination was focused mainly on the detection of
Surgical Implantation Technique recurrences, as well as on mesh-related complaints such as palpa-
ble mesh edges, paresthesia, or pain. Ultrasound examination
All meshes were implanted as underlays between the rectus mus- would reveal recurrences, dehiscence of the fascia, persisting sero-
cles and the posterior laminae of the rectus sheaths.I To com- mas, and adhesions to the intestines.
pensate for shrinkage of the mesh, with a consequent shortening The subjective assessment of the ability to bear physical strain is
of up to 40%, sufficient mesh overlap of at least 6 cm was pro- markedly affected by the selected material and correlates with its
vided. The mesh was held in place by interrupted absorbable 2-0 weight. This subjective feeling was objectified by three-dimensional
sutures. Direct contact of the intestines with the mesh surface was stereography to measure the stiffness of the abdominal wall. 15 To
thus avoided to prevent fistula fonnation. Moreover, a "buffer estimate abdominal wall mobility, a grid was projected onto the
zone" was created by interposition of the bernia sac or a small surface of the abdominal wall at maximum excursion. The defor-
cushion of omentum. In cases of considerable tension, we used mation of the projected squares was documented by a video sys-
relaxing incisions in the anterior rectus sheath. The inevitable tem. Pictures obtained from this system were digitized and
seromas were drained with tubes placed directly over the mesh analyzed by a special computer system. The curvature of the midre-
and subcutaneously for 2 to 5 days. All patients were postopera- gion was calculated from the defonnation of the squares by an au-
tively monitored by ultrasound examination after 3, 6, and 8 days. tomatic pattern recognition program (Institute of Aerodynamics,
Detectable liquid volumes of more than 60 ml were noted and re- RWTH-Aachen, Gennany). The video pictures were analyzed by
leased by puncture. software based on Matlab® 4.2b and developed for Windows®. The
calculated data of the corresponding height, the curvature at max-
imum bulge, and the radius at maximum abdominal wall excur-
Textile Analysis and Material Properties sion were compared with data from 21 healthy subjects.
Textile analysis was carried out by passing a circular mesh sample

under a stamp and measuring the force required to produce rup- Histological Analysis
ture. The defonnation (%) corresponds with the increased mesh
area compared with the initial area of the mesh before deforma- Sixty-two samples of implanted meshes were harvested at revision
tion. The elasticity of the mesh at a strength of 16 N/cm during operations and examined morphologically. The morphometric
the testing of pressing through the stamp was calculated. The ten- evaluation consisted of a quantitative cell analysis of the inflam-
sile strength of the whole mesh was estimated using a tensiome- matory reaction and the soft tissue reaction. Parameters measured
288 U. Klinge et al.
TABLE 38.2. Patient data

Marlex Atrium Vypro
Year of implantation 1991-97 1997-98 1997-98

No. of examined patients 106 36 71
Mean follow-up (months) 24 9 6
No. male 72 22 48
No. female 34 14 23
Mean age (years) 58 56 63
Mean height (cm) 172 172 172
Mean weight (kg) 81 83 82
Mean body mass index 27.2 27.8 27.8
Mean size of the mesh (cm 2 ) 280 280 351
A
mean follow-up periods were 24 months for the heavyweight Mar-

lex group, 9 months for the intermediate weight Atrium group,
and 6 months for the lightweight Vypro mesh.
Age, weight, height, body mass index, the number of previous
recurrences, as well as the mesh size all show no significant dif-
ferences. Forty-three percent of the patients had primary incisional
hernia; 57% had up to 8 recurrences of incisional hernia.
Textile Analysis
B The textile analysis of the heavy mesh Marlex showed a weight of
95.1 g/m 2, with a pore size of 600 Mm and for the Atrium mesh,
90.2 g/m2 (95% of Marlex) , with a pore size of 800 Mm; the light-
weight Vypro has a reduced weight of 26.8 g/m2 (28% of Marlex)
for the permanent polypropylene part and 54.6 g/m2 (57% of Mar-
lex) for the combination with polyglactin, with a markedly in-
creased pore size of 5000 Mm.
As proved experimentally, the supplemental polyglactin in the
Vypro mesh system loses 50% of its strength within 3 weeks and is
totally absorbed within 3 months. The proportion of pores as a
parameter of transparency always exceeds 85%, essential for use
in laparoscopy. The tensile strength of strips of 5 cm width shows
a marked asymmetry for both the Vypro and its pure polypropyl-
c ene part. Nevertheless, the tearing forces of these two meshes show
similar vertical and horizontal values, whereas in this test the heav-
ier meshes showed pronounced differences. The bending stiffness
FIGURE 38.1. Mesh materials: (A) Marlex, heavyweight, small pore size, increases with the mesh weight. The forces tearing out the seam
monofilament, polypropylene; (B) Atrium, intermediate weight, increased correspond with the mesh weight in both the vertical and the hor-
pore size, monofilament, polypropylene; (C) Vypro, lightweight, large pore izontal directions. The crease recovery angle as a parameter of
size, multifilament, polypropylene, and polyglactin. the memory capability is lowered for the Vypro mesh, at least in
the horizontal direction. Test pressing through the stamp is the
most suitable test because it stimulates the simultaneous strain in
all directions. All tested meshes exceeded a calculated tensile
were the inflammatory infiltrate (partial volume [PVl %), con- strength of 16 N/cm, the heavier meshes by as much as three
nective tissue (PV %), fat cells (PV %), vessels (PV %), macro- times.
phages (%), granulocytes (%), and fibroblasts (%).
Early Complications
Results
Clinical signs of wound infection could be detected in seven pa-
In the period of 1991 to 1999, 213 patients (142 male, 71 female) tients (3.3%) (Table 38.3) without significant differences between
were examined (Table 38.2). Of these, 106 patients received a the various materials. None of these cases required a removal of
heavyweight Marlex mesh (Bard), 36 patients an intermediate the mesh, as they were treated successfully with antibiotics. Revi-
weight Atrium mesh (Braun-Dexon), and 71 patients the light- sion operations for hematoma were necessary in eight cases
weight Soft Hernia Mesh (Ethicon, Norderstedt, Germany). The (3.8%). The rate of hematoma was not influenced by the im-
38. Vypro®Polypropylene Mesh 289
TABLE 38.3. Infection, hematoma, seroma, and recurrences following TABLE 38.5. Three-dimensional stereography following mesh implanta-
mesh implantation tion: height, curvature, and adjusted radius at maximum abdominal wall
excursion
Marlex Atrium Vypro
Controls Marlex Atrium Vypro
Infection (%) 1.9 5.6 4.2
Revision operation for hematoma (n) 2 4 2 Total number 21 41 33 42
Seromas (%) (calculated volume> 60 ml) 10.4 2.8 2.8 Mean height (cm) 5.5 3.1 3.8** 3.9**
Recurrences (n) 4 Mean curvature 0/100 cm) 6.2 3.7 4.4** 5.4**
Mean radius (cm) 41.0 68.5 55.4** 58.7**
*P < .05 versus Atrium, **P < .05 versus Marlex; for all mesh patients, P<
planted mesh type, although four of them happened after im- .05 versus controls.
plantation of Atrium.
The routinely performed ultrasound usually detected small vol-
umes of liquid beneath the implanted mesh. A calculated volume increased adjusted radius at maximum abdominal wall excursion
of more than 60 ml was considered to be a relevant seroma and (Table 38.5). Compared with the control group of healthy sub-
was released by puncture. This occurred in 10.4% of the patients jects, the extent of stiffness increases for meshes of high weight
who received a Marlex mesh, in 2.8% of the Atrium group, and and small pore size and is correspondingly reduced in the light-
in 2.8% of the group with the lightweight mesh Vypro (p = .059) weight, large pore size mesh group. The reduced curvature cor-
(Table 38.3). responds significantly with the rate of reported complaints.
Despite frequent complaints, almost all patients are fully satis-
fied, except for the patients with recurrences and the five patients
Recurrences with pain even at rest. One male with a Marlex prosthesis experi-
enced increasing pain, even during small movements, corre-
Only four patients in the Marlex group, one in the Atrium group, sponding with increasing stiffness of the abdominal wall (Fig.
and one in the Vypro group developed recurrences (2.8%). These 38.2). When the Marlex mesh was replaced by lightweight Vypro
always occurred at the edge of the mesh, probably because of in- mesh, the complaints ceased.
sufficient overlap at the periphery.
Long-Term Tissue Reaction
Long-Term Complaints Commonly, a vigorous foreign body reaction with typical foreign
body granulomas including epithelioid cells and giant cells was ob-
Apart from postoperative complications and recurrences, the sat-
served in all Marlex meshes investigated (Fig. 38.3). Persistent
isfaction of the patients and their quality of life are affected mainly
acute inflammation with varying amounts of CD IS-positive poly-
by minor problems and the degree of the restriction of abdomi-
morphonuclear neutrophils and focal fibrinoid necrosis is found
nal wall mobility. Many patients complained of the palpable mesh
as a rule. The inflammatory process is accompanied by a pro-
edges (Table 38.4) . The rate of paresthesia decreases over time,
nounced connective tissue with numerous collagen fibers that
surprisingly not significantly influenced by the number of recur-
forms a thick capsule in which the whole mesh is integrated. More-
rences or prior hernia repairs. A considerable restriction of the
over, in these heavy meshes pores are completely penetrated by
abdominal wall mobility was reported in 41 % of the Marlex group,
connective tissue. Thus, mesh and newly formed connective tissue
in 28% of the Atrium group, and in 13% of the Vypro group.
Whereas with the heavier mesh most patients complained of prob-
lems during daily activities, patients with the Vypro mesh were ca-
pable of doing heavy work with little or no complaint. Three
patients of the Marlex group and two patients with an Atrium mesh
had intense pain even during rest. The extent of restriction cor-
relates significantly with the paresthesia and the measured curva-
ture, but not with the mesh size or the number of previous
operations.
For all meshes, three-dimensional stereography showed a con-
siderable increase in stiffness, correlating significantly with the
weight of the mesh. The reduced extensibility of the abdominal
wall is indicated by decreased height, diminished curvature, and
TABLE 38.4. Complaints (%) following mesh implantation

Marlex Atrium Vypro
No physical complaint 59 72 89
Complaints during heavy work 7 14 11 FIGURE 38.2. Maximum bulge of the abdominal wall 28 months after im-
Complaints during daily activities 29 8 0 plantation of a heavyweight polypropylene mesh in underlay position. Note
Complaints at rest 5 6 0 that there is no increased abdominal wall curvature, indicating a decreased
abdominal wall mobility and a stiffness of the artificial abdominal wall area.
290 U. Klinge et al.
FIGURE 38.3. Interface of heavyweight mesh/recipient tissues; the mesh is FIGURE 38.4. Interface of lightweight mesh/recipient tissues showing the
entirely encapsulated in a collagen-rich scar plate and shows signs of in- fibrosis mainly limited to the perifilamentary region, with pores filled with
flammation (XlOO). fat tissue (X250).
form a complex unit. Fibroblasts in the interface are still frequent, a thin scar plate oriented parallel to the mesh. The number of fi-
whereas vascular structures are rare. After more than 1 year, the broblasts is low in contrast to the increased vascularization.
inflammatory reaction is reduced but still detectable within the in- Histological analysis reveals that an inflammatory reaction at the
terface (Table 38.6). interface persists for years, together with proof of cell damage
The inflammatory response to the Vypro mesh is markedly less (apoptosis as an indicator for cell death, Ki67 as an indicator for
than that associated with the Marlex mesh (Fig. 38.4). The tissue proliferation). Some months after implantation, this foreign body
reaction is characterized by the formation of granulomas of the reaction seems to be largely unaffected by time. As in our animal
foreign body type with a moderate number of multinuclear giant experiments, use of the lightweight mesh significantly reduced the
cells. Signs of acute inflammation such as infiltrates of polymor- inflammatory changes. The samples of the low mesh both showed
phonuclear neutrophils and fibrinoid necrosis are rare. The col- a reduction in the number of macrophages and polymorphonu-
lagen fibers form a moderate capsule around the mesh structures clear cells. DNA strand breaks as an indicator of cell death and pro-
and encircle single mesh filaments, whereas the periphery shows liferation (Ki67) is seen in the interface, particularly of the heavy
mesh Marlex. For the heavyweight meshes, a significant increase
in the partial volume of the inflammatory infiltrate and connective
TABLE 38.6. Morphometry at the interface mesh/recipient tissues: means tissue could be observed compared with the lightweight meshes,
(and ranges) whereas their partial volume of fat tissue was decreased.
Heavyweight meshes
(Marlex, Prolene, Lightweight mesh
Atrium) (Vypro) Discussion
Number 49 13 Animal experiments proved that all meshes lead to a significant
Implantation time 19 (2-72) 9 (2-20) increase in stiffness of the abdominal wall. This effect is minimized
(months) when a lightweight mesh is used. The restricted mobility corre-
Partial volume (PV %) lates with the morphologically proven development of a strong
Inflammatory infiltrate 40 17*
scar plate, usually completely surrounding the mesh. Whereas
Connective tissue 39 20*
heavyweight meshes induce an intense acute inflammation, the
Fat tissue 45 69
Vessels 9 13* lightweight meshes show a significantly reduced extent of inflam-
Cells at the interface (%) mation, favoring the formation of granulomas with foreign body
Macrophages 41 25* giant cells. The connective tissue is limited locally to the perifila-
PMNs 12 2* mentary area, the pores being filled mainly with fat. 1O•11 ,14-16 The
Fibroblasts 14 11 clinical data confirm both the results of our animal studies and
Cell response (%) the favorable effect of a reduction of mesh material in humans. 2
DNA strand breaks 33 2* The enormous inflammatory capacity of the heavier meshes is
(Tunel) confirmed by morphometric analysis at the interface of mesh sam-
Proliferation (Ki67) 26 3*
ples. In general, the tissue response to the lightweight mesh is
Stress (HSP 70) 33 92*
more moderate with less inflammation, fibrosis, cell damage, apo-
HSP 70, heat shock protein 70; PV, partial volume; PMN, polymorphonu- ptosis, and proliferation. The expression of heat shock protein 70,
clear neutrophil. an indicator of cell stress, may play an important role in stress pro-
*p < .05. tectionP
38. Vypro® Polypropylene Mesh 291
Conclusion 4. Wagh PV, Read RC. Defective collagen synthesis in inguinal hernia-
tion. Am] Surg. 1972;124(6):819-822.
The comparison of the three meshes underlines the importance 5. DeGuzman Lj, Nyhus LM, Yared G, Schlesinger PK Colocutaneous fis-
of the material itself for the development of local wound problems, tula formation following polypropylene mesh placement for repair of
a ventral hernia: diagnosis by colonoscopy. Endoscopy. 195;27(6):
as Amid 7 indicated. The data confirm that reduction of implanted
459-461.
prosthetic material and increased pore size can reduce the unde-
6. Stelzner F. Function of the abdominal wall and development and ther-
sirable qualities of a mesh. Even though the short follow-up period apy of hernias. Langenbecks Arch Chir. 1994;379,2:109-119.
permits no assessment of the long-term complications such as mi- 7. Amid P. Classification of biomaterials and their related complications
gration and fistula formation or the long-term histological response in abdominal wall hernia surgery. Hernia. 1997;1:5-8.
of the host tissue, the present data strongly confirm the recom- 8. Klinge U, Klosterhalfen B, MUller M, Schumpelick V. Foreign body re-
mendation to use only as much material as necessary with a pore action to meshes used for the repair of abdominal wall hernias. Eur]
size as large as possible. With respect to the improved tissue reac- Surg.1999.
tion and the reduced functional restriction, the use of the light- 9. Klinge U, Klosterhalfen B, Conze j, et aI. Modified mesh for hernia
weight mesh appears conclusively to be advantageous. repair that is adapted to the physiology of the abdominal wall. Eur]
Surg. 1998;164(12):951-960.
To analyze the influence of the mesh material itself, a random-
10. Klosterhalfen B, Klinge U, Schumpelick V. Functional and morpho-
ized international, multicenter study was begun in mid-1999 to ex-
logical evaluation of different polypropylene-mesh modifications for
amine the results of implantation of heavyweight small pore abdominal wall repair. Biomaterials. 1998;19:2235-2246.
polypropylene meshes, lightweight small pore polyester meshes, 11. Klosterhalfen B, Klinge U, Henze U, Bhardwaj R, Conze j,
and lightweight large pore polypropylene meshes. Schumpelick V. [Morphologic correlation of functional abdominal
wall mechanics after mesh implantation.] Langenbecks Arch ChiT. 1997;
382 (2) :87-94.
Acknowledgments 12. Vestweber K, Lepique F, Haaf F, Horatz M, Rink A. [Results of recur-
rent abdominal wall hernia repair using polypropylene-Mesh.] Z Chir.
The authors would like to acknowledge the financial support of 1997;122:885-888.
the IZKF-BIOMAT, Aachen, Germany, the Deutsche Forschungs- 13. McLanahan D, King LT, Weems C, Novotney M, Gibson K Retrorec-
tus prosthetic mesh repair of midline abdominal hernia. Am] Surg.
gemeinschaft (DFG), Bonn, Germany, and Ethicon, Norderstedt,
1997;173(5):445-449.
Germany. 14. Klinge U, Conzej, Klosterhalfen B, et al. [Changes in abdominal wall
mechanics after mesh implantation. Experimental changes in mesh
stability.] Langenbecks Arch Chir. 1996;381 (6):323-332.
References 15. Klinge U, Muller M, Briicker C, Schumpelick V. Application of three
dimensional stereography to assess abdominal wall mobility. Hernia.
1. Schumpelick V, Conze j, Klinge U. [Preperitoneal mesh-plasty in in- 1998;2:11-14.
cisional hernia repair. A comparative retrospective study of 272 oper- 16. Klinge U, Klosterhalfen B, Muller M, Ottinger A, Schumpelick V.
ated incisional hernias.] Chirurgie. 1996;67(10):1028-1035. Shrinking of polypropylene meshes in vivo (an animal study). Eur]
2. Schumpelick V, Kingsnorth G. Incisional hernia of the abdominal wall, 1st Surg. 1998;164:965-969.
ed. Berlin: Springer-Verlag; 1999. 17. Klosterhalfen B, Klinge U, Tietze L, et al. Expression of heat shock
3. Wagh P, Read R. Collagen deficiency in rectus sheath of patients with protein 70 (HSP 70) at the interface of polymer implants in vivo.
inguinal herniation. Proc Soc Exp BioI Med. 1971;137:382-384. ] Mater Sci Mater Med. 1999;10:1-7.
39
Combined Absorbable and
Nonabsorbable Prostheses in the Treatment
of Major Defects of the Abdominal Wall
Giovanni Trivellini
The existence of polyester and polypropylene prosthetic meshes tents are reduced into the peritoneal cavity. The peritoneum is
has provided a new dimension in the treatment of inguinal and incised along a curved line, extending bilaterally from the pubic
incisional hernias. With the safety of these materials established, tubercle, along the Cooper's ligament, anterior to the iliac ves-
methods have been devised that would at last conquer pathology sels and psoas muscle, further laterally along the parietocolic gut-
that was once thought untreatable. These methods have gained ter, to the anterior superior iliac spine, to reach anteriorly, along
popularity in Europe and throughout the world, thanks to the ef- the flat muscles and the semicircular line of Douglas to the um-
forts of the French authors Rives et al. 1 and Stoppa and Warlau- bilicus (Fig. 39.1). The urinary bladder is partially mobilized
mont2 in particular. They and other authors3.4 have described anteriorly. A free edge of peritoneum is thus obtained that has
operative techniques using prosthetic materials in preperitoneal not been scarred by previous operations and is therefore easily
sites. identified.
Unfortunately, despite the success of materials and procedures, A Vicryl® prosthesis is secured with inverted absorbable inter-
infection and detachment of prostheses can still occur. Recur- rupted sutures to the peritoneal free edge so prepared. The Vicryl
rence of a hernia after preperitoneal prosthetic mesh repair can prosthesis, placed in direct contact with the viscera, allows closure
and does happen and presents a situation that is not easily solved. of the peritoneal cavity, creating a new preperitoneal space be-
The mesh becomes markedly adherent to surrounding tissues; tween the Vicryl prosthesis and the abdominal wall (Fig. 39.2). A
granulomas, often infected, make it difficult if not impossible to new, nonabsorbable mesh is then positioned in this space and an-
handle the detached prosthesis. On occasion, the peritoneum is chored to the two ligaments of Cooper with Prolene® sutures. This
fused to a thinned out and ulcerated skin: a situation Rives et nonabsorbable mesh (Dacron® or, more recently, Bard® mesh) is
al.I called "loss of abdominal wall substance," a wide loss of soft located in a deep retromuscular, preperitoneal site, adjacent to
tissues such that the margins of the breach cannot be approxi- the just inserted Vicryl mesh (Fig. 39.3). The old prosthesis with
mated. its adherent parietal peritoneum remains in situ, acting as an ad-
These factors stimulated us to develop a technique involving the ditional supporting and padding layer. When possible, the mus-
use of two prostheses. 5 The first one, absorbable (polyglycolic cular layer is approximated over the prostheses with interrupted
acid), substitutes for the peritoneum; the second one, nonab- full-thickness sutures.
sorbable and made of polyester, functions as a supporting en-
doabdominal fascia.
Discussion
Surgical Technique Between 1988 and 1998, this technique was carried out on 11 pa-
tients who presented with recurrent hernias and 2 patients with
The technique is proposed for recurrent, often bilateral, inguinal large incisional hernias and loss of abdominal wall substance. One
hernias and incisional hernias, where there is a loss of peritoneum of the patients had undergone 13 operations, elective and emer-
and abdominal wall substance. In cases where the peritoneal space gency, for recurrent inguinal hernias.
cannot be entered by the usual techniques because of adhesions The average hospital stay was 10 days. The average follow-up pe-
or infected granulomas, we create a new peritoneal and preperi- riod was 30 months. Preoperative and intraoperative antibiotics
toneal space. were used. No complications were encountered in the immediate
The patient is placed on an operating table tilted to a moder- postoperative period.
ate Trendelenburg position. The incision extends from the um- One failure has taken place 1 year postoperatively due to the
bilicus to the pubis. When it is confirmed that the old prosthesis detachment of the nonabsorbable prosthesis. The two incisional
cannot be dissected out, the hernial sac is incised and the con- hernias fared well despite the major loss of abdominal wall

39. Combined Prostheses 293
substance where peritoneum and skin had become widely fused

and therefore unavailable for closure of the peritoneal cavity.
We believe that this technique will also prove useful following
radical resection of neoplasms that have invaded the abdominal
wall.
The good results obtained to date are encouraging and have
led us to recommend this technique despite the small number in
this series.
References
1. Rives], Pire]C, Flament]B, et al. Le traitement des grandes eventra-
tions. Nouvelles indications therapeutiques a propos de 322 cas.
Chirurgie. 1985;111:215.
2. Stoppa R, Warlaumont CR The preperitoneal approach and prosthetic
FIGURE 39.1. New peritoneal cavity and new preperitoneal space consti- repair of groin hernia. In Nyhus LM, Condon RE, (eds) : Hernia, 3rd
tuted by a resorbable mesh sutured to the peritoneal flap. Intestinal loops ed. Philadelphia:]B Lippincott; 1989: 199-221 .
are in contact with the mesh. 3. Wantz GE. Giant prosthetic reinforcement of the visceral sac for man-
agement of the hernias of the groin at high risk for recurrence. Surg
GynecoIObstet. 1989;196:408-417.
4. Chevrel ]P. Les eventrations de la paroi abdominale. Rapport presente au
92e congres Fran~ais de Chirurgie. Paris: Masson; 1990.
5. Trivellini D, Danelli PG. Use of two prostheses in the surgical repair of
recurrent hernias. Postgrad Gen Surg. 1992;4:135-138.
Commentary
Robert Bendavid
In 1989, I began using a composite mesh intraperitoneally, con-
sisting of expanded polytetrafluoroethylene (ePTFE) and poly-
propylene, with excellent results in 10 patients. I reported this
FIGURE 39.2. Large incisional hernia.
experience in Prostheses and Abdominal Wall Hernias. l Subsequently,
an update with 30 cases was published,2 confirming the previous
good results. I believe this combination, as seen in the commer-
cially available Composix® mesh, is the ideal choice at the present
time. Clinically, ePTFE is not totally adhesion free; I am not sure
that any material ever could be. However, I am not aware of any
cases of fistulization or transmigration with ePTFE. Adhesions, if
any, are filmy and easily lysed. In the twenty-first century, I am sure
we will see much research and development in this area and some
very interesting results.
References
1. Bendavid R. Commentary on Chapter 28. In Bendavid R (ed): Prosthe-
ses and abdominal wall hernias. Austin: RG. Landes Company; 1994:290.
2. Bendavid R Composite mesh (polypropylene-ePTFE) in the intraperi-
FIGURE 39.3. Result after 3 years. toneal position. A report of 30 cases. Hernia. 1997;1:5-8.
40
Prosthetic Materials and Adhesion Formation
Riccardo Annibali
Fibrovascular adhesions are found in 50 to 95% of patients who

have undergone open abdominal surgery.I-3 Mechanical trauma,
Patterns of
Fibrous Ingrowth and
thermal injury, infections, tissue ischemia, and foreign materials
Adhesion Formation
are the most important contributing causes of adhesion forma-
WagnerI7 has proved Marlex® mesh to be the least reactive after
tion. 4 Foreign bodies have been reported in 61 to 69% of post-
examining several plastic prosthetic materials, including expanded
operative adhesions. In 50 to 68% of cases the foreign material
polytetrafluoroethylene (ePTFE). Usher I9 found Marlex to be in-
was talc; other materials included sutures, cotton lint, filaments
tact at 4 years in an experimental study. Elliott andjuler,I9 on the
from dressings, starch, extruded gut contents, and prosthetic im-
other hand, reported microporous PTFE to be less reactive than
plants. Combinations of different materials have also been noted
Marlex in a rabbit study. According to the authors, this positive
(usually talc and thread).2.5
finding was due to inordinate, rapid fibroblastic cellular ingrowth.
The common pathway leading to adhesion formation is in-
The higher foreign body reaction of polypropylene was, however,
flammation, which produces exudates containing high quantities
found to be responsible for its fragmentation in some some areas
of fibrinogen. 6--8 Fibrin clots develop and cause adhesions, at least
studied with polarized light microscopy. This phenomenon, asso-
temporarily, between surfaces otherwise unattached. Granulation
ciated with marked inflammation and dense scar tissue produc-
tissue results after colonization of the fibrin network by fibroblasts,
tion, would cause a distortion and dislocation of the Marlex mesh
macrophages, and new blood vessels. A healthy and well-vascular-
implant in the groin area. Expanded PTFE sheets, however, were
ized peritoneum has an effective fibrinolytic system due to a plas-
incorporated into the host tissue with little distortion and retained
minogen activator, which is able to completely absorb the newly
flat disposition of scar tissue, stimulating the host's production of
developed fibrinous attachments. 4•9 Prosthetic materials can con-
a "neofascial" structure. 19
siderably impair the fibrinolytic activity by two different mecha-
Interestingly, Amid et al. 20 came to completely different con-
nisms:
clusions. They have shown experimentally that polypropylene
mesh is better tolerated because of increased host tissue fixation
1. Tight suturing and grafting induce peritoneal ischemia. Is-
and complete incorporation into the tissue. The observed pene-
chemic tissues are potent stimuli to adhesion formation and ac-
tration of fibroblasts from the host tissue into the depth of ePTFE,
tively inhibit fibrinolysis in adjacent peritoneal tissue. 6.8-11 Thus,
on the other hand, was only about 10% 4 years after its implan-
retention of vascularization is essential for proper, adhesion-
tation (when a superimposed infection was present, this was fur-
free peritoneal healing.6.I2.I3
ther decreased). 20
2. Mesothelial cell proliferation seems to be another inhibitor of The finding that penetration of fibroblasts from the host tissue
adhesion formation 14.I5; its reduction, observed in infected into the depth of ePTFE is poor (again, around 10%) has been
wounds and in those where a prosthetic mesh is applied, cor- confirmed by a study of Law and Ellis. I5 These authors also ob-
responds with a decreased fibrinolytic activity.I5 served that Marlex mesh was incorporated by dense collagen fibers
with a mild foreign body reaction, whereas collagen penetration
A number of experimental and clinical studies have been con- of the interstices of an ePTFE patch was regular and evenly dis-
ducted to better understand the mechanism of adhesion forma- tributed. Mesothelial cells were observed in an irregular pattern
tion and prevention. One of the major difficulties encountered over a Marlex patch but appeared as a continuous layer after four
has been the development of an animal model that could be re- weeks on the ePTFE mesh. This has been related with a different
producible, quantifiable, and reliable. The rabbit uterine horn appearance of the two meshes in low power scanning micrographs:
model has gained widespread popularity.I6 This model involves a The peritoneal surface of Marlex mesh was irregular, but that of
traumatic deperitonealization of the rabbit uterine horn. The re- ePTFE was smooth. According to Taylor and Gibbons,21 a rounded
sulting raw surface can develop adhesions with other raw surfaces and smooth surface stimulates encapsulation, whereas a rough one
within the abdominal cavity in approximately 2 weeks. prevents it. Bauer et al. 22 and Lamb et al.,23 in separate papers,

40. Prosthetic Materials and Adhesion Formation 295
have also reported a better fibrous tissue annexation of PTFE over An additional element should, however, be taken into consid-
polypropylene, with better embedding in fibrous tissue and a more eration: the difference in adhesion formation between laparotomy
complete incorporation into a healing wound. Again, what seems and laparoscopy. In 1990, Lucian0 35 completed an experimental
to be an adverse factor of polypropylene for proponents of ePTFE, randomized study comparing postoperative adhesions in rabbits
namely, roughness of the surface or the weave of the fabric, ac- subjected to laser incisions, by laparotomy or laparoscopy, over
cording to Amid et al.,20 is a positive aspect that increases fibro- one uterine hom and over the peritoneal surface of either lower
blastic reaction and host tissue incorporation. quadrant. He demonstrated that in the laparotomy group post-
Actually, one criticism of hernia repair with PTFE is that it reoperative adhesions were not only present on the tissues involved
lies entirely on the strength of the prosthesis, as fibrous ingrowth with initial injury but also at the laparotomy incision as well. In
is reduced. 24 Moreover, both Monaghan and Mean 25 and Van der addition, adhesions were often found where no apparent injury
Lei et al. 26 have independently noted that poorly secured ePTFE had been inflicted. No adhesions were observed in the laparoscopy
patches show a decreased collagen ingrowth, with an increased in- group.
cidence of buttonhole hernias between sutures at the patch/fas- Filmar et al.,36 on the other hand, reported no significant dif-
cia interface. According to Van der Lei et al.,26 this is due to the ference between the two procedures (as far as postoperative ad-
short internodal space of ePTFE patches, insufficient to allow good hesion formation is concerned) in an animal model analogous to
ingrowth. Monaghan and Mean 25 point out that poor collagen in- the one used by Luciano. However, the difference may be because
growth means poor anchorage of the graft with tissue reaction Filmar et al. 36 inflicted the injury with sharp scissors, with subse-
alone and recommend a running suture at the edge of the graft quent bleeding that was not immediately controlled. According to
to prevent herniation between interrupted sutures. several authors, the presence of intraperitoneal blood associated
Among the advantages advocated by some authors in favor of with drying of the serosal surface dramatically increases subse-
expanded PTFE compared with polypropylene is a lower rate of quent adhesion development. 37.38 However, large volumes offresh
adhesion formation after the implant.22.27.28 Again, however, there and clotted blood, without the simultaneous presence of serosal
seems not to be a complete agreement on this aspect. In the ex- injury, do not promote adhesion formation and are completely re-
perimental study of Goldberg et al.,29 ePTFE increased postoper- sorbed by normal peritoneum within 2 days. 38-40
ative peritoneal adhesion formation, possibly because it incited The results in favor of laparoscopic surgery support a number
some degree of inflammatory and foreign body reaction. Finally, of clinical observations in which the incidence of adhesion for-
Jenkins et al. 30 noticed exactly the same rate and density of ad- mation was over 50% following open laparotomy for infertility
hesions to both ePTFE and Marlex when these prostheses were (discovered at a second-look operation). When the procedure was
used to repair abdominal defects in rats. accomplished laparoscopically, the incidence was considerably
Dacron® has been used both in the United States and in Eu- 10wer. 35 These conclusions are confirmed also by the results of an
rope, especially in France by the groups of Stoppa et al. 31 and experimental study on the swine model conducted by our group
Rives. 32 Hanson, after comparing abdominal wall implants of poly- at Creighton University.41
dimethylsiloxane/Dacron and Marlex in rats whose peritoneal cav- In conclusion, laparoscopic surgery decreases the incidence of
ities had been contaminated with feces, reported a significantly adhesion formation by avoiding incisions, reducing the amount of
lower incidence of infections in the Dacron group. He attributed blood loss, preventing talc shed in the abdominal cavity, allowing
this result to the different host response toward the two meshes: precise dissection with magnification, and eliminating traumatic
Dacron laminate was encapsulated, whereas the Marlex interface microinjuries due to the use of sponges.
was obviously characterized by tissue ingrowth. This difference
would justify the different responses to the infection. Also, in this
instance, fibrous ingrowth has been seen as a factor promoting Prevention of Adhesion Formation
bacterial proliferation and adhesion formation.
Absorbable meshes have been proposed recently for temporary Several types of adjuvants have been tried to decrease adhesion
peritoneal coverage in contaminated cases after extensive sep- formation. They belong to different classes.
sis. 20.33 Favorable results with implantation of a polyglactin (Vy- The high viscosity instillates recall fluids into the peritoneal cav-
cril®) mesh for inguinal hernia have been reported by Brenner. 34 ity, creating a sort of "hydroflotation bath." They reduce the ap-
In 1983, however, Lamb et al. 23 had reported that a Vicryl mesh position of the serosal and peritoneal surfaces, thus decreasing
was not detectable 12 weeks after implantation in rabbit abdomi- adhesion formation during the period of epithelial regeneration
nal walls. At 3 weeks, the mesh showed peritoneal covering, but and probably also preventing fibrin deposition.42 In this class, 32%
there was no demonstrable fibrous tissue growth over the ab- Dextran 70 (molecular weight 70,000), or Hyskon®, is the sub-
dominal wall defect. The authors considered the material unsat- stance more commonly employed. It proved to be effective at high
isfactory for safe and successful hernia repair.23 Similar results were dosage in animal studies43; in human studies, however, results were
obtained by Amid et al. 20 in another experimental study on rab- contradictory. Both a prospective randomized multicenter trial44
bits. Polyglycolic acid mesh (Dexon®) did not induce a strong fi- and an additional retrospective study45 demonstrated beneficial
brous response or give adequate support to the abdominal wall in effects of 32% Dextran 70, but two other studies in humans failed
the comparative study conducted by Law and Ellis. 15 to reveal any advantage. 46 Various infrequent allergic reactions
In conclusion, this review of the literature may generate some have been reported as side effects following peritoneal instillation
confusion in the reader's mind. If one had to draw a conclusion, of Hyskon, which prevent wide use of this drug. 42
it might be suggested that polypropylene is best employed within Mechanical barriers represent another class of adjuvants. These
the preperitoneal space, whereas ePTFE could respond better in materials are interposed between two surfaces to impede their ad-
intraperitoneal placement, in direct contact with viscera. herence. Fascia, peritoneum, omentum, tunica vaginalis, vena
296 R. Annibali
cava, cellophane, Teflon®, silastic, and nylon are only some of the weight heparin, and hexuronyl hexosaminoglycan sulfate, have in-
barriers employed. To reduce the potentiating effect of foreign creased the effectiveness of Interceed in preventing adhesions
bodies on bacterial virulence, absorbable materials have usually when directly applied on the fabric. 42
been preferred. Among them, two have gained a certain popu- Tissue plasminogen activator (t-PA) converts plasminogen to
larity: Oxidized cellulose (Surgicel®) was first tested in two ex- plasmin and specifically acts on the fibrin surface without activat-
perimental studies on laboratory animals and did not promote ing the liquid-phase plasminogen. Recombinant genetic technol-
adhesions when left in the abdominal cavity after surgery.47,48 In ogy has recently made t-PA available in pharmacological quantities
another laboratory study, however, adhesion formation was in- (rt-PA). Applied topically in a gel formulation in the rabbit uter-
creased. 49 Subsequently, modifications in the degree of oxidation, ine hom model, it proved effective in reducing both the number
porosity, and density led to the development of a new absorbable and the density of adhesion formation and reformation. 56
and biocompatible barrier called Interceed® (TC7).50,51 This pre- Sodium tolmetin in a hyaluronic acid carrier administered in-
sents a finer knit pattern, with consequent swelling of the fibers traperitoneally at the end of surgery reduced adhesion formation
within a few hours after insertion inside the body, which allows in a study conducted on rabbits. In addition, tolmetin signifi-
pores in the fabric to close rapidly. In two rabbit studies, a signif- cantly reduced the number of red blood cells recovered from
icant reduction in adhesion formation was achieved after the use peritoneal lavage postoperatively. Different mechanisms have
of Interceed. been proposed to explain the preventive action of tolmetin: me-
The good results were subsequently confirmed in a study with chanical separation of the wounded serosa from normal serosa
humans. In 74 infertility patients treated for bilateral pelvic side- by viscous macromolecules; suppression of bleeding, with conse-
wall adhesions with laparotomy adhesiolysis, and followed up by quent reduction of the number of blood clots; and the pharma-
second-look laparoscopy, the deperitonealized area of one side was cological effect of tolmetin on the function and migration of
covered with Interceed and the other served as a control. The cov- postoperative inflammatory cells, which may lead to an increased
ered area showed a 90% improvement over control sidewalls in fibrinolytic activity (obtained by reducing the levels of plas-
preventing adhesion formation. In our experience, Interceed has minogen activator inhibitor activity and elastinolytic activity se-
not proved to be highly effective in preventing adhesion forma- creted by macrophages).57
tion. In fact, in a swine study conducted at Creighton University, Carboxymethylcellulose (CMC) action consists of coating the in-
the average percentage of the surface area of prosthetic patches traperitoneal surface to prevent direct apposition of injured struc-
covered by adhesions was not significantly different when a com- tures. Its action in decreasing postoperative adhesion formation is
posite patch of oxidized regenerated cellulose (Interceed) and relatively prolonged, as it is very slowly absorbed. 42 CMC proved
polypropylene (Prolene®) was compared with one of polypropyl- to be effective in significantly reducing adhesion formation and
ene alone. 41 Finally, it is interesting to note that an increase in de reformation in three studies on the rabbit model. 46,57-60 In two of
novo intraperitoneal adhesion formation caused by Interceed in these studies, CMC was more effective than 32% Dextran 70 in
a murine model has been also reported. 52 preventing adhesion reformation. 46,58,59-61 In another study, how-
Recently, Hooker et al. 53 published a study comparing the inci- ever, CMC not only increased adhesions in treated rats but also
dence of adhesions after repair of full-thickness abdominal wall promoted anastomotic leaks and a high mortality in the treated
defects (excluding skin) with polypropylene in rats receiving ei- group. 62
ther a hyaluronidate-based bioresorbable membrane or no mem- Nonsteroidal anti-inflammatory agents have also been tried, as
brane. Analysis of adhesion severity and percentage of mesh they stabilize lysosomes and reduce vascular permeability and his-
surface covered demonstrated that in the membrane group there tamine release. In particular, oxyphenbutazone63 ,64 and ihupro-
was a significant reduction in the grade of adhesion between small fen 65-67 seem to reduce the intensity of adhesion formation in
bowel (intentionally abraded for the experiment) and mesh and animal studies.
in the percentage of mesh covered with adhesions at 4 and 8 weeks. Iloprost, a prostacyclin analogue, has proved to be effective in
There was no difference between the two groups in tensile strength reducing postoperative primary posttraumatic adhesion formation
of repair, tissue thickness, degree of inflammation, and fibrosis. 53 in hamsters when administered perioperatively. 68 The effectiveness
Inevitably, pharmacological methods have also been employed of steroids in preventing adhesion formation is controversial. A
in experimental studies in an effort to reduce adhesion formation. beneficial effect of these drugs was demonstrated in the past. 69,70
The difficulty of delivering the drug in an effective concentration Swolin,71 and more recently Jansen,72 used hydrocortisone in-
at the potential site of action, however, has often jeopardized the traperitoneally before peritoneal closure and subsequently re-
potential good results. ported that all patients showed a considerable reduction in
Calcium channel antagonists, such as nifedipine, verapamil, and adhesion formation during laparoscopy a few months later. Other
diltiazem, have been used following the hypothesis that adhesion authors, however, were not able to confirm the usefulness of
formation could be prevented by blocking the intracellular mech- glucocorticosteroids in preventing postoperative adhesions. 73-75
anisms of the cellular elements involved in the action of peritoneal Moreover, an increased postoperative morbidity is to be expected
repair (fibroblasts, platelets, phagocytes, and endotheial cells). if immunological defences are decreased. 4
Thus far, some promising results have been noted in a rabbit The hypothesis that antihistamines decrease fibrin-rich inflam-
model after treatment with verapamil. 54 matory exudate in the abdominal cavity (and consequently limit
The assumption that heparin could reduce fibrin deposition and adhesion formation) has also been promoted. 69 ,7o,76 In a recent
initiation of adhesion formation led to its clinical employment, randomized, controlled, and laparoscopically monitored study
both intravenously and as an instillate, to irrigate the peritoneal conducted by Jansen 72 among 90 patients, however, no beneficial
cavity, but this had little success when used alone. 55 However, hep- or deleterious effect on the extent of postoperative adhesions was
arin and its derivatives, such as dermatan sulfate, low-molecular- reported.
40. Prosthetic Materials and Adhesion Formation 297
Conclusion 24. Filipi CJ, Fitzgibbons RJ, Salerno GM, et al. Laparoscopic herniorrha-
phy. Surg Clin North Am. 1992;72(5):1109-1124.
25. Monaghan RA, Mean S. Expanded polytetrafluoroethylene patch in
Adhesion formation has been one of the most challenging prob-
hernia repair: a review of clinical experience. Can] Surg. 199;34.
lems associated with abdominal wall surgery. The presence of pros-
26. Van der Lei B, Bleichrodt RP, Simmermacher RK, et al. Expanded poly-
theses in the abdominal cavity has added a new dimension to this tetrafluoroethylene patch for the repair of large abdominal wall de-
challenge. Adhesion-free surgery remains a goal sure to stimulate fects. Br] Surg. 1989;76:803-805.
research for years to come. 27. Brown GL, RichardsonJD, Malangoni MA, et al. Comparison of pros-
thetic materials for abdominal wall reconstruction in the presence of
contamination and infection. Ann Surg. 1985;201(6):705-711.
References 28. Murphy JL, FreemanJB, Dionne PG. Comparison of Marlex and Gore-
Tex to repair abdominal wall defects in the rat. Can] Surg. 1989;
1. Ellis H. The cause and prevention of intestinal adhesions. Br] Surg. 32:244-247.
1982;69:241-243. 29. GoldbergJM, Toledo AA, Mitchell DE. An evaluation of the Gore-Tex
2. Weibel M, Majno G. Peritoneal adhesions and their relation to ab- surgical membrane for the prevention of postoperative peritoneal ad-
dominal surgery. Am] Surg. 1973;126:345-353. hesions. Obstet Gynecol. 1987;70(6):846--848.
3. Haney AF, Doty EBA. Murine peritoneal injury and de novo adhesion 30. Jenkins SD, Klamer TW, Parteka J, et al. A comparison of prosthetic
formation caused by oxidized-regenerated cellulose (Interceed® materials used to repair abdominal wall defects. Surgery. 1983;94:392-
[TC7]) but not expanded polytetrafluoroethylene (Gore-Tex® Surgi- 398.
cal Membrane). Fertil Sterii 1992;57:202-208. 31. Stoppa RE, Rives JL, Warlaumont CR, et al. The use of Dacron in the
4. Breland U, Bengmark S. Peritoneum and adhesion formation. In Beng- repair of the hernias of the groin. Surg Clin North Am. 1984;64(2):
mark S (ed): The peritoneum and peritoneal access. London: Wright; 269-285.
1989:122-129. 32. Rives J. Surgical treatment of the inguinal hernia with Dacron patch.
5. Myllarniemi H. Foreign material and adhesion formation after ab- Int Surg. 1967;47:360-361.
dominal surgery. Acta Chir Scand (SuPPI). 1967;377. 33. Read RC. Prostheses in abdominal wall hernia surgery. In Bendavid R
6. Ellis H. The aetiology of post-operative abdominal adhesions: an ex- (ed): Prostheses and abdominal wall hernias. Austin: R.G. Landes Com-
perimental study. Br] Surg. 1962;50:10-16. pany; 1994:417-422.
7. Ellis H. The cause and prevention of postoperative intraperitoneal ad- 34. Brenner J. Implantation of Vicryl patch for inguinal hernia. Presented at
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8. Raftery AT. Regeneration of peritoneum. A fibrinolytic study. ] Anat. 35. Luciano AA. Laparotomy versus laparoscopy. In di Zerega GS, Mali-
1979;129 (3) :659-664. nak LR, Diamond MP, et al. (eds): Treatment of postsurgical adhesions.
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Res. 1976;21:67-76. abdominal surgery: a comparative study on postoperative adhesion for-
10. Buckmann RF, Woods MC, Sargent L, et al. A unitying pathogenetic mation in the rat model. Fertil Steril. 1987;48:486-489.
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1976;20:1-5. ficacy of barrier adhesion reduction in the rabbit uterine horn model.
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12. Robbins GF, Brunschwig A, Fook FW. Deperitonealization: clinical and study of the mechanism. Am] Pathol. 1971;65:117-148.
experimental observations. Ann Surg. 1949;130:266. 39. Hertzler AE. The peritoneum. St Louis: Mosby; 1919.
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14. Renvall S, Lehto M, Pentinen R. Development of peritoneal fibrosis 41. Salerno GM, Fitzgibbons RJJr, Corbitt RJ, et al. Laparoscopic inguinal
occurs under the mesothelial cell layer. ] Surg Res. 1987;43:407-412. hernia repair. In Zucker KA (ed): Surgicallaparoswpy update. St. Louis:
15. Law NH, Ellis H. Adhesion formation and peritoneal healing on pros- Quality Medical Publishing, Inc., 1993;373-394.
thetic materials. Clin Mater. 1988;3:95-101. 42. Diamond MP, Hershlag A. Adhesion formation/reformation. In di-
16. Linsky CB, Cunningham T, Diamond MP, et al. Development of a uter- Zerega GS, Malinak LR, Diamond MP, et al. (eds): Treatment of post-
ine horn model of adhesions in the rabbit. Infertility. 1987;10:71-85. surgical adhesions. New York: Wiley-Liss, 1990;23-33.
17. Wagner MW. Evaluation of diverse plastic and cutis prostheses in a 43. Mazuji MK, Fadhi HA. Peritoneal adhesions. Arch Surg. 1965;91:872.
growing host. Surg Gynecol Obstet. 1970;130:1077-1081. 44. Adhesion Study Group. Reduction of post-operative pelvic adhesions
18. Usher FC. Hernia repair with Marlex mesh. In Nyhus LM, Condon RE with intraperitoneal 32% Dextran 70: a prospective, randomized clin-
(eds): Hernia. Philadeiphia:J.B. Lippincott; 1978:561-580. ical trial. Fertil Steril. 1983;40:612-619.
19. Elliott MP, Juler GL. Comparison of Marlex mesh and microporous 45. Rosenberg SM, Board JA. High-molecular weight Dextran in human
Teflon sheets when used for hernia repair in the experimental animal. fertility surgery. Am] Obstet Gynecoi 1984; 148:380-385.
Am] Surg. 1979;137:342-345. 46. Diamond MP, De Cherney AH, Linsky CB, et al. Assessment of car-
20. Amid PK, Schulman AG, Lichtenstein IL. Selecting synthetic mesh for boxymethyicellulose and 32% Dextran 70 for prevention of adhesions
the repair of groin hernia. Postgrad Gen Surg. 1992;4:150-155. in a rabbit uterine horn model. Int] Fertil. 1988;33(4):278-282.
21. Taylor SR, Gibbons DF. Effect of surface texture on soft tissue response 47. Larsson B, Nisell H, Granberg 1. Surgicel-an absorbable hemostatic
to polymer implants.] Biomed Mater Res. 1983;17:205-227. material-in prevention of peritoneal adhesions in rats. Acta Chir
22. Bauer JL, Salky BA, Gelernt 1M, et al. Repair of large abdominal wall Scand. 1978;144:375-378.
defects with expanded polytetrafluoroethylene (PTFE). Ann Surg. 48. Raftery A. Absorbable hemostatic materials and intraperitoneal adhe-
1987;206(6) :765-769. sion formation. Br] Surg. 1980;67:57.
23. Lamb JP, Vitale T, Kaminski DL. Comparative evaluation of synthetic 49. Hixson C, Swanson LA, Friedman CI. Oxidized cellulose for prevent-
meshes used for abdominal wall replacement. Surgery. 1983;93(5): ing adnexal adhesions.] &prod Med. 1986;28:662.
643-648. 50. Diamond MP, Linsky CB, Cunningham T, et al. A model for sidewall
298 R. Annibali
adhesions in the rabbit: reduction by an absorbable barrier. Micro- 63. Kapur BML, Gulati SM, Talwar JR. Prevention of reformation of peri-
surgery. 1987;8:197-200. toneal adhesions: effect of oxyphenbutazone, proteolytic enzymes
51. Interceed (TC7) Adhesion Barrier Study Group. Prevention of post- from carica papaya, and Dextrose 40. Arch Surg. 1972;105:761-766.
surgical adhesions by INTERCEED (TC7) , an absorbable adhesion bar- 64. Larsson B, Svanberg SG, Swolin K. Oxybutazone-an adjuvant to be
rier: a prospective, randomized multicenter clinical study. Fertil SteriL used in the prevention of adhesions in operations for fertility. Fertil
1989;51 (6):933-938. SteriL 1977;28:807-808.
52. Hanney AF, Doty E. Murine peritoneal injury and de novo adhesion 65. Nishimura K, Nakamura RM, diZerega GS. Biochemical evaluation of
formation caused by oxidized-regenerated cellulose (Interceed* [TC7]) postsurgical wound repair: prevention of intraperitoneal adhesion for-
but not expanded polytetrafluoroethylene (Gore-Tex® Surgical Mem- mation with ibuprofen.] Surg Res. 1983;34:219-226.
brane). Fertil SteriL 1992;57(1):202-208. 66. Siegler AM, Kontopoulos V, Wang CE. Prevention of postoperative ad-
53. Hooker GD, Taylor BM, Driman DK. Prevention of adhesion forma- hesions in rabbits with ibuprofen, a non-steroidal anti-inflammatory
tion with use of sodium hyaluronate-based bioresorbable membrane agent. Fertil SteriL 1980;34:46--49.
in a rat model of ventral hernia repair with polypropylene mesh-a 67. Bateman BG, Nunley WC, Kitchen JD. Prevention of postoperative
randomized, controlled study. Surgery. 1999;125(2):211-216. peritoneal adhesion: an assessment of ibuprofen. Fertil SteriL 1982;38:
54. Steinleitner A, Kozensky C, Lambert H. Calcium channel blockade pre- 107-115.
vents adhesion reformation following adhesiolysis [abstract]. Atlanta; 68. Steinleitner AS, Lambert H, Suarez M, et al. Reduction of primary
1989. posttraumatic adhesion formation with the prostacyclin analog iloprost
55. Jansen RPS. Failure of peritoneal irrigation with heparin during pelvic in a rodent model. Am] Obstet GynecoL 1991;165:1817-1820.
operations upon young women to reduce adhesions. Surg Gynecol Ob- 69. Home RW, Clyman M, Debrovner C, et al. The prevention of post-
stet. 1988;166:154-160. operative adhesions following conservative operative treatment for hu-
56. Doody KJ, Dunn RC, ButtramJr VC. Recombinant tissue plasminogen man infertility. Int] FertiL 1973;18:109-115.
activator reduces adhesion formation in a rabbit uterine hom model. 70. Replogue RL, Johnson R, Gross RE. Prevention of postoperative in-
Fertil SteriL 1989;51:509-512. testinal adhesions with combined promethazine and dexamethasone
57. Abe H, Rodgers KE, CampeauJD, et al. The effect of intraperitoneal therapy: experimental and clinical studies. Ann Surg. 1966;163:580-
administration of sodium tolmetin-hyaluronic acid on the postsurgi- 588.
cal cell infiltration in vivo.] Surg Res. 1990;49:322-327. 71. Swolin K. Die Einwirkung von grossen, intraperitonealen Dosen
58. Elkins TE, Bury RJ, Ritter JL, et al. Adhesion prevention by solutions glukokortikoid anf die Bildung von postoperativen Adhaesionen. Acta
of sodium carboxymethylcellulose in the rat, I. Fertil SteriL 1984;41: Obstet Gynecol Scand. 1967;46:1-15.
926--928. 72. Jansen RPS. Clinical approach to prevention. In diZerega GS, Malinak
59. Elkins TE, Bury RJ, Ritter JL, et al. Adhesion prevention by solutions LR, Diamond MP, Linsky CB (eds): Treatment of postsurgical adhesions.
of sodium carboxymethylcellulose in the rat, II. Fertil SteriL 1984;41: New York: Wiley-Liss; 1990:177-192.
929-932. 73. Gomel V. Recent advances in surgical correction of tubal disease pro-
60. Diamond MP, De Cherney AH, Linsky CB, et al. Adhesion re-forma- ducing infertility. CUrT Prob! Obstet GynecoL 1978;1(10):28-29.
tion in the rabbit uterine hom model: I. Reduction with carboxy- 74. Seitz HMJr, SchenkerJG, Epstein S, et al. Postoperative intraperitoneal
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61. Fredericks CM, Kotry I, Holtz G, et al. Adhesion prevention in the rab- key. Fertil SteriL 1973;24:935-940.
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1986;155:667. of peritoneal adhesion. Fertil SteriL 1982;38:491-492.
62. Felton RJ, Tuggle DW, Milewicz AL, et al. High mortality with an in- 76. Berman JK, Habegger ED, Berman EJ. The effect of antihistamine
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41
Intraperitoneal Prostheses
R.K.]. Simmennacher
The abdominal wall surrounds and protects the contents of the Elective Repair
abdominal cavity and participates in a great variety of functions of
the body, including maintenance of the upright position, cough- Abdominal wall defects resulting from a long-standing incisional
ing, and straining. These functions can be guaranteed only by the hernia or created by tumor resection allow thorough preparation
integrity of the myoaponeurotic part of the abdominal wall. for the operation. There should be consensus between doctor and
Defects of this part of the abdominal wall include primary full- patient about the indication for operation, the type of recon-
thickness loss due to external violence, en bloc resection of neo- struction, and the anticipated effect of the operation on all aspects
plasia or necrotizing infection or secondary pathology such as a of the patient's life. In such cases, one can determine preopera-
long-standing incisional hernia causing retraction of the muscles; tively what kind of reconstruction will offer the greatest chance
such defects interfere with abdominal wall function and should of success with the least chance of major disadvantages for the
therefore be repaired. patient.
Small defects with a greatest diameter less than 3 cm may be re-
paired primarily.! Defects with a diameter between 3 and 10 cm
are normally suitable for closure with autologous tissue at hand. Acquired ''Primary'' Closure
For this purpose, many different methods with excellent results
have been described. 2 Defects larger than 10 cm, whether primary If tissue expansion or pneumoperitoneum has preceded the final
or secondary, do not permit primary closure, which would increase repair operation of a long-standing incisional hernia, coverage of
intraabdominal pressure, causing circulatory and respiratory prob- the viscera with peritoneum, using either the evenly enlarged peri-
lems and exerting undue tension on sutures in already damaged toneum or the hernia sac, will not likely be a problem. The liter-
tissue. 3 Depending on the site of the defect and its origin, recon- ature tells us nothing, however, about adhesion formation after
struction may be possible, by rearrangement4 oflocal myoaponeu- this kind of repair. On the other hand, oncological resections will
rotic tissue or its artificial distension before operation by means probably not be preceded by either of these time-consuming
of pneumoperitoneum5 or tissue expanders. 6 preparations, which neither patient nor physician may consider
As an alternate approach, particularly appropriate in very large wise.
defects, an animal-derived or artificial substitute must be used to
augment the myoaponeurotic reconstruction repair or to bridge
the defect. 7 Epidermal Graft
It has been generally accepted that direct contact must be
avoided between viscera and any substitute for abdominal wall tis- Although unusual, in rare circumstances one might decide to close
sue. Either the greater omentum or, preferably, peritoneum a defect just with a split skin graft. This will not offer adequate
should be interposed to protect the viscera. Since the introduc- support to the abdominal viscera and will therefore end in a (re-
tion of laparoscopic hernia repair, this issue is once again being current) hernia. Initially, the split skin graft will adhere firmly to
debated. 8 the underlying unprotected viscera. Mter a certain time, however,
The literature offers excellent papers advising which prosthesis usually about 6 months, the split skin graft becomes detached. This
would be appropriate in certain situations.9 ,lO This chapter will, unusual and unsatisfactory solution buys time in which to plan a
however, discuss the behaviors of different substitutes for abdom- definitive repair.
inal wall tissue available for the repair of large defects lacking peri-
toneum or greater omentum to protect the viscera.
The guidelines concerning the use of any kind of prosthesis as Fascial and Myofascial Tissues
outlined by Amid et al. 9 and Goldstein 10 are generally valid in these
special cases. However, one of the first aspects to be considered is The literature does not give any clue about possible adhesion for-
whether we have to deal with an elective or an acute situation. mation after a rotation flap is used to reconstruct the abdominal
299
300 R.KJ. Simmermacher
wall. The myofascial rotation flaps with either the tensor fasciae Metal Meshes
latae muscle or the rectus femoris muscle are suitable for these
procedures. One might speculate that as long as there is hardly Since Billroth stated that "if an adequate tissue replacement could
any damage to the serosa of the viscera and the muscular part of be found the problem of hernia would no longer exist," a large
the flap is applied directly to the viscera, the procedure might not number of fabrics have been used to repair all kinds of abdomi-
initiate adhesions. This is hypothetical, however, as there are no nal wall defects. In the beginning, silver filigree was used for some
investigations in this field. time. 16 However, corrosion due to contact with tissue fluids made
it unsuitable. In the 1920s, steel became very popular and was used
for many decades but later was abandoned largely because of frag-
Free Vascularized Myocutaneous Flaps mentation and migration. Mter World War II, tantalum gauze was
popularized mainly by Koontz l7 but later also revealed a tendency
Again, there is no literature about adhesion formation in free vas- to fragmentation.
cularized myocutaneous flaps. In principle, the procedure will be Generally, metallic meshes have lost popularity as a substitute
similar to the use of rotation flaps, and the results will depend for abdominal wall defects due to their tendency to fragment, mi-
mainly on the type of flap used. grate, and cause patient discomfort. There are no reports of ad-
In summary, the use of autologous tissue mayor may not pro- hesion formation between these implants and the viscera, but it is
duce a limited number of visceral adhesions. It does present the easily conceivable that major complications might arise at least at
disadvantages of a secondary incision, long operations, and a rel- the fragmentation margins. Metallic meshes should not be used
atively limited applicability. in direct contact with viscera.
Artificial Substitutes Polypropylene Mesh

Basically, we have to choose between natural and synthetic mate- Since its introduction in 1958 by Usher and Wallace,18 polypropyl-
rials for use as abdominal aponeurotic substitutes. Biological ma- ene mesh has gained great popularity and has been cited in a large
terials like processed dermal sheep collagen and human or bovine number of reports in the literature. 19 Originally introduced as a
dura mater have been successfully applied in small defects, but high density polyethylene mesh, it was changed in 1962 into poly-
generally their use in the repair of abdominal wall defects has been propylene and since then has been frequently used in the repair
limited. One report on the experimental use of human dura for of many kinds of abdominal wall defects. It is a monofilament knit-
defect closure stated that no visceral adhesions were seen. 7 Anec- ted polypropylene mesh with a pore size of about 600 /-tm, de-
dotally, in humans loose adhesions have been formed. I1 For use pending on the manufacturer. In surgical and gynecological
in humans, however, the available size of these patches is limited. publications it is extensively proven that Marlex® mesh in direct
Bovine dura mater used as an abdominal wall substitute in rabbits contact with viscera will initiate many firm adhesions 2o ,21 (Fig.
showed only 16% loose visceral adhesions.12 Dura is intended to 41.1) with unwanted sequelae. 22 It is strongly recommended to
function as a kind of lattice for the host connective tissue and is avoid this contact. 23 ,24 Possible reasons for this are the shrinkage
expected to be replaced by the patient's own tissue. The host's re- of the mesh area, with 46% after 4 weeks accompanied by folding,
placement tissue may not be strong enough to prevent rehernia- which increases its stiffness. The folded edges have a saw-like
tion. One might also be concerned about the dura's potential for appearance. 24
transmitting viral diseases, including human immunodeficiency There are other monofilament polypropylene meshes that dif-
virus. I1 fer from Marlex in their filamentous structure, pore size, and/or
knitting pattern. Although the brand name is not always retriev-
Synthetic Substitutes
Synthetic substitutes are either absorbable or nonabsorbable pros-
thetic materials. The absorbable materials are intended to function
as scaffold for the formation of new collagenous tissue and to sup-
port the abdominal wall until the new tissue takes over. The cor-
rect orientation of the newly formed collagen fibers depends on
the forces exerted on them by the abdominal wall musculature, but
the presence of the prosthesis neutralizes these forces; fibers in the
resulting tissue thus tend to be randomly oriented. The disap-
pearance of the absorbable material leaves a weak tissue with ir-
regular, loosely arranged collagen fibers that will not be able to
support the abdominal contents. The recurrence rate after the use
of absorbable prostheses is very high. 13,14 A report of polyglycolic
acid (Dexon®) mesh used in direct contact with the viscera showed
that this was associated with thinning and erosion of the mesh into
the intestinal lumen, creating a high number of fistulas.14 When
polyglactin 910 (Vicryl®) was used, adhesions were seen in the same FIGURE41.1. Photograph showing visceral adhesions to the polypropylene
number as with nonabsorbable prosthetic material. 15 (Marlex) 8 weeks after intraperitoneal application in the rat.
41. Intraperitoneal Prostheses 301
able from the publications, the meshes probably all provoke firm
adhesion formation. 8 One publication interestingly suggests
that the number and firmness of adhesions when polypropylene
mesh is used are independent of its intra- or extra(pre)peritoneal
position. 25
Polyester Mesh
Although developed earlier than polypropylene mesh, the poly-
ester mesh became more popular only after the introduction of
the polypropylene mesh. It is a macroporous multifilament knit-
ted mesh composed of polyethylene terephthalate and is less stiff
than the polypropylene mesh. There is some controversy about its
use on unprotected bowel. Experimental 26 and clinical 27 studies
show even less adhesion formation when it is compared with ex-
panded polytetrafluoroethylene. Follow-up in the clinical study was
FIGURE 41.2. Photograph showing a so-called buttonhole hernia at the fas-
not more than 11.6 months, however, and no intraabdominal in-
cia patch interface in a lumbotomy 6 months after repair with an ePTFE
vestigation was performed to count adhesions. There are reports
Soft Tissue Patch.
raising doubts about its safety28 or describing migration of the ma-
terial into the small bowel. 29
sions between the viscera and ePTFE32,37 compared with poly-

propylene 20 and, furthermore, that these adhesions are mostly very
Polytetrafluoroethylene
loose and can be removed quite easily.34 Some years ago this state-
ment was called into question by an experimental study showing
Polytetrafluoroethylene (PTFE) is available in two very different
the same number and firmness of adhesions when ePTFE or
versions. The original PTFE was made of solid fibers woven into a
polypropylene was applied intraperitoneally.38 There have been
cloth structure that became known as Teflon® mesh; it was used
experimental efforts to improve this favorable characteristic by
in the 1960s and was rapidly abandoned due to associated infec-
rendering the ePTFE patch even more hydrophobic; this failed to
tions and sinus tract formation. Later another manufacturing
improve the quality because the modification induced an impor-
process was developed that produced expanded PTFE (ePTFE),
tant architectural change in the surface of the ePTFE patch that
which was first used as a vascular prosthesis31 and later became
increased the number and firmness of the adhesions despite en-
available as a sheet for reconstruction of abdominal wall defects.
The material is smooth, very strong and pliable and has excellent hanced hydrophobia. 39 The standard ePTFE patches avoid adhe-
sion formation but require fixation to the abdominal wall,
handling qualities,32 but there is some controversy about its use as
according to Van der Lei et al. 36
a replacement for the abdominal wall.
This controversy centers on the possibility of tissue ingrowth into
the material. Elliott and Juler3 3 report complete incorporation of Silas tic Sheets
the ePTFE patch into the abdominal wall, whereas our own expe-
rience shows no ingrowth of tissue into the micro pores of this ma- Silicone sheets have been used temporarily for the successful man-
terial. Due to its hydrophobia and the size of the pores, which agement of abdominal wall defects in children. 4o Occasionally its
ranges between 10 and 90 p.m, some fibroblasts may be detected use in adults has been mentioned, but without data concerning
within the patch after 3 months' implantation, but it never reaches adhesion formation. As silastic has often been associated with dif-
an amount that would be sufficient to guarantee adequate an- ficulties in cases of infection, its use for adult abdominal wall de-
choring of the patch to the abdominal wall. 34 Thus far, in the re- fects has never been widespread .
pair of abdominal wall defects, complete ingrowth of fibroblasts
into the patch has not been shown. In vascular ePTFE prostheses,
there is fibroblast ingrowth into the interstices of the material,35 as Double Layer Principle
the pore size in the vascular prosthesis is larger than in the ePTFE
sheets for abdominal wall repair. For this reason, ePTFE patches Two contradictory properties are required in materials used to
are not generally used for the repair of abdominal wall defects; bridge defects in which peritoneal or omental protection of the
firm anchoring of the patch to the margins of the defect can only viscera is lacking. First, collagenous tissue should be able to pen-
be gained by a double row of interrupted nonabsorbable sutures, etrate and anchor the prosthesis to the surrounding tissue, allow-
as described by Van der Lei et al. 36 This is a time-consuming pro- ing ingrowth of capillaries to supply adequate defense in case of
cedure but necessary to prevent the so-called buttonhole hernias contamination of the prosthesis. Second, there should be hardly
at the patch/tissue interface (Fig. 41.2). any ingrowth of any kind of tissue into the prosthesis from the vis-
On the other hand, precisely this characteristic makes ePTFE ceral side to cause adhesion formation. This goal can be reached
suitable for application in abdominal wall defects where the vis- only by use of a prosthesis with two different sides. One solution
cera cannot be protected by peritoneum or greater omentum and is to modify one side of a currently available synthetic prosthesis
direct contact between the prosthesis and the viscera cannot be in such a way that the surface quality is changed. Another solu-
avoided. Various studies show that there are certainly fewer adhe- tion would be to use a composite mesh.
302 R.KJ. Simmermacher
In a pilot study it was shown that a modified ePTFE patch would been nicely described by Fabian et al. 45 In the first stage, when
be able to fulfill the demands for adhesion prevention on the vis- prostheses are applied directly onto often unhealthy bowel, an ab-
ceral side and sufficient anchoring at the abdominal side of the sorbable mesh like polyglactin 910 (Vicryl) is favored because of
patch. 39 However, this has not yet been proved in a study with hu- its acceptable durability, easy removal, and lower cost. Adhesion
mans. Recently, a new patch was introduced with different quali- and fistula development, however, do not differ from that with
ties on the two sides, achieved by different pore size for each side. polypropylene meshes. In open treatment, a temporary macro-
Thus far no reports on the adhesion formation characteristics of porous mesh should be chosen that makes drainage of intraab-
this patch are available. This is the only known prosthesis in which dominal fluid possible. If repeated laparotomies are expected to
the same material displays different properties. be performed through the mesh, a nonabsorbable mesh will be
Two methods might be used to produce this effect with two dif- stronger, facilitating attempts to close the abdominal cavity grad-
ferent materials, the so-called composite meshes. First, one might ually. Prolene® often appears to have more desirable handling
use a composite mesh that has been constructed by stitching two qualities. 3
different nonabsorbable synthetic prostheses together. In an ex- If it is foreseen that the open treatment will take more than 2
perimental study, a patch composed of a visceral ePTFE layer and weeks or if there is substantial absolute deficit of abdominal wall
an abdominal polyurethane layer proved to combine the desired tissue in a contaminated area where daily lavage is not required,
qualities of nonadhesion formation and sufficient ingrowth of col- nonabsorbable prostheses should not be used; they can promote
lagen tissue of the abdominal side. However, this patch was not infection or adhesion formation. Furthermore, the bowel in these
strong enough to be used in a human abdominal wall defect. 39 In cases is usually vulnerable and more susceptible to firm adhesions.
mid-1994, positive results were reported with the use of a poly- Expanded PTFE, which would appear suitable in these cases, is ill
propylene ePTFE mesh for the repair of abdominal wall defects advised because the patch will disintegrate if contaminated. 39 Two
with naked bowel. 9 More experience with this composite mesh is polypropylene meshes, Marlex and Prolene, which are applicable
needed for full assessment. in contaminated wounds, have been used extensively in these
Second, attempts to repair abdominal wall defects by using a cases. When covered with split skin grafts, they have shown wrin-
composition of an outer polypropylene mesh and a visceral kling of the mesh with subsequent protrusion through the split
polyglactin 910 mesh have met with outcomes 29 more unfavorable skin graft.3.46 This can stimulate fistula formation and necessitates
than favorable. 41 Earlier repairs with a polyester/polyglactin 910 operative removal of the mesh. Therefore, in these cases, an ab-
composite mesh have been published. Mter initial enthusiasm,42 sorbable mesh should be used to bridge the abdominal wall de-
more negative reports followed. 43 fect and be covered with a split skin graft after apparent ingrowth
In summary, elective repair of large abdominal wall defects is of granulation tissue. Later, the incisional hernia can be closed on
particularly challenging when peritoneum or greater omentum to an elective basis. Normally, this can be done when the split skin
protect the viscera is lacking. A literature review reveals that at the graft can be lifted off the abdomen, indicating that adhesions are
end of the twentieth century, the ePTFE prosthesis is the only suit- loosening (Fig. 4l.3).
able prosthesis yet devised for this purpose. The currently avail- When dealing with acute abdominal wall defects, a staged ap-
able standard ePTFE soft tissue patch is the only prosthesis that is proach to reconstruction is preferred. Depending on the neces-
proven to keep the number and firmness of visceral adhesions to sity of daily lavage of the abdominal cavity, either a nonabsorbable
the prosthesis to a minimum. However, a number of disadvantages macro porous polypro!ylene or a polyester mesh should be used if
should be taken into account. To prevent buttonhole hernias, the frequent reopening of the abdomen is expected. In all other cases,
prosthesis should be anchored to the surrounding tissue, and con- an absorbable prosthesis is preferred.
tamination of the operation field should be carefully avoided.
Modifications of the ePTFE patch either by chemical treatment of
the outer layer or fixing it to another (nonabsorbable) prosthesis
have not been used for a long enough period to allow conclusions
to be drawn.
The feasibility of the proposal by Soler et al. 29 to use an ab-
sorbable prosthesis sandwiched between viscera and a nonab-
sorbable prosthesis is inconclusive. From a theoretical point of
view, protecting the viscera with a resorbable membrane such as
the sodium hyaluronate-based bioresorbable membrane 44 be-
tween a prosthesis and viscera could prevent adhesions. Up to now,
this has been demonstrated only experimentally.38
Acute Abdominal Wall Defects

The management of acute abdominal wall defects due to trauma
or infection is different from elective management. In acute man-
FIGURE 41.3. Photograph showing a 50-year-old patient 6 months after
agement, the life of the patient must be saved and reconstruction open treatment of a generalized purulent peritonitis following anastomotic
of the abdominal wall is of secondary importance. The infectious leakage after a low anterior resection. After temporary closure of the wall
parameters and the clinical appearance of the wound and the with a nonabsorbable prosthesis, this was removed and a split skin graft
bowel determine whether reconstruction of the abdominal wall is was directly applied on the viscera. Patient now waits for closure of the ab-
a matter of days or months. A four-stage management scheme has dominal wall.
41. Intraperitoneal Prostheses 303
References by an intraperitoneal Mersilene mesh and an aponeurotic graft. Surg

GynecolObstet. 1987;165:204-206.
1. Herszage L. Personal communication, Hilversum, 1999. 28. Cubertafond P, Sava P, Gainant A. Cure chirurgicale des eventrations
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ciones. Buenos Aires, EI Ateneo; 1988. 1989;15:66-71.
3. Stone HH, Fabian TC, Turkelson ML, et al. Management of acute full- 29. Soler M, Verhaeghe P, Essomba A, et al. Le traitement des eventrations
thickness losses of the abdominal wall. Ann Surg. 1981;611-618. post-<lperatoires par prothese composee (polyester-polyglactine 910).
4. Ramirez OM, Ruas E, Dellon AL. "Components separation" method Ann ChiT. 1993;47:598-608.
for closure of abdominal wall defects: an anatomic and clinical study. 30. Drainer IK, Reid DK Recurrence-free ventral herniorrhaphy using a
Plast Reconstr Surg. 1990;86:519-526. polypropylene mesh prosthesis.] R Coll Edinb. 1972;17:253-260.
5. Goni-Moreno I. Chronic eventrations and large hernias. Surgery. 1947; 31. Tizian C, Demuth RJ, Glass KD, et al. Evaluation of microvascular pros-
22:945. thesis of microporous polytetrafluoroethylene.] Surg Res. 1981 ;30: 159-
6. Jacobsen WM, Petty PM, Bite U, et al. Massive abdominal-wall hernia 164.
reconstruction with expanded external/internal oblique and trans- 32. Toy FK. Rationale for the use of ePTFE in the intraperitoneal position.
versalis musculofascia. Plast Reconstr Surg. 1997;100:326-335. In Arrequi ME, Nagan RF (eds): Inguinal hernia advances or controver-
7. Rodgers BM, Maher JW, TalbertJL. The use of preserved human dura sies. Oxford: Radcliffe Medical Press; 1994.
for closure of abdominal wall and diaphragmatic defects. Ann Surg. 33. Elliot MP, Juler GL. Comparison of Marlex mesh and microporous
1981;193:606-611. Teflon sheets when used for hernia repair in the experimental animal.
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niques Am Surg. 1994;60:157-159. ter repair of the abdominal wall with expanded polytetrafluoroethyl-
9. Amid PK, Shulman AG, Lichtenstein IL, et al. Biomaterials for ab- ene.] Am Coll Surg. 1994;178.
dominal wall hernia surgery and principles of their application. Lan- 35. Bellon JM, Contreras LA, Sabater C, et al. Pathologic and clinical as-
genbecks Arch ChiT. 1994;379:168-171. pects of repair of large incisional hernias after implant of a polytetra-
10. Goldstein HS. Selecting the right mesh. Hernia. 1999;3:23-26. fluoroethylene prosthesis. World] Surg. 1997;21:402-407.
11. Root M, Lockhart JL, Vorstman A, et al. Long-term follow-up with the 36. Van der Lei B, Bleichrodt RP, Simmermacher RKJ, et al. Expanded
use of lyophilized dura mater for abdominal wall closure in children: polytetrafluoroethylene patch for the repair of large abdominal wall
report of 3 cases.] Urol. 1992;148:858-860. defects. Br] Surg. 1989;76:803.
12. Bellon JM, Contreras LA, Pascual G, et al. Neoperitoneal formation 37. diZerega GS. Contemporary adhesion prevention. Fertil Steril. 1994;61:
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wall defects in rabbits. Eur] Surg. 1999;165:145-150. 38. Narm 10, Pulley D, Seaulan K, et al. Reduction of postoperative ad-
13. Gross E, Eigler FW. Prostheses for abdominal wall closure in post- hesions to Marlex mesh using experimental adhesion barriers in rats.
operative peritonitis, incisional hernia and reconstruction of the ab- ] Laparoendo Surg. 1993;3:187-190.
dominal wall. Z ChiT. 1984;109:1238-1250. 39. Simmermacher RKJ. Biomaterials in the repair of abdominal wall de-
14. Greene MA, Mullins RJ, Malangoni MA, et al. Laparotomy wound clo- fects. Thesis, University of Groningen, 1994.
sure with absorbable polyglycolic acid mesh. Surg Gynecol Obstet. 40. Ong TH, Strong R, Zahan Z, et al. The management of difficult ab-
1993;176:213-218. dominal closure after pediatric liver transplantation. ] Pediatr Surg.
15. Rokitansky AM, Kolankaya A, Semsroth M. Patchplasty with expanded 1996;31 :295-296.
polytetrafluoroethylene and skinplasty for the closure of large con- 41. Porter JM. A combination ofVicryl and Marlex mesh: a technique for
genital abdominal wall defects. Pediatr Surg Int. 1994;9:227-230. abdominal wall closure in difficult cases.] Trauma. 1995;39: 1178-1180.
16. Witzel O. Ueber den verschluss von bruchwunden und bruchpforten 42. Loury IN. Traitement des eventrations. Utilisation simultanee du treil-
durch versenkte silberdrahtnetze. Centralbl F Chir Leipz. 1900;27:257. lis de polyglactine 910 et de Dacron. Presse Med. 1983;12:2116.
17. Koontz AR. Preliminary report on the use of tantalum mesh in the re- 43. Dasika UK Does lining polypropylene with polyglactin mesh reduce
pair of ventral hernia. Ann Surg. 1948;127:1079-1085. intraperitoneal adhesions? Am Surg. 1998;64:817.
18. Usher FC, Wallace SA. Tissue reactions to plastics. Arch Surg. 1958; 44. Becker JH, Dayton MT, Fazio VW, et al. Prevention of postoperative
76:997-999. abdominal adhesions by a sodium hyaluronate-based bioresorbable
19. Liakakos T, Karanikas I, Panagiotidis H, et al. Use of Marlex mesh in membrane: a prospective randomized double-blind multicenter study.
the repair of recurrent hernia. Br] Surg. 1994;81:248-249. ] Am Coll Surg. 1996;183:297-306.
20. Murphy JL,FreemanJB, Dionne PG. Comparison of Marlex and Gore- 45. Fabian TC, Croce MA, Pritchard FE, et aI. Planned ventral hernias of
Tex to repair abdominal wall defects in the rat. Can] Surg. 1989;32: the abdominal wall: principles and management. Ann Surg. 1994;219:
244-247. 643-653.
21. Iglesia CB, Fenner DE, Brubaker L. The use of mesh in gynecologic 46. Voyles CR, RichardsonJD, Bland KJ, et al. Emergency abdominal wall
surgery. Int UrogynecolJ 1997;8:105-115. reconstruction with polypropylene mesh: short term benefits versus
22. Kaufinan Z, Engelberg M, Zager M. Fecal fistula: a late complication long term complications. Ann Surg. 1981;194:219-223.
of Marlex mesh repair. Dis Colon Rectum. 1981;24:543-544.
23. Trupka AW, Hallfeldt KKJ, Schmidbauer S, et al. Die versorgung kom-
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polypropylennetz. Chirurgie. 1998;69:766-772.
24. Klinge U, Klosterhalfen B, Muller M, et al. Shrinking of polypropylene Commentary
mesh in vivo: an experimental study in dogs. Eur] Surg. 1998;164:965-
969.
25. Attwood SEA, Caldwell MTP, Marks P, et al. A comparison of extra-
Robert Bendavid
versus intraperitoneal placement of a polypropylene mesh in an ani-
mal model. Surg Endosc. 1994;8:77-80. Solutions to the problems associated with the intraperitoneal pres-
26. Pans A, Pierard CE. A comparison of intraperitoneal prostheses for ence of prosthetic material are a worthy task for the start of the
the repair of abdominal muscular wall defects in rats. Eur Surg Res. new century. The currently available prostheses have all been as-
1992;24:54-60. sociated not only with visceral adhesions but also with erosion,
27. AdloffM, AmaudJP. Surgical management oflarge incisional hernias transmigration, and fistulization. l The introduction of prosthetic
42
Use of Absorbable Mesh in the Staged Repair of
Contaminated Abdominal Wall Defects
Merril T. Dayton
Introduction prosthesis after the wound has cleaned up and contamination

resolved.
Virtually every abdominal surgeon has faced the problem of clos-
ing a contaminated abdominal defect in which the fascia cannot
be easily brought together primarily. Infected fascia may be inad- History of Mesh Use
equately debrided in the hope of leaving enough fascia for pri-
mary closure without tension, or, as observed by Stone et al, l there While the search for the ideal prosthetic in a contaminated field
may be an obsession with obtaining fascia-to-fascia approximation is particularly difficult, the history of the search for an acceptable
regardless of tension. Usually, however, the surgeon recognizes prosthetic in a clean field has been extensive and complex. The lit-
that closure of an extensively contaminated abdominal defect un- erature includes a host of studies that describe materials that have
der tension virtually guarantees a return trip to the operating room been tested for use as a permanent prosthesis. They include stud-
to repair a fascial dehiscence. Whatever the circumstances, inad- ies that have evaluated silastic, preserved human dura, nylon wo-
equate debridement of necrotic fascia, or fascia of questionable ven mesh, polyester fiber mesh, braided carbon fiber, stainless steel
viability, is a violation of surgical principles. mesh, polytetrafluoroethylene, and polypropylene. These agents
Commonly, the scenario involves the gastrointestinal surgeon have all been tested to see if they would satisfY the criteria of an
recognizing necrotic fascia and dead skin and performing a com- ideal prosthetic. The characteristics of an ideal prosthetic are
plete debridement back to healthy tissue. Upon completing the (1) chemically inert, (2) nonrigid, (3) comformable to different
debridement, the surgeon finds that he or she is unable to bring shapes, (4) noninflammatory, (5) hypoallergenic, (6) unmodified
the fascia back together primarily and must try to reconstruct this by tissue fluids, (7) sterilizable, (8) resistant to mechanical strain,
defect using a nonabsorbable prosthetic. There is voluminous lit- and (9) noncarcinogenic. The most commonly used prosthetic to-
erature regarding the placement of nonabsorbable prostheses in day is polypropylene mesh, probably because of its strength and
an infected field, and the usual outcome is infection, eventual fail- low reactivity.
ure of the prosthesis, and its subsequent removal. For this reason, Although Witzel 3 and Goepel4 recommended the use of silver
in the past, many surgeons have simply packed the abdominal wall mesh to repair large abdominal wall defects as long ago as 1900,
with saline-moist gauze and used abdominal binders. This strategy it was not until 1958 that a prosthetic mesh was developed that
has a number of significant limitations, including the patient's in- was consistently successful in repair of these large defects. 5 In their
ability to ambulate and be active postoperatively. The patient study that evaluated a variety of synthetic meshes, Usher and Wal-
spends prolonged periods in bed until the viscera are fixed. This lace5 introduced Marlex® mesh as their choice for a near ideal
is associated with a host of postoperative complications, including prosthetic material. Since that time, Marlex has been used exten-
thromboembolic problems, muscle wasting, contracture, decubi- sively in the repair of large abdominal wall defects.
tus sores, and general body weakness. In 1967, Schmitt and Grinnan 6 described the successful use of
In addition to packing the abdominal defect, a host of pros- Marlex mesh to repair grossly contaminated abdominal wall de-
thetic options have been attempted in this setting. The hope is fects. They reported on three Vietnam War patients with massive
that the prosthesis placement will restrain the viscera to allow abdominal wall injuries, including significant contamination and
early ambulation and provide closure of the defect and impart loss of abdominal wall. They described using Marlex and reported
abdominal wall stability. One solution to this dilemma was de- incorporation of the mesh into granulation tissue, which was then
scribed in the mid-1980s, when absorbable mesh was used to grafted without difficulty. Since their report, multiple investigators
close abdominal wall defects in a contaminated setting. 2 Unfor- have confirmed their findings. For example, Eng and colleagues7
tunately, these closures virtually always resulted in hernias at the reported a case of clostridial myonecrosis of the anterior abdom-
site of the absorbable mesh placement, and it became clear that inal wall in a patient who had resection of the abdominal wall fol-
the use of absorbable mesh in this setting should be part of a lowed by Marlex mesh placement and subsequent skin grafting.
staged plan including eventual placement of a nonabsorbable Gilsdorf and ShayB similarly reported on six patients with wound

42. Absorbable Mesh in Contaminated Abdominal W all Defects 307
TABLE 42.1. Fate of nonabsorbable mesh in contaminated hernia repair
No. patients No. patients

with mesh with mesh (%) Mesh
Author Mesh removed placed removal
Ger Marlex 3 3 100

Blom Marlex 0 1 0
Lewis Marlex 1 2 50
Kaufman Marlex 0 2 0
Eng Marlex 2 50
Morgan Mersilene 100
Schmitt Marlex 1 3 33
Gilsdorf Marlex 2 4 50
Wouters Marlex 15 20 75
Boyd Marlex 4 8 50
Voyles Marlex 20 24 83
Stone Marlex 21 23 91
Stone Prolene 80 101 80
Bauer Gore-Tex 1 2 50
J o nes Marlex 4 5 80
Total 154 200 77
quire removal if the mesh was initially placed in a dirty field. It is

also notable that removal of the mesh in this setting is a compli-
cated procedure, often associated with bleeding, fistula, hernia, or
FIGURE 42.1. Patient 1 without skin coverage. Postoperative care consisted
recurrent infection. The excellent review by Jones andJurkovich l2
of saline soaks three times a day.
in 1989 looked at their own experience with 5 patients as well as
128 patients who had had Marlex mesh placed in an infected field.
Four of their five patients developed small bowel fistulas, and
dehiscence who had abdominal wall reconstruction with Marlex wound dehiscence occurred in one. The four patients with com-
mesh in a massively septic abdominal wall defect. Two of the four plications had the mesh removed eventually. Their review also
patients had successful incorporation of the mesh into the field. cited 14 studies reporting on a total of 125 patients who had had
Wouters and his group9 from the Netherlands reported on the use placement of polypropylene mesh in a contaminated setting. The
of Marlex mesh in 20 patients with massive contamination and or- overall complication rate was 55 % in that setting. Patients who did
gan failure . In their work, Marlex mesh was used for wound clo- not have skin coverage had mesh extrusion in 44%, and enteric
sure but was incorporated into the wound in only 5 of their 20 fistulization was present in 23% of the patients. The authors con-
patients.9 Finally, BoydlO described the use of Marlex mesh in an cluded that, while occasionally the surgeon will be able to place
abdominal wall defect that had become infected and described polypropylene mesh in the contaminated setting, the unaccept-
four out of eight patients successfully incorporating the Marlex able complication rate argues for alternative methods of wound
mesh. These reports clearly detail the fact that sometimes Marlex care in these difficult patients.
mesh can be used in a contaminated field successfully. However,
most of the series reported in the early literature were small se-
ries and, unfortunately, did not include long-term follow-up . Absorbable Mesh in Animal Studies
Recently, two large series and one small series with long-term
follow-up demonstrated that while Marlex mesh may be success- In response to the high incidence of long-term complications as-
fully used in a contaminated field on a short-term basis, a host of sociated with Marlex mesh placement in a contaminated field, ab-
serious complications are associated with its long-term use, in- sorbable meshes were developed. Two principal, absorbable
cluding fistula formation , erosion through the skin, bleeding, and meshes that were initially described include polyglycolic acid mesh
infected, chronically draining sinuses. I ,Il,12 For example, in the (Dexon®) and polyglactin mesh (Vicryl®). The mesh developed
study by Voyles et al.,u 20 of the 24 patients who had had Marlex by Davis and Geck (Dexon) is a soft stretchable mesh that is slowly
mesh placed under contaminated conditions had to have the Mar- biodegradable and disappears within about 50 to 60 days. This
lex mesh removed because of long-term complications. Similarly, mesh has large interstices, which allow the passage of fluid that
of the 124 patients studied by Stone et a1.,1 all of whom had had often drains after a contaminated case. The polyglactin mesh
placement in a contaminated field, 101 of the patients had their (Vicryl) is a tightly woven mesh that is inelastic and has very closely
mesh removed. placed interstices but is also quite strong and biodegradable as the
A careful review of the literature demonstrates the fate of non- polyglycolic acid is. Experience with these meshes demonstrates
absorbable mesh placed in contaminated hernia repairs in series that as they are absorbed, a hernia defect results. Thus, neither of
with long follow-up. Table 42.1 demonstrates that when long-term these meshes would ever be used in a clean abdominal wall de-
follow-up does occur, over 75 % of patients who require placement fect, which needs a permanent prosthesis to close the abdominal
of nonabsorbable mesh under contaminated conditions will re- wall.
308 M.T. Dayton
Some of the earliest animal studies regarding Dexon mesh were an abdominal wall defect that was either coated with polyglactin
performed in 1982 by Delaney et al.,l3 who showed that the mesh or into which fibrils of polyglactin were woven. The presence of
could be used to wrap injured and hemorrhaging dog spleens polyglactin coating actually inhibited incorporation of the per-
and successfully stop the parenchymal bleeding. Lamb and col- manent mesh. Conversely, the addition of polyglactin filaments or
leagues 14 repaired clean rabbit abdominal wall defects by using fibers appeared to favorably affect the mesh such that less adhe-
Vicryl mesh and found that at 3 weeks there was no weakness when sions occurred to the underlying small intestine.
compared with nonabsorbable meshes. However, at 12 weeks, the
bursting strength of the polyglactin repair was significantly less
than that of nonabsorbable meshes. In addition, 40% of the ani- Absorbable Mesh in Clinical Studies
mals whose wounds were repaired with polyglactin developed a
ventral hernia, and the authors believed that inadequate fibrous Absorbable mesh was used for the first time in human subjects in
tissue incorporation into the mesh occurred before hydrolysis. 1985, when Delaney et al. 21 described use of absorbable mesh for
They concluded that polyglactin is an inadequate material for per- so-called splenorrhaphy. The mesh was used in a number of ways
manent repair of abdominal wall defects. Conversely, Jenkins et with generally good results and usually resulted in preserving the
al. 15 used polyglactin mesh to repair clean abdominal wall defects spleen. Other authors have since used the polyglycolic acid mesh
in rats and found no difference in bursting strength at any time for repair of the injured spleen and kidney. Delaney et al. 22 addi-
(1 to 8 weeks) when polyglactin mesh was compared with poly- tionally described use of absorbable mesh to construct a pelvic
propylene, polytetrafluoroethylene, silicone rubber, and preserved sling, thus holding intestinal contents out of the pelvis for a lim-
human dura. Moreover, the absorbable mesh provided the best ited period while radiation was being applied to the pelvis fol-
long-term protection against adhesions of any of the substitutes. lowing resection of pelvic cancers.
Their study, however, included a follow-up of only 8 weeks. Fur- The first description of Dexon mesh used to repair contami-
ther follow-up may have revealed results similar to those of Lamb nated abdominal wall defects occurred in 1986, when Dayton and
and his colleagues,14 colleagues2 described placement of the mesh in eight patients. In
Tyrell and colleagues 16 compared polypropylene and polytetra- their study, four of the patients presented with previously placed
fluoroethylene as well as two absorbable meshes (polyglactin and polypropylene mesh that had become infected and was draining
polyglycolic acid) with respect to histological appearance, devel- infected material. The other four patients were patients who had
opment of adhesions, tensile strength, and occurrence of hernias massive abdominal wall sepsis and loss of abdominal wall sub-
in rabbits in which defects of the abdominal wall were repaired stance. Rather than placing a nonabsorbable prosthetic, polygly-
with the meshes. They noted that the inflammatory response was colic acid mesh was placed as the initial mesh with generally good
minimal with all products. Adhesions were more marked with results. Unlike the polypropylene mesh, which was rigid and some-
polypropylene and polytetrafluoroethylene. No such difference, what inflexible, the polyglycolic acid mesh used in these cases was
however, was noted between the absorbable meshes. In vitro ten- soft, pliable, and stretchable. In seven of the cases, the mesh was
sile strength at 10 weeks demonstrated that Marlex was superior sutured to healthy fascia along one side of the abdominal wall,
to the other materials; when the absorbable products were com- pulled slightly to place it under mild tension, and then sutured to
pared, polyglactin was superior to polyglycolic acid. No hernias the fascia on the opposite side. A single layer of the mesh was used
were initially observed with the nonabsorbable meshes, but all of except at the edges, where 2 cm of the mesh was doubled back to
the rabbits repaired with absorbable meshes had ventral hernias reinforce the area where the sutures were placed. Initially, an ab-
by the 10th week. They concluded that absorbable meshes are dominal binder was used for reinforcement during ambulation for
not indicated when prolonged tensile strength is required but the first week but subsequently was found to be unnecessary. Four
thought that they may be useful for other purposes, including the of the eight patients had initial skin coverage, which made wound
temporary repair of fascial defects since evisceration was not management quite easy. The other four patients, however, had
detected. large granulating defects that required normal saline moist dress-
A multitude of animal studies have been done in an attempt to ings until adequate granulation occurred, at which time split-
diminish adhesions from bowel to nonabsorbable mesh, prolong thickness skin grafts were placed. The authors of the initial study
absorption time of absorbable mesh, or strengthen absorbable hypothesized that the absorbable mesh may persist long enough
mesh to lessen the likelihood of hernia formation. One approach to serve as a template for collagenization, possibly obviating the
to this is the use of composite grafts. Klinge et alP added poly- development of abdominal wall hernia. However, it became clear
glactin to nonabsorbable polypropylene and found that there was that as the mesh absorbed, six of the eight patients developed a
less adhesive attachment to the nonabsorbable mesh with no de- large abdominal wall hernia within 3 months of its placement.
crease in mesh strength. Dasika and Widmann 18 demonstrated in Despite the development of the hernias, the authors concluded
a study using rats that lining polypropylene mesh with polyglactin that a case could be made for placing absorbable mesh in patients
mesh reduced intraperitoneal adhesions. who were critically ill with contaminated wound defects, allowing
A novel approach to strengthening absorbable mesh was taken the wound to heal and contamination to resolve, and subsequently
by Zieren and colleagues. 19 Their study, which was conducted in repairing any hernia that developed postoperatively with a non-
rats, compared animals that had polyglycolic mesh only with those absorbable mesh and/or full-thickness skin flaps. In follow-up ex-
that had polyglycolic mesh plus added fibrin and platelet re- perience, 17 additional patients underwent placement of the
leaseates. They found that the group that had added fibrin and absorbable mesh with the intent to use its placement as a tempo-
platelet releaseates had higher herniation pressures, higher hy- rary staging procedure until the contamination resolved and the
droxyproline content, and increased fibroblast and collagen fibers patient could have subsequent successful placement of a perma-
found at the time of animal sacrifice. A novel study by Klinge and nent prosthesis. In that series, 19 patients had necrotizing ab-
colleagues2o compared rats that had polypropylene placed to fix dominal wall infection, 4 had infected Marlex mesh from the
42. Absorbable Mesh in Contaminated Abdominal Wall Defects 309
previous repair, 1 had an extensive electrical burn of the abdom-

inal wall, and 1 had a hernia covered by a chronically infected scar.
Defect sizes varied from 8 by 15 cm to 45 by 30 cm. In 10 of the
original 25 patients who developed a large hernia at the site of the
mesh placement, a mean interval of 10 months elapsed before re-
operation and placement of a permanent mesh. In this group, re-
operation involved identification of the fascia and repair with
Marlex mesh in the standard fashion. Reoperating after the poly-
glycolic acid mesh had been placed revealed complete mesh re-
sorption. Specifically, there was no evidence of mesh-induced
complications such as dense adhesions, hypervascularity, obstruc-
tion, or residual infection.
In patients who had had placement of split-thickness skin grafts
on bowel covered with granulation tissue, over time a fine, ad-
ventitiallayer developed between the bowel surface and the skin.
This allowed relatively easy, bloodless removal of all the skin from
the bowel surface on reoperation. All of the 10 patients described
who had reoperation and operative placement of permanent mesh
recovered without complication and remain free of complications
today.
Additional reports in the literature have documented the use of
absorbable meshes in an emergency setting. McGahren et al. 23 de-
scribed the use of absorbable polyglactin mesh to close the ab-
domen of an infant who had a huge neuroblastoma resected and
whose viscera became massively edematous. 23 The temporary mesh
allowed the abdomen to be closed until edema resolved and a per-
FIGURE 42.2. Patient 1. Appearance of prosthesis at 4 weeks.
manent mesh was finally placed. Smith and associates 24 described
13 patients whose fascia could not be closed after life-threatening
trauma. Five of these patients were closed with absorbable mesh, concluded that this staged approach was associated with low mor-
which gave the abdominal wall stability until visceral edema had bidity and no technique-related mortality. They also concluded
resolved and a subsequent permanent mesh could be placed. that absorbable mesh provided the advantages of reasonable dura-
These authors, however, favored simply closing skin over the vis- bility, ease of removal, and relatively low cost. They concluded that
ceral mass with towel clips, returning a few days later to approxi- it had become the prosthesis of choice in this setting. Greens and
mate fascia after the edema had resolved. associates 29 agreed with Fabian et a1. 28 A polyglycolic acid mesh
Buck et al. 25 described the use of polyglycolic acid mesh in the was used in 59 critically ill patients to bridge abdominal wall de-
emergent setting in 26 critically ill patients who had placement of fects and prevent evisceration after trauma laparotomy. They noted
absorbable mesh as part of an emergent laparotomy. They found that the mesh was infiltrated by granulation tissue within 2 to 3
that mesh placement allowed drainage from contaminated ab- weeks and that 2 to 3 months after insertion the material was ab-
dominal wounds, was strong enough to allow ambulation, and gen- sorbed, resulting in a hernia. They were able to subsequently per-
erally improved recovery in this group of patients. They did note form definitive hernia repair some months later. They concluded
that while none of the patients had to be reoperated for dehis- that absorbable polyglycolic acid mesh was a useful technique for
cence, there was frequent hernia formation. They also noted that
there was no problem with mesh infection. Gentile et al. 26 de-
scribed the use of polyglycolic mesh for abdominal access in pa-
tients with necrotizing pancreatitis. They found the mesh
particularly helpful in those patients who required multiple re-
operations for debridement and abdominal cleaning. In their se-
ries, some patients even underwent repeat drainage procedures in
the intensive care unit. They concluded that polyglycolic acid mesh
is a useful adjunct in the surgical care of selected patients with
necrotizing pancreatitis. Chendrasekhar27 described use of local
anesthetic and bedside placement of polyglycolic acid mesh in
uncomplicated and localized abdominal dehiscence to prevent
evisceration.
One approach to the care of these extremely complicated her-
nia defects is a staged approach. Fabian and colleagues28 suggested
that stage I involves prosthetic insertion; stage II, prosthetic re-
moval; stage III, skin grafting of any large defect; and stage IV, 6
to 12 months later, definitive reconstruction. In their study in-
volving 88 cases, 27 patients had polyglactin mesh placed as a tem- FIGURE 42.3. Patient 1. Appearance of prosthesis being infiltrated by 14
porary prosthesis until the wound cleaned up. The authors weeks.
310 M.T. Dayton
achieving secure, tension-free closure of abdominal wounds on a

temporary basis.
Another novel approach that has been studied in a few patients
is the use of collagen coating of Vi cryI mesh. In an attempt to pro-
long the absorption life of polyglactin mesh, Ramadwar et al. 30
used collagen-coated Vicryl mesh to repair diaphragmatic defects.
However, they were not enthusiastic about this material as it re-
sulted in recurrent diaphragmatic defects. Carachi and associates 31
used collagen-coated polyglactin mesh in 28 patients who needed
repair of thoracic and abdominal wall defects, and their use of this
new mesh was quite encouraging.
The use of composite prostheses is also an interesting area of
study. Most of these composite prostheses include a nonabsorbable
polypropylene mesh attached to an absorbable polyglactin mesh.
Barie et al. 32 described the use of such a mesh to close a spigelian
hernia using a laparoscopic approach. Similarly, Porter3 3 described
the use of polyglactin and Marlex mesh to close the abdominal FIGURE 42.4. Patient 2 with massive necrosis of the abdominal wall, im-
wall in five patients with complex problems. Porter observed that mediately after surgery.
Vicryl mesh prevents enterocutaneous fistula and adhesions
and that Marlex mesh prevents late ventral hernias. [See Soler
In patients who had primary skin closure over the absorbable
et aI., Chapter 35, on a double prosthesis involving Vicryl-an
mesh, repair proceeds in the standard fashion with a cautious in-
important study.-Editor]
cision through the skin until viscera are encountered. Fascia is
A final interesting area of study involves the placement of an
then identified, and standard repair with Marlex mesh (now Bard®
adhesion-preventing membrane composed of carboxyrnethylcel-
mesh) is used to close the defect. In those patients who require a
lulose and hyaluronic acid (Seprafilm®) on the bowel before place-
split-thickness skin graft on granulation tissue immediately adja-
ment of either an absorbable mesh or a permanent mesh.
cent to bowel, over time an adventitial layer develops between the
Theoretically, placement of this material would prevent adhesions
skin graft and the bowel, allowing one to easily peel back the skin
and fistulas by inhibiting adhesion formation to the mesh that had
of the bowel with no injury. Permanent mesh is then placed, and
been placed. Alponat and colleagues34 used Seprafilm in an ani-
skin is extensively mobilized to bring over the nonabsorbable mesh
mal study that showed that it virtually eliminated adhesions to the
in the midline. Closure of that skin layer should be done in three
graft. At the author's institution, Seprafilm has also been placed
layers to obviate contamination and breakdown of that midline in-
underneath absorbable mesh and was thought to lessen adhesions
cision. Placement of a Jackson-Pratt drain also helps the skin flap
to the posterior surface of the mesh, making it much easier to re-
stay down so that seromas and hematomas are unlikely to form.
move after visceral edema had resolved and the temporary mesh
was ready to be removed.
Indications
Loss of Abdominal Wall Substance
and Contamination
Absorbable mesh has been used to close complicated abdominal
wall defects at the author's institution in now over 100 patients.
The absorbable meshes are now thought to be best used in the
staged repair of contaminated abdominal wall defects. The most
common indication for use of absorbable mesh is massive ab-
dominal contamination with loss of abdominal wall substance. In
this setting, the polyglycolic acid mesh is sewn to fascia using con-
tinuous No.2 absorbable suture. The skin should always be closed
over the fascia if it can be mobilized and brought together at the
midline without any tension. If there is significant loss of skin with
the necrotic fascia, it must be debrided back, and, occasionally,
packing of the wound and allowing it to heal by secondary inten-
tion is indicated. If the defect is large enough, a split-thickness
skin graft can be placed when the granulation tissue is healthy and
minimally contaminated. Mter healing of the tissue overlying the
defect, the clinician must ascertain that there is complete epithe-
lialization and absence of infection before considering going back
in to do the hernia repair. An interval of 10 to 12 months should
be allowed to pass before considering reoperation. FIGURE 42.5. Patient 2. Appearance of abdominal wall defect at 4 weeks.
FIGURE 42.6. Patient 2. Appearance of granulation tissue at 7 1/2 weeks. FIGURE 42.7. Patient 3 with a scarred, chronically infected abdominal
wound, following skin graft over an infected Marlex mesh.
Infected Nonabsorbable Mesh

To Be Removed
A second indication for use of the absorbable mesh includes the
patient with infected Marlex mesh from previous placement in a
contaminated setting. Patients who come in usually have foul-
smelling fluid draining from the infected mesh. Virtually always,
the entire mesh has to be resected as well as the infected skin over-
lying it. Mter the infected mesh is removed, the absorbable mesh
is placed as previously described. Again, it is always desirable to
mobilize the skin and close it primarily over the absorbable mesh
so that placement of the permanent mesh in a subsequent setting
is much safer and easier.
History of Infection
The third indication includes patients who previously had large
abdominal wall hernias who developed peritonitis or infection.
Placement of the mesh in this setting would involve treatment of
the primary disease problem, massive irrigation, and placement
of absorbable mesh in the fascia as previously described with skin
coverage. Similarly, patients with abdominal wall loss and multi-
ple enterocutaneous fistulas would be a candidate for use of the
mesh.
A fourth use of absorbable mesh includes the setting in which
tumor involves the abdominal wall and results in bowel resection
that grossly contaminates the wound. Use of mesh in a contami-
nated setting like this allows the surgeon to resect a wide margin
and not compromise the cancer operation. The absorbable mesh FIGURE 42.8. Patient 3. The infected Marlex mesh has been removed and
is then placed until the wound heals and contamination resolves. replaced with an absorbable mesh.
312 M.T. Dayton
Contamination Following Electrical Burns,

Explosions, and So On
Another indication includes patients who have traumatic loss of
abdominal wall with massive contamination due to electrical burn,
shotgun injuries, explosions, and so forth. The author has found
that the polyglycolic acid mesh can be quickly and easily placed
in these extremely ill patients who may be unstable and who have
been massively contaminated. The absorbable mesh appears to be
even safer to place in this setting because it can be more quickly
and safely placed than a permanent mesh, which the surgeon is
loathe to use because of the concerns previously enumerated.
Additional anecdotal experience by the author and others
demonstrates that in patients who have had massive bowel wall
edema due to severe intraoperative blood loss, gunshot i~ury to
the abdomen with massive blood loss, or general massive edema
from any source where there is difficulty in closure of the ab-
dominal wall, absorbable mesh can be used as a temporary clo-
sure by merely stapling it to the skin or sewing it to the fascia until
the bowel wall edema resolves in 7 to 10 days. As the edema re-
solves, the viscera can then be returned to the peritoneal cavity,
and a primary fascial closure can be effected. In some of these
cases, we have found that it is not necessary to attach absorbable
mesh to fascia to provide temporary support of the bowel. In some
cases, we have stapled absorbable mesh directly to the skin, and
the mesh provides strong support until the operation can result FIGURE 42.9. Patient 3. Completed repair with skin coverage.
in primary closure of the fascia.
One caveat should be noted at this point, however. If the sur-
in the pelvis. Certainly, regenerated cellulose, Gore-Tex®, and so-
geon waits too long to reoperate, the polyglycolic acid mesh be-
dium hyaluronate have been used in that setting, but there is lit-
comes tenaciously adherent to the serosa of the small bowel, and
tle experience with absorbable meshes. Clearly, this is another area
its removal is almost impossible. In the few occasions when this
of possible investigation for the near future.
was a problem, the author found that it is better to simply leave
fragments of the mesh attached to the bowel wall surface rather
than trying to remove it. Certainly, one of the significant advan-
tages of this mesh is that it does not have to be removed when re-
Summary
operating. There is also some evidence by Edlich et al. 35 that the
The absorbable meshes as described in this chapter did not ap-
mesh as it breaks down may provide some elements of antibacte-
pear to meet the definition of an ideal prosthesis. Although they
rial effect.
are soft, non traumatic, strong, noninflammatory, sterilizable, and
noncarcinogenic, their use is associated with hernia development
in virtually all cases. However, while the absorbable meshes would
New Approaches never be indicated in a clean, uncomplicated, large hernia repair,
they have some unique and specific advantages when used as a
As experience with the absorbable mesh and closure of the ab- temporary prosthesis to repair the defect in a grossly contaminated
dominal wall in a contaminated setting has increased, additional operative field. The mesh is soft and easy to work with in this group
considerations are being evaluated. Because it is somewhat diffi- of patients, who are often very ill at the time of placement. They
cult to remove the polyglycolic acid mesh when used short term, are extremely strong, allowing patient ambulation and mobility al-
some authors have suggested that a layer of the newly FDA- most immediately after operation. They can be placed in a grossly
approved adhesion-inhibiting absorbable film (Seprafilm) might infected field and do not exacerbate the infection or make it more
make the mesh easier to remove. A few patients at the author's in- difficult to resolve. Most importantly, they maintain their strength
stitution have had placement of Seprafilm on the bowel immedi- long enough to provide abdominal wall support until the field is
ately before the polyglycolic acid mesh was sewn in. Although the covered by skin and is free of infection. An additional, obvious fea-
use of the adhesion-reducing Seprafilm intuitively seems like a ture is that, because it is absorbed, reoperation to remove it is
good idea, there is not much experience yet to suggest that it will never required.
truly make a significant difference in the management of these pa- The author and others have observed that polyglycolic acid
tients. Nevertheless, further studies need to be done to see if it mesh can be used as a temporary prosthesis to close a contami-
might find some use. nated wound until the wound is cleaned and epithelialized, thus
Recent work on antiadhesion devices also suggests that regen- allowing reoperation and placement of a permanent mesh. Pa-
erated cellulose inhibits adhesions in the pelvis when infertility is tients who had infected or contaminated defects repaired with this
a problem. Some have raised the question as to whether absorbable mesh can be safely reoperated and a permanent mesh can be
meshes might be used in a similar setting to discourage adhesions placed with low morbidity and mortality. Thus, it is the author's
recommendation that until a superior prosthesis is developed, in- 19. Zieren J, Castenholz E, Baumgart E, et al. Effects of fibrin glue and
fected or grossly contaminated abdominal walls should be repaired growth factors released from platelets on abdominal hernia repair with
in a staged fashion using strong, absorbable mesh during the first a resorbable PCA mesh: experimental study.] Surg Res. 1999;85(2):
stage. Mter skin coverage and resolution of infection, the second 267-272.
20. Klinge U, Klosterhalfen B, Muller M, et al. Influence of polyglactin-
stage can be completed and reoperation for placement of a per-
coating on functional and morphological parameters of polypropylene-
manent prosthesis effected.
mesh modifications for abdominal wall repair. Biomaterials. 1999;
20(7):613-623.
21. Delaney HM, Rudavsky A, Lan S. Preliminary clinical experience with
References the use of absorbable mesh splenorrhaphy.] 7Tauma. 1985;25:909.
22. Delaney HM, Solanki B, Driscoll WB. Use of absorbable mesh for splen-
1. Stone HH, Fabian TC, Turkles ML, et al. Management of acute full- orrhaphy and pelvic peritoneum reconstruction. Contemp Surg. 1985;
thickness losses of the abdominal wall. Ann Surg. 1981;193:612-617. 27:11.
2. Dayton MT, Buchele BA, Shirazi SS, et al. Use of an absorbable mesh 23. McGahren ED, Rodgers BM, Waldron PE. Successful management of
to repair contaminated abdominal wall defects. Arch Surg. 1986;121: stage 4S neuroblastoma and severe hepatomegaly using absorbable
954-960. mesh in an infant.] Pediatr Surg. 1998;33(10):1554-1557.
3. Witzel O. Ueber die Verschliessung von Bauchwunden unter Brucht- 24. Smith PC, TweddellJS, Bessey PQ. Alternative approaches to abdom-
pforten durch Versenkte Silverdrahtnetze. Cent Chir. 1900;27:257. inal wound closure in severely injured patients with massive visceral
4. Goepel R. Uber die Verschliessung von Bruchpforten durch ein- edema.] Trauma. 1992;32(1) :16-20.
heilung Geflochtener Feriger Silberdrahtnetze. Verh Dtsch Ges Chir. 25. BuckjR, Fath lJ, Chung SK, et al. Use of absorbable mesh as an aid
1900;29:4. in abdominal wall closure in the emergent setting. Am Surg. 1995;
5. Usher FC, Wallace SA. Tissue reaction to plastics: a comparison of ny- 61 (8) :655-658.
lon, Orlon, Dacron, Teflon, and Marlex. Arch Surg. 1958;76:997-999. 26. Gentile AT, Feliciano PD, Mullins RJ, et al. The utility of polyglycolic
6. SchmittJHJr, Grinnan GLB. Use of Marlex mesh in infected abdom- acid mesh for abdominal access in patients with necrotizing pancre-
inal war wound. Am] Surg. 1967;113:825-828. atitis.] Am Coll Surg. 1998;186(3):313-318.
7. Eng K, Casson P, Berman IR, et al. Clostridial myonecrosis of the ab- 27. Chendrasekhar A. Bedside placement of polyglycolic acid mesh: a
dominal wall. Am] Surg. 1973;125:367-371. novel treatment of uncomplicated abdominal wound dehiscence. W V
8. Gilsdorf RB, Shea MM. Repair of massive septic abdominal wall de- MedJ 1996;92(3):136-137.
fects with Marlex mesh. Am] Surg. 1975;130:634-638. 28. Fabian TC, Croce MA, Pritchard FE, et al. Planned ventral hernia.
9. Wouters DB, Krom RAF, Slooff ~H, et al. The use of Marlex mesh in Staged management for acute abdominal wall defects. Ann Surg. 1994;
patients with generalized peritonitis and multiple organ system failure. 219(6):643-653.
Surg Gynecol Obstet. 1983;156:609-614. 29. Greens MA, Mullins RJ, Malangoni MA, et al. Laparotomy wound clo-
10. Boyd WC. Use of Marlex mesh in acute loss of the abdominal wall due sure with absorbable polyglycolic acid mesh. Surg Gynecol Obstet. 1993;
to infection. Surg Gynecol Obstet. 1977;144:251-252. 176(3):213-218.
11. Voyles CR, RichardsonJD, Bland KI, et al. Emergency abdominal wall 30. Ramadwar RH, Carachi R, Young DG. Collagen-coated Vicryl mesh is
reconstruction with polypropylene mesh. Ann Surg. 1981;194:219-223. not a suitable material for repair of diaphragmatic defects.] Pediatr
12. Jones jW, Jurkovich GJ. Polypropylene mesh closure of infected ab- Surg. 1997;32(12):1708-1710.
dominal wounds. Am Surg. 1989;55:73. 31. Carachi R, Audry G, Ranke A, et al. Collagen-coated Vicryl mesh: a
13. Delaney HM, Porreca F, Mitsudo S, Solanki B, Rudavsky A. Splenic cap- new bioprosthesis in pediatric surgical practice.] Pediatr Surg. 1995;
ping: an experimental study of a new technique for splenorrhaphy us- 30(9):1302-1305.
ing woven polyglycolic acid mesh. Ann Surg. 1982;196:187. 32. Barie PS, Thompson WA, Mack CA. Planned laparoscopic repair of a
14. Lamb JP, Vitale T, Kaminskin DL. Comparative evaluation of synthetic spigelian hernia using a composite prosthesis.]Laparoendosc Surg. 1994;
meshes used for abdominal wall replacement. Surgery 1983;93:643. 4(5):359-363.
15. Jenkins SD, Klamer TW, PartekalJ, et al. A comparison of prosthetic 33. Porter JM. A combination of VicryI and Marlex mesh: a technique for
materials used to repair abdominal wall defects. Surgery. 1983;94:392. abdominal wall closure in difficult cases. ] Trauma. 1995;39(6):
16. Tyrell J, Silberman H, Chandrasoma P, et al. Absorbable versus per- 1178-1180.
manent mesh in abdominal operations. Surgery. 1989;168:227-232. 34. Alponat A, Lakshminarasappa SR, Yavuz N, et al. Prevention of adhe-
17. Klinge U, Klosterhalfen B, Conze J, et al. Modified mesh for hernia sion by Seprafilm, an absorbable adhesion barrier: an incisional her-
repair that is adapted to the physiology of the abdominal wall. Eur] nia model in rats. Am Surg. 1997;63(9):818-819.
Surg. 1998;164(12):951-960. 35. Edlich RF, Panek PH, Rodeheaver GT, et al. Physical and chemical con-
18. Dasika UK, Widmann WD. Does lining polypropylene with polyglactin figuration of sutures in the development of surgical infection. Ann
mesh reduce intraperitoneal adhesions? Am Surg. 1998;64(9) :817-820. Surg. 1997;177:679-687.
Part VI
Adjuncts to Surgery
43
Local Anesthesia
Oreste Terranova, Luigi De Santis , and Francesco Battocchio
Introduction Germany tested several solutions and established that half a gram
of cocaine per liter of saline made an effective anesthetic; he pre-
In hernia surgery, several kinds of anesthesia can be used: local, sented his results at the Surgical Congress in Berlin. He asserted
locoregional, and general. Local anesthesia is a safe and effective that this technique was safe and that narcosis was no longer justi-
technique, and it is particularly suited to primary hernias of the fied. Edoardo Bassini was familiar with the use of cocaine as a lo-
inguinofemoral region, in some cases of recurrent inguinal her- cal anesthetic and considered its use particularly favorable in
nia, and in small umbilical hernias. l This kind of anesthesia facil- minor interventions, as well as in some cases when the patient's
itates outpatient surgery in selected patients. In the choice of condition did not permit general anesthesia. 4 In America, cocaine
patients, general factors have to be considered to identify the class was studied by William Stewart Halsted, who went so far as to test
of anesthetic risk. Some characteristics of hernias have to be con- it on himself; he became addicted but overcame the addiction. In
sidered (such as stage, size, primary or recurrent), as well as 1885, he was able to demonstrate that a region of the body can
whether the surgery is emergency or elective and the proposed be anesthetized by the injection of cocaine around the nerve
technique of the hernial repair. The use of local anesthesia must trunk. In 1900, Harvey Cushing of Halsted's school reported his
not induce the surgeon to underestimate the nature of the oper- experience with 49 patients who had been operated on for in-
ation. In fact, the surgeon must have adequate experience with guinal hernia under local anesthesia. He affirmed that "almost all
this surgery, good knowledge of the anatomy of the region, metic- cases of hernia, with the possible exception of those in young chil-
ulous preparation of the surgical planes, and concentration on dren, could undoubtedly be subjected to the radical operation un-
minimizing trauma. 2 Because of local anesthesia, problems linked der similar local methods," but he added that "when a general
to hospitalization are avoided, as the patient is guaranteed im- anesthetic can safely be administered, for various reasons, it is
mediate mobilization and return to usual daily occupations, an un- much to be preferred by both patient and operator. "5
deniable economic and social benefit. In 1905, Einhorn in Germany prepared a more effective sub-
stance, named procaine hydrochloride (Novocain®), and later
Heinrich Braun noticed that the anesthetic effect lasted longer if
Historical Note epinephrine was added to the solution; by causing vasoconstric-
tion, this substance lengthens the clearing time of the anesthetic
Local anesthesia has been known and used for a long time, but around the site of injection. The first modem local anesthetic, syn-
with unsatisfactory results at first. The abolition of sensibility to thesized in 1943 by Lofgren at Lundqvist, is lidocaine, which is still
pain was attempted by means of empirical methods such as me- used today and serves as a reference for the safety of its frequent
chanical compression of the region or by freezing. During Rus- and recurrent use, its short latency period, long duration, and
sia's retreat, in cases of amputation because of freezing, it was depth of anesthesia.
noticed that Napoleon's soldiers felt hardly any pain. The use of
ice and salt was thus learned.
The discovery of local anesthetic substances began in the 16th Local Anesthetics
century, when the Spanish conquistadores learned from the Indi-
ans the use of coca leaves as a drug and local anesthetic. In 1858, Because of toxicity and side effects, the choice of local anesthet-
Albert Nienmann isolated cocaine, an alkaloid extracted from Ery- ics for clinical use has been narrowed to a few well known mole-
throxylum coca, a plant that grows in the Andes. The potential use cules: the amino-esters (procaine, chloroprocaine, and tetracaine)
of cocaine in surgery was understood by Moreno y Maiz, a Peru- and amino-amides (lidocaine, mepivacaine, bupivacaine, and ropi-
vian physician who 10 years later published a description of its vacaine).6 These last are presently preferred in clinical practice
pharmacological properties. In 1880, Von Anrep observed that, because of their better ratio between effect, duration of action,
when cocaine was injected subcutaneously, it was able to nullify and systemic toxicity, therefore their greater safety.7 Their mole-
sensitivity to pain. 3 Mter 1884, cocaine was used as a local anes- cule is made of four subunits: an aromatic part responsible for li-
thetic by oculists and dentists. In 1892, Karl Ludwig Schleich in posolubility, an amidic or esteric part responsible for the metabolic
317
318 O. Terranova et aI.
pathway, a hydrocarbon chain that increases the liposolubility of and to the diameter of the nerve fibers in question: The fibers
the molecule, and a tertiary amine responsible for the water sol- containing less myelin are most exposed to the drug's action. Lo-
ubility of the molecule. The presence of an asymmetrical carbon cal anesthetic blocks the sympathetic fibers first, leading to vaso-
atom permits two isomers of each molecule: The levorotary iso- dilation and a rise in temperature. There follows, in order, loss of
mers are generally less toxic than the dextrorotatory isomers or sensitivity to heat, pain, proprioception, touch, and pressure. Mus-
the racemic compound of the same molecule. Only ropivacaine is cular paralysis appears last.
entirely levorotary. The amino-amides are metabolized by oxida- The principal local anesthetics in current use are lidocaine,
tive dealkylation in the liver. These compounds are weak bases, mepivacaine, bupivacaine, and ropivacaine. Lidocaine and bupiv-
barely soluble, and unstable in water; they are therefore combined acaine have intrinsic vasodilation capability; mepivacaine and ropi-
with a strong acid (hydrochloric acid), becoming stable and solu- vacaine are relatively vasoconstrictive. Anesthetic efficacy is related
ble salts in water with a pH of 4 to 7. When they are prepared with to the lipophilia of the molecule: the higher it is, the faster and
epinephrine, they have a more acid pH. In water solution, they stronger the fixation to adipose tissue. Bupivacaine and ropiv-
stay in equilibrium between the cationic water-soluble, ionized acaine are of high efficacy, lidocaine and mepivacaine intermedi-
form and the un-ionized free, lipid-soluble form. This last feature ate. The anesthetic onset of lidocaine and mepivacaine is fast; it
is responsible for the diffusion of the drug through cell mem- is intermediate for ropivacaine and slow for bupivacaine, both of
branes, particularly in axons, while the water-soluble ionized frac- which produce prolonged anesthesia. In clinical practice, it is usu-
tion is the pharmacologically active component. These properties ally possible to combine a fast-acting anesthetic with a slow-
can be exploited in clinical practice by modifying the pH by al- acting one; synergism between the two drugs reduces the risk of
kalinization of the local anesthetic. overdose of a single drug.
Three parameters determine the activity of an anesthetic: la- Lidocaine is commercially available in concentrations of 1% and
tency, intensity, and duration of action. s The rapidity of onset de- 2%; it is a fast-acting drug, and its length of action is about 90 min-
pends on the ease with which an anesthetic diffuses; the dose and utes. Mepivacaine is commercially available in concentrations of
its concentration are less important. Only the un-ionized form of 1% and 2%; it is fast acting (in a few minutes), and its duration
anesthetic is diffusible, and this fraction is related to the intrinsic is about 2 hours. Bupivacaine is commercially available in con-
characteristics of the drug and to the pH of the solution; if this is centrations of 0.25%, 0.50%, and 0.75%. Its onset time is about
alkaline, the diffusion is greater. The intensity of action increases 20 minutes, with a half-life of 2 to 3 hours and a length of action
with liposolubility and diminishes with the affinity for proteins; it of 3 to 6 hours. Ropivacaine is used in clinical practice in a con-
is related to the total dose administered but not to the concen- centration of 7.5 or 10 mg/ml, and the anesthetic effect begins
tration of the anesthetic. The duration of action is related to the on average within 5 to 10 minutes; length of action is 3 to 6 hours.
percentage of the protein-linked quota: the higher the percent- Local anesthetics are stable and water-soluble salts. The solu-
age, the longer the duration of action. tions obtained from them always have an acid pH, and at the time
The factors that condition the activity and toxicity of local anes- of injection this produces a painful burning sensation. To avoid
thetic are systemic absorption, local and systemic distribution, me- this drawback and improve the efficacy of the local anesthetic,
tabolism, and excretion. The absorption is related to the site of which diffuses more easily with an alkaline pH, it is possible to
injection, presence of a vasoconstrictor, dose, and concentration. neutralize the solution at the time of use by the addition of 0.84%
With regard to the site of injection, important factors are the vas- sodium bicarbonate, which is commercially available in 10 ml
cularization of the area, the volume of the anesthetic, the local vials. ll Lidocaine and mepivacaine can be easily neutralized by
temperature, the density of fat (only lipophilic local anesthetic set- addition of bicarbonate to bring the pH to 7.4, which is better
tles in adipose tissue), the density of tissue proteins (which can in- tolerated. Neither bupivacaine nor ropivacaine can be neutral-
crease latency and duration and decrease intensity), and the ized, as an alkaline pH causes them to precipitate out of solution
presence of impediments to fixation to neuronic membranes. The (Table 43.1).
vasoconstrictor epinephrine, 1/200,000, can decrease absorption Even buffered anesthetic may be painful to some patients and
of the drug into the circulation and its local distribution, thus pro- may cause anxiety. To improve the patient's comfort, a new topi-
longing the duration of action. These features are useful when cal local anesthetic may be used; it is an ointment called EMLA
anesthesia is being carried out in a highly vascularized area, but (eutectic mixture oflocal anesthetics), an equimolecular blend of
in inguinal hernias the use of epinephrine is not advisable because lidocaine and prilocaine for use in cutaneous anesthesia. Local
of the risk of bleeding from small blood vessels when its vasocon- anesthetics are poorly absorbed through the skin, being ionized
striction action ceases. The absorption of epinephrine may itself
give rise to undesirable reactions: agitation, increased heart rate, TABLE 43.1. Quantity of NaHC03 necessary to bring the pH to
palpitations, chest pain, epinephrine reversal, and, rarely, shock. 9,lO 7.4 in the tissues
Once absorbed, local anesthetics act on the central nervous sys- Anesthetic pH Quantity of NaHC03
tem. In toxic doses, they first cause central stimulation, with agi-
tation, tremors, and clonic convulsions. This is followed by Lidocaine 1 % 5.80 7.4%
depression, which may appear either when the maximum recom- Lidocaine 2% 5.74 lO.7%
mended dose is exceeded or when the drug is inadvertently in- Mepivacaine 1 % 6.25 8.2%
jected into a blood vessel. Mepivacaine 2% 5.18 13.0%
The mechanism of action of local anesthetic is blocking of nerve Procaine 1% 4.51 2.0%
Procaine 2% 4.40 3.0%
conduction. Propagation of the action potential to the axon is
Ropivacaine 0.75% 5.80
hampered by the displacement of calcium ions from the cell mem- Bupivacaine 0.50% 6.18
brane; this causes inhibition of the cell's Na+ permeability. The
efficacy of the inhibition is related to the activity of the anesthetic Data are from Battocchio and Terranova.!
43. Local Anesthesia 319
basic solutions. EMLA, on the other hand, is a lipoid solution with by a Valsalva maneuver, or by raising the head and shoulders makes
a high water content, being an un-ionized form oflocal anesthetic. it is easy to identify multiple wall defects and to evaluate the so-
Both molecules of amino-amides have short onset, intermediate lidity and efficacy of the wall repair.21 At this time, tension in the
effect, moderate length of action, and low toxicity; they pass eas- repair can be gauged, and, if need be, a relaxing incision can
ily through the cutaneous barrier, spread throughout the derma, be made.
and fIx to the cutaneous nociceptors and their free nerve endings.
An hour after application, EMLA penetrates to a depth of 3 to 4
mm and after 2 hours to 5 mm. EMLA must thus be applied at Toxicity and Allergic Reactions
least 1 hour before the local anesthetic. EMLA is very useful to
ease the pain and anxiety caused by inoculation of local anesthetic
to Local Anesthetics
and allows reduction of the dose of local anesthetic that must be
Toxic reactions to local anesthesia manifest themselves as neuro-
inoculated in the superfIcial planes.
toxicity or cardiotoxicity; most are caused by an excessive dose of
the drug or by its inadvertent injection into a blood vesse1. 9
Neurological symptoms are generally progressive and consist of
Indications paresthesia of the tongue, metallic taste in mouth, loquacity, su-
perciliary tremor, paralalia, dysarthria, tremors, loss of conscious-
A local anesthesia can be used in most primary hernias and bilat-
ness, and convulsions. To avoid neurotoxic effects, the suggested
eral hernias. 12 This kind of anesthesia requires the patient's col-
maximum dose for each anesthetic is as follows (Table 43.2): pro-
laboration and therefore it is not recommended for use in children
caine, 13 mg/kg; lidocaine, 4.0 mg/kg; mepivacaine, 6.0 mg/kg;
under age 12 years or in particularly anxious, psychologically la-
bupivacaine, 1.6 mg/kg; and ropivacaine, 3.0 mg/kg.
bile patients or those suffering from severe psychiatric disorders.
The vascular system is less sensitive to the effects of local anes-
Epilepsy is usually a contraindication to the use of a local anes-
thetics. Cardiotoxicity occurs as myocardial depression causes
thesia; lidocaine is tolerated up to a point, but the risk of convul-
diminution in electrical excitability, speed of conduction, and
sions cannot be entirely eliminated. The use of lidocaine does not
power of contraction; lidocaine and mepivacaine usually do not
appear to have harmful effects in pregnant women.
produce heavy myocardial depression, but this is a risk with bupiv-
Obesity and voluminous inguinoscrotal hernias make local anes-
acaine: This anesthetic is 15 times as arrhythmogenic as lidocaine.
thesia technically more difficult and require larger doses. In these
Acidosis, hyperkalemia, hypoxia, and concomitant use of antiar-
cases, another method of anesthesia may be preferred. In recur-
rhythmic drugs, calcium blockers, and beta blockers exacerbate
rent hernias, the presence of scar tissue makes an operation more
the toxic effects.
difficult and interferes with the diffusion of local anesthetics. It is
Neurological symptoms in mild forms can be relieved by hyper-
nevertheless possible in these cases, by exercising particular care
ventilation and administration of 0.1 mg/kg of diazepam; in more
and diligence, to perform the operation under local anesthesia us-
severe forms, it may be necessary to ensure ventilation by means
ing an inguinal approach,13 especially if a suprainguinal preperi-
of endotracheal intubation, preceded, if required, by administra-
toneal approach cannot be used. 14 Local anesthesia can be utilized
tion of succinylcholine, which prevents convulsions. Cardiotoxic
in some selected cases of recurrent unilateral hernias treated
symptoms can be relieved, depending on the circumstances,
by the Wantz suprainguinal preperitoneal technique in slim and
with epinephrine, dobutamine, atropine, clonidine, or diphenyl-
cooperative patients with a surgeon well experienced in this
hydantoin.
technique. 15
Allergic reactions are very rare with amino amides; they appear
Hypersensitivity to local anesthetics is rare, but it is an absolute
as cutaneous rash, urticaria, itch, bronchospasm, edema of Quincke,
contraindication to this technique.
and anaphylactic shock. They are interpreted as secondary allergic
reactions to paraminobenzoic acid (methylparabene) used as a
preservative. It is possible to prevent them by using commercial
Advantages
Local anesthesia offers numerous advantages compared with gen- TABLE 43.2. Maximum recommended doses of the most common local
eral, spinal, or epidural anesthesia. 16 It is undoubtedly safer. Mor- anesthetics
tality in elective operations is nil, even i.n very old patients and
those whose general condition is precariousp,18 Postoperative res- Maximum dose Maximum dose
piratory complications (atelectasis, respiratory infections) and cir- Anesthetic Percent (weight) (volume; ml)
culatory complications (deep venous thrombosis) are markedly Lidocaine 0.5 500mg 100
reduced in comparison with other types of anesthesia. In fact, res- 1.0 50
piratory dynamics are not altered in any way, and patients can walk 2.0 25
as soon as the operation is ended. There is no postoperative nau- Mepivacaine 1.0 500 mg or 7 mg/kg 60
sea, vomiting, or pharyngeal pain, such as one may have after en- 2.0 25
dotracheal intubation, nor the retention of urine and severe Procaine 0.5 1000 mg or 10-12 mg/kg 200
headache that often occur after other kinds of anesthetic tech- 0.5 100
niques.l 9 0.5 50
Bupivacaine 0.25 150 mg or 7 mg/kg 60
Local analgesia persists for a few hours after the operation, and
0.50 30
normal oral alimentation can be resumed. 20 During the operation, Ropivacaine 0.75 225 mg or 3 mg/kg 30
the patient is awake and perfectly able to cooperate actively; the
ability of a patient to increase abdominal pressure by coughing, Data are from Battocchio and Terranova.!
320 o. Terranova et al.
pharmaceutical preparations without preservative. Vagal crises, par-

ticularly in anxious patients, frequently occur during the interven-
tion, particularly during handling of the hernial sac.
Preoperative and
Intraoperative Medication
Premedication is not regularly administered. Thirty minutes be-
fore operation, diazepam 10 mg and atropine 0.5 mg are admin-
istered intramuscularly to anxious patients if indicated. The object
of this medication is to obtain mild sedation while keeping the pa-
tient awake and able to cooperate and also to prevent the onset
of vagal reactions during the operation. These are secondary to
emotional or painful stimuli during the surgical dissection of the
hernial sac; they are manifested as a feeling of malaise, nausea,
sometimes vomiting, bradycardia, and profuse sweating; they can FIGURE 43.2. Infiltration of local anesthetic deep to the external oblique
become progressively more severe, even to the point of cardiac ar- aponeurosis.
rest. It is important to recognize these symptoms early, as they re-
spond rapidly to the intravenous administration of 2 to 3 ml of a
When the external oblique aponeurosis has been identified, 7
diluted atropine solution (1 mg in 10 ml of saline solution). The
to 8 ml of 2% mepivacaine is injected deep to it. This produces a
presence of an anesthetist is always preferred in such situations.
preliminary block of the regional sensory nerve branches and fa-
cilitates the subsequent dissection, as the injection detaches the
external oblique aponeurosis from the underlying planes (Fig.
Technique of Local Anesthesia 43.2). When the external oblique aponeurosis has been divided,
for Inguinal Hernias the iliohypogastric and ilioinguinal nerves are identified and sep-
arately infiltrated (Fig. 43.3). One or 2 ml of 0.5% bupivacaine is
The technique that we use is specific and provides infiltration of sufficient to produce effective and extended analgesia.
the anesthetic, layer by layer, to guarantee accurate anesthesia to Before mobilization of the spermatic cord, the inguinal ligament
different anatomical structures. 22- 24 The skin and the subcuta- and posterior wall of the inguinal canal are infiltrated near the
neous tissue are initially infiltrated along the proposed line of in- pubic tubercle. Mter dissection of the cremaster, at the level of
cision (Fig. 43.1). First, the drug is injected directly underneath the deep inguinal ring, the spermatic vessels and the genital
the dermis medial and inferior to the anterior superior iliac spine branch of the genitofemoral nerve are identified and the nerve
with a 25 gauge spinal needle, advanced slowly toward the pubic infiltrated (Fig. 43.4). If the hernia is indirect, 2 or 3 ml of anes-
crest. Anesthesia is obtained almost immediately. For this phase, thetic must be injected in the perihernial and preperitoneal fat
on average, a dose of 10 to 12 ml of 2% mepivacaine solution and.into the incision in the peritoneal sac for contact anesthesia
buffered with sodium bicarbonate (1 ml of bicarbonate and 10 ml (Figs. 43.4, 43.5).
of anesthetic) is sufficient.
FIGURE 43.3. After division of the external oblique aponeurosis. The il-
ioinguinal and iliohypogastric nerves are identified. The genital branch
FIGURE 43.1. Infiltration of the skin and subcutaneous tissues along the of the genitofemoral nerve is seen on or within the substance of the
proposed incision line for an inguinal hernia. cremaster.
FIGURE 43.4. Infiltration of local anesthetic within the wall of the hernia
sac.
Recurrent Inguinal Hernias FIGURE 43.6. Skin infiltration for a suprapubic preperitoneal approach, 2
to 4 cm below the anterior superior iliac spine.
In a slim patient with a recurrent hernia and a small defect (2 cm
or less), it is possible to put a prosthetic plug into the defect un-
der local anesthesia. It is very important to mark on the skin with local anesthesia, using a 2% mepivacaine solution. IS This approach
an indelible felt-tipped pen the exact site of the defect. The skin is, in fact, less painful for the patient than a direct inguinal ap-
over the hernia is infiltrated with 3 to 5 ml of anesthetic solution. proach. After the infiltration of the skin and subcutaneous tissues
When the skin, subcutaneous tissue, and external oblique aponeu- along the proposed incision line, a transverse incision of about 7
rosis have been incised, the hernial sac is identified. This phase is to 10 cm is made 2 to 4 cm below the anterior superior iliac spine
facilitated by asking the patient to increase intra-abdominal pres- and 2 to 3 cm above the external inguinal ring (Fig. 43.6). The
sure. Particular attention must be paid at this point to avoid dam- anterior rectus sheath is identified and infiltrated, together with
aging the elements of the cord and the sensory nerves of the the rectus muscle, the internal oblique, and transversus abdominis
region. aponeuroses, with mepivacaine. The rectus abdominis muscle is
Before isolating the peritoneal sac and freeing it from adhe- retracted medially and the wide abdominal muscles laterally. Anes-
sions, 2 to 3 ml of anesthetic should be injected into its wall and thetic infiltration has to be done layer by layer; after the incision
inside it. The sac must be completely isolated and reduced into of the transversalis fascia, it is a good practice to infiltrate the
the abdomen. The deep introduction of the plug and its suturing preperitoneal space with anesthetic solution to minimize sensitiv-
into position are entirely painless. A preperitoneal prosthesis can ity to surgical maneuvers (Fig. 43.7). When the sac is markedly ad-
also be easily inserted by a suprapubic approach.26 This type of herent to the neighboring structures, numerous injections oflocal
operation can be performed without any particular difficulty with anesthetic may be required to free it (Fig. 43.8). At the end of
( I
FIGURE 43.5. After the hernia sac is opened, a few cc's are injected within FIGURE 43.7. Infiltration oflocal anesthetic within the preperitoneal space
the sac to protect against pain and vagal response. to allow exposure of the iliac fossa and parietalization of the cord.
322 O. Terranova et al.
.......
, ,
--'
FIGURE 43.8. Infiltration of the hernia sac as seen in the suprapubic

preperitoneal approach.
FIGURE 43.11. Cutaneous infiltration about an umbilical hernia.
these maneuvers the prosthesis is inserted and fixed into position

practically painlessly.
/ Femoral Hernias
Local anesthesia in the case of femoral hernias is particularly sim-
ple and rapid. The skin and the subcutaneous tissue along the pro-
posed incision are infiltrated by 8 to 10 ml oflocal anesthetic (Fig.
43.9). The incision is parallel to the inguinal fold and centered
on the hernial swelling. The presence in this region of many very
FIGURE 43.9. Cutaneous infiltration for an infrainguinal approach to a important veins (long saphenous vein and its afferents and the
femoral hernia.
FIGURE 43.10. Femoral hernia: infiltration of the hernial sac. FIGURE 43.12. Infiltration of an umbilical hernial sac.
References
1. Battocchio F, Terranova O. Prosthetic surgery under local anesthesia.
In Bendavid R, ed.: Prostheses and abdominal wall hernias. Austin: R.G.
Landes Company; 1994;250-257.
2. Lichtenstein I. Anesthesia. In Hernia repair without disability. St. Louis,
Tokyo: Ishiyaku Euroamerica, Inc.; 1986:46-44.
3. Ritchie], Murdoch], Greene], Nicholas M. Local anesthetics. In: L.S.
Goodman, A. Gilman: The pharmacological basis of therapeutics. (8th ed.) .
New York: Pergamon Press; 1990:311-331.
4. Bassini E. Lezioni di medicina operatoria raccolte e pubblicate da P. Scarsini.
Padova, 1890.
5. Cushing H. The employment of local anaesthesia in the radical cure
of certain cases of hernia with a note upon the nervous anatomy of
the inguinal region. Ann Surg. 1900;31:1-34.
6. Moore DC. Anestesia regionale. Padova: Piccin Editore; 1969.
7. Zenz M, Panhans C, Nielsen H, et al. Regional Anaesthesia. Chicago:
Year Book Medical Publisher, Inc.; 1988.
FIGURE 43.13. Infiltration of the preperitoneal space and of the base of an 8. Scott DB. Techniques of regional anaesthesia. Norwalk: Appleton & Lange
umbilical hernia. Mediglobe; 1989.
9. D'Athis F. Pharmacologie des anesthetiques locaux. Paris: EMC; 1986.
10. Moore DC. Regional block. Springfield, IL: Charles C Thomas; 1965.
11. Wantz GE. Anesthesia. In: G. Wantz Atlas of hernia surgery. New York:
Raven Press; 1991: 17-23.
12. Amid PI(, Shulman AG, Lichtenstein IL. Simultaneous repair of bilateral
femoral vein) dictate the withdrawal of the plunger before the in-
inguinal hernias under local anesthesia. Ann Surg. 1996;223:249-252.
jection of the drug. No particular nerve structures are found su-
13. Terranova O. La Chirurgia delle ernie inguinali recidive. Protesi per
perficially at this site. The only painful event is associated with via inguinale. II Conv Intern "Attualita e prospettive nella chirurgia
isolation of the hernial sac; the anesthetic must be injected into delle ernie e dei laparoceli." Padova 8-9 Novembre 1991:7-10.
its wall and inside it (Fig. 43.10). 14. Lichtenstein I, Shore M. Simplified repair of femoral and recurrent
inguinal hernias by a "plug" technique. Am] Surg. 1974;128:439-444.
necolObstet. 1989;169:408-417.
Epigastric, Umbilical, and Small 16. Young DY. Comparison of local, spinal and general anesthesia for in-
Incisional Hernias guinal herniorrhaphy. Am] Surg. 1987;153:560-563.
17. Terranova 0, Battocchio F. Indicazioni chirurgiche delle ernie nell'
anziano. Atti del V Congresso Naz Soc Ital Chir Gen. Perugia; 1991 :
Epigastric, umbilical, and small incisional hernias lend themselves
237-241.
ideally to surgery under local anesthesia, even when prosthetic 18. Nehme AE. Groin hernias in elderly patients: management and prog-
meshes are required (Figs. 43.11-43.13). General anesthesia nosis. Am] Surg. 1983;746:257-260.
should be reserved for children, voluminous hernias, and multi- 19. Terranova 0, Battocchio F. L'anestesia locale in chirurgia erniaria. Ann
ply recurrent hernias. ltal Chir. 1993;64:113-118.
20. Terranova 0, Battocchio F. L'anestesia locale. In: La chirurgia delle ernie
della regione inguinale e crurale. Padova: La Garangola; 1988;19-24.
21. Terranova 0, Battocchio F, Nistri R, et al. II trattamento chirurgico, in
Conclusions anestesia locale, dell'ernia inguinale dell 'anziano. Acta Chir. 1988;44:
1-7.
Local anesthesia must be considered whenever possible in her- 22. Battocchio F. Anestesia locale. In: Testo atlante di Chirurgia delle ernie.
nia surgery. It provides the necessary anesthesia without risks, es- Milano: UTET; 1994;13-20.
pecially in a population that is growing older. In an environment 23. Ponka]L. Seven steps to local anesthesia for inguinofemoral hernia
that is ever more conscious of the cost of preoperative investi- repair. Surg Gynecol Obstet. 1963;117:115-120.
gations and hospitalization, local anesthesia provides welcome fi- 24. Amid PI(, Shulman AG, Lichtenstein IL. Local anesthesia for inguinal
hernia repair: step-by-step procedure. Ann Surg. 1994;220:735-737.
nancial relief. A further important advantage of local anesthesia
25. Maruotti RA, Viani MP, Zannini P, et al. La tecnica dell'anestesia lo-
is the patient's prompt return to normal activities, a feature that cale per il trattamento chirurgico delle ernie inguinali. Chirurgia;
satisfies both patients and health-care institutions. For the sur- 1989;2:595-600.
geon, the challenge will be a more thorough knowledge of 26. Nyhus LM, Pollack R, Bombeck CT, et al. The preperitoneal approach
anatomy and pharmacology and the application of patient and and prosthetic buttress repair for recurrent hernia: the evolution of a
gentle technique. technique. Ann Surg. 1988;280:733-737.
44
Antibiotics in Hernia Surgery
John M.A. Bohnen
Introduction taminating bacteria may come from within or on the patient or

from the operating room environment. Various preventive mea-
Despite the large volume of hernia operations that are performed sures are used to limit the number of bacteria that contaminate
worldwide, widespread use of antimicrobial agents in hernia the operative field, including disinfection of the operating room
surgeryl-4 and some recent publications dealing with antibiotic environment, preoperative antiseptic showers, and antiseptic
prophylaxis, controversy surrounds this topic. The literature on preparation of the skin of the surgical site and the operating team's
prophylactic antibiotics in hernia surgery is short on hard data surgical scrub. 7 The rationale for prophylactic antibiotics is that
and conclusions. they neutralize bacterial contaminants in the surgical site before
Abdominal wall hernia operations are classified as clean cases,5 tissue lodgement and invasion occur.
for which antibiotic prophylaxis traditionally has not been rec- The virulence of pathogens that contaminate the operative field
ommended because of low expected incidences of surgical site in- plays a role in determining whether infection will follow an oper-
fection. 6 Three developments in the 1990s have challenged this ative procedure. Some bacteria, such as Staphylococcus aureus and
dogma: findings of higher than expected infection rates associ- Streptococcus pyogenes are especially pathogenic,lo and some, such
ated with hernia operations, clinical trials that have shown that anas Staphylococcus epidermidis, have advantages in the presence of im-
tibiotic prophylaxis may improve clinical outcomes, and the planted foreign materials.l 1
widespread use of prosthetic biomaterials, which is a relative in-
dication for antibiotic prophylaxis. 6
Determinants and Risks for Preoperative Status of the Patient

Surgical Site Infections Adverse indicators of preoperative health have been associated
with increased risk of developing postoperative surgical site in-
The effects of the bacterial contaminants, the preoperative status fection, including immunosuppressive medications, malnutrition,
of the patient, the preoperative preparation of the patient and op- morbid obesity, elevated blood sugar level, and infections remote
erating room, and the type of operative procedure all interact to from the operative site. 7,12 Some, such as obesity, malnutrition, and
determine whether a surgical site infection will occur. These fac- diabetes control, may be amenable to improvement before the op-
tors, considered below, have been reviewed in the guideline for eration is undertaken.
the prevention of surgical site infection recently published by the
Centers for Disease Control and Prevention. 7 Several prospectively
validated indices of risk for surgical site infections, based on these
determinants, have been developed following studies in large pa- Patient Preparation and Operating
tient populations. 5,8,9 Stratification of patients according to infec-
tion risk has been used for epidemiological purposes since the Room Environment
seminal study that grouped surgical wounds into "clean," "clean-
contaminated," "contaminated," or "dirty" categories based on the Before the skin incision is made, a number of factors affect the
degree of microbial contamination of the wound. 5 probability that an infection will develop at the surgical site, in-
cluding shaving hair at the incision site (which promotes infec-
tion, especially if done earlier than immediately preoperatively),
Bacterial Contaminants antiseptic skin preparation, and contamination from inanimate
objects in the operating room. 7 Devastating outbreaks of surgical
The most important determinant of infection related to bacteria site infections in cardiac operations have been traced to contam-
is the number of pathogens that enter the operative field. 5 Con- ination from inside the operating room. 13

44. Antibiotics in Hernia Surgery 325
Operative Procedure lowest in reports that focus on operative technique, in which in-
fection is not a primary outcome measure. 20 For example, the
Numerous factors related to the type and conduct of operative Lichenstein inguinal hernia repair has been associated with a less
procedures are believed to influence the development of postop- than 1% incidence of wound infection at the Lichtenstein clinic,21
erative surgical site infections. Some, such as asepsis, operative but the recent, prospective trial of prophylactic antibiotics of Tay-
technique, and duration of operation, apply to all types of opera- lor et al. 19 found that the Lichtenstein procedure was associated
tions. 7,9 The important infection risk issues in hernia procedures with a 6% incidence of surgical site infection. The most reliable
are type of hernia, use of drains, laparoscopic versus open ap- information comes from studies in which infection rates were de-
proaches, and use of prosthetic biomaterials. Based on the avail- termined by independent objective observers, prospective study,
able evidence, which is referenced and discussed in more detail appropriate definitions, stratification and patient selection crite-
under "Incidence" below, some conclusions can be drawn: Ventral ria, and appropriately long follow-up duration (that is, at least 1
incisional hernia repairs are associated with higher wound infec- month).2o Unfortunately, most of the published studies on post-
tion rates than are umbilical and inguinal herniorrhaphy; drains operative infection rates following hernia operations have not ad-
appear to promote the development of wound infections; the in- hered to these criteria.
sertion of prosthetic biomaterials does not appear to increase the Besides issues of study methodology and reporting, variations in
risk of surgical site infection; and laparoscopic inguinal hernia re- infection rates following hernia repair can be attributed to real
pairs may be associated with lower risk of wound infection than differences in patient characteristics and preparation and in how
open repairs. In the absence of conclusive data on the benefit of hernia operations are performed in terms of preoperative shav-
prophylactic antibiotics, the relationships between these factors ing, antiseptic agents, surgical technique, drains, and so on. This
and the potential for infection should be considered when decid- variation is reflected in a multicenter study of 1487 patients un-
ing whether to use antibiotic prophylaxis in individual situations. dergoing all types of hernia repair that showed infection rates
The lack of evidence that biomaterial implantation increases in- among 11 different hospitals ranging from 1.2 to 7.6%; these rates
fection risk is surprising, as there is considerable experimental ev- were attributed to technical factors, especially the use of drains,22
idence that implanted foreign material promotes local infection. but hernia incarceration and coexistent infection were also found
It has been known for decades that the number of bacteria re- to be associated with the subsequent development of surgical site
quired to cause tissue infection is diminished about a WOO-fold in infection. Another multicenter study showed an interhospital
the presence of foreign material,14,15 The mechanisms by which range of infection rates from 3 to 12%, differences the authors
bacteria flourish in the presence of biomaterials are the subject of could not attribute to factors such as duration of operation, sur-
intense research efforts because of the clinical importance of in- geon experience, antiseptic preparation, preoperative shave, anes-
fected cardiac, vascular, and orthopedic prostheses. 16 thetic modality, type of repair, suture type, suture for fat, skin
closure method, or wound analgesia,19
Despite the limitations of the published literature, some gener-
alizations can be made about the incidence of postoperative
Infections Following Hernia Operations wound infection following hernia repair as listed above, under
"Operative Procedure." The reported incidence of infection fol-
Microbial Etiology lowing incisional hernia repair appears to exceed that of groin
hernia. Laparoscopic inguinal hernia repair has been associated
In infections following clean operations such as hernia surgery, with lower rates of postoperative wound infection than open re-
gram-positive pathogens such as staphylococcal and streptococcal pairs. The use of prosthetic biomaterials does not appear to in-
species predominate. Infections with gram-negative pathogens crease the incidence of surgical site infection. Wound drainage
such as Escherichia coli and anaerobes such as Clostridia spp. or Bac- promotes infection but appears to decrease the incidence of
teroides spp. can occur, especially if there has been intestinal con- seroma formation following ventral hernia repair; increasing du-
tamination or tissue ischemiap,18 Published reports on infections ration of wound drainage is associated with higher infection rates.
following hernia operations have demonstrated a similar pattern. The following paragraphs examine some of the published evi-
For example, in a large prospective trial studying prophylactic an- dence for these statements. The effect of prophylactic antimicro-
tibiotics in inguinal hernia repair, Taylor et al,19 encountered 50 bial agents on the incidence of surgical site infection following
cases of surgical site infection, from which bacterial pathogens hernia operations is highly controversial and is discussed in a
were isolated in 21 instances. Of those, S. aureus predominated separate section below, "Prophylactic Antibiotics in Hernia
(n = 14), followed by various streptococci (n = 4), and one iso- Operations."
late each of S. epidermidis, Enterobacter aerogenes, and an unidenti-
fied coliform enteric organism.
Type of Hernia
Incidence The reported incidence of surgical site infections following in-
guinal hernia repair is less than 10%. The published literature de-
Despite the classification of hernia procedures as "clean" opera- scribes significantly higher infection rates following ventral hernia
tions, expected to carry a low risk of wound infection within a nar- repair, up to 25%. Infection rates after femoral and umbilical her-
row range,8 the reported frequencies of surgical site infection nia repairs appear to be intermediate between those after inguinal
following hernia repair differ widely among published articles. It and ventral repairs. A number of studies in the 1990s have
has been observed that the incidences of infection appear to be recorded postoperative infection rates following hernia repair in
326 J.M.A. Bohnen
the settings of either randomized trials or prospective cohort stud- umbilical hernia, and 1 % in a historical control group of inguinal
ies. 3,17,19,21,23-28 In some cases, infection rates of different types of hernia repairs.
hernia repair have been compared within the same study.22,29,30,31 An interesting study by Houck et al.,31 found a higher wound
Prospective, randomized trials of antibiotic prophylaxis have infection rate with ventral than inguinal hernia, and they postu-
produced widely divergent infection rates following open inguinal lated a reason related to persistent bacterial contamination of the
hernia repair. Taylor et al.,19 in a multicenter randomized, surgical field. They reported a 16% incidence of wound infection
double-blind, placebo-controlled trial involving over 500 patients, following 80 ventral hernia repairs in contrast to an 0.8% infec-
found an overall wound infection rate of 9%.19 Lazorthes et al.,23 tion rate following 241 inguinal hernia repairs. The incidence of
in a randomized nonblinded, non placebo trial of intraincisional wound infection following ventral hernia repair was significantly
antibiotic administration in over 300 patients, found an overall greater when the previous abdominal operation had been com-
wound infection rate of 2%. Platt et al. 3 studied over 600 patients plicated by a wound infection, 41 %, versus 12% if no infection
undergoing inguinal hernia repair as part of a double-blind, had occurred previously. In five of seven cases in which bacteriol-
placebo-controlled trial of antibiotic prophylaxis that also included ogy results were available for both operations, the same organism
breast operations. 3 This study was notable for its meticulous post- was found, S. aureus. The authors believe that persistent contami-
operative infection surveillance, which would be expected to yield nation leads to infections following ventral hernia repairs, which
a relatively high incidence of wound infection; yet an overall no longer should be classified as "clean" procedures.
wound infection rate of only 1.6% was detected. Several studies limited to ventral hernia repair have reported
Prospective cohort studies designed to record infection rates fol- postoperative wound infection rates higher than what has been re-
lowing inguinal hernia repair have yielded incidences of wound ported in similar types of observational studies of inguinal hernia
infection similar to those found in randomized trials. Bailey et al. 24 repairs. Gilbert and Graham32 found a wound infection rate of 8%
studied prospectively 510 patients who underwent inguinal hernia in 66 patients who underwent ventral hernia repair with prosthetic
repairs. 24 Their follow-up included community-based surveillance biomaterial. White et al. 4 found a 14% incidence of wound infec-
for surgical site infections, which were found in 9% of cases. Two- tion in a review of 250 ventral hernia repairs, less than half of
thirds of these infections were found in the community, under- which included prosthetic biomaterial. Molloy et al. 33 and Bauer
scoring the importance of active postdischarge surveillance. et al. 34 reported wound infection rates of 8% and 7% in reviews
Holmes and Readman,25 who followed prospectively 97 patients of 50 and 28 patients, respectively, undergoing ventral hernia re-
after inguinal hernia repair, found a 4% incidence of wound in- pairs with prosthetic biomaterials. Morris-Stiff and Hughes 35 found
fection. Gilbert and Felton 17 reported a prospective database that a 6% incidence of wound infection following ventral hernia repair
recorded the incidence of wound infection following inguinal her- in a collective review.
nia repair in 2493 patients at multiple centers. Wound infection
surveillance depended on replies to questionnaires sent to the op-
erating surgeons, so it is not surprising that a surgical site infec-
Laparoscopic Versus Open
tion rate of only 0.8% was detected. Inguinal Hernia Repair
Studies describing surgical techniques of inguinal hernia repair,
with less emphasis on infection rates, have found very low inci- As the number of published reports on laparoscopic repair of in-
dences of postoperative wound infection. Shulman et al. 21 and guinal hernia increases, it has become evident that postoperative
Berliner26 each found wound infection rates of 0.03% in studies wound infection rates are as low as those of open inguinal hernia
of over 3000 and 300 patients, respectively, who underwent pros- repair or lower. The results of randomized trials have favored lap-
thetic repairs of inguinal hernias. Kark et al. 27 found a similar 0.3% aroscopic repair. The highest infection rates were found in the
incidence of deep wound infections following a study of over 3000 study of Wright et al.,36 who compared open mesh with laparo-
prosthetic inguinal hernia repairs, but this number did not in- scopic inguinal hernia repair in a randomized trial with over 60
clude an added three late infections, which brought their infec- patients per treatment group. Wound infections occurred in 5%
tion rate to 1.5%. Hay et al.,28 in a randomized trial ofl647 patients of the open operation group versus 7% of the laparoscopic group,
who underwent different types of inguinal hernia repair without a difference that was not statistically significant. All infections were
prosthetic material, found a 1% incidence of "wound abscess." termed "minor" and responded to oral antibiotics. Stoker et al. 37
Studies that have compared infection rates among inguinal, reported a randomized trial that compared laparoscopic with open
femoral, umbilical, and ventral hernia repairs have diverged widely repair without mesh in two groups of 75 patients each. They found
in absolute wound infection rates recorded for each type of her- wound infections in 7% of patients treated with open operation
nia repair but found consistently that postoperative wound infec- versus 1% of patients treated laparoscopically. The most carefully
tions occurred more frequently in patients who underwent ventral designed and conducted trial was that of Liem et al.,38 whose ap-
hernia repair. Olson et al.,29 in a 5-year prospective surveillance proximately 500 patients per group were treated with either lap-
study of many types of operation, found 1222 patients who had in- aroscopic or open inguinal hernia repair, and complications were
guinal hernia repairs, 104 who underwent ventral hernia proce- studied for 2 years. Prophylactic antibiotics were used in less than
dures, and 76 who had umbilical hernia repairs; infection rates 3% of cases, and in 3% of open operations prosthetic biomateri-
were 1.2%,4.8%, and 5.3%, respectively. Simchen et al. 22 prospec- als were used. Six patients in the open operation group (1.2%)
tively studied 1487 patients who underwent hernia repairs; post- and none in the laparoscopy group developed wound abscesses, a
operative wound infection rates were 9.2% for ventral, 7.7% for statistically significant difference.
femoral, and 3.3% for inguinal hernia repairs, respectively. In a large uncontrolled cohort study of laparoscopic inguinal
Abramov et al.,30 in a small (n = 35), prospective antibiotic study, hernia repair, Phillips et al. 39 found a 0.2% incidence of wound
found overall (combined antibiotic and no antibiotic groups) infection at the trocar site in over 2500 patients studied for a mean
wound infection rates of 25% for ventral hernia repair, 26% for of 22 months. Only one mesh infection occurred.
Laparoscopic hernia repair may be associated with lower wound rence of the hernia. Light microscopy revealed that bacteria had
infection rates because the biomaterial prosthesis is introduced infiltrated the infected mesh. However, this case was the only
through a trocar without contact with the skin and placed deep wound infection that occurred in 350 patients who underwent
and the operation site is away from the trocar wound. 4o Based on ePTFE patch inguinal hernia repairs and formed the patient co-
evidence from larger abdominal operations, laparoscopic ap- hort for this review, an incidence of 0.03% . The follow-up period
proaches may reduce postoperative infection rates by modifying for Berliner's study26 was 18 to 96 months, with a mean of 42
the systemic response to injury.41 If the surgical site infection rate months.
is indeed lower for laparoscopic approaches, the results of clini- It would be useful to know if any particular type of biomaterial
cal trials of antibiotic prophylaxis in open hernia repair may not is more likely to incur infectious complications for given types of
apply to laparoscopic repair. hernia repair (Fig. 44.1). Experimental models could help by
stereotyping the infectious challenge with different meshes at dif-
ferent tissue levels. However, as commented by Morris-Stiff and
Prosthetic Biomaterial Hughes,35 there is surprisingly little work on this in animal mod-
els. Brown et al. 44 compared polypropylene to ePTFE mesh con-
Biomaterial-derived prosthetic implants are used for inguinal her- taminated with S. aureus in repair of guinea pig abdominal wall
nias to reduce the extent of dissection and the degree of postop- defects; they found that significantly fewer bacteria adhered to
erative pain and for ventral hernia repairs to reduce the high ePTFE than to polypropylene whether or not antibiotics were ad-
recurrence rates associated with primary tissue repairs. With bio- ministered. Bleichrodt et al. 45 found similar incidences of wound
material use comes a risk of infection that may resist treatment be- infection associated with polypropylene versus ePTFE implants in
cause of infection of the prosthetic implant. It is perceived by some a rat abdominal wall infection model.
clinicians that the use of implanted foreign material increases the Important information about the association of particular bio-
incidence of operative site infection. Despite the perception that materials with infection has come from clinical trials. Morris-Stiff
biomaterials promote infection, clinical studies have not found and Hughes 35 collated the results of 49 clinical trials of mesh re-
that operative site infection rates are increased by the use of impair of ventral hernia. The incidence of surgical site infection was
planted prostheses. This conclusion is derived from clinical stud- 6%; comparison was not made with ventral hernia repair without
ies that have recorded surgical site infection rates in otherwise mesh. The authors commented on the marked interseries differ-
similar cohorts of patients with and without prosthetic implants ence in the incidence of infection, which varied from 0 to 29%.
and from audits of patient cohorts that uniformly received im- Infection rates were 4.8% with polypropylene, 7.2% with ePTFE,
planted prosthetic biomaterials. and 8.3% when polyester mesh (Mersilene®) was used. Gilbert and
In a prospective multicenter audit of wound infections follow- Graham 32 reviewed their experiences with 66 ventral hernia re-
ing inguinal hernia repairs, Gilbert and Felton 17 recorded an 0.8% pairs, of which 27 included polyester and 36 included polypropyl-
incidence of wound infection in 2493 patients, of whom 1514 re- ene implants; associated surgical site infection rates were 11 % and
ceived implanted biomaterials. Polypropylene mesh was used in 6% , respectively. However, although polyester was associated with
most cases. The incidence of surgical site infection was not asso- higher infection rates, it was used for larger hernias.
ciated with whether biomaterials were used, and no prosthetic The findings of higher infection rates associated with polyester
mesh required removal because of infection. In a study of ventral are consistent with the study of Leber et al.,46 who reviewed 200
hernia repair, White et al. 4 reviewed 250 operations, of which pros- patients studied a mean of 7 years not included in the collected
thetic mesh was used in 99 cases. Patients who received meshes series of Morris-Stiff and Hughes. 35 Each patient was given a pros-
tended to have larger hernias and were more likely to be given thetic mesh of polypropylene, ePTFE, or polyester. Although not
drains. The incidence of surgical site infection was 12% when no documented clearly in the paper, it appears that the incidence of
mesh was used versus 16% with mesh, a difference that was not surgical site infection was 26 (13%) overall, derived from adding
statistically significant. Furthermore, whether or not mesh was
used, surgical site infection was more common when drains were
inserted. Overall, the incidence of infection was 19% when drains
were used and 10% in the absence of a drain. Therefore, it ap-
peared that the incidence of infection was affected by the use of
drains and not by the placement of mesh per se.
Thill and Hopkins42 found infection rates of 0.54% and 1.2% for
prosthetic mesh and Bassini inguinal hernia repairs, respectively,
and Mann et al. 43 concluded that prosthetic me~h use does not ap-
pear to alter the incidence of superficial wound infection after re-
viewing the evidence in previous clinical studies of inguinal hernia
repair. However, they cautioned that the true incidence of late on-
set deep graft infection is not yet known. They claim, and I agree,
that it is not yet known if there is a relationship between early su-
perficial wound infection and late onset deep graft infection. 43
To advance their point about late onset, deep wound infection
associated with prosthetic mesh, Mann et al. 43 cited the study of
Berliner,26 who reported a case of deep S. aureus expanded poly-
tetrafluoroethylene (ePTFE, Gore-Tex®) patch infection that FIGURE 44.1. Electron microscopy, bacteria on ePTFE mesh. (Courtesy Dr.
required removal of the implanted prosthesis, followed by recur- Y. Schumpelick)
328 J.M.A. Bohnen
cases of early cellulitis to cases of later "chronic infection/sinus thetic biomaterial and the associated risk of recurrent herniation,
tract." A further seven cases of enterocutaneous fistula occurred. whether or not mesh is removed. Removal of prosthetic biomate-
Both surgical site infection and fistula were significantly associated rial from the abdominal wall, especially when in contact with the
with the use of polyester mesh, which had a 16% incidence of these peritoneal cavity, brings the dreaded risk of intestinal injury and
two complications46 compared with incidences of 0 to 6% and 0 to subsequent abdominal infection and intestinal fistula. In a tertiary
2%, respectively, with the other biomaterials. Not surprisingly, poly- care center for these complications, we have observed the enor-
ester mesh was associated with a greater incidence of recurrent her- mous resources that individual cases of this nature demand from
nias and greater length of stay in hospital. The authors concluded society at large.
that polyester mesh should not be used for incisional hernia re- Many wound infections following hernia repair are subcuta-
pair.46 Although their findings are clear, it should be noted that neous processes that respond to incision and drainage of the sub-
this is a single study and that the greater infection risk for poly- cutaneous space with or without antibiotics. In their collection of
ester cited by Morris-Stiff and Hughes35 and Gilbert and Graham 32 published reports, Morris-Stiff and Hughes stated that of 130 in-
were only marginally higher than for other biomaterials. fections following placement of abdominal wall prostheses, in only
To conclude, the point that biomaterials (with the possible ex- 12 cases was removal of the mesh required. What factors led to
ception of polyester) are not associated with higher infection rates, the need for mesh removal have not been elucidated. The study
several other reports of low incidences of biomaterial-related in- of Berliner,26 who presents the case of S. aureus deep prosthetic
fection are cited. Shulman et al. 21 reported a 0.03% infection rate graft infiltration (see above), implies that bacterial infiltration of
for over 3000 mesh repairs of primary inguinal hernias. Kark et a mesh will make an infection resistant to treatment with antibi-
al. 27 found a 1.5 % incidence of surgical site infections in a prospec- otics and debridement alone. However, whether a bacterially
tive audit of over 3000 patients with mesh repairs of inguinal her- infiltrated graft can ever be saved and what promotes some pros-
nias. In a retrospective analysis of 41 patients treated for ventral thetic implants to become irreversibly infected are not known. As
hernia with mesh implants, Muller et al. 47 found a 5% incidence described above, Mann et al. 43 logically distinguish between su-
of surgical site infection. perficial and deep wound infection; however, this distinction is
made infrequently in the published literature, and there is not ad-
equate information with which to draw any conclusion about the
Use of Drains relative consequences of infection at different levels of wound
tissue.
Surgeons frequently use drains in hernia repairs to prevent the Whether or not a prosthetic biomaterial implant has been
development of serous collections in the subcutaneous space. The placed or removed, wound infection following hernia repair pre-
collected review of abdominal wall prostheses by Morris-StifI and disposes to recurrent hernia. This was established by the study of
Hughes35 suggests that drains may achieve that function. However, Glassow,49 who found a fourfold increase in the risk of develop-
a link between seroma formation and infection has not been es- ing a recurrent inguinal hernia after occurrence of a wound in-
tablished, and the use of drains in ventral hernia repairs has been fection. Devlin et al. 50 published similar findings in an audit of
associated with an increased risk of infection. 4,22 Simchen et al. 22 696 patients who underwent inguinal hernia repairs without pros-
found with multivariate analysis that the use of drains was more thetic biomaterial implantation. They found that of four patients
strongly associated with subsequent wound infection than was any who developed wound sinuses requiring suture removal, all four
other factor. In their prospective study of 1487 patients with all hernias recurred.
types of hernia repair, surgical site infections occurred in 2.5% of
patients who did not receive drains versus 13.7% of those who did,
a statistically significant correlation that was associated with a 4:1 Principles of Antibiotic Prophylaxis
relative risk of infection when drains were used. Drains promoted
the development of infection at each of the hospitals in the study The seminal studies of Burke51 in animals, and Polk and Lopez-
and with all types of hernia repair. The risk of postoperative in- Mayor52 in patients, established that effective prophylaxis requires
fection increased linearly with the duration of drainage. 22 As cited the administration of an antimicrobial regimen before the skin is
above, the retrospective study of White et al. 4 found that drain use incised. Since then, several principles of antibiotic prophylaxis
was associated with the development of surgical site infection. have become established. 6,48,53 The regimen of choice should be
based on the results of scientifically conducted clinical trials wher-
ever possible; prophylactic agents should target the bacterial
Adverse Effects of Surgical Site Infection pathogens expected for a particular type of operation; adequate
concentration of the drug(s) should be established in the opera-
Although some surgical wound infections appear trivial, in the tive site tissues at the time of contamination; and the safest and
population operative site infections cause patient anguish and least expensive regimen should be used for cost-effective care.
enormous clinical, economic, and medicolegal burdens. These
consequences are related to patient anxiety, pain, regional spread
of infection, increased length of hospitalization and other com- Take an Evidence-Based Approach
ponents of care, need for reoperation, and indirect costs (such as
loss of work) associated with surgical site infection following any Hundreds of scientifically conducted, prospective randomized,
type of operation. 48 double-blinded clinical trials have established important principles
Wound infection subsequent to repair of an abdominal wall her- of clinical care and guide clinicians to use prophylactic antibiotics
nia incurs the same potential for adverse effects as that of wound appropriately and effectively. From clean orthopedic and vascular
infection elsewhere, plus the possible need for removal of pros- procedures to clean-contaminated gastrointestinal operations,
there exist abundant data on the value of specific prophylactic reg- Mter this study, the same team of investigators published a pair
imens. For clinicians without the time to stay informed of a rapidly of articles that reported on the efficacy of prophylactic antibiotic
expanding pool of information, the authoritative publication Med- in samples of over 2500 patients undergoing breast54 and both
ical Letter prints a succinct guide to prophylactic antibiotics in breast and hernia55 operations. Both of these studies included pa-
surgery every 2 years. 6 One hopes that the recent interest in us- tients from the original studt plus other patients from observa-
ing antibiotics for clean operations and the proliferation of her- tional data sets. All studies found significantly fewer infections
nia centers worldwide will stimulate more scientific studies of associated with the use of antibiotic prophylaxis. Although the
antibiotic prophylaxis in hernia operations, for which they are still studies of Platt et al. have not answered definitively whether an-
lacking. tibiotic prophylaxis is indicated for hernia repair, they have raised
that possibility with scientific inquiry. Besides stimulating consid-
erable debate on the issue, the ground-breaking studies have led
Target Expected Pathogens to further investigations into what had been shunned previously
as a topic for clinical trials.
Surgical operations are categorized according to whether or Two other investigations have tested the value of antibiotic pro-
not an epithelium-lined tract or infected tissue is encountered. phylaxis in heterogeneous patient populations that included her-
If not ("clean operation"), skin organisms are the most common nia operations. In a randomized, double-blind trial with 4- to
causes of surgical wound infections. If a site of infection or a tract 6-week follow-ups, Lewis et al. 56 compared prophylaxis with cefo-
such as the gut is traversed ("dirty," "contaminated," or "clean- taxime 2 g to placebo for clean operations stratified for risk of
contaminated"), the exposed flora will predominate in any post- wound infection according to epidemiological criteria. Over 300
operative surgical site infections. Numerous studies in a wide patients per group were studied, including over 75 patients per
variety of procedures such as colonic and biliary operations have group with unspecified hernia procedures. They found that pro-
established that targeting drug agents against expected flora phylaxis significantly reduced the incidence of surgical site infec-
correlates with clinical efficacy in preventing postoperative tion in low risk patients, but only a trend was seen in favor of
infections. 6 prophylaxis in the high risk group. Besides giving this paradoxi-
In general, operative procedures that enter the uninfected res- cal result in terms of efficacy, the study's value to the hernia sur-
piratory tract encounter a small number of gram-positive and geon is hampered by the small number of unspecified hernia cases
gram-negative organisms. The urinary tract may be nearly sterile and the lack of analysis of results specific to hernia repairs.
or may harbor gram-negative aerobic and facultative pathogens Nevertheless, this otherwise rigorously conducted trial has yielded
such as Pseudomonas aeruginosa and E. coli, respectively. The ali- further evidence in favor of antibiotic prophylaxis for clean
mentary tract contains relatively large numbers of gram-negative operations.
rods such as E. coli and anaerobes such as Bacteroides spp. Specific In a prospective, randomized trial, Rotman et al. 57 compared
antibiotic choices for hernia repairs that may include these prophylactic cefazolin or cefotaxime with a control group (no an-
anatomical structures, such as parastomal hernia repair, are dis- tibiotic but no placebo) in over 3000 patients undergoing a vari-
cussed below. ety of abdominal operations stratified for risk of wound infection
What about clean operations? Are these procedures conducted and studied for 30 to 40 days. In the low risk stratum, which in-
in a friendly, near-sterile operative field, or is the inoculum den- cluded groin and abdominal hernias, antibiotic prophylaxis
sity of skin flora large enough to cause infections that could be was associated with significantly fewer wound infections than the
prevented by antibiotic prophylaxis? It has been accepted that an- control group. The results specific to hernia repairs were not
tibiotic prophylaxis is indicated for clean operations if infection specified.
would be a disaster or ifforeign biomaterial is implanted. 6 For ex-
ample, the published literature supports the use of antibiotic pro-
phylaxis in biomaterial-related vascular and orthopedic operations
and in cardiac procedures in which prosthetic implants are not
Ensure Adequate Drug Concentrations at the
used. 6 If prophylaxis works for those procedures in which infec- Time of Contamination
tions are caused by skin organisms, then, should it not work for
other clean procedures? This question, and a recent appreciation Clinical trials and pharmacokinetic data have shown generally that
that clean wound infections may be more common than previously prophylactic agents should be given 30 minutes before the inci-
believed, has led to the performance recently of clinical trials of sion is made. If an operation is prolonged, repeated doses should
antibiotic prophylaxis in clean operations, including hernia probe administered after two half-lives of the drug or 2 to 3 hours for
cedures, starting with the study of Platt et a1. 3 most agents. 6 Numerous studies have found that further doses of
Platt and colleagues3 changed the way we view the potential for antibiotic agents after operation do not add value ,58,59 yet surgeons
surgical site infections following clean operations. Their study broke commonly administer antimicrobial agents for hours to days post-
from traditional indications and tested antibiotic prophylaxis in operatively. This unnecessary practice incurs added cost, risk of
clean, nonimplant operations (breast and hernia procedures) in side effects, and development of antibiotic-resistant microflora. 60 •61
which postoperative infections usually do not threaten life or limb. Two issues related to timing of antibiotic dosing deserve com-
Their results showed a trend toward fewer surgical wound infections ment. The first is the apparently simple requirement that the drug
in patients who received prophylactic antibiotic for elective groin regimen be started 30 minutes before operation. Unfortunately,
hernia repair. A similar finding held for patients undergoing elec- the implementation of this goal has been elusive according to sev-
tive breast operations. Statistical significance was reached only if eral studies62 and an unpublished audit from our institution that
breast and hernia patients were combined and wound infections showed that drug administration took place "too early" about one-
were combined with urinary infection and pneumonia. third of the time. This occurs often because the prophylactic agent
330 J.M.A. Bohnen
is administered when the patient is called to the operating room prospective, randomized, placebo-controlled, double-blind trials
area but the operating team takes longer than expected to proof antibiotic prophylaxis in hernia operations. These investigations
ceed to the case. Drug administration too soon before operation studied intravenous administration of two different prophylactic
is associated with an increased incidence of surgical site infec- agents in groin hernias and yielded conflicting results related to
tion. 62 Several successful approaches have been taken to remedy antibiotic efficacy. Therefore, the recommendations derived from
this important problem, including using quality improvement the published literature are based on inadequate information.
methods 63 and computer-assisted decision support systems. 64 A Besides parenteral administration, prophylactic agents can be
simple and reportedly successful remedy is to adopt the institu- delivered locally into the surgical wound by binding them to bio-
tional policy that the responsibility for administering timely pre- materials or by topical application into the wound. Impregnation
operative antibiotics belongs to the anesthetist. 65 of antimicrobial agents into prosthetic biomaterials has been stud-
The other issue related to antibiotic dosing is the proscription ied in experimental models 71 ,72 but not clinically. The use of top-
against administering prophylactic agents after the operation. Al- ical antibiotics to prevent hernia wound infections has theoretical
though the published literature supports limiting antibiotics to the advantages. High wound tissue levels of antimicrobial agent are
preoperative and intraoperative periods,6,58 studies on which this achieved with this method. Using an experimental canine model,
recommendation is based have not included hernia surgery specif- Matushek et al. 73 found that topical administration of cefazolin
ically. Is there another type of clean operation for which postop- produced higher and more prolonged concentrations of antibi-
erative prophylactic antibiotics have demonstrated merit? It has otic in wound fluid than did intravenous administration. Because
been argued without supporting evidence from clinical trials that of rapid systemic absorption, serum concentrations of the drug
prophylactic agents in cardiovascular operations should be con- reached therapeutic levels within minutes and equaled those of
tinued until vascular and urinary catheters are discontinued, to the intravenous route within 1 hour, followed by similar rates of
avoid bacteremic seeding of prosthetic graft material. 66 This ap- decline.
proach has been criticized on the basis of lack of supporting evi- Troy et al. 74 studied the topical administration of bacitracin in
dence,53 and indeed in cardiac operations administration of a rabbit model of S. aureus-<:ontaminated polypropylene mesh. Al-
antibacterial agents postoperatively had no benefit in a large ran- though topical bacitracin reduced bacterial growth compared with
domized clinical trial. 67 However, in a prospective, randomized saline control, intravenous cefazolin was at least as effective. Com-
trial comparing preoperative with preoperative plus postoperative bining topical bacitracin with intravenous cefazolin gave no added
antibiotics in vascular operations, continuing antibiotics postop- benefit over either of the agents alone.
eratively until lines were removed (an average of 4 days) was as- Several published series have given testimonial evidence for the
sociated with a significant decrease in postoperative surgical site efficacy of topical antimicrobial prophylaxis, including the studies
infections. 68 Whether postoperative administration of antibiotics of Shulman et a1. 21 and Berliner,26 discussed above, which report
until drain removal would reduce wound infection rates in ven- infection rates ofless than 1%with topical prophylaxis for inguinal
tral hernia repairs has not been studied and should be subjected hernia repairs with prosthetic mesh.
to a randomized trial. The two placebo-controlled, double-blind trials of antibiotic pro-
phylaxis are those of Platt et al. 3 and Taylor et al.I 9 Both groups
studied open groin hernia repairs in large studies with rigorous
Use the Least Expensive, Safest Antimicrobial follow-up of 4 to 6 weeks. Yet there were substantial differences in
their study methods and conclusions. Platt and colleagues3 ad-
Regimen for Cost Effectiveness ministered cefonicid 1 g intravenously versus placebo to over 300
patients per group. Although breast surgery patients were also in-
Postoperative surgical site infections greatly add to the costs of
cluded in this study, they are reported separately. The incidence
clinical care. 69 Used appropriately for established indications, an-
of wound infection was 1% in the cefonicid group and 2% in pa-
tibiotic prophylaxis is safe and cost effective. 61 .70 Although phar-
tients who did not receive antibiotic prophylaxis, a trend that was
maceutical company-sponsored clinical trials may demonstrate
not statistically significant. Because the incidence of all infections
the efficacy of expensive "new" antimicrobial agents, for clean pro-
(including urinary and pneumonia) was diminished in the breast
cedures inexpensive agents such as cefazolin generally are as safe
and hernia studies combined, the authors concluded that antibi-
and effective and are much less expensive. 6
otic prophylaxis is "useful" in hernia and breast surgery-a weak
Whether antibiotic prophylaxis is cost effective in hernia oper-
but positive endorsement. 3 Taylor et al.I 9 used a different antimi-
ations is not known because cost effectiveness requires efficacy,
crobial agent, co-amoiclav, 1.2 g intravenously (amoxicillin 1 gwith
which has not been established. Clinical trials that have found
clavulanic acid 200 mg), administered to approximately 280 pa-
benefit to antibiotic prophylaxis have argued that antibiotic costs
tients per group. Their observed incidence of wound infection was
are outweighed by savings related to decreases in postoperative
9%, with no difference between antibiotic and control groups. Nat-
infections.3,23
urally, they concluded that antibiotic prophylaxis is of no benefit.
Several other clinical trials have compared antibiotic prophy-
laxis with no antibiotic, with a variety of methodological limita-
Prophylactic Antibiotics in tions. Lazorthes et a1. 23 compared intraincisionally administered
Hernia Operations cefamandole 750 mg (mixed with local anesthetic) with "no an-
tibiotic" control in a study of two groups of 162 patients under-
Many surgeons use prophylactic antibiotics for hernia repairs, but going inguinal hernia repairs. The patient sample is not described
is this practice supported by reliable data? It is difficult to aggre- well (for example, how they were selected or other risk factors for
gate and evaluate claims from retrospective analyses and uncon- wound infection). The method of randomization is not stated,
trolled observational studies. Unfortunately, there are only two there was no placebo, and the investigators and patients were not
blinded to treatment group. "Wound abscesses" did not occur in Used appropriately, prophylactically administered antibiotics
antibiotic-treated patients versus a 4% incidence in patients who are not associated commonly with adverse effects. 53 Any history of
did not receive prophylaxis, a statistically significant difference. drug sensitivity should be heeded. Even with single dose prophy-
These results are interesting but cannot be considered scientifi- laxis, complications such as hypersensitivity reactions, pseudo-
cally valid because of the way the study was conducted. membranous colitis, and coagulopathy can occur, but they are
Abramov et al. 30 reported a small clinical trial with 35 patients more frequent when prolonged drug dosing is administered.
undergoing umbilical and incisional hernia repairs. They com- Because the subject is so controversial, the pros and cons of an-
pared cefonicid 1 g intravenously with a non placebo control group timicrobial prophylaxis in hernia surgery are listed in Table 44.1.
that did not receive antibiotic. Patients were not allocated ran- Table 44.2 lists my own recommendations and practice. The reg-
domly to treatment, and the study was unblinded. Forty-four per- imens in Table 44.2 are based on a synthesis of the literature cited
cent of untreated patients developed wound infections versus 6% above and on my belief that prophylaxis with cefazolin is safe, in-
of patients who received antibiotic prophylaxis. It is difficult to inexpensive, and probably effective. Topical use is suggested for elec-
terpret such a striking finding in a study with so many method- tive groin hernia repairs because of the theoretical advantages
ologicallimitations. cited and simplicity. The potential disadvantage of topical admin-
Abo Rahmyl reported a series of 1524 consecutive patients who istration is that it must await the start of the procedure rather than
underwent groin and incisional hernia repairs with a variety of be given 30 minutes before. The intravenous route is chosen for
techniques and received one of a number of antibiotic regimens ventral hernia repair because of the greater surface area and un-
prophylactically. The 0.06% incidence of wound infection in this certainty that topical agents would achieve uniformly adequate
patient cohort was compared with a poorly described historical tissue concentrations. One of many possible replacements for
control group of 1048 patients who had received antibiotics that cefazolin in beta-Iactam-sensitive individuals is listed. Similarly,
were started after their operations and had incurred an "infection" many other regimens would be acceptable for cases in which in-
rate (not specified as wound) of 9%. These results suggest that an- testinal pathogens are expected (parastomal and incarcerated/
tibiotic prophylaxis is beneficial, but they are impossible to inter- strangulated hernias). The recommendations listed in Table 44.2
pret scientifically. apply to open hernia procedures; as laparoscopic repairs appear
Other clinical studies have reported wound infection rates with to be associated with a lower incidence of surgical site infection,
and without prophylactic antibiotics in prospective audits and ret- prophylaxis is not indicated in that setting until there is support-
rospective analyses. Gilbert and Felton l7 reported a prospective ive evidence.
audit of 2493 patients who underwent inguinal hernia repairs in I am asked occasionally whether antibiotic prophylaxis is indi-
a multicenter registry study. Approximately half the patients re- cated for patients undergoing hernia operations and who are at
ceived one of a variety of prophylactic agents. Antibiotic use was risk for endocarditis because of cardiac abnormalities. Because of
not associated with any difference in the incidence of wound in- the very low risk of bacteremia associated with clean hernia oper-
fection. Kark et al. 27 published a prospective audit of 3175 inguinal ations, antibiotic prophylaxis is not indicated for this purpose. Rec-
hernia repairs in which the last 2000 did not receive antibiotic pro- ommendations for endocarditis prophylaxis appear in the same
phylaxis, with no change in their wound infection rate of less than issue of Medical Letter as do those for antibiotic prophylaxis in
2%. White et al. 4 reviewed the results of 250 ventral hernia repairs surgery.6.75
in which 198 patients received antibiotic prophylaxis; the wound
infection rate was 14% in those patients versus 13% in the 52 pa-
tients who did not receive antibiotics. In one study, however, an-
tibiotic prophylaxis was associated with fewer wound infections.
Therapeutic Antibiotics
Houck et al. 3l reviewed the outcomes of 80 ventral hernia repairs. in Hernia Operations
In a stepwise regression analysis they found a trend that was not
quite statistically significant: wound infection occurred in 11 % of Antimicrobial agents are required sometimes to treat surgical site
patients who received antibiotic prophylaxis versus 21 % in those infections that complicate hernia repairs. The published literature
who did not. The antimicrobial agents were not named. on this topic offers even less than for prophylactic use. There is
TABLE 44.1. Pros and cons of antibiotic prophylaxis in hernia repair

Pro Con
Hernia repairs, especially ventral hernias, are associated with significant Surgical site infection following clean operations such as hernia repair is
incidences of wound infection, which can have serious consequences uncommon
Prospective clinical trials and audits have shown strong trends favoring High wound infection rates following clean operations such as hernia
the efficacy of antibiotic prophylaxis in preventing wound infections repair should focus attention on asepsis and other infection control
following hernia repairs measures that should not be replaced by antibiotic prophylaxis
Prophylactic agents given as a single dose or as a short course are safe No clinical trial has shown definitively that prophylactic antibiotics
and inexpensive reduce wound infection rates following hernia repair; one large trial
Prophylactic agents can achieve high wound concentrations when showed no difference whatsoever
administered topically Unnecessary administration of antibiotics is costly and invites adverse
reactions
Many surgeons administer prolonged courses of prophylactic anti-
microbial agents, further increasing costs and the risk of adverse
events and potentially promoting antibiotic-resistant bacteria
332 J.M.A. Bohnen
TABLE 44.2. Recommendations for antibiotic prophylaxis in specific situations

Situation Prophylaxis
Small epigastric hernia that requires little dissection and leaves No prophylaxis
little dead space
Elective open inguinal, femoral, or umbilical hernia repair Cefazolin 1 g in 500 ml saline, administered topically via wound lavage
throughout the procedure
Elective ventral hernia repair Cefazolin N 1 g (2 g if obese) 30 min before operation; repeat 1 g dose
if procedure is prolonged (greater than 2% hours). For f3-lactam
hypersensitivity, use gentamicin and clindamycin as above
Elective parastomal hernia repair (small intestine, colon, or urinary) Prophylaxis as for any elective colon operation (oral neomycin plus
erythromycin base 1 g each thrice on the day before operation; ur
cefotetan N 1 g, 30 min before operation; ur gentamicin plus clin-
damycin (or metronidazole 500 mg) N 30 min before operation
Incarcerated or strangulated inguinal, femoral, umbilical or ventral Prophylaxis as for colon operation with N agents as for elective
hernia parastomal hernia repair, as above, only if there are associated signs
and symptoms of bowel obstruction
no comparative study of therapeutic antimicrobial therapy for avoid surgical site infections is to practice meticulous aseptic and
postoperative wound infections; most of the published literature surgical technique. Undoubtedly, some of the interhospital dif-
is anecdotal. My own practice is to treat the majority of surgical ferences cited above are related to differences in how the patient
wound infections following hernia or other procedures by open- is prepared and operated on.
ing the wound to obtain a bacterial culture and provide adequate Although no definitive study has demonstrated that ventral her-
drainage, which is achieved by packing the wound with saline or nia repair causes wound infections more frequently than does in-
antiseptic agent soaked gauze. Antibiotic therapy is reserved for guinal hernia repair, the available evidence is convincing. The
cases complicated by regional spread, such as cellulitis, or if a re- higher wound infection rate associated with ventral hernia repair
mote prosthetic biomaterial implant is present, such as a cardiac should be recognized by clinicians, clinical researchers, and in-
valve. In such cases, an agent with activity against S. aureus should fection control personnel. Unless they have data to the contrary,
be used, such as cefazolin 1 g intravenously every 8 hours, until practicing surgeons should warn patients about the wound infec-
the microbiology results are available. Treatment will then depend tion risk associated with ventral hernia repair and factor for the
on what pathogen has been isolated from the infected wound. type of hernia repair into decisions about antibiotic prophylaxis.
Whether antimicrobial therapy can salvage a prosthetic bioma- Clinical trials of antibiotic prophylaxis, which have yielded equiv-
terial graft in the presence of wound infection is an important, ocal results with inguinal hernia, should be applied to ventral her-
unresolved issue. In my experience, an implanted prosthetic graft nia repair. The higher infection rates associated with ventral hernia
can usually be saved with wound drainage, vigorous follow-up repair provide greater rationale foI,i antibiotic study and would
wound care, and no antibiotic therapy. Gilbert and Graham 32 re- make such trials more powerful statistically. Surgical investigators
ported on five patients who developed surgical site infections as- who feel compelled to provide antibiotic prophylaxis for their ven-
sociated with incisional hernia grafts. Four of the five patients tral hernia patients should determine the optimal duration of pro-
received therapeutic courses of antibiotics, and none required re- phylaxis through clinical trials: Should the drugs be given
moval of the graft. preoperatively only or until the drains come out? Infection con-
Sometimes a superficial wound cellulitis can be treated with an- trol teams should stratify ventral hernia repairs separately and
tibiotics alone, without incision and drainage. Gilbert and Felton l7 avoid the common practice of grouping "hernia repair" as a sin-
reported 21 patients with wound infections following inguinal her- gle type of operation. 8
nia repair, of which 14 had associated biomaterials. Oral antibi-
otics were used in 16 cases, and only 10 required drainage (they
did not specify how many avoided drainage while on antibiotics).
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45
Imaging Hernias of the Abdominal Wall
J. Andrew Hamlin
Introduction Positive Contrast Peritoneography

The diagnosis of abdominal wall hernia is usually made on physi- Detailed radiographic evaluation of the peritoneum awaited the
cal examination by the palpation of a peritoneal impulse on cough- development of an opaque contrast agent that could be safely in-
ing or the detection of a reducible or changeable mass. When the troduced into the peritoneal cavity. In practice, water-soluble con-
diagnosis of hernia is certain and the symptoms and physical ex- trast agents had been seen to enter the peritoneal cavity in patients
amination correlate, there is no need for an imaging study to con- with intestinal perforation and during sonography for wound in-
firm the hernia. Many patients, however, present with symptoms vestigation. The volume of intraperitoneal contrast was usually
that are either nonspecific or are suggestive of hernia but are un- small, but no untoward effect was observed. Peritoneography, us-
accompanied by physical signs indicating the presence of a her- ing a high volume of water-soluble contrast material, was intro-
nia. These patients are referred for an imaging study. duced in the 1960s after the safety of these agents in the peritoneal
Abdominal wall hernias were recognized in early radiographic cavities of animals had been established. 7- 9
examinations, and the appearance of a variety of hernias was re- Seeing pediatric patients, Ducharme et al.lO were the first to
ported in the literature.1,2 The presentation, however, depended utilize this procedure in the evaluation of inguinal hernias and in-
on two variables: First, the hernia had to contain a segment of introduced the term hemiography. Other investigators quickly fol-
testine at the time of the examination, and, second, at the time of lowed suit, and in the decade that followed most reports in the
the exposure the herniated intestine had to contain contrast ma- literature were about pediatric patients, discussing primarily the
terial, such as barium or gas. The hernia sac not occupied by opaci- contribution of herniography to the evaluation of the contralateral
fied or gas-filled bowel remained elusive. groin in children with unilateral inguinal hernias.l l - 15 Subsequent
reports have principally addressed the utility of herniography in
adults. 16-22 Herniography is discussed below in more detail.
Pneumoperitoneography
A radiographic method of demonstrating the hernia sac inde- Computed Tomography
pendent of its contents was first described using diagnostic pneu-
moperitoneum with an appropriately positioned patient and the Computed tomography (CT), introduced in the 1970s, provides a
x-ray beam tangent to the hernia. FaI"r3 reported on a patient with method of investigating internal hernias as well as hernias of the
two incisional hernias, one of which was void of intestine or omen- abdominal wall. 23-26 The CT diagnosis of hernia relies on finding
tum while the other contained omentum and gas. In a second herniated abdominal contents, such as fat, intestine, or other or-
patient with upper abdominal but no groin symptoms, he demon- gans or fluid, within a hernia sac. Most CT examinations are per-
strated ballooning of the scrotum by way of a patent funicular formed for indications other than hernia investigation, however,
process. Pneumoperitoneography became an accepted radio- and the recognized hernias are often incidental to the patient's
graphic tool for evaluation of the subdiaphragmatic spaces and primary complaint. A hernia that has reduced at the time of the
the female pelvis but generated little interest as a method for her- scan, leaving only a potential or empty sac, is unlikely to be rec-
nia diagnosis. Arner and Fernstrom4 reported their experience us- ognized by CT.
ing pneumoperitoneum in 21 patients with inguinal symptoms, Most patients are routinely scanned in the supine position, fa-
only three of whom had palpable hernias. In their series, 11 of 12 voring reduction of nonincarcerated anterior abdominal wall and
patients with suspected but nonpalpable hernias were operated on groin hernias. If the scan is being performed specifically for her-
and found to have hernias. Of these 11,9 had positive radiographs. nia and a hernia is not clearly evident on the initial images, the
Pneumoperitoneum without radiography has also been recom- patient should be scanned during a Valsalva maneuver in order to
mended for the demonstration of hernia sacs while the patient is increase intra-abdominal pressure and maximize conspicuity of
on the operating table. 5,6 the hernia. With the older instruments and longer scan times, it
335
336 J.A. Hamlin
was difficult for a patient to sustain the increased intra-abdominal pelvic floor hernias, may not lend themselves to palpation. Other
pressure throughout the examination, but with the newer helical situations in which herniography is useful include the evaluation
scanners a limited region of interest can be scanned in just a few of women with groin pain of obscure origin39 and athletes with
seconds. groin pain. 40,41
Ultrasonography Technique of Herniography

Ultrasonic (US) imaging, like CT, largely relies on finding a mass The herniographic procedure and expectations are explained in
in the abdominal wall corresponding to the contents of the her- detail to the patient, who is instructed to void before the exami-
nia sac and distinguishing it from other masses such as cysts, nation is begun. An empty urinary bladder ensures that the dome
hematomas, neoplasms, varicoceles, hydroceles, and undescended of the bladder will not be penetrated by the needle.
testes. Observing peristalsis within a herniated loop of intestine A midline approach is used, the linea alba being relatively de-
confirms the nature of the mass. An empty sac may not be demon- void of significant vascular structures. The skin is marked in the
strable, although a fascial defect can be appreciated in certain her- midline at the level of the sciatic notch as determined by fluo-
nias and peritoneal bulging seen with Valsalva. A high resolution, roscopy with the patient supine. An adjustment superiorly or in-
short focus transducer, 5 to 7 MHz, is best for examining the ab- feriorly may be necessary when a protuberant abdomen brings the
dominal wall. umbilicus to the level of the sciatic notch. Hair is shaved from the
In the evaluation of the groin, US imaging has an advantage area, if necessary, and the skin is cleansed with an iodophor solu-
over CT in the ability to examine the patient in the upright position. Buffered 1% lidocaine local anesthesia in the skin and sub-
tion with alternate straining and relaxation. Preoperative US imag- cutaneous tissues to the level of the peritoneum is delivered with
ing in infants and children to evaluate the contralateral groin in 27 and 25 gauge needles.
patients with unilateral inguinal hernias has been addressed. Find- Low osmolar nonionic contrast material is used for the exami-
ing the upper limits of the width of the internal inguinal ring to nation. The volume injected varies with the size of the patient.
be 4 to 6 mm in boys, greater diameters were associated with her- The usual volume in adults is 75 ml for men and 50 ml for women.
nias in 95 to 96%.27,28 On the other hand, Lawrenz and col- A 20 gauge, two-and-a-half-inch spinal needle is introduced
leagues 29 were only 65% accurate in predicting the presence of a through the abdominal wall. In most patients a "pop" can be felt
patent processus vaginalis in the contralateral groin of patients as the needle tip passes through the peritoneum. If the peritoneal
who were explored. US imaging has been found useful in the postanesthesia is incomplete the patient experiences momentary dis-
operative examination of patients with inguinal hernia repair30 comfort as the needle tip passes through the peritoneum. Injec-
and examination of female infants with inguinal masses.31 tion of 1 to 2 ml of contrast material under fluoroscopic
observation will quickly determine the position of the needle tip.
If the material flows freely from the needle tip, forming opaque
Nuclear Scintigraphy arcuate densities outlining the intestine (Fig. 45.1), the injection
can continue under intermittent fluoroscopic observation. Con-
Scrotal swelling associated with peritoneal dialysis may occur with trast material that stays about and obscures the needle tip indi-
leakage of dialysate at the catheter insertion site with subcutaneous cates an interstitial injection and necessitates repositioning of the
dissection and extension into the scrotum as well as in patients needle. Assuming that the needle is through the abdominal wall,
with a patent processus vaginalis or communicating hydrocele. slowly retracting the needle will draw the tip into the intraperi-
Scintigraphy after intraperitoneal instillation of 99mtechnetium
with the dialysate solution has successfully demonstrated peri-
toneal communication with the inguinal canal and scrotum. 32 ,33
Testicular scintigraphy using intravenous 99mtechnetium pertech-
netate for the evaluation of the tender scrotum has also shown
increased activity due to inflammation associated with an incar-
cerated inguinal hernia with a normal testis. 34,35
Herniography
Indications for Herniography
A clinically evident hernia needs no imaging study to confirm its
presence. Herniography is useful, however, in the evaluation of
those patients who present with symptoms but without a palpable
hernia. Many patients are sufficiently obese, tender, or shy that an
adequate physical examination cannot be done. Patients with per-
sistent or recurrent symptoms following a hernia operation may
be difficult to examine, and herniography is more sensitive than FIGURE 45.1. Intraperitoneal injection of contrast material. Arcuate
physical examination in detecting hernias of the groin at previ- opaque lines are demonstrated as contrast material dispenses about loops
ously operated symptomatic sites. 36-38 Some, such as obturator or of intestine.
45. Imaging Hernias of the Abdominal Wall 337
toneal space. Similar repositioning is necessary if the contrast is

injected within the lumen of the intestine. This is easily deter-
mined by observing peristaltic movement of the intraluminal ma-
terial. When the injection is complete, the needle is withdrawn
and a small sterile dressing is applied.
The intraperitoneal contrast material must then be directed to
the area(s) of interest. For most patients the groin is the region
in question. With the patient supine, the fluoroscopic table is
raised to an erect position. The patient is instructed to turn fac-
ing the table, which is then lowered until the head of the table is
approximately 15° to 20° from horizontal, allowing the injected
material to flow anteriorly and fill the inguinal fossae. To achieve
even distribution of the material, the patient may be turned from
side to side. With the patient prone, the table is again elevated to
a standing position, and the patient turns with his or her back to
the table for frontal and oblique fluoroscopic exposures of the in-
guinal fossae during straining (Valsalva). The patient is then again
turned to face the table, and padding is placed between the pa- FIGURE 45.2. Normal inguinal fossae and peritoneal folds. The lateral and
tient's knees and the table, which is then lowered to 25° head of medial inguinal fossae are separated by the lateral umbilical fold (arrows),
elevation. Two overhead exposures are then taken, centered at the while the medial umbilical fold (arrowheads) divides the medial inguinal
groin. The first is perpendicular to the raised table, and the sec- fossa into medial (supravesical) and lateral compartments.
ond is with 35° cephalic angulation.
Examining for other anterior wall hernias is done using a hor-
the lateral aspect of the indirect sac, which is directed inferome-
izontal beam exposure taken tangent to the anterior abdominal
dially, continues without indentation or significant deviation from
wall with the patient on knees and elbows. In this position the con-
the lateral abdominal wall (Fig. 45.3). The sac may be confined
trast material bathes the anterior peritoneum. All exposures are
to the inguinal canal or exit the external ring and descend into
made with the patient straining.
the scrotum or labium majus pudendi.
Most, if not all, indirect hernias are considered congenital as
the sac is formed by the unobliterated tunica vaginalis. If the oblit-
Normal Anatomy eration is incomplete, a slender extension of contrast material
through the internal ring may be seen. When this extension is less
The peritoneum of the lower anterior wall of the abdomen is raised
than 5 mm in diameter and but a few centimeters in length, it is
into folds by anatomical structures. Conflicting names have been
termed a persistent patent processus vaginalis. The tip of the proces-
given these folds by various authorities. According to Gray's
sus usually appears abruptly tapered rather than saccular (Fig.
Anatomy,42 in the midline, the middle umbilical fold is raised by the
45.4). These are demonstrated in 5 to 10% of herniograms. The
middle umbilical ligament, which is the cord-like remnant of the
development of an indirect inguinal hernia in an adult without a
urachus. On either side are the medial umbilical folds, which over-
preceding patent processus vaginalis has been reported.44
lie the obliterated hypogastric arteries. Further lateral still are the
Similarly, a communicating hydrocele occurs with incomplete
lateral umbilical folds, produced by the inferior epigastric vessels
that form the lateral sides of Hesselbach's triangles. The lateral
umbilical folds serve to separate the medial and lateral inguinal
fossae, which present as broad shallow recesses on herniography.
The medial inguinal fossae are crossed by the medial umbilical
folds. These folds and fossae may be demonstrated by herniogra-
phy (Fig. 45.2). Of these various folds the most conspicuous are
the medial umbilical folds, while the lateral umbilical folds are
demonstrable on less than half of herniograms. 43
Hernia Presentation on Herniography

Indirect inguinal hernias arise from the lateral inguinal fossae.
Small, somewhat triangular protrusions, up to 2 cm, are frequently
demonstrated at the internal ring and considered normal or in-
cipient hernias. The significance of these protrusions is uncertain,
as there is no compelling correlation with symptoms. Indirect her-
nias extend through the internal inguinal ring and pass down the
inguinal canal. On herniography a hernia is labeled indirect if it FIGURE 45.3. Indirect left inguinal hernia. The lateral wall of the hernia
arises lateral to the lateral umbilical fold. Because identification sac continues without significant deviation from the lateral aspect of the
of this fold is problematic, however, other criteria may be required abdominal wall. No intestinal loops were within the sac at the time of this
to properly classify an indirect hernia. Typically, the contour of exposure.
338 JA Hamlin
FIGURE 45.4. Persistent patent processus vaginalis on the right, angled view. FIGURE 45.6. Direct left inguinal hernia. There is a broad left direct in-
A slender extension of contrast material passes through the right internal guinal hernia projecting between the lateral and medial inguinal folds.
inguinal ring and down the inguinal canal in this 34-year-old male with The reason for the thickened medial inguinal fold on the right is unknown.
left groin symptoms. The diameter is less than 5 mm and is therefore too
small to admit intestine.
obliteration of the tunica vaginalis in which a saccular region com- Direct inguinal hernias arise from the medial inguinal fossae with
municates with the peritoneal cavity by a tract that may be only an axis that tends to be perpendicular to the inguinal canal (Fig.
thread-like (Fig. 45.5). Herniography may demonstrate the con- 45.6). They may protrude from either or both sides of the medial
trast-filled saccular region without the communicating segment be- inguinal ligament. Identification of a diverticular outpouching of
ing clearly visualized. In this situation the patient, having been the medial inguinal fossa as a direct hernia is rather straightfor-
previously unaware of the condition, may experience delayed ward. However, a broad bulging of the medial inguinal fossa, which
swelling of the scrotum during the period of a few hours follow- displaces or distorts the medial inguinal ligament, may be more
ing the procedure. difficult to label as a hernia, and deep fossa and broad fossa are terms
used to describe such an appearance. This represents incompe-
tence of the transversalis fascia and relaxation of the inguinal floor.
The axes of femoral hernias also tend to be perpendicular to
the inguinal canal. The entry into the femoral canal, the femoral
ring, is a restricted space bounded anteriorly and medially by the
inguinal and lacunar ligaments, respectively, posteriorly by the fas-
cia of the pectineus muscle, and laterally by the fibrous sheath me-
dial to the femoral vein. Passing through this constricted canal,
femoral hernias have a relatively narrow neck, while the protrud-
ing sac expands, is more rounded, and may be lobulated (Fig.
45.7) . Oblique or almost lateral views may be necessary to distin-
guish femoral from some direct hernias. Because of their relatively
posterior position in the groin, femoral hernias may opacifY dur-
ing injection of contrast material with the patient supine, partic-
ularly if the head of the table is slightly elevated.
Other hernias that fill with contrast material when the patient
is supine or erect include sciatic hernias, pouch of Douglas or per-
ineal hernias, and obturator hernias. Standing lateral views help
to clarifY the sites of these hernias, which can retain contrast and
be mistaken for groin hernias on exposures made with the patient
prone.
Anterior abdominal wall hernias (spigelian, umbilical, inci-
sional) are best demonstrated using exposures made with the
beam horizontal and tangent to the anterior abdominal wall while
the patient is on knees and elbows (Fig. 45.8). This position al-
lows the contrast material to bathe the anterior peritoneum and
opacifY hernia sacs. Depending on the location of symptoms,
oblique exposures, tangent to the area in question, are made with
FIGURE 45.5. Communicating hydrocele on the left. Note the slender, not the beam horizontal while the patient lowers the symptomatic side.
quite obliterated, processus vaginalis within the inguinal canal. The testis It is often helpful to place an opaque marker (nipple marker) on
presents as a negative image within the scrotal contrast material. the skin at the symptomatic site. Umbilical "hernias" that are filled
45. Imaging Hernias of the Abdominal Wall 339
the contrast material may not be positioned to fill the hernia sac.
Second, the sac may be occluded by intestinal loops, omentum,
or an overly distended urinary bladder and not allow entry of con-
trast material. If the peritoneal contour is smooth and regular with
no adjacent bowel, a negative diagnosis can be relied on. If no
hernia is demonstrated but the peritoneal margin is irregular and
bowel is adjacent, the possibility of an occluded sac must be con-
sidered. Delayed exposures after 10 minutes of exercise may re-
sult in visualization of a previously occluded sac.
Complications of Herniography
Complications have been reported to occur in up to 6% of
herniographies. 45 ,48 They are largely of no consequence and are
related to either the mechanics of the procedure or side effects
of the i~ected medications and contrast material.
Hemorrhage in the anterior abdominal wall due to the needle
FIGURE 45.7. Left femoral hernia. The femoral canal is cone shaped, and puncture is unlikely when a midline approach is used because ves-
the hernia sac expands as it exits the canal. sels in the linea alba are sparse. Intramural hemorrhage necessi-
tating segmental resection ofthe small intestine has been reported
in children,5o.51 but no similar occurrences have been described
with preperitoneal fat may contain little or no peritoneal sac and in adults. Some authors have recommended using a sheathed nee-
show no evidence of hernia on radiological examination. dle so that once the intraperitoneal location has been established
only the flexible sheath remains within the abdomen during in-
jection of contrast material.
Results of Herniography Cellulitis of the anterior abdominal wall with an associated gas-
troenteritis has been reported in a child. 51 With sterile technique,
Herniography has proved to be a highly accurate and specific ex- introduction of external pathogens should not occur.
amination for the evaluation of patients with suspected hernia. Interstitial contrast in the anterior abdominal wall, omentum/
In our experience, the herniographic findings correlated with the mesentery, or bladder wall is quickly appreciated at fluoroscopy
operative findings in 98% of those who subsequently underwent with only 1 to 2 ml injected. Intraluminal injection into the in-
an operation for hernia. Herniography has also been effective in testine is recognized by the familiar fold pattern of the gut and
discovering non palpable and/or unsuspected hernias. Hernias peristalsis, while with injection into a distended urinary bladder
have been demonstrated on herniography in 12 to 54% of the contrast material seems to disappear as it is diluted by the
patients in whom the physical examination failed to reveal a urine. Each of these situations indicates the necessity of reposi-
hernia. 17,19,21,22,39,45-47 tioning the needle. These misdirected injections are asymptomatic
False-positive findings on herniography are unlikely to occur ex- both during and following the procedure.
cept when a deep fossa or a patent processus vaginalis is called a Painful delayed scrotal swelling may occur in a patient with a
hernia. On the other hand, false-negative diagnoses may result communicating hydrocele. Patients with a persistent patent proces-
from several situations. If the herniographic technique is faulty, sus vaginalis or any thread-like extension of contrast material from
the lateral fossa are warned that this may occur and are advised
to wear an athletic supporter and remain supine overnight until
the contrast material is absorbed.
The injected contrast material may produce complications,
specifically peritoneal pain and allergic reactions. Although the
mechanism of the peritoneal pain is unclear, it does correlate with
high osmolarity and is unlikely to develop when low osmolar non-
ionic contrast material is used. 52 The incidence of allergic reac-
tions to iodinated contrast materials is also considerably reduced
by using the non ionic compounds.
Conclusion
There is no need for an imaging study when the symptoms and
physical examination are diagnostic of hernia. However, when a
hernia is suspected, a variety of imaging modalities can be used
FIGURE 45.8. Umbilical hernia. With the patient on knees and elbows, con- to confirm the specific diagnosis. These modalities include plain
trast material bathes the anterior abdominal wall and enters a small um- radiography with or without intestinal contrast, pneumoperi-
bilical hernia. The exposure is made with the beam horizontal and tangent toneography, computed tomography, ultrasonography, nuclear
to the anterior abdominal wall. scintigraphy, and herniography. No studies have compared these
340 J.A. Hamlin
modalities to determine their relative merits. Herniography, be- 26. Zarvan NP, Lee FT, Yandow DR, et al. Abdominal hernias: CT find-
cause of its ability to image the peritoneal cavity and delineate the ings. AJR 1995;164:1391-1395.
peritoneal boundary, can specifically diagnose hernias and offers 27. Uno T, Mochida Y, Wada H, et al. Ultrasonic exploration of the con-
the best opportunity to demonstrate an otherwise empty peri- tralateral side in pediatric patients with inguinal hernia. Surg Today.
toneal sac. Although minimally invasive, the procedure carries a 1992;22:318-321.
28. Chou TY, Chu CC, Diau GY, et al. Inguinal hernia in children: US ver-
low risk and provides highly dependable results.
sus exploratory surgery and intraoperative contralateral laparoscopy.
Radiology. 1996;201:385-388.
29. Lawrenz K, Hollman AS, Carachi R, et al. Ultrasound assessment of
the contralateral groin in infants with unilateral inguinal hernia. Clin
References Radiol. 1994;49:546--548.
30. Furtschegger A, Sandbichler P, Judmaier W, et al. Sonography in
1. Case JT, Upson WOo Roentgenologic aspects of various types of her- the postoperative evaluation of laparoscopic inguinal hernia repair.
nia. ]AMA. 1926;87:891-898. ] Ultrasound Med. 1995;14:679-684.
2. Laurell H. Uber die rontgenuntersuchung von briichen, insbesondere 31. Mundan M, McEniff N, Mulvihill D. Sonographic investigation of fe-
klinisch schwer zu diagnostizierenden formen. Acta Radiol. 1929;10: male infants with inguinal masses. Clin Radiol. 1995;50:696--698.
462-498. . 32. Turpin S, Lambert R, Querin S. Another "rim sign"-a patent proces-
3. Farr RE. Pneumoperitoneum as an aid in the diagnosis of hernia. sus vaginalis demonstrated by peritoneal Tc-99m SC scintigraphy. Clin
]AMA. 1924;82:1774-1775. Nucl Med. 1995;20:729-730.
4. Arner 0, Fernstrom I. The value of pneumoperitoneum in the diag- 33. Ziegelbaum M, Kovach C, Siegel S. The use of 99mtechnetium in the
nosis of hernia in the inguinal region. Surgery. 1970;67:741-747. diagnosis of patent processus vaginalis.] Urol. 1988;139:599--600.
5. Biilow S. Artificial pneumoperitoneum during inguinal herniotomy in 34. Sokoloff RM, Waxman AD. Tc-99m pertechnetate scrotal imaging of
children. Acta Chir Scand. 1974;140:127-130. an inguinal hernia simulating testicular inflammation. Clin Nucl Med.
6. Kahn AM, Thompson JE. Pneumoperitoneum: an adjunct to hernior- 1995;20:1021-1022.
rhaphy. Contemp Surg. 1998;52:28-29. 35. Tulchinsky M, Tulli MA, Eggli DF. Progressive accumulation of activ-
7. Sternhill V, Schwartz S. Effect of hypaque on mouse peritoneum. Am ity on scrotal scintigraphy in early incarcerated inguinal hernia. Clin
] Roentgenol. 1960;75:811-814. Nucl Med. 1994;19:1019-1020.
8. Margulis R, Burhenne HJ, Rambo ON. Evaluation of celiography in 36. Ekberg 0, Blomquist P, FritzdorfJ. Herniography in patients with clin-
rats. Radiology. 1964;82:290--295. ically suggested recurrence of inguinal hernia. Acta Radiol Diagn.
9. Meyers MA. Peritoneography. Am] Roentgenol. 1973;117:353-365. 1984;25:225-229.
10. DucharmeJC, Bertrand R, Chacar R. Is it possible to diagnose inguinal 37. Smedberg SGG, Broome AEA, Elmer 0, Gullmo A. Herniography: a
hernia by x-ray? A preliminary report on herniography. ] Can Assoc diagnostic tool in groin symptoms following hernial surgery. Acta Chir
Radiol. 1967;18:448-451. Scand. 1986;152:273-277.
11. WhitelJ, Parks LC, Haller JA The inguinal herniogram: a radiologic 38. Hamlin JA, Kahn AM. Herniography in symptomatic patients follow-
aid for accurate diagnosis of inguinal hernia in infants. Surgery. 1968; ing inguinal hernia repair. West] Med. 1995;162:28-31.
63:991-997. 39. Ekberg 0, Kesek P, Bergenfelt M, et al. The value of herniography in
12. Swischuk LE, Stacy TM. Herniography: radiologic investigation of in- elderly women with groin pain of obscure origin. Acta Chir Scand.
guinal hernia. Radiology. 1971;101:139-146. 1989;155:99-101.
13. Guttman FM, Bertrand R, Ducharme JC. Herniographyand the pedi- 40. Smedberg SGG, Broome AEA, Gullmo A, et al. Herniography in ath-
atric contralateral inguinal hernia. Surg Gynecol Obstet. 1972;135: letes with groin pain. Am] Surg. 1985;149:378-382.
551-555. 41. Ekberg 0, Persson NH, Abrahamsson P-A, et al. Longstanding groin
14. Oh KS, DorstJP, White lJ, et al. Positive-contrast peritoneography and pain in athletes: a multidisciplinary approach. Sports Med. 1988;6:
herniography. Radiology. 1973;108:647-654. 56--61.
15. Jewett TC, KuhnJP, AllenJE. Herniography in children.] Pediatr Surg. 42. Clemente CD, ed.: Gray's Anatomy, 13th American ed. Philadelphia:
1976;11:451-454. Lea & Febiger; 1984.
16. Gullmo A. Herniography: the diagnosis of hernia in the groin and in- 43. Ekberg 0, Kesek P. Herniographic appearance of the lateral inguinal
competence of the pouch of Douglas and pelvic floor. Acta Radiol. fossa. Acta &diol. 1987;28:563-569.
1980;361 (suppl):1-76. 44. Kahn AM, Hamlin JA, Thompson JE. The etiology of the adult indi-
17. Ekberg O. Inguinal herniography in adults: technique, normal rect inguinal hernia: revisited. Am Surg. 1997;63:967-969.
anatomy, and diagnostic criteria for hernias. &diology. 1981;138:31-36. 45. Hall C, Hall PN, Wingate JP, et al. Evaluation of herniography in the
18. Gullmo A, Broome A, Smedberg S. Herniography. Surg Clin Nmth Am. diagnosis of an occult abdominal wall hernia in symptomatic adults.
1984;64:229-244. Br] Surg. 1990;77:902-909.
19. Smedberg SGG, Broome AEA, Gullmo A, et al. Herniography in ath- 46. Cohen RH, TurkenburgJL, van Dalen A Herniography in 79 patients
letes with groin pain. Am] Surg. 1985;149:378-382. with unexplained pain in the groin: a retrospective study. Eur] Radiol.
20. Estes NC, Childs EW, Cox G, et al. Role of herniography in the diag- 1990;11:184-187.
nosis of occult hernias. Am] Surg. 1991;162:608-610. 47. Estes NC, Childs EW, Cox G, et al. Role of herniography in the diag-
21. van den Berg JC, Strijk SP. Groin hernia: role of herniography. Radi- nosis of occult hernias. Am] Surg. 1991;162:608--610.
ology. 1992;184:191-194. 48. Ekberg O. Complications after herniography in adults. Am] Roentgenol.
22. HamlinJA, Kahn AM. Herniography: a review of 333 herniograms. Am 1983;140:491-495.
Surg. 1998;64:965-969. 49. Butsch JL, Kuhn JP. Intramural hematoma of the small bowel: a pos-
23. Wechsler RJ, Kurtz AB, Needleman L, et aJ. Cross-sectional imaging of sible lethal complication of herniography. Surgery. 1978;83:121-122.
abdominal wall hernias. Am] Roentgenol. 1989;153:517-521. 50. Ducharme JC, Guttman FM, Poljicak M. Hematoma of bowel and cel-
24. Lee GM, Cohen AJ. CT imaging of abdominal hernias. Am] Roentgenol. lulitis of the abdominal wall complicating herniography.] Pediatr Surg.
1993;161:1209-1213. 1980;15:318-319.
25. Hahn-Pedersen J, Lund L, H0jhus JH, et al. Evaluation of direct and 51. Ekberg 0, Nilsson PE. Herniography: comparison of morbidity and
indirect inguinal hernia by computed tomography. Br] Surg. 1994; image quality after use of high and low osmolality contrast material.
81:569-572. Invest Radiol. 1986;21:404-407.
46
Techniques of Pneumoperitoneum
Leon Herszage
Pneumoperitoneum is a simple procedure, but one with enonnous dominal cavity, slowly and comfortably (Fig. 46.2). When the
potential for improving the outcome of treatment of massive in- higher bottle is empty and the lower filled, the tubes are clamped,
cisional hernias. 1- 7 The necessary equipment is minimal and con- the bottles are exchanged, and the process is started anew.
sists of drainage bottles, tubing, antiseptic solutions, Intracath
needles, and a syringe with a two-way stopcock.
At all times, pneumoperitoneum should be created aseptically Fractionated Injection
(mask, gloves, skin preparation), with or without local anesthesia.
A spot should be marked, preferably on the left side of the ab- A thick needle may be used, or a needle that allows the intro-
domen, along a line joining the umbilicus to the anterior supe- duction of a plastic catheter into the abdominal cavity. Air is in-
rior iliac spine, 2 to 3 cm medial to the latter. jected as tolerated (abdominal, subcostal, shoulder pain, and/or
The needle will go through two layers of resistance-the "give" light nausea). Excess air, which creates pain, may be released
sensation corresponds to the external oblique aponeurosis and the through a simple secondary puncture (Fig. 46.3).
peritoneum. When the needle is in place, a syringe must be used
to aspirate and confirm, through the absence of aspirated liquid
or air, that no viscus has been entered. If liquid should be in the
aspirate, the needle must be removed and the procedure sus-
Complications
pended, usually without complications, until the following day. If
Technical failure may provoke subcutaneous or retroperitoneal
not, the easy introduction of air, with the syringe, confinns the
emphysema, which may be localized or generalized. There may be
good intraperitoneal location of the needle.
crepitations, temporary defonnation, but no serious conse-
quences. Other manifestations of air tracking have been neck dis-
tension, a change in the voice, air cysts within intestinal loops, and
Techniques dissection of a gallbladder from its bed.
Pump Technique
One bottle is filled with diluted antiseptic solution and connected Recommendations
to a second bottle by a rubber tube. A Richardson pump is con-
nected to the filled bottle to displace the solution into the empty The results of pneumoperitoneum can be gauged by palpation of
bottle, thus forcing air through a catheter and needle into the ab- the flanks, which become soft, or by normalization of pulmonary
dominal cavity (Fig. 46.1). function studies.
Pneumolysis of intraperitoneal intervisceral adhesions may be
achieved with pneumoperitoneum within a few days. Replacement
Continuous Drip Technique of visceral contents into the abdominal cavity proper requires
pneumoperitoneum for at least 15 days. Maximum benefit will be
Diluted antiseptic solution is allowed to drip from a higher bottle derived from no less than 15 days and usually no more than 30
into a lower one, displacing air from the lower bottle into the ab- days.
341
342 L. Herszage
FIGURE 46.1. Usual apparatus for pneumoperitoneum (pump technique). FIGURE 46.3. Catheter in place (fractionate injection technique).
References
1. Barroetavena J, Herszage L, et al. Cirurgia de las evetraciones. Buenos
Aires: EI Ateneo; 1988.
2. Connolly DP, Ferri FR. Giant hernia managed by pneumoperitoneum.
JAMA. 1969;209:71.
3. Goni-Moreno I. Pneumoperitoneum. Surgery. 1947;22:945.
4. Jorge JM, Goni-Morena I. Discussion. XII Congr Arg Cir, Benos Aires,
1940.
5. Koontz AR. Hernia. New York: Appleton-Century-Crofts; 1963.
6. Mason EE. Pneumoperitoneum in the management of giant hernia.
Surgery. 1956;39:143.
7. Wantz GE. Incisional hernia symposium. JAm Coll Surg. 1999;188(4):
432.
FIGURE 46.2. Continuous pneumoperitoneum (drip technique).

47
Relaxing Incisions
Robert Bendavid
In his Traite du Narcisse (1893), the French author and 1947 fect as any that I had seen. Dr. Harvey Cushing, house surgeon at
Nobel laureate Andre Gide gives us a memorable statement that the time, made a sketch of this act of the operation, which Brodel
applied very appropriately to his surgical contemporaries: "Every- has kindly elaborated" (Fig. 47.2).5 In another attempt at reduc-
thing has already been said, but because no one listens, we have ing tension at the suture line in hernia repairs, when feasible "in
to keep going back and start allover again!" 75% of cases,"3 Halsted used the cremaster to bridge the gap be-
Poring over Hernia, the textbook of Professor Amos R. Koontz tween the transversus aponeurotic arch and the inguinal ligament.
of the Johns Hopkins University School of Medicine, one can read "The closure with the cremaster seems almost ideal in some cases;
that "the relaxing incision was described by Halsted in 1903, but it is a method so inviting during the operation, and so true, when
he devoted only two paragraphs to it in the course of another ar- finished, to one of the great principles of surgery; there is no tension.
ticle. Its importance is far greater than the space devoted to it. It is in this respect as a plastic operation should be."3
Much later it was described by FaIT (1927), Fallis (1938), Reinhoff Joseph Ponka,5 in one of the finest texts on hernia surgery, re-
(1940), and Tanner (1942). In England the incision is called the viewed the various contributors since Wolfler, identifYing the ac-
Tanner Slide. If it is anybody's 'slide', it is Halsted's slide because tual incision in terms of site and length (Fig. 47.3) and also agreed
he described it thirty-nine years before Tanner did."1 These paeans with Koontz that the relaxing incision should be resorted to more
from Koontz to his teacher and predecessor as professor and sur- often than not. I concur without any reservation and may claim
geon in chief at Johns Hopkins are admirable and forgivable. In to have performed more than 1500 of them without having ever
fact, the relaxing incision had already been described by Berger2 encountered a recurrence through a relaxing incision. It is in-
in 1902, and Halsted3 quoted him on page 8 of his monograph teresting that Rutledge, who has published the largest series of
on hernias. 3 Bloodgood, who worked and published with Halsted, McVay repairs, covered the opening left by relaxing incisions with
suggested "a transplantation of the rectus muscle" to close the de- a patch of polypropylene,6 while Koontz confirms experimentally
fect of the posterior inguinal wal1. 3 By transplantation Bloodgood that "not only does an incision in fascia over good muscle not
meant the apposition of the lower and lateral border of the rec- weaken the structure, but the fascial covering is readily regener-
tus abdominis against the inguinal ligament. Halsted credits An- ated."1.7.8
ton Wolfler with this maneuver, making a longitudinal incision in No study, to my knowledge, has compared hernia surgery where
the anterior rectus sheath and "sliding" the lateral fibers of the patients have been assigned randomly to a group with relaxing in-
rectus abdominis. Wolfler4 provided a clear drawing of his tech- cision and a control group without, yet there can be no doubt that
nique in a textbook dedicated to his teacher, Billroth (Fig. 47.1). when the tension of a Bassini, Shouldice, or McVay repair seems
Realizing that suture lines under excessive tension were the bane excessive, a relaxing incision leaves one satisfied that the tension
of hernia surgery, Halsted proceeded with another interesting has been lifted. Unfortunately, we cannot readily measure that ten-
technique whereby a flap from the anterior rectus sheath is ro- sion at operation, nor can we as yet assess "the quality of the tis-
tated inferiorly and sutured to the ligament of Poupart, creating sues," a term often used by hernia surgeons but unquantifiable
both a relaxing incision and a rotation flap! The year was 1899, and thus meaningless.
and Halsted wrote that he "used, for the first time, a part of the The principle of the relaxing incision is well demonstrated dur-
aponeurosis covering the right rectus muscle to close the lower ing incisional hernia repairs when longitudinal incisions of the an-
part of the right inguinal canal. I felt compelled in this case to re- terior rectus sheaths allow approximation, at the midline, of the
sort to some such measure, for the internal oblique was fatty and medial borders of incisional hernia margins. In this respect the
attenuated to a degree not very often seen by us, and the rectus Gibson operation (Fig. 47.4) and those of Clotteau and Premont
muscle did not seem to promise so much as its fascia did. This pa- (Fig. 47.5) are good examples of relaxing incisions of the anterior
tient was a college-mate of mine and for this reason I wished, per- abdominal wall. 9 By the same token, I have used a relaxing inci-
haps, more than ever to be very sure of the result. One year ago sion for femoral hernias that I reported in 1992. 10 It consists of a
I examined this patient very carefully and was gratified to find as 3 to 5 cm incision on the lowest fibers of the external oblique
solid a closure as one could desire. I considered the result as per- aponeurosis, parallel to the inguinal ligament, which allows this
343
344 R. Bendavid
FIGURE 47.1. Original drawing of A. Wolfler depicting the relaxing inci-

sion on the anterior rectus sheath. (Reprinted from Wolfler, with permis-
sion.4 )
FIGURE 47.3. Various relaxing incisions as performed by various authors.
The width of the anterior rectus sheath is somewhat exaggerated, medial
ligament to be brought down and sutured to the ligament of to the linea semilunaris. The incision is usually dependent on the pre-
Cooper. This anterior approach to femoral herniorrhaphy should senting anatomy rather than the surgeon's choice. (Reprinted from
only be used when the defect is 1 cm or less and when the liga- Ponka. 5 W.B. Saunders, with permission.)
ment of Cooper is easily reached (Fig. 47.6). It can be used in all
open approaches to a femoral hernia (Bassini, Bassini-Kirschner,
Moschowitz, and Lotheissen-McVay).
The most elaborate and sophisticated application of the prin-
Technique
ciples of relaxing incisions is seen in the operative procedure re-
The steps described by Wolf1er, Halsted, Tanner, and others are
ferred to as components separation by Ramirez (Chapter 72). The
deceptively simple. Their illustrations all show a vertical incision
operation described by Ramirez provides coverage of a defect
on an anterior rectus sheath that is not always readily seen or avail-
through use of dynamic vascularized and innervated tissue, which
able on the patient. The drawing provided by Ponka5 (see Fig.
may respond and adapt as only living tissue can.
47.3) , when closely scrutinized, reveals the various incisions to be
over the whole width of the anterior rectus abdominis sheath. This
is an unacceptable degree of surgical or illustrative license.
When the external oblique aponeurosis is incised along the di-
rection of its fibers, the medial flap is undermined as far medially
as possible; this means to the linea semilunaris. At this level, in
the coronal plane, there is fusion of the aponeuroses of the ex-
ternal oblique, internal oblique, and transversus abdominis
aponeuroses. II
The aponeurosis of the external oblique muscle does not always
or readily separate from the deeper layers to allow the "classic" re-
laxing incision, longitudinally drawn on the lateral aspect of the
anterior rectus sheath. The alternative and most frequent ma-
neuver is a generous incision along the curved course of the con-
joined tendon, if the latter is present as such, or simply an incision
through the aponeurosis of the internal oblique, which will facil-
itate the sliding of the internal oblique laterally, and possibly the
deeper transversus abdominis.
Some diagrams erroneously show the lateral fibers of the rectus
abdominis brought down to the inguinal ligament over its entire
length. This would be a most difficult task and would of itself re-
FIGURE 47.2. The Halsted relaxing incision. (Reprinted from Halsted, with sult in a most undesirable new tension, if it were feasible at all!
permission.3) The Shouldice repair, which calls for the inclusion of rectus ab-
47. Relaxing Incisions 345
A B
FIGURE 47.4. The Gibson incision (A) is a good example of the extent of a relaxing incision to facilitate closure of the abdominal wall (B). (Reprinted
from Gibson CL. Operation for the cure oflarge ventral hernias. Ann Surg 1920;72:214B, with permission.)
dominis fibers, does so over one-third to one-half of the distance

as one proceeds from the pubic crest to the internal ring.
A true relaxing incision can be done on the anterior rectus
sheath near its lateral border, after undermining the skin to a level
medial to the linea semilunaris. Another approach, when the
preperitoneal space of Bogros is entered, is to identify the lateral
edge of the rectus abdominis muscle and perform a relaxing in-
cision anteriorly to it.
In conclusion, the relaxing incision in inguinal hernia surgery
is a harmless step in the creation of a tension-free repair. It is an
important surgical move that every surgeon must know and per-
form without reservation when the need arises.
anterio~ .super~or ~J
Iliac sPine.,
FIGURE 47.5. "Pie-crusting" relaxing incision. (From Clotteau JE, Pre- FIGURE 47.6. Femoral relaxing incision (dotted line) along the lowest fibers
mont M. Histoire du traitement des eventrations. Monographie GREPA of the external oblique aponeurosis. (From Bendavid R, ed. Prostheses and
1986;8:17-19. Courtesy J.B. Flament.) abdominal wall hernias. Austin: R.G. Landes Company; 1994.)
346 R Bendavid
References 6. Rutledge RH. The Cooper ligament repair. Surg Clin North Am. 1993;
73(3):471-485.
7. Koontz AR Muscle and fascia suture with relation to hernia repair.
1. Koontz AR. Hernia. New York: Appleton-Century-Crofts; 1963:52- Surg Gynecol Obstet. 1926;42:222.
53. 8. Koontz AR Experimental results in the use of dead fascia grafts for
2. Berger P. La hernie inguino-interstitielle et son traitement par la cure hernia repair. Ann Surg. 1928;83:523.
radicale. Rev chir.Janvier 1902. 9. FlamentJB, PalotJP. Prosthesis and major incisional hernia. In Ben-
3. Halsted WS. The cure of the more difficult as well as the simpler in- david R (ed): Prosthesis and abdominal wall hernias. Austin: RG. Landes
guinal ruptures. Johns Hopkins Hosp BulL 1903;149:1-18. Company; 1994;456-471.
4. Wolfler A Zur radikal operation des freien leistenbruches. Beitr. ChiT. 10. Bendavid R A relaxing incision for femoral herniorrhaphy. Postgrad
(Festsch. Gewidmet Theodor Billroth), Stuttgart, 1892:552. Gen Surg. 1992;4(2):174.
5. Ponka JL. The relaxing incision. In Ponka JL (ed): Hernias of the ab- 11. Skandaiakis]E, Gray SW, Mansberger JL, et al. Surgical anatomy and
dominal wall Philadelphia: W.B. Saunders; 1980:525-533. technique. New York: McGraw-Hill; 1989:7.
48
Drains in Hernia Surgery
Paolo Bocchi
Introduction the peritoneal cavity.4 Unfortunately, experimental studies on an-

imals are not applicable to humans because the production of flu-
Evidence-based medicine is a method particularly difficult to ap- ids is not the same. The possibility of creating a drain without
ply to the use of drains in surgery. The difficulty lies in the com- complications has been doubted since 1891.5- 7 It was demon-
plexity of setting up a search based on randomized data. The strated that microbes can go back into the abdominal cavity and
usefulness of drains in the therapy of suppuration or other col- that contamination is time dependent. 8 Drains can also cause per-
lections can be assessed on the basis of results in the majority of foration of the bowel. 9
the cases. The same approach does not apply to the preventive use Concerning the usefulness of drains in various surgical opera-
of drains. There are arguments for their use in gastric, colonic, tions, there are few prospective randomized trials. When a trial
and biliary surgery, but if a preventive approach is contemplated, is performed in this field, it is apparent that the results are not
great intellectual effort and sound knowledge of the postopera- statistically significant. Recently, a group at Memorial Sloan-
tive period and possible complications are required. Some simple Kettering Cancer Center in New York published a study on ab-
guidelines are provided, based on a review of the medical litera- dominal drainage in pancreatic surgery that concluded that a
ture and on personal experience. drain may not be necessary in pancreatic resections. 10 In perfo-
rated peptic ulcer, the utility of drains is uncertain,u and in liver
surgery it may depend on the extent of resection. 12 More clinical
trials are needed before the utility of a pelvic drain in colon
Historical Background surgery can be definitively assessed.1 3.l 4 In the treatment of pos-
sibly contaminated wounds, placement of a subcutaneous drain
The concept "ubi pus ibi evacua" ("if there is pus you will drain") does not reduce infection, although it may be useful only in the
has been known since the third century Be. In the Corpus Hippo- obese patient. 15
craticum, it is shown how a pleural empyema is drained. Erasistrato
in Alexandria (300 Be) treated empyema as reported by Celso
(born in Rome in 25 Be) in De Medicina. There is also a report
about the Dakota Indians, who drained collections by means of a
Purpose of Drains in
quill. I In all these cases, drainage was used for healing. It is nec- Abdominal Wall Surgery
essary to look at the modern era of surgery to see a preventive
drain. In ventral hernia surgery, drainage seemingly does not affect the
Chassaignac introduced the use of rubber drains in 1859, and postoperative period or reduce the amount of fluid collection,
Kehrer used the first cigarette drain in 1882. In 1895, Kellog as this is related to the type of operation. 16 The formation of
showed a type of sump drain,2 and, in 1898, Heaton applied suc- seromas is enhanced in operations where prostheses are used
tion to a drain. 3 due to the trauma of wide dissection and the presence of foreign
bodies. 17
In inguinal hernia there is no reason for any preventive subcu-
taneous drains,18 and their use could lead to increased infectious
Drains in Clinical and complications. 19
Experimental Situations In the Rives technique for the treatment of groin hernias,2o us-
ing a preperitoneally placed prosthesis, a drain is not usually nec-
The ideal drain must empty all collections without complications essary. Only for the Stoppa procedure for bilateral hernia of the
until no longer needed. More than 50 years ago, Mikulicz demon- inguinal and femoral region is it necessary to leave one or two
strated in cadavers and Yates in animals that it is impossible to dry drains in the preperitoneal space. 21 However, the position of the
347
348 P. Bocchi
drain is rarely well defined, and there is a great difference if the 5. The simple tube drain can be made of rubber or silicon and
drain is subcutaneous or more deeply positioned. can be connected to a bag to create a closed system.
6. A sump Penrose drain is a Penrose with a sump drain in the
lumen to increase the quantity of fluid collection.
Position of Drains 7. The Mickulicz drain is a composite drain made with a large
gauze mesh that forms a bag for other gauze or rubber tubes.
A drain can be used in groin hernia and incisional hernia repairs 8. The electrified drain is a Penrose with two electrodes, with the
in the subcutaneous or prefascial or subfascial position or in the purpose of killing all microorganisms. 27
preperitoneal space. The position depends on the intention: A 9. A Redon drain is a tube with multiple lateral holes that is con-
drain is placed subcutaneously to prevent wound complications, nected with a suction system, and it is the prototype of a closed
whereas a more deeply positioned drain is intended to collect suction system.
blood and prevent seroma formation. If a prosthesis is used, the
The open system has the danger of contamination and is not
position of a drain can depend on the position of the prosthesis.
recommended in abdominal wall surgery. Also irrigation is not rec-
Surgeons most experienced in the treatment of large incisional
ommended in the presence of a prosthesis unless a suppurative
hernias recommend the insertion of a deep drain in contact with
collection is already present.
the prosthesis and, in selected cases, another in the subcutaneous
position. 22- 24 If the prosthesis is in the prefascial position, as in
the Chevrel technique, the drain becomes more important. 25
The wide use of drains is in apparent contrast with the scien-
Clinical Experience
tific data, but for all experienced surgeons the drain is left in place
Groin and incisional hernia cases from 1988 to June 1999 were
for as short a time as possible and never for more than a few days,
studied retrospectively. The prosthesis used was always polypropyl-
for the drain is itself a foreign body and can exacerbate the tissue
ene, except in one case where a composite polypropylene/e-poly-
reaction. For this reason, the preventive drain should be inserted
tetrafluoroethylene was employed in an incisional hernia repair.
to collect fluids for the first few hours only, following surgery.
Types of Drains Groin Hernias

Operations performed were the Shouldice, Lichtenstein, and "var-
The basic reasons for drainage are the obliteration of dead space
ious." "Various" included Marcy, Bassini, mesh and plug, plug,
and the removal of foreign or harmful material from a particular
Wantz, sutureless, and PHS techniques. The 25 Stoppa procedures
location. The greater the amount of dissection, the larger can be
are not considered in this study (Table 48.1).
the collection of blood and fluids. A well-positioned drain collects
Total groin hernias repaired were 4684, and the only preventive
and controls the predictable blood loss in the first few hours af-
drain was inserted in the subcutaneous space of a cirrhotic patient
ter operation. This is the reason why it is important to choose the
with very poor coagulation. The operation was a Bassini type for
correct drain.
a recurrent left inguinal hernia. The drain was a suction type with
Drains can be simple drains, suction drains, composite drains,
a closed system. Total drainage was 300 ml in 3 days, and the
water-seal type, and open or closed system.
patient was discharged on the fifth postoperative day without
1. The Penrose drain is a very thin rubber tube that can be cor- complications.
rugated for better action. A gauze may be placed inside to form In all hernias complicated by a subcutaneous as well as a deep
a cigarette drain to increase the capillary action. hematoma, a curative drain was inserted in the subcutaneous
2. The sump drain has a double lumen that allows air to enter the or deep position for 24 hours, with a median blood collection of
drained area; it is used when the adjacent tissues may occlude 15 ml daily.
the openings of a single-bore drain. Ecchymoses, which were common, were not considered a com-
3. For the same reason, a triple-lumen drain was created to allow plication, nor were they treated.
an irrigating s()!ution to be run through one lumen. Surgeons In 67 cases, a seroma necessitated needle aspiration; the cause
take advantage of the possibility to irrigate the drained area, was not known, but in 30 cases with a Lichtenstein repair, a very
and Parneix et al. 26 have studied the use of this drain in treat- large amount of pure iodopovidone solution had been used. The
ing peritonitis. seroma stopped occurring as soon as we discontinued use of
4. The Babcock drain is composed of two tubes, one inside the iodopovidone.
other. There were 28 wound infections, a rate of 0.6%. In these cases,
TABLE 48.1. Inguinal hernia and preventive drain

Needle aspiration Subcutaneous Deep
Operation No. Drain for seroma Infection hematoma hematoma
Shouldice 2119 0 4 16 12 0
Lichtenstein 2090 0 43 4 3 0
Various 475 1 20 8 0 1
Total 4684 1 67 28 15 1
48. Drains in Hernia Surgery 349
TABLE 48.2. Incisional hernia and preventive drain

Needle
Deep Subcutaneous aspiration for Subcutaneous Deep
Operation No. drain drain seroma Infection hematoma hematoma
With prosthesis 180 180 12 0 3 o o

Without prosthesis 34 0 8 0 1 o o
Total 214 180 20 0 4 o o
the wound was promptly opened and left open until healing was and in the last 5 years we have removed the drain before the third
complete. The removal of a prosthesis was never necessary. postoperative day.
Figure 48.1 shows the median amount of blood drained daily in
the first 7 days. The range in the first postoperative day is from
Incisional Hernia 500 to 20 ml of blood, with a median of 125 ml. Mter the second
postoperative day, the collected fluid is light blood-tinged serum.
When prostheses were employed, the techniques were the retro-
muscular prefascial Rives procedure in supraumbilical and the
Stoppa preperitoneal procedure for infraumbilical incisional her- Subcutaneous Drain
nias. In primary suture, the techniques were mostly Judd or Welti-
Eudel repair (Table 48.2). In 180 incisional hernias repaired with a prosthesis, a subcuta-
neous drain was used 12 times (6%), while in 34 pure tissue re-
pairs, a subcutaneous drain was used 8 times (23%). Insertion of
Deep Drains the drain depended on the condition of the wound at the end of
surgery.
In prosthetic repairs (180 cases), two drains (deep drains) were In situations in which a pure tissue repair is indicated, it is likely
left in place in 100% of the cases over the prosthesis and in con- that the source of blood loss will be in the prefascial plane.
tact with it. The premuscular fascia is normally closed over the As in deep drainage, after the second postoperative day the
drain and the prosthesis. amount of fluid (blood) collected is minimal (Fig. 48.2). The in-
The drain was a closed system Redon multiperforated type and fection rate was 2% in incisional hernia repair, and there is no sta-
was never manipulated. tistical difference among the various types of operation. In only
A broad spectrum first generation cefalosporin was adminis-
one case was it necessary to remove the prosthesis because of in-
tered at the beginning of the operation and discontinued after
fection (a composite prosthesis: polypropylene and expanded
drain removal. Fever up to 38°C was present in 58% of cases in
polytetrafluoroethylene). Seromas following prosthetic repair
the first 4 days following surgery. were never problematic and never required aspiration.
In primary suture repairs, the antibiotic therapy was started at
the beginning of the operation and stopped at the end, except in
cases necessitating an associated bowel resection. A deep drain for Conclusion
the abdominal wall was never used in 34 simple repairs, except as
an intraperitoneal drain for a colon or small bowel resection. In surgery of the abdominal wall, the use of drains is still contro-
The reason for not using a prosthesis was usually a formal con- versial. Although preventive drainage is not indicated in inguinal
traindication, such as a contaminated operative field. hernia repairs except in special cases, it is not so easy to pronounce
At the beginning of our experience, the deep drains were left definitively on the use of drains in incisional hernia repair.
in place until the seventh postoperative day, but, as we realized Without an adequate number of prospective and randomized
that the amount of fluid collection did not reduce progressively, studies with a sufficient number of cases to be statistically signifi-
we shortened more and more the time of maintenance of the drain cant, it is necessary to refer mainly to the experiences in medical
centers where abdominal wall surgery is performed.
Blood drainage In incisional hernia with
prosthetic repair Blood drainage in subcutaneous drains
140
\-
120 40
100 30
80
i
.. .
E
... ----.•
60 20
40 10
20 ---' •
0 O+-----.---~----_.----,_----.----.----_,
2 3 4 5 6 7 2 3 4 5 6 7
PoeI:operative days Postoperative days
FIGURE 48.1. Time related amount of collection in deep drains. FIGURE 48.2. Time related amount of collection in subcutaneous drains.
350 P. Bocchi
TABLE 48.3. Indications to a safe use of preventive drains 6. Cohn LH. Local infection after splenectomy relationship of drainage.
Arch Surg. 1965;90:230.
Subcutaneous 7. Cerise EJ, Pierce WA, Diamond DL. Abdominal drains: their role as a
Inguinal hernia repair Deep drain drain source of infection following splenectomy. Ann Surg. 1970;171:764.
8. AginskyJ, Riesenfeld G, Wallisch G. Infection due to surgical drainage.
With prosthesis No No
Int Surg. 1975;60:606.
Without prosthesis No No
9. Nomura T, Shirai Y, Okamoto H, et al. Bowel perforation caused by
Poor coagulation
silicone drains: a report of two cases. Surg Today. 1998;28(9):940-942.
without prosthesis No Yes
10. Heslin MJ, Harrison LE, Brooks AD, et al. Is intra-abdominal drainage
Poor coagulation
necessary after pancreaticoduodenectomy? Gastrointest Surg. 1998;2 (4):
with prosthesis Yes Yes
373-378.
Ascitic patients Yes in cases of poor
11. Pai D, Sharma A, Kanungo R, et al. Role of abdominal drains in per-
peritoneal closure
forated duodenal ulcer patients: a prospective controlled study. Aust
NZ] Surg. 1999;69(3):210-213.
12. Bona S, Gavelli A, Huguet C. The role of abdominal drainage after
TABLE 48.4. Indications to a safe use of preventive drains major hepatic resection. Am] Surg. 1994;167(6):593-595.
13. Merad F, Hay JM, Fingerhut A, et al. Is prophylactic pelvic drainage
Incisional hernia repair Deep drain Subcutaneous drain useful after elective rectal or anal anastomosis? A multicenter con-
trolled randomized trial. French Association for Surgical Research.
With prosthesis Yes Yes/no
Surgery. 1999;125(5):529-535.
Without prosthesis No Yes/no
14. Merad F, Yahchouchi E, Hay jM, et al. Prophylactic abdominal
Poor coagulation without prosthesis No Yes
drainage after elective colonic resection and suprapromontory anas-
Poor coagulation with prosthesis Yes Yes
tomosis: a multicenter study controlled by randomization. French As-
Ascitic patients Yes Yes
sociation for Surgical Research. Arch Surg. 1998;133(3):309-314.
15. Higson RH, Kettlewell MG. Parietal wound drainage in abdominal
surgery. Br] Surg. 1978;65(5):326-329.
16. White 1J, Santos MC, ThompsonJS. Factors affecting wound compli-
cations in repair of ventral hernias. Am Surg. 1998;64(3):276-280.
The drain must be placed in the region of dissection with the
17. Bendavid R. Seroma and prostheses (part 1). In Bendavid R, ed.: Pros-
purpose of draining blood; it must be withdrawn as early as feasi-
theses and abdominal wall hernias. Austin: R.G. Landes Company; 1994;
ble. It does not have to be manipulated in order to avoid devel- 367-369.
oping infection, nor does it have to be irrigated. 18. Peiper C, Conze J, Ponschek N, et al. Value of subcutaneous drainage
The preferred drain is a closed suction system. In extensive dis- in repair of primary inguinal hernia. A prospective randomized study
sections, two drains are recommended. of 100 cases. Chirurgie. 1997;68(1):63-67.
Drains do not compensate for poor surgical technique, inade- 19. Simchen E, Rozin R, Wax Y The Israeli Study of surgical infection of
quate hemostasis, or rough handling of tissues. The drain itself is drains and the risk of wound infection in operations for hernia. Surg
a foreign body that can stimulate the production of fluid. The de- GynecolObstet. 1990;170(4):331-337.
cision to insert a drain is an integral part of the operative proce- 20. Rives J, Flament JB, Delattre JF, et al. La chirurgie moderne des hernies
de l'aine. Cha Med. 1982;7:1205-1218.
dure and often affects the outcome of the operation. Tables 48.3
21. Stoppa R, Warlaumont C. The preperitoneal approach and prosthetic
and 48.4 outline the indications for safe use of drainage in ab-
repair of groin hernias. In Nyhus LM, Condon RE, eds.: Hernia, 3rd
dominal wall surgery. ed. Philadelphia: J.B. Lippincott; 1989;199-22l.
22. Rives J, Pire JC, Flament]B, et al. Le traitement des grandes eventra-
tions. Nouvelles indications therapeutiques it propos de 322 cas.
References Chirurgie. 1985;111:215-225.
23. Stoppa R, Moungar F, Verhaeghe P. Traitement chirurgical des even-
1. Knut H. Stana illustrata della chirurgia. Roma: 11 Pensiero Scientifico Ed- tration medianes sus ombilicales.] Chir. 1992;129:335-343.
itore; 1989. 24. Wantz]E. Incisional hernioplasty with Mersilene. Surgery. 1991;172:
2. Yates JL. An experimental study of the local effects of peritoneal 129-137.
drainage. Surg Gynecol Obstet. 1905;1:473. 25. ChevrelJP. Traitement des grandes eventrations medianes par plastie
3. Heaton G. Siphon to apply suction to intraperitoneal drain. BMJ en pale tot et prothese. Nouv Presse Med. 1979;8:695-696.
1898;1:207. 26. Parneix, Fon Marty C, La Porte. Etude physiopathologique et
4. Hanna EA. Efficiency of peritoneal drainage. Surg Gynecol Obstet. 1970; anatomico-pathologique de l'irrigation peritoneale dans les peri-
131:983. tonites aigues generalisees.] Chir. 1975;109.
5. Rosenberg IL, Pollock AV. Cephaloridine and gentamicin in prophy- 27. Shafik A. The electrified drain. A new device for sterilizing the field
laxis of surgical wound infection. BMJ 1974;2:5918. of drainage. Int Surg. 1993;78(4):357-359.
Part VII
Techniques of Open
Groin Hernia Repair
Introduction to Pure Tissue Repairs
Robert Bendavid
Pure tissue repairs have characterized the practice of hernia sur- The secure feeling provided by the "House that Bassini built"
geons for most of the twentieth century, thanks to Edoardo Bassini, (WJ.M. Brandon)4 needs reevaluation today in light of the cur-
who dominated the surgical scene with his timeless contribution rent understanding of the metabolic aspect of hernia disease
in 1887 of "the radical cure of inguinal hernia."1 If "glory is the and of the ever more widespread use of prosthetic material to
sunshine of the dead" (Victor Hugo), no eclipse is expected for reduce tension and aid in the creation of new fibrous tissue re-
Bassini in the next century. His contribution, unchallenged de- inforcement. What is needed is comprehensive follow-up infor-
spite attempts by Halsted, Marcy, Gallie, Ferguson, Czerny, Kocher, mation on these repairs after 10 and 20 years of follow-up.
Billroth, Willys-Andrews, McVay2 and many others, remains the Follow-up of patients with prosthetic repairs has not been easy;
point of departure for all subsequent techniques and approaches my own attempts to study 400 patients between 1986 and 1996
in the open repair of inguinal hernias. resulted in a dismal 10% follow-up rate! Yet I have seen patients
A recent survey examined the practices of 706 general surgeons who had Bassini and Shouldice repairs with normal groins 40
in Canada, where surgery tends to follow U.S. patterns. The fre- years later!
quencies of operative techniques performed were found to be Clearly, the verdict will be delivered in the twenty-first century.
Bassini, 23%; mesh plug, 20%; Lichtenstein, 16%; laparoscopic,
15%; Shouldice, 11 %; and McVay, 11%. For recurrent and bilat-
eral inguinal hernias, laparoscopic herniorrhaphies were used in
34% and 35% of the cases, respectively.3 Because the Shouldice
repair is in fact a Bassini repair, the Bassini can be considered to References
command 34% of the operations performed.
1. Bassini E. Un nuovo metodo per la cura radicale dell'ernia inguinale.
The Bassini operation, as the prototype of the pure tissue re-
Arch Soc It ChiT. 1887;IY.
pair, provides unequalled satisfaction and reward because of its
2. Bendavid R New techniques in hernia repair. World] Surg. 1989;13:
simplicity. The same can, of course, be said of the Shouldice. The 522-531.
thoroughness of their dissection reveals an anatomy that lends it- 3. Des CoteauxJG, Sutherland F. Inguinal hernia repair: a survey of Cana-
self to reliable repair. It is an operation that every surgeon must dian practice patterns. Can] Surg. 1999;42(2):127-132.
know, understand, and perform well, for surely it will be resorted 4. Brandon ~M. Inguinal hernia: the house that Bassini built. Lancet.
to at some time in a surgeon's career. 1945;Feb:167.
353
49
The Bassini Operation
Oreste Terranova, Luigi De San tis, and Luigi Ciardo
Historical Note The Bassini Operation

The Byzantine Medical School cured inguinal hernias by the re- The Bassini operation consists of the reconstruction of the in-
moval of the ipsilateral testicle. Guy de Chauliac (1300-1368), a guinal musculoaponeurotic walls, and this remains the sound ba-
great surgeon of the French school, wrote the Grande Chirurgie, sic principle for the repair of primary inguinal hernias. In the
the book of reference for centuries. In cases of inguinal hernia, reconstruction of the inguinal wall, the suture includes superiorly
the author suggested this cure: a triple layer, consisting of the internal oblique muscle, transver-
sus abdominis muscle and the transversalis fascia and inferiorly
The physician should prescribe laxatives and bloodletting to aid in- the inguinal ligament and the iliopubic tract, a thickening of trans-
testinal motility. The patient should not eat beans, fresh fruits, brown versalis fascia. 5 ,6 The spermatic cord lies against the newly recon-
bread, port wine, fish, cheese or radishes. New wine and pure water structed posterior inguinal wall, with the external oblique apo-
are allowed, while intensive body exercises (coitus included) are for- neurosis closed over it (Figs. 49.2 to 49.5; see also color insert).7
bidden. The gut must be kept cleansed by enemas, laxatives and sup-
positories. Food must be seasoned with sage and each meal should
include a pill of coriander and nasturtium covered with sugar. More- The Cutaneous Incision
over, the physician should try to push back the hernia by hand and
keeping the patient hung up by the legs. Now a special poultice must The Bassini repair is carried out easily under local anesthesia, and
be applied on the hernial orifice. The patient should stay in bed for it is performed with the patient lying supine and the surgeon on
50 days, and the poultice should be changed every nine days.!
the side of the hernia. 8 The important landmarks are the pubic
tubercle, immediately lateral to the pubic symphysis, and the an-
In the eighteenth century, Pott favored the intervention for terior superior iliac spine. The cutaneous incision begins at the
strangulated hernia, although these were daring procedures be- pubic tubercle and is extended parallel to the inguinal ligament
fore the introduction of antiseptics and narcosis. Astley Paston for 8-lO cm toward the anterior superior iliac spine (Fig. 49.6). It
Cooper (1768-1841) published a treatise about hernia surgery is sometimes necessary to dissect and ligate the superficial epi-
based on several years of experience in dissection and surgery. He gastric vessels. On a deeper plane, the Scarpa's fascia and the in-
was the first to understand the importance of the fascial structures nominate fascia are incised to reveal the external oblique
of the inguinal region, which were the fundamental elements for aponeurosis and the superficial inguinal ring. To identify the lower
hernia repair. aspect of the inguinal ligament, it is necessary to incise the crib-
More than lOO years ago, in 1884, Edoardo Bassini (Fig. 49.1) riform fascia of the thigh from the pubic tubercle to the femoral
proposed his original technique for the repair of inguinal her- vein to mobilize the inguinal ligament and reveal a possible con-
nias. 2,3 Bassini was Professor of the Surgical Clinic of the Univer- comitant femoral hernia.
sity of Padua and a revered figure in Italian surgery. 4 He published
his book, New operative Method for the Treatment of Inguinal Hernias,
in 1889. Bassini wrote: "It will seem extremely bold to write about Incision of External Oblique Aponeurosis
the radical repair of inguinal hernias, especially nowadays after all
the publications in the past and the restless activity in the present." The external oblique aponeurosis is opened by means of an inci-
He continues: "I thought of a surgical technique of physiological sion along the direction of its fibers from the superficial inguinal
reconstruction of the inguinal canal, consisting of two openings, ring to a level just lateral to the deep inguinal ring (Fig. 49.7).
an abdominal and a subcutaneous, and of two walls, a posterior The wide lower flap of fascia thus obtained will later be used to
and an anterior, with the spermatic cord between them."2 This reconstruct the anterior wall of the inguinal canal. g The upper
happy insight was greeted with great enthusiasm and became the flap of external oblique aponeurosis is grasped with two clamps
touchstone of inguinal hernia repair, thanks to its simplicity and and dissected free of the underlying spermatic cord and internal
its respect for anatomy. oblique muscle. The lower flap is also dissected clear of the sper-
354
FIGURE 49.1. Prof. Edoardo Bassini (1844-1924). FIGURE 49.3. Suture of the triple layer above to the iliopubic tract and in-
guinalligament below. Although the suture shown is continuous, the text
describes interrupted sutures. (Reprinted from Bassini,2 with permission.)
(See color insert.)
FIGU RE 49.2. Appearance following dissection of the groin. The triple layer
is evident superiorly, as well as the presence of fat in the preperitoneal FIGURE 49.4. Closure of the external oblique aponeurosis over the sper-
space. (Reprinted from Bassini,2 with permission.) (See color insert.) matic cord. (Reprinted from Bassini,2 with permission.) (See color insert.)
355
FIGURE 49.7. Incision of the aponeurosis of the external oblique muscle.

(Reprinted from Catterina A. L'lijJeration de Bassini. Paris: Librairie Felix Al-
can; 1934, with permission.)
Isolating the Spermatic Cord

The spermatic cord is freed from the posterior wall by the index
FIGURE 49.5. Sagittal section showing that the normal anatomy has been finger, which is wrapped around the cord near the pubic tuber-
reestablished. (Reprinted from Bassini,2 with permission.) (See color in- cle. The separation from the posterior wall is extended to the level
sert.)
of the deep inguinal ring (Figs. 49.8 to 49.11). A Penrose drain
is looped around the spermatic cord to draw it out of the field
laterally.
matic cord (or round ligament, in the female). Particular care
must be taken to recognize the iliohypogastric and ilioinguinal
nerves, which lie on the internal oblique muscle, and the genital Resection of the Cremaster Muscle
branch of the genitofemoral nerve, which runs along the anterior
surface of the cremaster muscle: these nerves could be inadver- The cremaster muscle is incised longitudinally over its entire
tently severed or trapped during the parietal reconstruction. Be- length. The thin and poorly vascularized medial portion can be
cause of the sensory nature of these two nerves, it is necessary to cauterized and resected, while the lateral portion, which contains
anesthetize them by direct injection. the cremasteric vessels and the genital branch of the genitofemoral
nerve, is cut between forceps; both stumps are ligated (Figs. 49.12
."
/' '"
'" "
,-
."
,-
'" "
."
FIGURE 49.6. Diagram of the cutaneous incision. (Reprinted from Catte- FIGURE 49.8. Separation of the cord with the handle of a scalpel.
rina A. L'lijJeration Ik Bassini. Paris: Librairie Felix Alean; 1934, with per- (Reprinted from Catterina A. L'operation Ik Bassini. Paris: Librairie Felix AJ-
mission.) can; 1934, with permission.)
49. The Bassini Operation 357
FIGURE 49.9. Isolation of the cord at the external abdominal ring. FiGURE 49.11. Separation of the cord performed by the assistant.
(Reprinted from Catterina A. L'operation de Bassini. Paris: Librairie Felix Al- (Reprinted from Catterina A. L'operation de Bassini. Paris: Librairie Felix Al-
can; 1934, with permission.) can ; 1934, with permission.)
and 49.13). In women, the genital branch of the genitofemoral ally, the myoaponeurotic layers of the transversus abdominis and
nerve is spared, for it supplies the labia. Exploration is now car- internal oblique muscles; inferiorly and laterally the iliopubic tract,
ried out for direct and indirect inguinal hernias. At this stage, the the prevascular fascia, and Cooper's ligament become visible. On
sac is freed from the cord (Fig. 49.14). the internal aspect of the inferior leaf of transversalis fascia the
iliopubic vein can be seen; it is necessary to ligate or coagulate it
to avoid troublesome bleeding.
Splitting the Transversalis Fascia
The transversalis fascia is now opened from the deep inguinal ring Management of an Indirect Sac
to the pubic tubercle; the incision should run parallel to the in-
guinalligament and 7 to 8 mm superior to it to leave an intact il- In indirect hernia, the sac is freed and separated from the sper-
iopubic tract (Fig. 49.15). During this step care must be taken not matic cord as far as possible beyond the inferior epigastric vessels
to injure the inferior epigastric vessels, which run immediately un- within the deep inguinal ring. The sac is opened and inspected
der the transversalis fascia, usually near the deep inguinal ring. (Fig. 49.16). Viscera are reduced after lysing some adhesions.
The medial border of the incised transversalis fascia is grasped Through the peritoneal cavity, the femoral region is explored to
with two clamps, and the preperitoneal fat of the space of Bogros exclude femoral defects. The sac is then ligated at the neck with
is bluntly dissected away from the deep aspect of the transversalis a transfixing slowly absorbable suture and then resected (Fig.
fascia with a peanut sponge stick. In this way, anteriorly and me- 49.17). If the dissection has been adequate, the stump retracts
dially, the rectus abdominis muscle is revealed with, more later-
/ /
/
FIGURE 49.12. Dissociation of the cremaster muscle and other coverings

FIGURE 49.10. Isolation of the whole cord. (Reprinted from Catterina A. from the sac and spermatic cord. (Reprinted from Catterina A. L'operation
L'operation de Bassini. Paris: Librairie Felix Alcan; 1934, with permission.) de Bassini. Paris: Librairie Felix Alcan; 1934, with permission.)
FIGURE 49.13. Complete isolation of the cremaster muscle and other cov- FIGURE 49.15. Exposure and incision of the transversalis fascia. (Reprinted
erings-their resection. (Reprinted from Catterina A. L'opiration de Bassini. from Catterina A. L'opiration de Bassini. Paris: Librairie Felix Alcan; 1934,
Paris: Librairie Felix Alcan; 1934, with permission.) with permission.)
spontaneously into the preperitoneal space. In sliding hernias, the

wall of the sac consists partly of a retroperitoneal organ (bladder,
cecum, or sigmoid colon); it should not be opened in order to
avoid accidental injury to the herniated organs. The safest way to
treat sliding hernias is to isolate the sac from the cord and simply
to push the sac back into the preperitoneal space.
Suture of the Deep Plane

After exploration of the femoral region to exclude the presence
of a femoral hernia, the deep parietal reconstruction begins. The
first suture approaches the anterior aspect of the medial half of
the incised transversalis fascia, but medially enough to include the
lateral edge of the rectus sheath and muscle, the internal oblique,
transversus abdominis, and transversalis fascia (Figs. 49.18 and
49.19). By pushing the handle of the forceps under the transver-
salis fascia, the prevescical and preperitoneal fat are moved away FIGURE 49.16. Opening of the sac and disposition of the contents.
to avoid inadvertent inclusion of the underlying peritoneum and (Reprinted from Catterina A. L'opiration de Bassini. Paris: Librairie Felix AI-
can; 1934, with permission.)
FIGURE 49.14. Isolation of the spermatic cord from the sac. (Reprinted FIGURE 49.17. Twisting of the sac and its removal. (Reprinted from Catte-
from Catterina A. L'opiration de Bassini. Paris: Librairie Felix Alcan; 1934, rina A. L'opiration de Bassini. Paris: Librairie Felix Alcan; 1934, with per-
with permission.) mission.)
49. The Bassini Operation 359
FIGURE 49.18. First sutures in the deep layer. (Reprinted from Catterina FIGURE 49.21. Suturing the aponeurosis and subcutaneous tissue. (Re-
A. L'operation de Bassini. Paris: Librairie Felix Alean; 1934, with permission.) printed from Catterina A. L'operation de Bassini. Paris: Librairie Felix Alean;
1934, with permission.)
viscera. A retractor is used to move the triple layer and the un-
derlying structures upward to facilitate insertion of the first suture
inferiorly at the pubic tubercle level, when the pubic periosteum,
iliopubic tract, and inguinal ligament are sutured.
The subsequent sutures take the triple layer at about 3 cm from
its free margin. The stitches are placed roughly 1 cm apart; this is
the optimum distance to avoid leaving weak areas or causing isch-
emia of the tissues. Care must be taken not to incorporate the il-
iohypogastric and ilioinguinal nerves in the suture. All subsequent
sutures involve only the iliopubic tract and the inguinal ligament.
The sutures must be tied loosely; the triple layer must be simply
approximated to the inguinal ligament. Sutures ligated too tightly
cause ischemia and cut through the involved tissues, weakening
the parietal reconstruction. 6 The deep inguinal ring is recon-
structed with the most lateral suture. This suture must not be so
tight as to constrict the spermatic vessels. When closure is com-
FIGURE 49.19. Completion of the suture of the deep layer. (Reprinted from
plete, it must be possible to insert the tip of a Kelly forceps into
Catterina A. L'operation de Bassini. Paris: Librairie Felix Alean; 1934, with
permission. )
the ring with no difficulty. Cord mobility, when longitudinal trac-
tion is exerted on it, must be preserved. The number of sutures
varies from six to eight according to the length of the inguinal
canal.
Closing the Anterior Wall of the Inguinal

Canal and the Superficial Planes
The spermatic cord is replaced into the inguinal canal, and the free
borders of the incised external oblique aponeurosis are approxi-
mated by means of a continuous suture (Figs. 49.20 and 49.21).
References
1. Knut H. Storia illustrata della Chirurgia. Roma: II pensiero seientifieo ed-
itore; 1989:66-89.
2. Bassini E. Nuovo metodo operativo per La cura dell'ernia inguinale. Padova:
Prosperini; 1889.
FIGURE 49.20. Replacement of the cord. (Reprinted from Catterina A. 3. Catterina A. L'operazione di Bassini per La cura radicale dell'ernia inguinale.
L'operation de Bassini. Paris: Librairie Felix Alean; 1934, with permission.) Bologna: Cappelli; 1932.
360 R Bendavid
4. Fasiani GM, Catterina A. Scritti di Chirurgia erniaria, vol 1. Padova: Ti- after 115 years and more, when more than 81 variations have been
pografia del seminario di Padova; 1937. proposed, 3 only the Shouldice repair has remained; this is surely
5. Bendavid R The Shouldice method of inguinal herniorrhaphy. In Ny- because it is in essence a Bassini repair with nary a change but for
hus LM, Baker RJ (eds): Mastery of surgery, 2nd ed. Boston/Toronto/ continuous rather than interrupted sutures. For the same reason,
London: Little-Brown; 1992;1:1584-1594. the results of the Shouldice Hospital-less than 1% recurrence-
6. Terranova 0, Battocchio F. L'intervento di Bassini. In La chirurgia delle
can be seen as validation of the Bassini repair. G. Wantz5 and
ernie della regione inguinale e crurale. Padova: La Garangola (eds); 1988:
19-24.
R. Read6 have emphasized that the operations are similar enough
7. Peracchia A. L'intervento di Bassini per l'ernia inguinale da la chirurgia to be referred to as the Bassini-Shouldice.
dell'ernia inguinale. Padova: Abstracts; 1986:25-28. The corrupt technique, the so-called "modified Bassini," is al-
8. Battocchio F. Intervento di Bassini per l'ernia inguinale. In Testo at/ante ways characterized by its omission of three steps of the original
di chirurgia delle ernie. Milano: UTET (eds); 1994:37-42. Bassini operation. The first omission is the resection of the cre-
master. Omission of this step leads to an uncertain search for an
indirect inguinal hernia and accounts for 37% of recurrences?
Second, the "modified Bassini" fails to incise the posterior wall of
the inguinal canal. This step allows the identification of the proper
structures for reconstruction of the posterior wall. It also allows
Commentary the resection of poor tissues which in the "modified" operation
are simply imbricated, with an attendant 45% rate of a direct in-
Robert Bendavid guinal hernia recurrence. 7 Third, the search for additional her-
nias must not be omitted, as a second one will be found in 14%
"In this rapidly changing world, it is well, now and then, to re- of patients. 4
turn to fundamentals. In so doing, progress and change can be It is often said that modern hernia treatment began with Bassini,
evaluated, and credit due to great originators can be reaffirmed" and, when correctly carried out, the Bassini is still an effective re-
(w. and C. Mayo). pair. In short, whether Bassini or Verdi, let us keep to the score.
This foreword by the Mayo brothers written in 1933 for A. Cat-
tarina's book on the operation of Bassini reflects an attitude that
must ever be present. Reviewing the operations that Bassini per- References
formed between 1884 and 1889 on 216 patients, Cattarina
recorded meticulously 11 cases of "suppuration" (5.1 %) and 5 re- 1. Catterina A. L'operation de Bassini. Paris: Librairie Felix Alcan; 1934.
currences (2.3%).1 In various series, ranging from 46 to 1102 pa- 2. Bendavid R Expectations of hernia surgery. In Patterson-Brown S, Gar-
tients, the recurrence rate has varied from 2.9% to 25%.2 Why den J (eds): Principles and practice of surgicallaparoscopy. Philadelphia:
such a marked variation in results from those of the master? W.B. Saunders; 1994:387-414.
The answer in fact is simple and can be summarized in one word: 3. Bendavid R New techniques in hernia repair. World] Surg. 1989;
corruption. 13(5):522-531.
Surgeons, like primo tenores (the male version of the prima 4. Bendavid R The Shouldice repair. In Nyhus LM, Condon R (eds): Her-
nia, 4th ed. Philadelphia: J.B. Lippincott; 1995:217-236.
donna), tend to be individualistic and truly convinced that their
5. Wantz GE. The operation of Bassini as described by Attilio Catterina.
own version of the operation is an improvement on that of the
creator. Quite often, these variations, much like the da capo ("from 6. Read R. The centenary of Bassini's contribution to inguinal hernior-
the head") arias of the tenors, bear no resemblance to the origi- rhaphy. Am] Surg. 1987;153:324.
nal. Just as Toscanini brooked no divergence from the written mu- 7. Obney N, Chan CK Repair of multiple time recurrent inguinal hernias
sic of the composer, the surgical teacher must insist on adherence with reference to common causes of recurrence. Contemp Surg. 1984;
to the authentic description of a technique. It is significant that, 25:25-30.
50
The Darn Repair
Jack Abrahamson
Introduction inguinal ligament but did not bring them together by force if this
generated tension. This was followed by a second continuous su-
The dam repair of groin hernias is a pure tissue repair and is one ture, also of monofilament nylon, passing from the pubic tuber-
of the classic open herniorrhaphies. It is simple, generally appli- cle laterally between the healthy, strong tissues of the rectus sheath
cable to primary and recurrent hernia repairs, and has a remark- and the tendinous portion of the aponeurosis of the internal
ably low recurrence rate. The technique has been very popular in oblique muscle above to the inguinal ligament below and contin-
the English-speaking world but is less commonly used in Europe uing beyond the internal ring. Their recurrence rate was less than
and parts of North America. 1--8 In a 1991 survey of 240 consultant 1 %. These results have been confirmed by others. 1--8 In 1987 and
surgeons in England, the dam repair was the most popular tech- 1988, I reported a series of more than lOOO cases of inguinal her-
nique 9; 35% of surgeons used it as their sole method of repair. nia repaired by my modification of the nylon dam and using
The Shouldice operation alone or combined with other tech- monofilament polyamide sutures, with a recurrence rate of 0.8%
niques was used by only 20%. In the United States, Mansberger et for primary repairs of inguinal hernia. 7,24
al. 8 reported their series of dam repairs in 1992.
The concept of the dam developed as surgeons sought the ideal
tension-free means of reinforcing the posterior wall of the inguinal
The Operation 24
canal with either natural tissue or biological or synthetic material
woven between the myoaponeurotic arch (conjoined tendon) and
Preoperative Assessment and Preparation
the inguinal ligament. Dams are not new in hernia surgery. They As for any other operation, the general condition of the patient
have been reported fairly regularly since the beginning of the twen- should be assessed by appropriate history, clinical examination,
tieth century, but they failed mainly for lack of suitable suture ma- and laboratory tests. Cardiovascular, pulmonary, renal, and other
terial. The earliest of the darners was McArthur,1O who, in 1901, conditions such as diabetes mellitus should be looked for and con-
reported using pedicled strips of the external oblique aponeuro- trolled. Smokers should be urged to stop the habit or at least sus-
sis woven between the co~oined tendon and the inguinal liga- pend it for some weeks before the operation.
ment. In 1910, Kirschnerll reported using fascial grafts from the
thigh. In 1918, Handley12 introduced the "darn and stay-lace" pro-
cedure using silk. Gallie and Le Mesurier18 published in 1921 the Anesthesia
use of fascia lata strips as sutures woven into the muscles, the
inguinal ligament, and the tissues of the posterior wall of the in- Local infiltration anesthesia is commonly used for repair of in-
guinal canal. Mair14 used strips of skin cut from the edges of the guinal hernia and is also suitable for the dam repair. In about half
incision. These living tissues were difficult to harvest and tended of the cases in my practice, spinal or epidural anesthesia is used. 25
to be absorbed. They also caused complications inherent in the Most of the rest is done with local anesthesia. General anesthesia
tissue used. The recurrence rate was still significant. is employed in special cases or according to the preference of the
Later, silk was used, in the form of twisted or braided threads anesthetist or patient. The recurrence rate is not influenced by
or floss,15-18 but it was abandoned because of the high rate of in- the type of anesthesia.
fection, chronic sinuses, and recurrences. When nylon became
available, its use in surgery was explored, and already in 1942 re- Skin Preparation
ports began to appear of the use of braided, multifilament nylon
for the repair of inguinal hernia. 19-21 This was soon replaced by The area of the lower abdomen, pubis, and upper thigh is shaved
monofilament nylon threads. 22 immediately before the patient is transferred to the operating
In 1948, Moloney et al. 23 introduced the forerunner of the mod- room. The skin of that area is scrubbed for 5 minutes with
em nylon darn technique. They used a continuous suture of povidone-iodine scrub or chlorhexidine scrub, dried, and then
monofilament nylon to approximate the conjoined tendon to the painted with a povidone-iodine or chlorhexidine solution.
361
362 J. Abrahamson
The Incision The Repair

A long, transverse incision is preferred, centered over the inter- First Step
nal ring, stretching from the line of the anterior superior iliac
spine almost to the midline. In thin persons, the incision may cross The first step in the repair is the suturing of the medial edge of
the inguinal crease, but this is of no consequence as long as the rectus sheath and the musculoaponeurotic arch to the poste-
Langer's lines are followed. In obese patients, a convenient, slightly rior edge of the inguinal ligament and to the iliopubic tract, with
curved skin fold can be used. A long incision gives good exposure a continuous 2-0 polyamide or polypropylene suture. The suture
of the rectus sheath at the important medial end of the repair and is begun at the medial end by passing through the fascia on the
of the region lateral to the internal ring; it also avoids strong re- pubis, the medial end of the inguinal ligament, and the remains
traction, which increases the incidence of wound infection. A well- of the fascia transversalis. It then takes a good bite through the
placed and well-closed incision heals cleanly with a delicate scar, lowest portion of the medial edge of the rectus sheath and ten-
and it is of no importance whether it is a few centimeters longer don and is tied. The suture continues laterally in a simple over-
or shorter, whereas good exposure is vital to a good operation. and-over fashion to include along the lower edge some fibers of
the posterior edge of the inguinal ligament, the iliopubic tract,
and the lower part of the transversalis fascia. Along the upper line,
The Dissection the medial edge of the rectus sheath and muscle is sutured as far
laterally as possible, after which the suture passes on to take in the
The standard approach to the inguinal canal is used, cutting lower edge of the aponeurosis of the transversus abdominis and
through the skin, fat, and condensed layer of the superficial fas- the aponeurotic part of the internal oblique as well as part of the
cia and slitting open the aponeurosis of the external oblique from transversalis fascia. The fleshy part of the internal oblique is not
the apex of the external ring to beyond the line of the internal included in the suture. Fairly large bites of tissue are taken along
ring. The spermatic cord and its coverings are cleared off the in- the upper edge as would be done in a continuous mass closure.
ner aspect of the inguinal ligament up to the pubic tubercle. The Suture bites on the inguinal ligament are staggered, some more
superior leaf of the aponeurosis of the external oblique muscle is forward and others further back in order to spread the burden on
mobilized in all directions but especially cranially and medially. It the inguinal ligament so that the repair will not be dependent on
is peeled off the aponeurosis of the internal oblique muscle and only a few fibers of the inguinal ligament.
the anterior rectus sheath by blunt gauze dissection to expose the The aim is to approximate the rectus sheath and conjoined ten-
anterior surface of the rectus sheath and the fibers of the aponeu- don to the inguinal ligament. This is easily achieved without ten-
rosis of the internal oblique muscle. A wide area must be exposed sion, or under only minimal tension in most cases. When this is
to obtain strong, healthy aponeurotic tissue for the repair, well not possible, we do not force the approximation under tension
away from the canal. The cord is mobilized, and its cremaster and but leave a gap, usually only a narrow one, between the upper el-
other coverings and fat are removed so that only the essential con- ements of the repair and the inguinal ligament, which will later
stituents remain. A thin cord facilitates exposure and snug closure be covered by the darn. At the lateral end, the edges of the in-
of the internal ring, exposes the myoaponeurotic arch and the ternal ring are picked up and included in the sutures to achieve
transversalis fascia, and facilitates the reconstruction of the in- a fairly tight and snug closure of the ring around the cord. The
guinal canal. The iliohypogastric nerve, the ilioinguinal nerve, and line of suture is carried laterally beyond the internal ring for 1 to
the genital branch of the genitofemoral nerve should be preserved 2 cm with the object of covering the internal ring with the mus-
during this dissection, if possible. culoaponeurotic tissue of the arch in order to reinforce the ring
When operating on a recurrent inguinal hernia, the dissection against indirect recurrence. At the same time, the spermatic cord
should aim at restoring the normal anatomy as far as possible, at is redirected laterally after it exits the new internal ring. At this
which stage the situation may be assessed. If sufficient healthy tis- point the suture is tied.
sues are present and the planes are pliable and mobile, as is the
case in most recurrent hernias, the repair may proceed as for a
primary operation. However, if the hernia opening is large, Second Step: The Darn
scarred, and immobile and the tissues and planes around it are
likewise fixed, a prosthetic mesh repair of the Rive's type should The darn is done with a commercially available monofilament
be considered. thread of polyamide 6, 1.5 m long and doubled to form a loop 75
Short or medium length indirect sacs are freed off the cord, mo- cm long, with the free ends swagged onto an atraumatic curved
bilized up into the retroperitoneum, and invaginated. Longer sacs 40 mm round-bodied needle. Starting at the medial end, a bite is
are mobilized close to the internal ring and cut across. The distal taken of the most medial fibers of the inguinal ligament where
segment is left undisturbed. The proximal segment is dissected they sweep over the pubic tubercle. The point of the needle is
high up into the retroperitoneum and invaginated. The sac is nei- then pushed under the lateral edge of the rectus muscle and
ther ligated nor sutured. No special dissection of a direct sac is sheath, just above where they are inserted into the pubis, and a
needed, although occasionally it is convenient to reduce a sac pro- deep, wide bite is taken of the muscle and sheath so that the nee-
lapsing through a punched-out hole in the transversalis fascia and dle appears on the anterior surface of the sheath and is extracted.
to suture the opening with an absorbable synthetic thread. A large The needle is then passed through the tail end of the loop, and
sliding hernia, opened or unopened, may simply be reduced and the end is tightened, eliminating the inconvenience of a knot.
the edges of the tear in the transversalis fascia closed with a con- The suture is continued laterally, taking bites of the inguinallig-
tinuous suture to render the repair more manageable. The trans- ament below and deep, wide bites of the rectus muscle and its
versalis fascia is not split open in the darn repair. sheath to ensure a good darn in the critical medial angle of the
50. The Darn Repair 363
repair where recurrences tend to occur. When the rectus sheath this tunnel, the cord changes direction and turns to run medially
can no longer be used, the sutures pass onto the coryoined ten- toward the pubic tubercle. This new configuration around the in-
don. The stitches on the inguinal ligament are staggered to spread ternal ring should contribute to the prevention of indirect hernia
the tension between the fibers. At the upper end, the suture passes recurrence.
over the fleshy muscular lower part of the internal oblique and The cord is laid on the darn, and the anterior wall of the in-
transversus abdominis but takes a deep and wide bite of the white guinal canal is reconstituted in front of the canal by suturing to-
aponeurotic area of the conjoined tendon. Each stitch is placed gether the cut edges of the aponeurosis of the external oblique
in a vertical fashion, more or less at 90 degrees to the inguinallig- with a continuous suture of monofilament polypropylene. Scarpa's
ament. The stitches are held just tight enough to straighten the fascia and the subcutaneous fat are not sutured. The skin is closed
thread. They are not placed under any tension whatsoever. The with a continuous 5-0 intradermal synthetic absorbable thread.
tendency is to err in the opposite direction and to leave them quite The darn repair for inguinal hernia resembles the mass closure
loose. This vertical line of sutures is continued laterally in front technique for abdominal incisions. The monofilament nonab-
of, and even slightly beyond, the internal ring, displacing the cord sorbable synthetic thread must be thick enough not to cut through
more laterally. The same suture now changes direction and re- the tissues but not so thick as to be unpliable and difficult to han-
turns medially as the second layer of the darn, in front of the cov- dle. Large mass bites of full-thickness tissue must be taken to hold
ered internal ring. The stitches are placed in a sloping fashion, the sutures. The stitches should not be so close as to cause ischemia
passing upward and medially from the inguinal ligament to the of the tissues between them but not so far apart as to allow ex-
conjoined tendon and later to the rectus sheath, crossing the trusion of abdominal contents. The sutures in the conjoined ten-
stitches of the first run at an angle. Here too the bites on the in- don must be carefully placed in good, healthy tissue at a distance
guinalligament are staggered and in a line a bit anterior to those from the stretched and attenuated muscles around the hernia. The
of the first run in order to spread the tension. As before, large smooth, pliable thread can slide in the tissues and adjust to the
bites are taken of the aponeurotic fibers of the conjoined tendon, changing tensions of the suture lines.
but this time they are placed more cranially than the first row. No
tension is placed on the sutures. At the medial end, a bite is taken
on the inguinal ligament at the pubic tubercle and of the lower Discussion
end of the rectus sheath and then tied.
The third line of sutures is the same as the second, but the A good hernia repair should last the patient for the rest of his or
stitches slope in the opposite direction, that is, cranially and lat- her life, no matter what the age at the time of the operation. How-
erally from the inguinal ligament. The suture is passed through ever, although almost 40% of recurrences following primary re-
the medial end of the ;nguinal ligament and through the rectus pair of groin hernia appear during the first postoperative year,
sheath, then through the loop, and tightened. At the medial end, almost 25% occur later than 10 years after the operation and even
the suture takes up all of the inguinal ligament where it forms the 30 to 40 years later. As the causes of early recurrence after hernia
lower limb of the external ring, but more laterally it passes onto repair were eliminated-faulty technique, ignorance of the func-
the inguinal ligament. At this stage, the original line of repair as tional anatomy and physiology of the abdominal wall, repair with
well as the first two runs of the darn occupy most of the inguinal tension, the use of incorrect suture material, and infections-it
ligament, and there may not be any room left for a third line, became apparent that even with the finest technique and materi-
which may get "pushed" forward onto the aponeurosis of the ex- als and the best intentions on the part of the surgeon, a percent-
ternal oblique muscle, which is continuous with the inguinal lig- age of hernias will recur over the years because of factors beyond
ament. This gives an added advantage of wrapping the inguinal the control of the surgeon, mainly the natural weakening of the
ligament and lower flap of the aponeurosis of the external oblique tissues and deterioration of body fitness with time and aging and
around the inferior edge and anterior wall of the repair. The up- faulty collagen metabolism leading to production of abnormal col-
per end of the sutures of the third run should be placed at a higher lagen and its increased destruction. It was realized that in pure tis-
level than the second run. Big bites are taken of the tissues, and sue repairs some form of reinforcement was needed to overcome
the needle is brought out as high as possible. The needle may even the problems of aging scar tissue and of muscles and tendons ap-
hook up some of the external oblique aponeurosis along its line proximated by sutures, especially in direct hernia repair. A variety
of fusion with the internal oblique. In these cases, after closing of natural and foreign materials were used but with little success,
the anterior wall of the canal, the blue sutures of the polyamide until the advent of nylon and later the strong, smooth, pliable,
can be seen as a series of parallel lines on the surface of the ex- and resistant threads of polyamide and polypropylene that are
ternal oblique aponeurosis. The third run is continued laterally used today.
beyond the internal ring and tied. The name dam is rather unfortunate in that it evokes how holes
The stitches of each run should be sufficiently close to form a in socks are mended. The hole remains the same size but is filled
darn with no large gaps through which a hernia could recur. Gaps in with a series of to and fro warp and woof threads. This was the
should be filled in when doing any of the three runs. It is of no basis of some of the darn repairs described in the past12,13 but is
importance if some of the filling-in sutures are placed in different not what is done today in the modern darn repair. However, as a
directions and at different angles. On completion of the darn, the result, it has been incorrectly compared with producing by hand
internal ring has been covered and reinforced by the tissues of the at the time of the operation the equivalent of a readymade Pro-
myoaponeurotic arch as well as by the three runs of the darn. The lene mesh, inlayed between the myoaponeurotic arch and the in-
cord now passes laterally as it emerges from the internal ring in guinal ligament. This unfortunate misunderstanding could be
a tunnel whose posterior wall is the fascia transversalis and part of avoided if the name dam were changed to reinforcement.
the internal oblique aponeurosis and whose anterior wall is the The myoaponeurotic arch and the rectus sheath are sutured to
myoaponeurotic arch and the sutures of the darn. At the end of the inguinal ligament. The next three layers of crisscrossing su-
364 ]. Abrahamson
tures are reinforcing layers between the conjoined tendon and the 5. Morris GE, Jarrett PEM. Recurrence rates following local anaesthetic
rectus sheath above and the inguinal ligament below. In this way, day case inguinal hernia repair by junior surgeons in a district general
three staggered overlapping layers of sutures and tissues are cre- hospital. Ann R Coll Surg Eng. 1987;69:97-99.
ated to cover and reinforce the repair and also to cover any gap 6. Ellis H. Inguinal hernia. Br J Hosp Med. 1970;4:9-23.
7. Abrahamson J, Eldar S. The nylon darn repair for primary and re-
that may have been left to avoid tension between the conjoined
current inguinal hernias. Contemp Surg. 1988;32:33-45.
tendon and the inguinal ligament. The technique creates a strong
8. Mansberger JA, Rogers DA,Jennings WD, et al. A comparison of a new
four-layered buttress of living tissues for the posterior wall, rein- two-layer anatomic repair to the traditional Shouldice herniorrhaphy.
forced by a lattice of permanent synthetic sutures without tension, Am Surg. 1992;58:211-212.
interwoven with the muscle and aponeurotic fibers on which is 9. Morgan M, Swan AV, Reynolds A, et al. Are current techniques of in-
laid a buttress of fibrous tissue. guinal hernia repair optimal? A survey in the United Kingdom. Ann
The darn repair solves the problem of early recurrence because R Coll Surg Eng. 1991;73:341-345.
the nylon lattice will hold the area intact for the first year until 10. McArthur LL. Autoplastic suture in hernia and other diastases: pre-
the natural connective tissue collagen scar matures to its full liminary report. JAMA. 1901;37:1162-1165.
strength. However, the muscle and scar tissue are not able to with- 11. Kirschner M. Die praktischen Ergebnissse der freien Fascien-Trans-
plantation. Arch Klin Chir. 1910;92:888-912.
stand the constant wear and tear of repeated stress over many
12. Handley WS. A method for the radical cure of inguinal hernia (darn
years. As they fail, the polyamide suture material, which is practi-
and stay-lace method). Practitioner. 1918;100:466-471.
cally indestructible in human tissues, will once more come into its 13. Gallie WE, Le Mesurier AB. The use of living sutures in operative
own and will maintain the integrity of the repair for many years, surgery. Can Med Assoc] 1921;11:504-513.
until the end of the patient's life. 14. Mair GB. Preliminary report on the use of whole skin-grafts as a sub-
stitute for fascial sutures in the treatment of herniae. Br J Surg.
1945;32:381-385.
15. Ogilvie WH. Hernia. In Maingot R (ed): Postgraduate surgery, vol 3. East
Conclusion Norwalk, CT: Appleton-Century-Crofts; 1937:367-380.
16. Maingot R. The floss-silk lattice posterior repair operation for direct
The modem darn repair is an excellent pure tissue repair for pri- inguinal hernia. Br Med] 1941;1:777-778.
mary and for most recurrent inguinal hernias with a very low re- 17. McLeod C. The treatment of indirect inguinal hernia: a critical review
currence rate, even on long-term follow-up. It is a simple and easily ofa small personal series. Lancet. 1955;2:106-110.
mastered technique for constructing a multilayered buttress to re- 18. Maingot R. The floss-silk lattice repair for inguinal hernias. Br J Clin
inforce or replace the failed fascia transversalis in groin hernias. Pract. 1979;3:97-110.
19. Nichols HM, Diack AW. Animal experiments with nylon sutures. West
J Surg Obstet GynecoL 1940;48:42-45.
20. Aries L]. Experimental studies with synthetic fiber (nylon) as a buried
References suture. Surgery. 1941;9:51-53.
21. Melick DW. Nylon sutures. Ann Surg. 1942;115:475-476.
1. Shuttleworth KED, Davies WH. Treatment of inguinal herniae. Lancet. 22. Haxton H. Nylon for buried sutures. BM] 1945;1:12-13.
1960;1:126-127. 23. Moloney GE, Gill WG, Barclay RC. Operations for hernia: technique
2. Leacock AG, Rowley RK. Results of nylon repairs in inguinal hernias. of nylon darn. Lancet. 1948;2:45-48.
Lancet. 1962;1:20-21. 24. Abrahamson]. Hernias. In Zinner ~ (ed): Maingot's abdominal opera-
3. Callum KG, Doig RL, Kinmonth JB. The results of nylon darn repair tions, 10th ed. Stamford; CT: Appleton & Lange; 1997:479-580.
for inguinal hernia. Arch Surg. 1974;108:25-27. 25. Robbins AW, Rutkow 1M. Mesh plug repair and groin hernia surgery.
4. Lifschutz H,Juler GL. The inguinal darn. Arch Surg. 1986;121:717-719. Surg Clin North Am. 1998;78:1007-1023.
51
The McVay Operation
JohnJ. Ryan
Historical Introduction ulous research work, the authors concluded that practically all her-
nia repairs were based on the erroneous theory that the internal
Chester Bidwell McVay was born in Yankton, South Dakota, in oblique and transversus abdominis muscles and fascial fibers nor-
1911. He graduated from Yankton College in 1933 cum laude. Mc- mally insert into the inguinal ligament. 1,2 They explained that "the
Vay then went to Northwestern University in Chicago, and he qual- lowermost fibers of the internal oblique and transversus abdominis
ified both M.D. and Ph.D. While at Northwestern, he did his muscles do not attach to the inguinal ligament, but insert into the
research in the anatomy laboratory, where he concentrated his fibrous covering of the pubic pecten, the ligamentum pubicum
studies on the anatomy of the abdominal wall and the inguinal superiorus (ligament of Cooper}." McVay concluded, therefore,
and femoral regions. This research culminated in several publi- that, to close direct inguinal and femoral hernia defects, the cor-
cations by McVay and his anatomical research associate, Barry J. rect anatomical reconstruction would be to suture the inferior part
Anson. McVay then went on to complete a surgical residency at of the aponeurosis of the transversus abdominis muscle and the
the University of Michigan. On completion of surgical training, transversalis fascia to Cooper's ligament, not to the inguinal
he served in the United States Army and, after World War II, re- (Poupart's) ligament.
turned to his home town of Yankton, where he practiced surgery McVay was not the first to describe this operation. It had previ-
continuously until his retirement in 1977. During his time as a sur- ously been recommended by Lotheissen,3 but only for femoral her-
geon in Yankton, not only did Dr. McVay continue to publish in nia. In 1898, Lotheissen had reported on published experiences
prestigious surgical journals, but he was also instrumental in the with this procedure both for femoral hernia and for recurrent in-
establishment of a 4-year medical school in the state of South guinal hernia. Lotheissen described the exposure of Cooper's lig-
Dakota and in the founding of a general surgical residency pro- ament by retracting the femoral vessels slightly laterally. He then
gram, the first of its kind in South Dakota. In 1977, Sacred Heart approximated the muscular edge of the internal oblique to
Hospital in Yankton was fully approved for general surgical resi- Cooper's ligament with heavy silk sutures. Fischer, in 1919, is cred-
dency training, and Dr. Chester McVay was appointed Founding ited with being the first to introduce this repair to the United
Chairman of the Department of Surgery at the University of South States and published his results of Lotheissen's operation for
Dakota School of Medicine. femoral hernia in the Annals of Surgery in 1919. 4 In the BritishJour-
During Dr. McVay's time as Professor and Chairman at the Uni- nal of Surgery in 1923, Groves 5 reported no recurrences in a series
versity of South Dakota School of Medicine, his reputation grew of 21 cases of femoral hernia using this technique, somewhat mod-
widely, and, on the national level, his numerous observations and ified. In his operation, Groves reported splitting the inguinal lig-
publications on the anatomy of the inguinal and femoral regions ament to gain visibility so that the conjoined tendon could be
and the technique of hernia repair earned him renown in Amer- approximated directly to Cooper's ligament from the pubic tu-
ican surgery. He was a Member and second Vice-President of the bercle laterally to the femoral vessels. In the British Medical Jour-
American Surgical Association, a Regent in the American College nalin 1927, Geoffrey Keynes6 ,7 reported on the modern treatment
of Surgeons, and President of the Central and Western Surgical of hernia and reported that, with this technique in 125 cases of
Associations. Mter a long and distinguished career, Dr. McVay died femoral hernia over a 6-year period, there were only three known
in October 1987. recurrences. In 1936, Dickinson8 further modified the method by
suturing only the transversalis fascia rather than the entire con-
joined tendon to Cooper's ligament.
Development of McVay's Concept It was left to McVay to point out emphatically that the internal
oblique and transversus abdominis fibers do not actually insert
Between 1938 and 1940, Chester B. McVay, in association with into the inguinal ligament, but into the fibers covering the pubic
Barry J. Anson, completed anatomical dissections on over 300 ca- pecten, that is, the ligamentum pubicum superiorus or ligament
davers at Northwestern University, investigating the anatomy of the of Cooper.l,2,9,lO On this anatomical basis, McVay advised suturing
abdominal wall and the inguinal region. As a result of this metic- of the inferior part of the aponeurosis of the transversus abdominis
365

366 J.J. Ryan
and internal oblique to Cooper's ligament in the repair of direct

inguinal, large indirect inguinal, and femoral hernias. This repair
led to superior outcomes, and the results obtained were replicated
by others.!l Thus, the application of the operation originally de-
scribed by Lotheissen was broadened and placed on a sound sci-
entific basis by McVay, and it became known as the McVay hernia
repair.
Technical Aspects
Assumptions obI iq ucz
The principles underlying the technical aspects of the McVay Re- Crczmast<2r
pair are that and fascia
1. The restoration of normal inguinofemoral anatomy is the ba- FIGURE 51.1. Anterior view of small indirect inguinal hernia in a female.
sis of inguinofemoral hernioplasty. It is the opinion of "this author" (McVay) and his "gynecologic consultant's
2. It is anatomically incorrect to use the inguinal ligament in any that the cutting of a round ligament is of no consequence as regards sup-
part of the repair of an inguinal or femoral hernia. port of the uterus." (Reprinted from McVay CB. The pathologic anatomy of
3. The posterior inguinal wall of the inguinal canal is the lower- the more common hernias and their anatomic repair. Springfield, IL: Charles C
most portion of the transversus abdominis aponeurosis; its in- Thomas; 1954, with permission.)
sertion is into Cooper's ligament. The transversalis fascia is
closely adherent to its deep surface, and the strength of the
posterior wall is directly proportional to the number of trans- vein; the sutures incorporate the anterior femoral sheath. Finally,
versus abdominis aponeurotic fibers that it contains. the external oblique aponeurosis is closed over the spermatic
4. A large indirect inguinal, a direct inguinal, and a femoral cord. In the McVay procedure, the end result of reconstruction
hernia are all either encroachments on or defects in this all- of the posterior inguinal wall is the same for a large indirect in-
important posterior inguinal wall. guinal, a direct inguinal, and a femoral hernia (Figs. 51.3 to 51.5).
In all three types, there is a strong free margin of posterior in-
guinal wall above as a result of the removal of all thinned fascial
and aponeurotic components over the direct defect in Hessel-
Technique of Repair bach's triangle.!o
In the case of an indirect inguinal hernia, if the abdominal (deep) In summary, McVay advocated deep inguinal ring repair for all
small, uncomplicated, indirect inguinal hernias after excision and
inguinal ring is not significantly dilated, a femoral hernia does not
high ligation of the hernia sac. In this case, there is no anatomi-
exist, and there is no weakness or herniation of the posterior in-
guinal wall, then McVay recommends "extirpation of the hernial
sac and closure of the abdominal inguinal ring." In this case, the
hernia sac is dissected free of the cord structures distal to the level
of the deep inguinal ring; it is ligated high, and redundant sac
is excised in the conventional manner (Fig. 51.1). The slightly
dilated deep inguinal ring is then snugly closed around the sper-
matic cord by one or two interrupted silk sutures, which approx-
imate the internal oblique aponeurosis, the transversus abdominis,
and the transversalis fascia to the anterior layer of the femoral
sheath (iliopubic tract of Thomson) medial to the cord. The ex-
ternal oblique aponeurosis is then closed over the spermatic cord, , Transv
which lies in its normal anatomical position. , abd.etpon.
In the direct inguinal hernia where the defect is large (Fig. (attenuatQd
51.2), McVay recommends excision of the attenuated aponeurotic by hernia)
fascial components of the posterior inguinal wall from the deep Fcm"l.oral
inguinal ring to the pubic tubercle. A relaxing incision is made sb~th
in the anterior rectus sheath in order that the structures can be
In~ulnal li~.
approximated without tension. Reconstruction begins with the in-
cision of the transversalis fascia from near the pubic tubercle to
the deep inguinal ring; below this incision line the transversalis
FIGURE 51.2. Anterior view of a direct inguinal hernia. The bulge of the
fascia is known as the anterior femoral sheath. The internal oblique, hernia is covered by attenuated transversus abdominis aponeurosis and
transversus abdominis, and transversalis fascia layer is approxi- transversalis fascia. (Reprinted from McVay CB. The pathologic anatomy of
mated with interrupted sutures to Cooper's ligament, beginning the more common hernias and their anatomic repair. Springfield, IL: Charles C
near the pubic tubercle and progressing laterally to the femoral Thomas; 1954, with permission.)
51. The McVay Operation 367
lata
In~uinal li~.
FIGURE 51.5. Reconstructed posterior wall of the inguinal canal. (1) Trans-
FIGURE 51.3. Anterior view of a femoral hernia. The anatomical defect is
versus arch brought down to Cooper's ligament and extending laterally to
a narrowing of the insertion of the posterior inguinal wall (transversus ab-
3 to 4 mm from the femoral vein. (2) Transition suture, so-called because
dominis aponeurosis) into Cooper's ligament. (Reprinted from McVay CB.
"the transversus abdominis aponeurosis with fused transversalis fascia
The pathologic anatomy of the more common hernias and their anatomic repair.
makes the transition from the deeply placed ligament of Cooper to the
Springfield, IL: Charles C Thomas; 1954, with permission.)
more superficially placed anterior femoral sheath ... but because this is
usually a very thin layer, it also picks up the fascia of the pectineus mus-
cle." (3) Inclusion of anterior femoral sheath for a snug deep ring.
cal defect in the posterior inguinal wall, and no additional repair (Reprinted from McVay CB. The pathologic anatomy of the more common her-
is necessary. In the case of direct, large indirect, and femoral hernias and their anatomic repair. Springfield, IL: Charles C Thomas; 1954, with
nias, however, reconstruction of the posterior inguinal wall is re- permission.)
quired. McVay demonstrated that these three types of hernia are
all defects in the posterior wall, which is, in effect, the transversus References
abdominis aponeurosis. Logical repair requires a reconstructive
procedure based on meticulous anatomical studies and surgical 1. McVay CB. An anatomic error in current methods of inguinal hernior-
demonstration to restore normal inguinal anatomy.12 rhaphy. Ann Surg. 1941;113:1111-1112.
2. McVay CB, Anson BJ. A fundamental error in current methods of in-
guinal herniorrhaphy. Surg Gynecol Obstet. 1942;74:746-750.
3. Lotheissen G. Zur radikaloperation der schenkelhernien [Radical op-
eration of the femoral hernia]. Z Chir. 1898;25:548-550.
4. Fischer H. Lotheissen's operation for femoral hernia. Ann Surg. 1919;
69:432-434.
5. Groves EWH. A note on the operation for the radical cure of femoral
hernia. BrJ Surg. 1923;10:529-531.
6. Keynes G. The modem treatment of hernia. BMJ 1927;1:173-179.
7. Keynes G. The modem treatment of hernia. BMJ 1927;1:595-596.
8. Dickinson AR. Femoral hernia. Surg Gynecol Obstet. 1936;63:665-669.
9. McVay CB. Inguinal and femoral hernioplasty; anatomic repair. Arch
Surg. 1948;57:524.
10. McVay CB, Anson BJ. Inguinal and femoral hernioplasty. Surg Gynecol
Obstet. 1949;88:473-485.
11. Harkins HN, Szilagyi MS, Brush BE, et al. Clinical experiences with
the McVay herniotomy. Surgery. 1942;12:364-377.
12. McVay CB. Inguinal and femoral hernioplasty anatomic repair. Arch
Surg. 1948;57:524-530.
Commentary
FIGURE 51.4. All attenuated posterior inguinal wall tissues are excised,
demonstrating Cooper's ligament and the femoral sheath. Care must be
exercised when identifying and ligating, if need be, the aberrant obtura-
Robert Bendavid
tor vessels. Relaxing incision involves the rectus sheath (transversus ab-
dominis and internal oblique aponeuroses) in the repair. (Reprinted from The operation that has been referred to as the McVay repair, the
McVay CB. The pathologic anatomy of the more common hernias and their anatomic Lotheissen repair, the Lotheissen-McVay repair, and the Cooper's
repair. Springfield, IL: Charles C Thomas; 1954, with permission.) ligament repair should all along have been called the Narath re-
52
The Shouldice Repair
Robert Bendavid
Introduction nal aspect of the repair was established in 1952, thanks to the con-
certed efforts of E.E. Shouldice, N. Obney, and E.A. Ryan, all sur-
The Shouldice repair is a pure tissue repair designed to correct geons on staff at that time.
direct and indirect inguinal hernias. The advantages of the repair
are (1) the thorough dissection and demonstration of the inguinal
anatomy, (2) surgery under local anesthesia, and (3) earlyambu- General Principles
lation.
To date, more than 250,000 operations have been carried out on
every conceivable hernia of tlIe abdominal wall. That experience
History has been carefully recorded to be shared.
The Shouldice repair has also been called the Canadian repair
and the Bassini-Shouldice repair. 1•2 Ironically, Bassini ushered in Weight Control
the modem era of herniorrhaphies at the end of the nineteenth
century,3 while the Shouldice operation remains a popular pure It has always been the custom to encourage patients at tlIe
tissue repair at the end of the twentieth, 116 years later! There Shouldice Hospital to lose weight before surgery. The advantages
have been over 79 attempts at various pure tissue repairs in that are obvious in tlIat tlIere is a lesser requirement of medication, se-
interval. 4 The fact that the Shouldice operation prevails is an in- dation, and local anestlIesia. Dissection is easier and less exten-
dication of the excellence of Bassini's original contribution. The sive. There is a lesser incidence of wound infections (less than 1%
two operations vary but little, and the essential difference is in the every year). Most of all, earlier ambulation allows elimination of
reconstruction of the posterior inguinal wall, which in the Bassini deep venous thrombophlebitis and pulmonary emboli, which I
repair is carried out with interrupted sutures while the Shouldice have not seen in 20 years. AltlIough obesity is an established fac-
uses continuous sutures back and forth (four lines), creating an tor for recurrence in incisional hernias, the same does not hold
overlap, as is described later. for inguinal hernias. 6 An interesting paradox!
The importance of the Shouldice contribution lies even more
importantly in the emphasis and later wide acceptance of local
anesthesia for what should not be considered minor surgery. Al- Incision of the Transversalis Fascia
though cocaine local anesthesia had been introduced in hernia
repairs by Halsted and by Cushing,5 it was E.E. Shouldice who es- The incision of tlIe transversalis fascia is very important. It is car-
tablished it convincingly and on a massive scale (in more than ried out from tlIe medial aspect of tlIe internal ring to the pubic
6000 cases a year). crest tlIrough tlIe anterior and posterior lamellae of the transver-
Another asset of the Shouldice contribution is earlyambulation. salis fascia. The space of Bogros is entered and recognized by tlIe
Realizing that children who underwent herniorrhaphies could not glistening, clear appearance of preperitoneal fat. This step allows
be easily kept in bed, E.E. Shouldice encouraged the same atti- a tlIorough search for secondary hernias, which occur in 13% of
tude for adults. Going a step further, these patients are put through patients operated on at tlIe Shouldice Hospital. These hernias,
mild, nonstrenuous exercises: stretch, flexion, extension. Not least when not recognized intraoperatively, take on tlIe appearance of
in importance to the success of the Shouldice institution is the an early recurrence when in fact they are "missed hernias." These
dedication of a team of surgeons to whom hernia repairs have be- overlooked hernias can be direct or indirect but also low spigelian,
come second nature. In fact, the surgeon at that institution does interstitial, Laugier, femoral, and paravesical hernias.
in 2 years 1400 to 1600 operations, as many hernia cases as the av- A major asset of entering tlIe space of Bogros is the identifica-
erage general surgeon does in a lifetime! tion of tissues of adequate consistence for reconstruction of a pos-
Although the Shouldice Hospital was established in 1945, the fi- terior inguinal wall, namely, the rectus, tlIe transversus abdominis,
370
52. The Shouldice Repair 371
and the internal oblique. Simultaneously, incision of the trans- Relaxing Incision
versalis fascia eliminates the possibility of using it by imbrication,
a technique that has contributed to the corruption of the Bassini First described by Wolfler in 1892, the relaxing incision has en-
and Shouldice repairs, with the expected poor results. Women joyed acceptance as an adjunct to hernia repair. Reintroduced
rarely have direct inguinal hernias (0.2% of all groin hernias); since by several authors, Halsted and Tanner in particular, it has
therefore, the posterior wall should be left intact. been widely practiced in the McVay repair.!4 I have used it gener-
ously in about 10% of my Shouldice repairs, thus providing a type
of tension-free pure tissue repair. It should extend from the level
The Hernial Sac of the pubic crest to the level of the internal ring, more or less
parallel to the transversus arch, as far medially as feasible on the
The high ligation of a hernial sac has been a hallowed practice conjoined tendon or the anterior rectus sheath.
since it was first proposed by Banks in 1887.8 This practice is not
necessary, as demonstrated by E. Ryan 9 and D. Welsh. 1O In fact, Suturing and Stainless Steel Wire
the practice may be dangerous particularly in female infants who
often have ovaries and fallopian tubes as a sliding component to Shouldice repair means stainless steel suture. E.E. Shouldice ex-
their hernia.!1 perienced complications with the use of silk in the late 1940s and
What is important, however, is a thorough dissection at the in- early 1950s: chronic, infected, discharging sinuses. Stainless steel
ternal ring, freeing the hernial sac from the surrounding adhe- sutures had been introduced in 1941 by Jones et al.,15 and its use
sions to the transversalis fascia layers and the overlying, though to was endorsed by Abel and Hunt16 in 1948. It is an ideal material,
varying degrees, cremaster muscle fibers, so that the sac may re- not all that difficult to use, and very inexpensive. Its major advan-
duce of itself into the preperitoneal space. It is the solidity of the tage lies in the fact that, in case of infection, this suture material
reconstructed posterior inguinal wall that will guarantee the so- need not be removed, and draining sinuses will not complicate
lidity of a repair. wound healing.
The important drawback of stainless steel is that the ends of the
wire can penetrate glove and skin, sometimes painfully so, leaving
Incision of the Cribriform Fascia the surgeon with the nightmare of wondering whether the patient
is a carrier of a deadly virus. Another technical aspect of wire is
Below the fibers of the inguinal ligament lies the cribriform fas- that it cannot be allowed to kink or it will lose its tensile strength
cia, which is an extension of the fascia lata of the thigh. The in- and may snap. The suture is continuous in order to distribute
cision of this fascia from the level of the femoral artery to the pubic evenly the tension of the repair, as well as to eliminate the defects
crest will reveal, if present, femoral and prefemoral hernias. Of- between sutures inherent to repairs with interrupted sutures. Many
ten, a femoral fat tab may be seen. It should not be dissected prox- surgeons use Prolene® sutures without deleterions effect.
imal to its neck; instead, it should be simply resected flush with
the femoral opening and the defect closed with a single nonab-
sorbable suture. This femoral fat tab serves the purpose of plug- Technical Aspects of the
ging a defect and should be left in place.
Shouldice Repair
Sedation
Resection of the Cremaster
Preoperative sedation consists of diazepam (Valium®) 10 to 20 mg
Resection of the cremaster is an important and integral part of orally 90 minutes before surgery and pethidine hydrochloride
the Shouldice repair. Introduced by Bassini, it allows a thorough (Demerol®) 25 to 100 mg intramuscularly 45 minutes before
examination for the presence of an indirect inguinal hernia. 12 The surgery.
possibility would seem farfetched that a general surgeon would
miss or overlook an indirect sac, yet the study by Obney and Chan 13
revealed that 37% of recurrent inguinal hernias are in fact indi- Local Anesthesia
rect (Table 52.1).
Procaine hydrochloride (Novocain®) 1 % is still used at the
Shouldice Hospital. It is safe, of rapid onset within 2 to 5 minutes,
TABLE 52.1. Types of hernia that were observed in a series of 1057 patients and may last up to 1 hour. Maximum volume used is 200 cc (of
referred to the Shouldice Hospital 1 %) or 100 cc (of 2%). It has not been associated with malignant
Type Recurrence (%) hyperthermia. Local anesthesia is injected intradermally first to
raise a bleb just inferior and medial to the anterior superior iliac
Direct inguinal hernia 45.0 spine and then subcutaneously along a line joining to the pubic
Medial floor 69.2 crest (Fig. 52.1). This infiltration may require 30 to 50 cc. When
Lateral floor 7.7 the skin has been incised and the bleeders tied or coagulated, the
Entire floor 23.1 skin edges are retracted to expose the external oblique aponeu-
Indirect inguinal hernia 37.0
rosis. Now, 15 to 30 cc are injected deep to the external oblique
Femoral hernia 8.0
aponeurosis, allowing the Novocain to spread (Fig. 52.2). The ex-
Two or more hernias 10.0
ternal oblique aponeurosis is now incised and the edges retracted,
372 R. Bendavid
,
~umbilicus
~TL/~
inferior epigastric
FIGURE 52.3. Exposure of the spermatic cord. An indirect inguinal hernia

is iden tifled.
FIGURE 52.1. Local anesthesia along a line from the anterior superior iliac
spine to the pubic crest. Incision also follows this line. medial flap of the external oblique aponeurosis is freed from its
underlying loose areolar tissue as far medially as the edge of the
allowing identification of the iliohypogastric and ilioinguinal rectus sheath. The same thing is done laterally, freeing the lateral
nerves and the genital branch of the genitofemoral nerve. Each flap of the external oblique aponeurosis from the overlying sper-
nerve can be separately infiltrated with 1 to 2 cc of Novo cain, which matic cord and cremaster.
is also injected around the internal ring (5 to 10 cc) (Fig. 52.3). The cremaster muscle is now divided along the direction of its
Novocain is also injected along the linea semilunaris from the pu- fibers from the level of the pubic crest to the internal ring. The
bis toward the internal ring to block sympathetic pain fibers pre- medial flap of the cremasteric is resected flush with the under-
sent at that level. lying internal oblique muscle or aponeurosis. On occasion, there
is a bleeder at the proximal end of this cremaster flap, and it is
ligated or cauterized. The lateral half of the cremaster, which con-
Dissection tains the external spermatic vessels and the genital branch of the
genitofemoral nerve, is doubly clamped and divided between the
Mter incision of the external oblique aponeurosis along the di- clamps, and each stump is doubly ligated with an absorbable su-
rection of its fibers, the lateral flap is held up with forceps and the ture (Fig. 52.5).
cribriform fascia is incised from the level of the femoral artery to At this stage, an indirect sac, if present, is dissected from the
the pubic crest, and the femoral orifice is checked (Fig. 52.4). The cord at the internal ring, opened and inspected, and then resected
or simply dropped back into the preperitoneal space.
FIGURE52.2. Local anesthetic should be generously injected deep to the FIGURE 52.4. The cremaster muscle is divided longitudinally from pubic
aponeurosis of the external oblique. crest to internal ring.
space of Bogros one can note a venous complex that forms a cir-
cle through the iliopubic vein, inferior epigastric veins, and rec-
tusial vein. Careless laceration of these veins can be the source of
an important bleed.
Reconstruction of the Posterior Inguinal Wall

Stainless steel as a continuous suture is used to reconstruct the
posterior inguinal wall. Two sutures are used, and each suture will
provide two "lines." The first suture will provide lines 1 and 2, and
the second suture will provide lines 3 and 4.
The first line begins near the pubis, approaching the iliopubic
tract from a lateral direction, including it and crossing over to en-
ter successively the transversalis fascia, the lateral edge of the rec-
tus, the transversus abdominis, and the internal oblique (Fig.
52.7). A knot is tied. Line one continues, repeating the same moves
until midway between the pubic crest and the internal ring, where
the rectus muscle goes in a more vertical direction and is there-
FIGURE 52.5. The undersurface of the inguinal ligament, medial to the
fore no longer available for inclusion in the new wall. The suture
femoral artery and vein, is freed from the thigh fascia to rule out femoral
continues to the level of the internal ring, where it will pick up
hernias and femoral fat tabs.
the lateral cremasteric stump. While going through the triple layer
medially, the suture carries the cremasteric stump deep to the
Now the posterior inguinal wall is assessed. In females this wall is triple layer of transversalis fascia, transversus abdominis, and in-
usually muscular and thick and need not be incised. In males, this ternal oblique.
wall will be incised from the medial aspect of the internal ring to All along, this first line left a free border of the triple layer, as
the pubic crest (Fig. 52.6). If a direct inguinal hernia is present, the shown in Figs. 52.8 and 52.9. The suture now reverses its course
redundant transversalis fascia is resected, leaving laterally a 1 cm toward the pubic crest as line 2, incorporating this free edge of
wide iliopubic tract, while medially the new edge is the lateral bor- triple layer and approximating it to the inguinal ligament (Fig.
der of the internal oblique-transversus abdominis layers. Medially 52.10). A knot is tied at the level of the pubic crest.
one can see the lateral edge of the rectus muscle. It is of interest to Line 3, with the second suture, begins at the internal ring, picks
note that the incision of the transversalis fascia goes through two up the triple layer (though blindly), and then crosses over to pick
layers or lamellae, the anterior thicker than the posterior, which is up the lower and inner side of the external oblique aponeurosis
very thin and diaphanous. This posterior layer forms at the deeper along a line parallel to the inguinal ligament all the way to the pu-
aspect of the internal ring another ring that Read17 calls the sec- bic crest, where it reverses its course to redirect toward the inter-
ondary internal abdominal ring and that I have seen to create an nal ring as line 4 (Figs. 52.11 to 52.13). Note that the medial one
incarceration of an indirect inguinal sac on two occasions. third of the lateral flap of the external oblique aponeurosis has
At this stage a search is carried out for femoral, Laugier, inter- been used to cover the medial portion of the repair, just lateral to
stitial, low spigelian, supravesical, and prevascular hernias. In the the pubic crest, a site of predilection for recurrences.
FIGURE 52.6. Splitting of the transversalis fascia from the internal ring to FIGURE 52.7. Appearance following completed dissection. Note the mar-
the pubic crest (in all males, as well as females who require it). ginal vein. Note the beginning of the first line of suture.
374 R. Bendavid
FIGURE 52.10. Second line of the first suture, returning to the pubic crest
to be tied.
FIGURE 52.8. First line of the first suture continued.
The spennatic cord is placed back in its nonnal anatomical bed,

and the free edges of the external oblique aponeurosis are ap-
Complications
proximated over it (Fig. 52.14). The subcutaneous tissues are ap-
Local anesthesia, early ambulation, and the long experience and
proximated with Vicryl® and the skin closed with Michel clips.
expertise of dedicated surgeons have reduced complications to the
degree that groin hernia repairs are considered "minor proce-
Postoperative Course dures." The incidence of testicular atrophy following primary in-
guinal hernia repairs is 0.036%, and after recurrent hernia repairs
Following surgery, the patient stands up and walks from the op- it is 0.46%.18 Hematomas, at 0.3% incidence, rarely require ex-
erating table and is then wheeled to his room. During 4 hours in ploration. Infections occur at the rate of less than 1%, due to the
bed, the preoperative sedation will be eliminated, after which the absence of nosocomial pathogenic flora associated with contami-
patient is free to move as he pleases. During the following 48 to nated surgery, which is never perfonned at the Shouldice Hospi-
72 hours, light exercises are perfonned to the accompaniment of tal. The rate of occurrence ofhydroceles is 0.7% and dysejaculation,
music. Mter 24 hours, half of the Michel clips are removed, the 0.25%. Mortality is not associated with the act of surgery and is on
remainder to be removed at 48 hours. the order of 0.009% in patients with an average age of 70 years: 15
FIGURE 52.11. The third line of suture. This is a different wire, which will
FIGURE 52.9. End of first line of the first suture and incorporation of the begin at the internal ring, go toward the pubic crest, and return as the
cremasteric stump. fourth line to be tied at the internal ring.
FIGURE 52.12. Continuation of the third line. FIGURE 52.14. Closure of external oblique aponeurosis.
myocardial infarctions, cerebrovascular accident in 1 patient, and

undetermined in 4 patients, aged 56, 66, 70, and 78 years over a
2D-year period. The cumulative recurrence rate for inguinal her- References
nias at the Shouldice Hospital is posted as less than 0.5% for pri-
maries and 1.5% following repair of recurrences. 1. Wantz G. The operation of Bassini as described by Attilio Catterina.
2. Read R. The centenary of Bassini's contribution to inguinal hernior-
Conclusion rhaphy. Am] Surg. 1987;153:324.
3. Bassini E. Nuovo metodo operativo per la cura radicale dell'ernia in-
The Shouldice Hospital has provided a significant literature on its guinale. Arch Soc ltal Chir. 1887;4:380.
4. Bendavid R. New technique in hernia repair. World] Surg. 1989;
250,000 and more operations on abdominal wall hernias, to be
13(5):522.
shared by the surgical community. The Shouldice repair is an ex- 5. Cushing H. The employment of local anaesthesia in the radical cure
ample of surgical sobriety, without pretense, with good results, at of certain cases of hernia, with a note upon the nervous anatomy of
a reasonable cost. the inguinal region. Ann Surg. 1900;31:1.
6. Abrahamson]. Factors and mechanisms leading to recurrence. Probl
Gen Surg. 1995;12(1):59-67.
7. Glassow F. Inguinal hernia in the female. Surg Gynecol Obstet. 1963;
116:701.
8. Banks WM. Some statistics on operation for the radical cure of her-
nia. BM]. 1887;1:1259.
9. Ryan EA. An analysis of 313 consecutive cases of indirect sliding in-
guinal hernias. Surg Gynecol Obstet. 1956;102:45-58.
10. Welsh DR]. Repair of indirect sliding inguinal hernias.] Abdom Surg.
1969;Il(lO) :204-209.
11. Koop CEo Inguinal hernias in infants and children. Surg Clin North Am.
1957;Dec:l675-1682.
12. Catterina A. The Bassini operation. Bologna: L. Capelli; 1932.
13. Obney N, Chan CK Repair of multiple time recurrent inguinal her-
nias. Contemp Surg. 1984;25:25-32.
14. Ponka]. Hernias of the abdominal walL Philadelphia: W.B. Saunders;
1980:525-533.
15. Jones TE, Newell ET, Brubaker RE. The use of alloy steel wire in the
closure of abdominal wounds. Surg Gynecol Obstet. 1948;2:379.
16. Abel AL, Hunt A. Stainless steel wire for closing abdominal incisions
and for the repair of hernias. BM]. 1948;2:379.
17. Read RC. Conceptual problems regarding hernial rings in the groin.
Probl Gen Surg. 1995;12(1):27-33.
18. Bendavid R, Andrews DF, Gilbert AI. Testicular atrophy: incidence and
relationship to the type of hernia and to multiple recurrent hernias.
FIGURE 52.13. Fourth line of suture. Probl Gen Surg. 1995;12(2):225-227.
Introduction to Tension-Free Repairs
Robert Bendavid
In surgery, the word tension is ominous. Whether in an intestinal

anastomosis, an abdominal wall repair, a pedicle graft, or a vas-
cular prosthesis, tension bedevils the outcome. Avoidance of ten-
sion is therefore a surgeon's ideal whenever structures must be
joined together. It was to be expected that the words tension free
would eventually become a marketable slogan and that a panoply
of techniques would be developed, all proudly bearing this sobri-
quet. Before the introduction of mesh, the phrase meant the ex-
tensive mobilization of tissues by dissection and relaxing incisions;
these have served us well in the past and will always be useful.
The trend of the past 30 years has been the incursion of the FIGURE C52.1. Prosthesis made of nylon, used by Aquaviva in 1944 and sub-
plastics industry into the surgical arena, in response at first to a sequently by Zagdoun and Sordinas (1959) .
perceived need and then to the opportunities for invention, man-
ufacturing, and marketing of sheets and readymade, often "one-
size-fits-all," devices. Tension-free repairs using these implants are
easy to perform and to learn; they can be done under local anes- credits, once again, in Winston Churchill's phrase, "Truth is the
thesia and have become very popular for these reasons. The short- victim." The earliest documented tension-free inguinal hernia re-
term results will be good, and probably the long term also, in pair was carried out by Aquaviva of Marseilles, France, in 1944. His
well-selected applications. Plugs and ready made inserts cannot, prosthesis was made of nylon and was the prototype for many of
however, be used satisfactorily in inguinofemoral hernias or in the the readymade onlay meshes. Sordinas wrote a doctoral thesis on
absence of an inguinal ligament. The major drawback is that they Aquaviva's technique in 1959 3 and in the same year published with
do not address the problem of the disease process in tissues adja- Zagdoun a series of 200 cases 4 using a sagittate, or arrowhead-
cent to the defect. Perhaps more importantly, there is a certain shaped, prosthesis (Fig. C52.1).
neglect of anatomy as a discipline and the principles of surgical Perhaps by further delving into the past we may discover what
practice. We have all heard the quip, "With the plug you don't lies ahead and beyond laparoscopy!
need to know anatomy" (or, for that matter, to understand the dis-
ease)! Time, harsh but fair, will be the judge.
The paternity of the tension-free operation has been disputed. References
Richard Newman (1956) is credited by Irving Lichtenstein l as be-
ing the "originator," although Lichtenstein himself was more suc- 1. Lichtenstein IL. Hernia repair without disability. 2nd ed. Tokyo: Ishiyaku
Euroamerica, Inc.; 1986:x.
cessful at promoting the technique that bears his name. Charles
2. Usher FC, Ochsner JL, Tuttle LL. Use of Marlex mesh in the repair of
Darwin's son, Sir Francis Darwin, remarked in 1914, "In science, incisional hernias. Ann Surg. 1958;24:69.
the credit goes to the man that convinces the world, not to the 3. Sordinas A. These medicale, Paris, 1959.
man to whom the idea first occurs." Francis Usher, who gave us 4. Zagdoun J, Sordinas A. L'utilisation des plaques de nylon dans la
first polyethylene and then polypropylene, introduced mesh pros- chirurgie des hernies inguinales. Academie de Chirurgie, France.
theses in tension-free operations as early as 1958. 2 In the war of Seance du 25 novembre, 1959.
376

53
Gilbert's Repair of Inguinal Hernias
Arthur I. Gilbert, Michael F. Graham, and Walter J. Voigt
It may seem strange that, after centuries of effort to understand Lotheissen, of Austria, contributed a repair based on restoring
and cope with a condition that affects more than 750,000 adults the continuity of what he believed were true anatomical tissue
yearly in the United States alone, new methods of repair are con- planes. 4 His repair, later popularized by Anson and McVay, of
stantly being described. The reason is clear: Surgeons are on a South Dakota, enjoyed a period of interest, but in the past 15 years
continuous quest to develop the ideal operation that will produce it has steadily lost popularity. It caused considerable and prolonged
the least discomfort, result in the fewest failures, and yet be sim- postoperative pain, and in many cases the repair failed because of
ple and safe enough to be performed on most patients by most the excessive suture line tension created when approximating the
general surgeons. transversus arch to Cooper ligament.
The design of a double-layer mesh device for groin hernia re- Halsted, of]ohns Hopkins, developed a four-layer repair for in-
pair was influenced by the results obtained from personal series guinal hernia at about the same time as Bassini's work. 5 Halsted's
using variations of a basic method and by reports in the surgical repair proved to have a basic flaw. Because the spermatic cord was
literature. These included techniques that employ flat mesh and brought out anterior to the external oblique aponeurosis, the ex-
others that use preformed prosthetic devices. Incorporated in this ternal ring was placed directly over the internal ring, creating a
new device is a doubly protective barrier, which repairs the pre- "straight shot" for reherniation, which came to be known as "tele-
senting defect in the groin and protects the remainder of the myo- scoping." Cooper had described the external oblique aponeurosis
pectineal orifice against hernia. as the "outer barrier" of the inguinal canal, and Halsted's repair
forfeited the protection of that barrier and the "stepdown" of the
spermatic cord, considered to be another protective feature of the
natural anatomy of the groin. Over the years, this flawed repair
Lessons from History has been responsible for many recurrent indirect hernias.
Shouldice, of Toronto, reincarnated Bassini's original opera-
Bassini of Padua is credited with ushering in the modem era of tion. 6 He and his staff, in a surgical practice devoted exclusively
hernia surgery. Through an anterior approach in the groin, he di- to abdominal wall hernia surgery, showed that the results can be
vided the posterior wall of the inguinal canal, ligated the peri- optimized when surgeons limit their surgical repertoire and de-
toneal sac in the iliac fossa, and carried out a sutured three-layer vote their entire activity to a particular field. Shouldice popular-
repair. At the end of the nineteenth century his approach departed ized groin herniorrhaphy under local anesthesia, enabling patients
so much from other procedures of the time that he called his op- to return promptly to normal activities. The Shouldice operation
eration "the radical cure of inguinal hernia." He used his tech- became the gold standard for tissue repairs by the middle of the
nique in 262 patients with a less than 3% failure rate, an amazing twentieth century and remained so until the concept of tension-
accomplishment for his era. l That his repair was a functional free surgery was introduced. The Shouldice Hospital has been a
hernioplasty rather than an anatomical reconstruction of groin valuable resource for surgeons interested in herniology. For over
anatomy was later pointed out by Anson and McVay. 2 Worldwide half a century, surgeons from around the world have gained im-
communication was so slow at the end of the nineteenth century measurable knowledge from their visits to the Shouldice Hospital.
that it took years for Bassini's work to be disseminated through-
out the world surgical community. By the time many surgeons
heard of his technique, it had been so altered that results were
much less impressive. None of the modifications to Bassini's tech- Tension-Free Repairs
nique improved on the original, and most resulted in higher fail-
ure rates. 3 Nevertheless, a modification that approximated the Biomaterials ushered in the current era of herniology, that of
transversus arch to the shelving edge of the inguinal ligament with tension-free hernioplasties. Various natural and synthetic materi-
interrupted sutures, known as the "Modified, or North American, als, including dermis, dura, aorta, pericardium, carbon fibers, tan-
Bassini repair," became the standard technique taught to surgical talum, Dacron®, fiberglass, nylon, stainless steel, polypropylene,
residents for some time. and polytetrafluoroethylene, have been tried. Each had some dis-
377
378 A.1. Gilbert et al.
advantage that limited its use. Usher et al} in 1958, successfully

employed polyethylene mesh to reinforce some difficult hernias,
but it was not heat-resistant and could not be autoclaved. In 1962,
polypropylene was introduced into the field of hernia repair. Be-
cause of its safe integration into abdominal wall tissues and its ef-
fectiveness in hernia repair, it became and has remained the
exemplar of mesh prostheses. Used initially to supplement tissue
approximation techniques, polypropylene is the material most of-
ten used in tension-free and incisional repairs.
Lichtenstein, of California, used it as an internal binder for
incisional hernia repair and, as a rolled plug, for tension-free "2-
suture" repairs of femoral hernias and type 5 inguinal hernias. 8
Richard Newman, of New Jersey, in an impressively large series,
simulated the tension-free technique of Marlex®mesh inguinal re-
pair described in 1960 by Usher et a1. 9 Mter successfully using his
technique in 1600 repairs, Newman passed it on to Lichtenstein,
who popularized it. Lichtenstein's tension-free hernioplasty is cur-
rently the most frequently performed open hernia repair used in
the United States, possibly in the world.l°
Polypropylene mesh was originally available as flat mesh. En- FIGURE 53.1. Prolene Hernia System double-layer mesh device.
couraged by the work of Shockett ll in 1984, we began using it rou-
tinely for all primary and recurrent hernias. By adding a swatch
of polypropylene mesh deep to the first layer of a Shouldice re- patch anterior to the defective layer. 20 Posterior approaches, in-
pair, we reduced failures from 2% to less than 0.5% in primary cluding laparoscopy, employ a mesh sheet or patch placed between
hernias and from 8% to 3% in recurrent hernias. Polypropylene the herniating mass and the abdominal wall defect. 21 .22 Each of
is currently available in various sizes and shapes under different these techniques has merit, but only the posterior approach gives
proprietary names from numerous surgical supply companies. lasting protection to the entire myopectineal orifice. 23 Improper
Even before the open tension-free anterior repair of inguinal use of prosthetic material causes failed repairs. 24
hernias became popular, open posterior preperitoneal repairs at- A new double-layered device was designed for the repair of pri-
tracted interest through the publications of Nyhus of Chicago, mary and recurrent inguinal hernias and the permanent protec-
Condon of Milwaukee, and Stoppa and Rives of France.12 .13 They tion of the myopectineal orifice. One author (A.G.) acted as a
helped to expand awareness of the posterior open approaches de- consultant to Ethicon, Inc., in the design of the Prolene Hernia
scribed by Cheatle 14 and Henryl5 to the repair of inguinal and System® mesh device (Fig. 53.1).·Mter it was approved, the sur-
femoral hernias. Stoppa and Rives deserve credit for employing geons of the Hernia Institute were furnished with a modest sup-
mesh in tension-free techniques through an open posterior apply of the initial prototype to explore various techniques of
proach. 16 Their concept of wrapping the peritoneal sac with a bar- insertion and to advise the manufacturer of the need for modifi-
rier of nonabsorbable prosthetic mesh assisted in the development cations such as a variety of sizes.
of laparoscopic hernia surgery. Attempts at pure tissue laparo-
scopic repair failed, and it quickly became evident to pioneers in
laparoscopy that a tension-free repair with mesh was the way to Functional Considerations
achieve a reasonable measure of success.
It is important to consider the elasticity of the canal's posterior
wall and the deforming effect on vulnerable tissues surrounding
Renaissance in Herniology the defect when repairing an inguinal hernia, especially when any
prosthetic device is used. Elasticity, in this context, is the physical
Hernia repair was traditionally considered a first-year resident's ability of any tissue layer to return to its original shape after it has
simple procedure; now it is recognized to be more challenging, been distended. Deformation is the destructive or degenerative ef-
and more senior surgical trainees now seek opportunities to perfect on a tissue that compromises its integrity. Plugs can be placed
form it. The increase in international conferences devoted to the in the internal inguinal ring, in indirect hernias, or in the defect
subject, the varieties of research into hernia etiology, the interest of direct hernias. The problem created by plug repairs of primary
shown by manufacturers in making available a great variety of in- hernias is that the rest of the canal's unprotected posterior wall,
dividually packaged sterile devices and flat meshes, and the ex- medial and lateral to the widened internal ring or the direct de-
ploration of laparoscopic techniques-these are aspects of the fect, is still subject to strain, and the risk of herniation rises at these
surge of interest and creativity of the past decade. points of lower resistance. Recurrences have been reported with
Most general surgeons have switched from classic pure tissue re- anterior onlay patches when the tails that accommodate the sper-
pairs, which yield less than ideal results, to tension-free techniques matic cord were cut too short (Fig. 53.2) or if they were not over-
using some type of prosthetic material. lO Anterior approaches in- lapped, allowing exposed posterior wall tissue to protrude between
clude various plug and patch techniques. Lichtenstein,17 in 1970, them (Fig. 53.3). Cases of recurrent indirect hernias have been
described a plug repair for femoral hernia. Plug techniques se- reported after the use of onlay grafts when nothing was done to
cure a rolled or manufactured mesh plug within the internal ring protect a widened internal ring: A peritoneal sac protruded be-
or within an actual defect. 18.19 Anterior patch techniques fit a mesh tween the posterior wall and the onlay patch. It is clear that an an-
53. Gilbert's Repair 379
Teale Prevascular
Ring
FIGURE 53.2. Mesh-only graft with short tails around spermatic cord.
FIGURE 53.4. Femoral hernias through inferior half of myopectineal

orifice.
terior patch acts only as a lid, not a stopper. Neither the plug nor
the anterior patch technique affords any degree of protection
against herniation that presents through the inferior half of the
myopectineal orifice (Fig. 53.4). Completion of the repair requires prevention of any portion of
the peritoneal sac from protruding through the deep inguinal
ring. Of the various techniques that we have used over the past 15
Gilbert's Repair of Inguinal Hernias years, each has principally employed a swatch of polypropylene
mesh placed in the preperitoneal space. Just as the pressure ofwa-
The basic principle applied to every type of indirect inguinal her- ter in a tub holds the stopper in place, the preperitoneal mesh in
nia repair is to reduce the herniated peritoneum and its contents each repair is held in place against the abdominal wall by normal
into the abdominal cavity and to prevent reherniation by restor- intraabdominal pressure. Since 1985, we have observed this prin-
ing the competency of the internal ring. To be successful, the re- ciple in the successful repair of all primary and most recurrent in-
pair must permanently close the musculoaponeurotic plane of direct inguinal hernias.
the abdominal wall. The portion of peritoneal sac that protrudes Our original technique and its two later generations embodied
through the deep inguinal ring must be reduced from that plane. the same three features: (1) The deep inguinal ring is a convenient
A long or large peritoneal sac should be divided and its proximal passageway to be used to get to the preperitoneal retromuscular
portion is fully dissected, ligated, and reduced. Regardless of how space; (2) polypropylene mesh is an excellent permanent barrier
the distal portion of the sac is treated, meticulous dissection to the to protect the deep inguinal ring; and (3) the body's intraabdom-
level of the true neck of the sac is required to free it from its at- inal pressure is sufficient to maintain the mesh in its preperitoneal
tachmeu'ts at the myofascial threshold of the deep ring. position.
Prolene Hernia System

The newest version of polypropylene mesh patch was conceived
as a three-dimensional device. It can be used to repair all types of
inguinal hernias. It is a three-in-one attached device that functions
as a unit. It has an underlay graft and an onlay graft, held together
by a connector. The device comes in three sizes, medium, large,
and extended (Table 53.1).
131< TABLE 53.1. Sizes of Prolene Hernia System
Descriptive name Onlay (em) Underlay (em) Connector (em)
Medium 10 7.5 1.5

Large 10 10 1.5
FIGURE 53.3. Opening in tails with a lipoma or peritoneum herniating Extended 12.5 10 1.5
through.
380 A.I. Gilbert et al.
Technique
Anesthesia is usually local, occasionally regional, and rarely gen-
eral. A low 2-inch transverse incision is made in the groin. The ex-
ternal oblique aponeurosis is opened. The first important space is
created by dissecting beneath the medial and lateral flaps of the
external oblique aponeurosis and then along the inguinal liga-
ment, clearing its shelving edge to the pubic tubercle (Fig. 53.5).
This anterior space will eventually receive the onlay patch of the
device. For indirect hernias, sharp dissection is used to separate
the sac from the cord and from the investing fibers of the trans-
versalis fascia at its neck. To expose the posterior space, the peri-
toneum is freed from its attachments to the posterior wall by
inserting a 4 by 4 soft gauze sponge through the internal ring (Fig.
53.6). A direct hernia in Hesselbach's triangle is opened, and its
protruding contents are dissected from it to actualize the preperi-
toneal space. This approach may be used for indirect hernias also.
Cooper ligament can be visualized after completion of the incision FIGURE 53.6. Sponge dissection.
through the posterior wall. The deep epigastric vessels are not dis-
turbed unless the hernia has a pantaloon presentation, in which rect hernias. The flaps of the slit must be overlapped and be se-
case they are divided and the two defects are converted to one. cured by a suture to prevent recurrence. Fixation of the onlay graft
With a finger in the direct defect or the internal ring, pulsation ensures immobility of the entire three-piece device (Fig. 53.8). At
of the iliac artery can be felt laterally.24 The device is slid down a minimum, we use three sutures for indirect hernias and four su-
the medial side of the finger into the preperitoneal space. The tures for direct hernias. Additional sutures can be placed in the
edge of the circular underlay graft is deployed from the connec- onlay graft if needed. Any excess of onlay graft is trimmed.
tor. The two leaves of the onlay patch are extracted with a finger Effectiveness of the underlay graft alone can be evaluated by hav-
held in the connector to keep the underlay patch in place (Fig. ing the patient cough and perform the Valsalva maneuver before
53.7). It is unrealistic to expect that the underlay graft will im- sutures are placed in the onlay graft. Mter final testing of the re-
mediately lie flat, yet it can be spread from the connector to pro- pair, the spermatic cord and nerves are laid on the onlay graft, and
vide full protection behind the defect in the posterior wall. The the leaves of the external oblique aponeurosis are approximated.
underlay graft will be flattened against the abdominal wall when The subcutaneous tissues are apposed, and the skin is closed with
the patient strains or by the weight of the viscera when standing. an absorbable subcuticular suture and a topical adhesive.
The connector remains in the internal ring or the direct defect.
Next, the lateral leaf of the onlay graft is placed in the anterior
space beneath the external oblique aponeurosis. This flattens it Results
and greatly facilitates the remainder of the procedure. The me-
dial part of the onlay graft is flattened against the transversus arch. From April 1998 through February 1999, 759 double-layer devices
The end of its medial leaf overlaps the pubic tubercle by 2 cm. were used to repair inguinal hernias. These included 405 indirect
We suggest that the onlay graft be sutured over the pubic bone hernias, of which 32 (8%) were recurrent; and 354 direct hernias,
medial to the tubercle, at the middle of the transversus arch and of which 45 (14%) were recurrent. Bilateral primary hernias were
the middle of the inguinal ligament. To accommodate the sper- repaired simultaneously in 17 patients using separate devices
matic cord through the onlay graft, a medial slit is created in the
onlay graft for most indirect hernias and a lateral slit for most di-
FIGURE 53.5. Divided external oblique; dissection of anterior space. FIGURE 53.7. Guided insertion of Prolene Hernia System device.
53. Gilbert's Repair 381
References
1. Bassini E. Sulla cura radicale dell'ernia inguinale. Arch Soc ltal Chir.
1887;4:380.
2. Anson BJ, McVay CB. Inguinal hernia; the anatomy of the region. Surg
GeneralObstet. 1938;66:186-191.
3. Kux M. Special comment, Bassini versus Shouldice. In Nyhus LM,
Condon RE (eds): Hernia, 4th ed. Philadelphia: J.B. Lippincott; 1995:
234-236.
4. Lotheiseen G. Zur radikaloperation der schenkelhernien. Centralbl
Chir. 1898;25:548.
5. Halsted WS. Surgical papers by WiUiam Stwart Halsted: The operative treat-
ment of ing;uinal hernia, vol. 1. Baltimore: Johns Hopkins Press; 1924.
6. Glassow F. The Shouldice repair for inguinal hernia. In Nyhus LM,
Condon RE (eds): Hernia, 2nd ed. Philadelphia: J.B. Lippincott; 1978:
163-173.
7. Usher FC, Ochsner J, Tuttle LLD Jr. Use of Marlex mesh in the repair
of incisional hernia. Am Surgeon. 1958;76:997.
8. Lichtenstein IL. Ventral and incisional hernias. In Hernia repair with-
out disability. St. Louis: Ishiyaku Euroamerica; 1986;179-215.
9. Usher FC, Cogan IE, Lowry n. A new technique for the repair of in-
guinal and incisional hernias. Arch Surg. 1960;81:847-854.
10. Shulman AG, Amid PK, Lichtenstein IL. The safety of mesh repair for
FIGURE 53.8. Prolene Hernia System graft sutured in place. primary inguinal hernias: results of 3,019 operations from five diverse
surgical sources. Am] Surg. 1992;58:255-257.
11. Shockett E. Routine rapid preperitoneal Marlex mesh buttressing in
the repair of all inguinal hernias. Contemp Surg. 1985;26.
12. Nyhus LM, Condon RE, Harkins HN. Clinical experiences with
through separate incisions. Sixteen other patients had bilateral
preperitoneal hernial repair for all types of hernia of the groin. Am]
hernias that were repaired from 2 to 6 weeks apart. Eight were bi-
Surg. 1960;100:234.
lateral primary, and four were bilateral recurrent hernias. Four pa- 13. Stoppa RE, Ries JL, Warlaumont CR, et al. The use of Dacron in re-
tients had unilateral primary and unilateral recurrent hernias pairs of hernias of the groin. Surg Clin North Am. 1984;64:269.
when they came for consultation. Local anesthesia was used for 14. Cheatle GL. An operation for the radical cure of inguinal and femoral
512 repairs, regional for 244 repairs, and general for 3 repairs. hernia. BM] 1920;2:68.
Follow-up by the operating surgeon has been done 1 week and 15. Henry AK. Operation for a femoral hernia by a midline extraperitoneal
1 month following operation for patients geographically close. approach. Lancet. 1936;1:531.
Telephone inquiry and progress reports were used with others. 16. Stoppa RE. The preperitoneal approach and the prosthetic repair of
There have been no recurrences reported. groin hernias. In Nyhus LM, Condon RE (eds): Hernia, 4th ed.
Philadelphia: J.B. Lippincott; 1995;188-210.
Seromas developed in 32 repairs, all of which subsided un-
17. Lichtenstein IL. Hernia repair without disability. St. Louis: Ishiyaku Eu-
eventfully. Hematomas occurred in six repairs and wound infec-
roamerica; 1986:130.
tions in six repairs. One 17-year-old male patient developed 18. Gilbert AI. Overnight hernia repair. South Med] 1987;80:2.
significant subcutaneous emphysema 14 hours following surgery. 19. Robbins AW, Rutkow 1M. The mesh-plug hernioplasty. Surg Clin North
A virulent gas-forming infection was suspected, so the prosthesis Am. 1993;75:501.
was removed immediately. A Shouldice repair was done, and the 20. Lichtenstein IL, Shulman AG, Amid PK, et a1. Tension-free hernio-
wound was packed open. It healed completely in 16 days. Inter- plasty. Am] Surg. 1988;157:188.
estingly, culture from that wound was sterile. We cannot explain 21. Wantz GE. Giant reinforcement of the visceral sac. Surg Gynecol Obstet.
that phenomenon. 1989;169:408.
In all other cases of infection or hematoma the wounds were 22. Arregui ME, Davis Cj, Castro D, et al. Laparoscopic inguinal hernior-
rhaphy: transabdominal preperitoneal approach. In Arregui ME, Na-
opened and irrigated, and in all patients the prostheses were left
gan RF (eds): Inguinal hernias: Advances or controversy. New York:
in place. All wounds healed without further event. There has not
Radcliffe Medical Press; 1994:251-260.
been a case of severe or sustained postoperative pain reported. 23. Read RC, Barone GW, Hauer:Jensen M, et a1. Preperitoneal prosthetic
The average level of postoperative discomfort was controlled with placement through the groin: the anterior (Mahorner-Goss, Rives-
small doses of acetaminophen or propoxyphene. A few patients Stoppa) approach. Surg Clin North Am. 1993;73:545.
experienced temporary orchialgia that gradually subsided in 3 to 24. Gilbert AI, Graham MF. Symposium on the management of inguinal
8 weeks. None developed testicular atrophy. hernias. Can] Surg. 1997;40(3):209-212.
54
The Mesh Plug Repair
Ira M. Rutkow and Alan Robbins
Introduction The pleated external configuration allows the plug to expand and
contract, allowing the plug to readily conform to the size and shape
The repair of inguinal hernia continues to be the operation most of varying hernia defects. The plug's internal petals prevent the
frequently performed by the general surgeon. Over 750,000 plug from collapsing, maintaining the device's open shape and
herniorrhaphies were performed in the United States in the year completely filling the defect. In addition, the gently tapered tip of
1997, according to data from the National Center for Health Sta- the PerFix plug appears less disconcerting than the pointed end
tistics. I More progress has been made in the evolution of hernia of a hand-rolled plug. If the overall bulk of the plug appears ex-
surgery in the past decade than in the preceding 100 years. cessive, as in the case of a narrow internal ring or a very thin pa-
Thanks to the advent of safe, modem prosthetic materials, a tient, some or all of the inside "petals" are easily removed with
new era in the surgical approach to the treatment of groin hernia scissors. Although the PerFix plug is supplied in four sizes (small,
has begun. Traditional methods were based on suturing one layer medium, large, and extra large), we almost universally employ the
of tissue to another under tension. Operations became more com- large size. The above characteristics allow the technique to be uti-
plex, utilizing tissue flaps, transposition of various tissue layers, and lized in the repair of all indirect, direct, and femoral hernias, both
relaxing incisions. The final common denominator was increased primary and recurrent.
surgical complexity, accompanied by greater degrees of compli- We classifY groin hernias according to the system that we have
cations and patient discomfort and disability, prolonged rehabili- previously described.!1 Types 1, 2, and 3 are indirect hernias of
tation, and no real improvement in recurrence rate. This resulted varying degrees of internal ring competency. Type 4 are fusiform
in a certain level of anxiety about hernia surgery among the gen- direct hernias, and type 5 are saccular direct hernias. Type 6 are
eral public and some physicians, resulting in an avoidance of treat- pantaloon hernias with both indirect and direct components, and
ment. It is not unusual in clinical practice to encounter patients type 7 are femoral hernias.
with hernias of 20 to 40 years duration.
Almost 75% of inguinal herniorrhaphies performed in the
United States today are prosthesis based. The majority of these uti- Preoperative Routine
lize "tension-free" techniques, originally advocated by Lichtenstein
and associates in 1986. 2,3 Their contribution is that the mesh pros- Patients are admitted to our office-based surgical suite I2 1 hour
thesis is not utilized to buttress or reinforce a sutured repair un- before the procedure. In healthy people under the age of 45 years
der tension, but is itself the repair. no preoperative laboratory tests are required. A complete blood
Further development has resulted in "plug" concepts as con- count or chemical profile is added on the basis of medical neces-
ceived by Lichtenstein and Shore4 and Shulman et al. 5 and fur- sity. Coagulation studies are not routinely requested, nor are chest
ther enhanced by Gilbert. 6 With this background, we performed x-rays, barium enemas, or colonoscopy. An electrocardiogram is
our first plug repair in 1989. As we gained experience, our indi- added for those over 45 years of age, as is a pregnancy test for fe-
cation for this approach has been extended to the repair of all males of childbearing age. Medical consultation is obtained when
groin hernias. Indeed, we have not used any other method for the needed. Finally, even if urinary tract symptoms are present, uro-
repair of groin hernias since 1991. Since 1993, all of our opera- logic consultation is not routinely obtained.
tions have been performed with the Bard® mesh PerFix® hernia Sensory epidural block is the anesthetic technique of choice.
plug (C.R. Bard, Murray Hill, NJ) (Fig. 54.1). Initial results have We find that it yields a greater depth of sensory blockade than ei-
been previously reported. 7- 10 ther local infiltration anesthesia or field block. Anatomy is not dis-
torted by injection of local anesthetic solution. Interruption of
surgical rhythm is avoided, and the procedure proceeds expedi-
The PerFix® Plug tiously as the entire surgical field, including spermatic cord and
peritoneum, is completely anesthetized. The agent utilized is 3%
The PerFix plug consists of a heat-molded, cone-shaped, pleated chloroprocaine HCl (Nesacaine®) supplied in a 20 ml vial to
outer shell combined with a filler of eight triangular mesh "petals." which 1 ml of sublimaze (Fentanyl®) is added. The patient is usu-
382
54. Mesh Plug Repair 383
FIGURE 54.1. The Marlex mesh PerFix hernia plug and keyhole onlay
patch.
ally able to move the lower extremities, and motor activity of ab- FIGURE 54.2. The indirect hernia sac is dissected from cord structures un-
dominal wall musculature is unaffected, allowing the patient to til the preperitoneal plane is entered.
cough and strain during the procedure. This drug has the short-
est onset and duration of the available anesthetic agents. The pa-
tient is fully ambulatory less than 1 hour following completion of and any lipomas are inverted through the internal ring. The Per-
the procedure and ready for discharge within 2 hours. Fix plug is inserted with an Allis clamp, tapered end first, through
Oral intake is stopped the night before surgery, except for car- the internal ring, so that the outer circumference lies just beneath
diac or antihypertensive medications. A limited shave is done by the muscular rim of the ring. The plug is sutured to the rim with
the surgeon in the operating room. No antibiotics are utilized. 1 or 2 sutures of 3-0 Vicryl® (polyglactin 910) in the case of a type
The prosthesis is not soaked in antibiotic solution. 1 or 2 hernia with a tight or normal ring (Fig. 54.3). In the case
of a type 3 hernia with a patulous internal ring and loss of sphinc-
teric function, more sutures may be required depending on the
Operative Technique degree of patulousness of the ring. The patient is asked to cough
or strain in order to test the repair.
Indirect Hernia An onlay patch consisting of a preshaped piece of Marlex®, with
a keyhole opening and a lateral slit to accommodate the cord, is
An oblique or transverse 4 to 6 cm incision is made directly over cut to fit the area of inguinal dissection. It is placed without su-
the internal ring and the posterior inguinal wall. Electrocautery is tures on the floor of the inguinal canal. The lateral tails are placed
used for all sharp dissection, providing excellent hemostasis and
diminishing the incidence of seroma and hematoma. A Beckman
self-retaining retractor with 2.5 X 2.5 cm blunt blades and a small
double-ended retractor are placed to maintain exposure. The ex-
ternal oblique aponeurosis is opened. Attempts to open the
aponeurosis lateral to the internal ring are avoided. To minimize
tissue trauma, tissue planes anterior and posterior to the aponeu-
rosis are not dissected. The cord is mobilized and elevated. Il-
ioinguinal and genitofemoral nerves are spared if readily located.
The spermatic cord is opened on its anterior surface, longitu-
dinally, in the direction of the cremaster fibers, to preserve the
cremasteric reflex. The hernia sac and any lipomas are dissected
from the cord structures until the preperitoneal space is entered
(Fig. 54.2), and the inferior epigastric vessels are visualized. In the
case of a tightly adherent sac or a large scrotal hernia, there is the
option of dividing the sac near the internal ring, leaving the open
distal sac in place, and ligating the proximal stump of the sac.
Every attempt is made to avoid opening the sac during dissection
or dividing any adhesions within the sac, a maneuver that may only
create new adhesions. Once high dissection is completed, the sac FIGURE 54.3. The plug is placed in the internal ring and sutured in place.
384 I.M. Rutkow and A. Robbins
FIGURE 54.4. Onlay patch in position on the floor of the inguinal canal
with lateral tails sutured together. FIGURE 54.5. A direct hernia is elevated, demonstrating the line of division
of transversalis fascia.
around the cord and held together with a single suture (Fig. 54.4). position. It is then sutured in place with a minimum of four
The ''Velcro-like" attributes of Marlex help to hold the patch in sutures.
place. The principal component of the repair is the plug, not the The onlay patch is placed without sutures in the same manner
onlay patch, which only reinforces the repair by inducing addi- as in the repair of the indirect hernia (see Fig. 54.4). It should be
tional fibroplasia. The cord is placed anterior to the onlay patch. noted that the largest of fascial defects in the inguinal canal may
The external oblique aponeurosis is closed with a continuous su- be repaired in this manner. In some unusually large hernia de-
ture. Scarpa's fascia is approximated with a single suture. A con- fects the extra-large plug may be employed. The usual operation
tinuous subcuticular suture is used to close the skin. A transparent is performed in 20 minutes.
plastic wound dressing is applied. The typical operation is per-
formed in 15 minutes.
Pantaloon Hernia
Direct Hernia Having gained experience with mesh plug techniques, we are more
likely to repair combined defects with a single large or extra-large
The operation is initiated in exactly the same manner as in the re- plug. If a small intact fascial bridge exists between the indirect and
pair of the indirect hernia. Following mobilization of the cord, direct components, the intervening transversalis fascia may be in-
and confirmation of the absence of an indirect hernia component, cised to expose the inferior epigastric vessels. They do not require
the fusiform (type 4) or the saccular (type 5) hernia sac is dis- division. They will be harmlessly displaced posteriorly by insertion
sected free from surrounding tissue to its base. It should be noted of the PerFix plug. The plug is then securely sutured in place from
that the fusiform hernia frequently occupies the entire inguinal
canal from the pubic tubercle to the inferior epigastric vessels.
The sac is elevated with an Allis clamp. In the case of the fusiform
hernia, the transversalis fascia is incised with electrocautery in a
plane that is 1 cm anterior to what appears to be the base of the
hernia. The incision is made just deep enough so that preperi-
toneal fat protrudes and is carried right around to complete a cir-
cle (Fig. 54.5). The peritoneal cavity is not entered. Care must be
taken not to make the incision too far posteriorly, as the fascial
defect may be made too large for the large PerFix plug, and the
inferior epigastric vessels may be exposed to injury.
The hernia sac is then inverted toward the iliac fossa, and the
PerFix plug is placed within the defect so that the outer edge of
the plug is level with the fascial margin. It is then sutured to the
margin of the fascial defect with a series of 8 to 10 sutures of 3-0
Vicryl (Fig. 54.6). The more patulous the defect, the more sutures
are required. The patient is asked to strain to test the repair.
In the repair of a saccular direct hernia, following incision of
the fascial attachments at the base of the hernia sac, the hernia is
similarly reduced so that the plug may be placed in a preperitoneal FIGURE 54.6. The mesh plug sutured in place within the direct defect.
the pubic tubercle to the lateral margin of the internal ring. When
two separate and distinct defects are encountered, two plugs may
be utilized. They may be two large plugs or a large and a medium
plug. When two plugs are employed, they may be sutured together
at their anterior edges following placement.
Femoral Hernia
The femoral hernia is repaired through an infrainguinal ap-
proach. The mushroom-like hernia is encountered in a subcuta-
neous plane, inferior to the inguinal ligament and dissected to its
base, freeing the neck of the sac (Fig. 54.7). It may be difficult to
reduce and frequently requires excision and ligation of the nar-
row neck of the sac or a 1 to 2 mm incision into the lacunar liga-
ment to facilitate reduction. A PerFix plug is then placed within
the femoral orifice, narrow end first, so that the outer circumfer- FIGURE 54.8. The plug is placed in the femoral orifice and sutured in place.
ence is level with the orifice. It is then sutured in place (Fig. 54.8).
Because the femoral orifice is usually less than 1 cm in diameter,
a medium plug with all petals removed is most commonly em-
ployed. Because there is no overlying external oblique aponeuro- the cord is left in place whenever possible, avoiding interruption
sis, an onlay patch is not applied. of collateral vessels.
Because we have not encountered a single primary femoral her- When cord structures are adherent to the sac they must be
nia in association with an indirect or direct hernia in this series, gently separated, and the hernia is inverted. In type 5 hernias, the
we do not explore the remainder of the inguinal canal when there plug is placed within the defect and anchored with a minimum of
is a preoperative diagnosis of femoral hernia. The femoral canal four sutures. The onlay patch is not employed unless the cord is
is similarly not routinely explored at the time of indirect or direct mobilized.
hernia repair. In the case of the type 4 fusiform direct recurrence occupying
the major portion of the inguinal canal, or the typical indirect re-
currence, it may become necessary to open the external oblique
Recurrent Hernia aponeurosis and to minimally mobilize the cord to identity the
defect.
Plug techniques are readily applicable to the repair of all types of When the finding is an indirect recurrence resulting from pre-
recurrent hernias. The basic rule is to minimize tissue dissection vious subcutaneous transposition of the cord, the hernia sac pro-
and manipulation of the cord. No attempts are made to dissect trudes through the single Halsted ring at the lateral end of the
fused and unrecognizable tissue planes. In primary hernia repair, inguinal canal. The sac, once it is dissected to its base, may be re-
the cord is routinely mobilized immediately upon opening the ex- duced beneath the aponeurosis without mobilizing the cord. The
ternal oblique aponeurosis; in contrast, in recurrent hernia repair plug is inserted and anchored with several sutures.
Postoperative Routine
A single dose of intramuscular ketorolac tromethamine (Tora-
dol®) is administered in the recovery room. No narcotics are pre-
scribed. Patients are given a prescription for propoxyphene
napsylate (Darvocet-N 100®) and advised to use their judgment
about substituting nonprescription medication. Normal daily ac-
tivities are resumed by the following morning, when they may
shower and drive a car. No restrictions are imposed beyond 2
weeks. Those who have had a plug placed within a competent in-
ternal ring sphincter may resume unrestricted lifting and exercise
immediately. They telephone the office the following morning and
return for examination in 1 week and annually.
Results
From January 1989 to December 1998, 3268 patients underwent
mesh plug repair of inguinal hernia. The classification of hernia
FIGURE 54.7. The femoral hernia sac dissected in a subcutaneous plane in- types and their anatomical location are given in Table 54.1. They
ferior to the inguinal ligament to its base. comprised patients suited to elective surgery in a freestanding am-
386 I.M. Rutkow and A. Robbins
TABLE 54.1. Physical classification and anatomic location of 3498 mesh retention resulting in prostatectomy was in 1993. There have been
plug repairs (January 1989-December 1998) no cases of mesh eroding into bladder or intestine, allergic reac-
Primary Recurrent tion or rejection, mesh migration, vascular or embolic phenom-
(n = 3,071) (n = 427) ena, or intestinal obstruction resulting from adhesions to the sac
or from "reduction en masse" of the sac with adherent contents.
No. Percent No. Percent All patients were discharged within several hours of surgery,
without a single overnight stay or admission to hospital. No post-
Classification
operative narcotics were utilized. Following discharge, 48% of pa-
Type 1 278 9 13 3
Type 2 1324 43 116 27 tients took pain medication. Nonprescription analgesics (aspirin,
Type 3 373 12 18 4 acetaminophen, or ibuprofen) were used by 39%, and the re-
Type 4 649 21 76 18 maining 9% filled their prescription for Darvocet-N 100.
Type 5 219 7 171 40
Type 6 192 6 26 6
Type 7 36 1 7 2 Discussion
Location
Right indirect 1111 36 85 20 The distillation of our experience in the treatment of over 3000
Right direct 466 15 145 34 patients with these techniques has convinced us of the compre-
Right femoral 24 <1 5 hensive and pragmatic nature of the plug in the repair of groin
Right pantaloon 98 3 16 4 hernias. The standardization of herniorrhaphy to a single system
Left indirect 867 28 60 14 of repair for all varieties of hernias has enabled reduction of re-
Left direct 399 13 104 24 currence and, more significantly, of operative morbidity. The ba-
Left femoral 12 <1 2 <1
sic principle of this method is that of complete dissection of the
Left pantaloon 94 3 10 2
hernial protrusion, reduction of the protruding elements through
the musculoaponeurotic defect, placement of the hernia plug into
the abdominal waIl defect like an internal truss, and suture fixa-
bulatory surgical unit. Patients with morbid obesity, those requir- tion of the plug. People are capable of returning to normal daily
ing a heparin window, and ASA class IV were specifically excluded. activities by the following day, and no restriction on strenuous ac-
Follow-up information is available on 63% of this series and ranges tivity is advised beyond 2 weeks.
from three months to ten years, with an average of five years. Given This technique is the simplest of surgical approaches currently
the older age status of our patients and the relatively mobile Amer- in use, takes the least amount of operative time, and utilizes a min-
ican population, we have had difficulty in obtaining follow-up re- imum of surgical resources. The learning curve is relatively short,
sults beyond three years. Results are based on both examination requiring only a few cases for the surgeon to feel comfortable in
by the surgical staff and communication with other surgeons who its performance. General anesthesia is not required, and the peri-
have disclosed evidence of our recurrences. toneal cavity is not entered, diminishing the incidence of postop-
Among the 3071 primary herniorrhaphies, there were 23 «1 %) erative nausea and ileus. The only relative contraindication to
known recurrences. Of these, 18 (78%) followed repair of direct mesh plug repair is the presence of a contaminated wound, as in
hernias; 20 (87%) were detected within 2 years of surgery and 3 a gangrenous intestine.
(13%) in the third year. The location-specific recurrence rate was There have been no major changes in surgical attitude since we
0.2% for primary indirect hernias and 1.7% for primary direct her- began our journey into plug-based techniques 10 years ago. Nat-
nias. There were no known instances of later recurrence. Of the urally, the operation is approached with a greater degree of con-
427 patients who had surgery for recurrent hernia, there were 17 fidence than when we first used these methods. The incision and
(4%) instances of re-recurrence. dissection of tissue planes have gradually diminished as we have
Of the primary hernia patients, 5% were female, as were 4% of grown more aware of the simplicity of the basic idea of merely
the recurrent hernia patients. Indirect hernias (64%) made up plugging the defect with a three-dimensional structure of fabric
the majority in the primary hernia series, whereas hernias with di- that supports ingrowth of fibrous tissue.
rect components predominated (64%) in the recurrent series. The plug repair of groin hernia is a preperitoneal repair via a
Only 1% of the primary series and 2% of the recurrent series were small anterior incision. The plug must always be placed in a
femoral hernias. Not a single patient had a femoral component preperitoneal location. This is accomplished in the indirect her-
combined with an indirect or direct hernia. None of the recur- nia when the plug is placed through the internal ring. In the di-
rences of primary hernia repair were femoral. No hernias were rect hernia, the method of incising the transversalis fascia before
found lateral to the internal ring. Of the recurrent hernias were the reduction of the hernia is mandatory. If this is not done, the
treated more than 10 years after the initial surgery. None of the plug will not be properly fixed in position, maintaining the her-
recurrences treated more than 5 years after initial surgery were nia in reduction.
preceded by prosthetic repair. Inversion of the hernia sac rather than resection and ligation
Wound infection requiring treatment occurred in 21 (0.6%) pa- with an absorbable suture diminishes peritoneal inflammation, a
tients. Treatment consisted of local wound care and a course of "mini-peritonitis" with resultant nausea and malaise. The inverted
oral antibiotic therapy as an outpatient. No patients were admit- hernia sac will simply conform to the shape of the abdominal waIl
ted to the hospital for treatment of infection. No mesh plug has within days. Kahn and Hamlin,13 utilizing postoperative herniog-
been involved in an infectious process requiring its removal. raphy 2 weeks after mesh plug repairs, have reported normal
There have been 9 (0.3%) cases of urinary retention requiring herniograms with no contour defects within the abdomen from
catheterization, all in the first half of the series. The last case of inverted sacs or plugs.
It is essential that all plugs be securely sutured in place. In in- mainder of the recuperation period. It is our strong feeling that
direct hernias with a competent internal ring sphincter, only one the degree of sensory block is significantly greater with epidural
or two sutures are required, as every time the patient strains and anesthesia than with local anesthesia. Reflex arcs are blocked at
the abdominal wall muscles contract, the internal ring closes, the spinal level, and there is less neural excitement. Neural block-
holding the plug in place. Dilated internal rings, which have lost ade suppresses formation of the sustained hyperexcitable state in
sphincter-like action, require a greater degree of suture fixation, the central nervous system that is responsible for the maintenance
necessitating three to six sutures. A small saccular direct defect of postoperative pain.
needs a minimum of four sutures, whereas a large fusiform direct Comparison with the tension-free operation of Lichtenstein re-
hernia may need eight to ten sutures. In more patulous defects, veals the same freedom from suture-line tension that produces
the plug must be firmly secured in place. pain and recurrence. The m.yor difference is that this operation
The use of absorbable suture material is significant. There is can readily be performed via smaller incisions and with markedly
rapid tissue ingrowth, fixing the mesh in place, which occurs be- less dissection and opening of tissue planes.
fore the synthetic absorbable suture loses strength. The use of ab-
sorbable sutures reduces long-term inguinodynia. Employment of
braided or multifilamented nonabsorbable sutures is not advised,
as they may be the cause of sinus formation, requiring suture re- References
moval.
Surgeons must be extremely circumspect with any prosthetic ma- 1. Rutkow 1M. Surgical operations in the United States: then (1983) and
terial or device that they implant in patients. Marlex mesh, unlike now (1994). Arch Surg. 1997;132:983-990.
2. Lichtenstein IL, Shulman AG. Ambulatory outpatient hernia surgery,
most of the other prosthetics utilized to repair hernias, has been
including a new concept, introducing tension-free repair. Int Surg.
in clinical use for 40 years.!4 Although there is a wealth of infor- 1986;71:1-7.
mation regarding biological compatibility and safety in the pres- 3. Lichtenstein IL, Shulman AG, Amid PK, et al. The tension-free hernio-
ence of infection, a literature search has failed to identify any plasty. Am] Surg. 1989;157:188-193.
reported instances of allergic reaction or rejection. 4. Lichtenstein IL, Shore JM. Simplified repair of femoral and recurrent
There is much concern on the part of many surgeons about il- inguinal hernias by a "plug" technique. Am] Surg. 1974;28:439-444.
ioinguinal and genitofemoral neuralgia. Before our experience 5. Shulman AG, Amid PK, Lichtenstein IL. The "plug" repair of 1402 re-
with prosthesis-based repairs, we were never able to correlate pain current inguinal hernias. Arch Surg. 1990;125:265-267.
with the sacrifice of the nerves. We have never operated on any 6. Gilbert AI. An anatomical and functional classification for the diag-
individual for supposed neuralgia. nosis and treatment of inguinal hernia. Am] Surg. 1989;157:331-333.
7. Robbins AW, Rutkow 1M. The mesh-plug hernioplasty. Surg Glin North
It is our practice not to obtain urological evaluation of patients
Am. 1993;73:501-512.
with a history of voiding problems or with prostatic enlargement 8. Rutkow 1M, Robbins AW. "Tension-free" inguinal herniorrhaphy: a pre-
on examination before surgery. It is widely believed that obstruc- liminary report on the "mesh plug" technique. Surgery. 1993;114:3-8.
tive uropathy leads to retention and is a m.yor factor in recurrence. 9. Rutkow 1M, Robbins AW. 1669 mesh-plug hernioplasties. Gontemp Surg.
In our series, however, the incidence of urinary retention has only 1993;43:141-147.
been 0.3%, and the recurrence rate remains quite insignificant. It 10. Rutkow 1M, Robbins AW. Mesh plug repair: a follow-up report. Surgery.
is also evident that the real cause of difficulty in voiding following 1995;117:597-598.
herniorrhaphy is pain and that, in the absence of significant pain, 11. Rutkow 1M, Robbins AW. Demographic, classificatory, and socioeco-
the ability to empty the bladder is not compromised. nomic aspects of hernia repair in the United States. Surg Glin North
Am. 1993;73:413-426.
There is little question in our minds that both the choice of
12. Rutkow 1M, Robbins AW. Groin hernia surgery in an office-based sur-
anesthesia and the degree of expertise with which it is adminis-
gical suite. In Nyhus LM, Condon RE (eds): Hernia, 4th ed. Philadel-
tered are m.yor determinants of postoperative complications and phia: JB Lippincott; 1995;250-252.
degree of patient discomfort in the initial days following surgery. 13. Kahn AM, Hamlin A. Herniography following indirect hernioplasty us-
Certainly, if a patient comfortably undergoes surgery while awake ing the Marlex "mesh plug" technique. Am] Surg. 1995;61:947.
and then has no pain in the first few hours following surgery, he 14. Usher FC, Ochsner JL, Tuttle LLD. Use of Marlex mesh in the repair
or she will tend to be free of significant discomfort for the re- of incisional hernias. Am] Surg. 1958;24:969-974.
55
Moran's Preperitoneal Mesh Repair
for Inguinal Hernias
Robert M. Moran
Bassini's principle of the importance of the transversalis fascia in ring, especially in its lateral portion (Fig. 55.1). The space must
repair of inguinal hernias was incorporated into the influential be large enough to insert a 1 by 4 inch polypropylene mesh so
Shouldice repair. 1- 3 Later, Usher's introduction of monofilament that it lies flat underneath the transversalis fascia and extends past
polypropylene mesh and Lichtenstein's concept of tension-free the pubic bone and well above the internal ring. Technically, it
repair revolutionized the methods used today to achieve reliable was found that the mesh can be drawn under the pubic bone by
hernia repairs with very few recurrences.4-6 Laparoscopic sur- beginning the 3-0 monofilament suture in the pubic region and
geons have followed Stoppa and Nyhus in using preperitoneal catching the mesh 1 inch from its end. This ensures that the mesh
placement ofmesh. 7,8 Over the past 10 years, the surgeons at the will extend past the pubic bone, thus preventing the diverticulum-
National Ambulatory Hernia Institute have incorporated these like recurrent direct hernias that characteristically occur at the
ideas into an open, transinguinal preperitoneal placement of very medial portion of the inguinal floor. This suture is continued
polypropylene mesh under minimum tension, with an excellent laterally, approximating the lateral transversalis fascia under the
outcome. 9 medial transversalis fascia, as performed in the first row of the
Shouldice repair, and incorporating the central portion of the
mesh, to hold the mesh firmly against the undersurface of the re-
pair. It is important to suture along the longitudinal midline of
Method the mesh to prevent it from rotating medially (Figs. 55.2 and 55.3).
The same 3-0 suture is continued back after forming a new inter-
FromJune 1989 to January 1,1999,3608 inguinal hernia opera- nal ring, suturing the medial flap of the transversalis fascia to the
tions were performed on 3247 patients by 12 surgeons at the Na- iliopubic tract.
tional Ambulatory Hernia Institute. The operation is performed The remaining layers are closed with absorbable sutures and the
with an anesthesiologist monitoring and administering intra- skin with subcuticular suture and Proxi-Strips®.
venous sedation. The local anesthesia is equal parts 1 % xylocaine An ice pack is applied to the wound on and off for 2 or 3 days
and 0.5% marcaine neutralized with sodium bicarbonate.I° A to decrease swelling, pain, and ecchymosis. Antibiotics are not rou-
transverse 4 to 5 cm incision is made 2 cm above the pubic bone tinely used. I3 Average operating time was 20 to 40 minutes.
over the palpable spermatic cord. The cord is mobilized from the
posterior inguinal wall, along with the external spermatic vessels
and the genital branch of the genitofemoral nerve. The cremas-
teric muscle and the internal spermatic fascia are incised longi- Results
tudinally over the cord and divided at the internal ring. This
allows dissection and ligation of an indirect peritoneal sac or Follow-up included examinations and communicating with private
preperitoneal fat. Large sacs are transected in the mid-inguinal referring physicians or insurance companies, with a 90% response.
region, leaving the distal sac in situ as recommended by G.E. Recurrences numbered 14, 5 direct and 9 indirect, for a 0.39% re-
Wantz ll currence rate. All of these recurrences were related to improper
At the medial edge of the internal ring, the transversalis fascia positioning of the mesh. No re-recurrence was found in any of the
is carefully incised, exposing the preperitoneal fat. There are two recurrent hernia group operated on using this technique.
layers to this fascia, and, until free fat is seen, the dissection has Cellulitis occurred in 15 patients, who were treated with oral
not reached the preperitoneal space. I2 The undersurface of the antibiotics; no prostheses were removed. One patient developed
transversalis fascia is freed of the preperitoneal fat with a moist Staphylococcus aureus septicemia with multiple organ failure. This
sponge. The dissection is carried distally past the pubic bone, me- required intensive care, intravenous antibiotics, and time, but
dially to the lateral border of the rectus abdominis muscle, later- this all cleared without removal of the mesh or recurrence of the
ally to the iliopubic tract, and proximally well above the internal hernia.
388
55. Preperitoneal Mesh Repair 389
Transversalis Fascia
Medial Flap
Ext. Obi. AponeurOlills--j
--I~ectus Abd. Muscle
Spermattc Cord
FIGURE 55.3. Transverse section at level of repair. The prosthesis lies deep
to the reconstructed posterior inguinal wall, reinforcing it.
FIGURE 55.1. Completed dissection of right groin, showing the preperi-

toneal space of Bogros.
References
1. Bassini E. Ueber die behandlung des leistenbruches. Arch Klin Chir.
1880;40:429-476.
2. Moran RM, Blick M, Collura M. Double layer of transversalis fascia for
Discussion repair of inguinal hernia: results of 104 cases. Surgery. 1968;63:423-429.
3. Welsh DR, Alexander MA. The Shouldice repair. Surg Clin Nmh Am.
We believe that there is no need to ligate the external spermatic 1993;73:451-469.
vessels or the genital branch of the genitofemoral nerves in most 4. Usher FC, Fries J, Ochsner JL, et al. Marlex mesh, a new plastic mesh
inguinal hernias as proposed by the Shouldice Hospital. With good for replacing tissue defects: clinical studies. Arch Surg. 1959:138-145.
mobilization, these structures can remain intact. 5. Usher FC, HillJR, OchsnerJL. Hernia repair with Marlex mesh: a com-
Removing the entire cremasteric muscle disables the cremas- parison of techniques. Surgery. 1959;46:718-724.
teric reflex and causes the testicle to drop. It is preferable to di- 6. Lichtenstein IL. Herniorrhaphy: a personal experience with 6,321
cases. Am Clin Surg. 1987;153:553-559.
vide the muscle longitudinally near the internal ring and preserve
7. Nyhus LM, Pollak R, Bombeck CT, et al. The preperitoneal approach
it to minimize these changes. and prosthetic buttress repair for the recurrent hernia: the evolution
Many of the recurrences reported by the Shouldice Hospital are of a technique. Am Surg. 1988;208:733--737.
femoral hernias. In our series, we found no evidence of any 8. Stoppa RE, Warlaumont CR, Verhaeghe PJ, et al. Prosthetic repair in
femoral hernia complicating the procedure. We believe that the the treatment of groin hernias. Int Surg. 1986;71:154-158.
femoral hernias arise from the tension created by the classic 9. Moran RM, Brauns J, Petrie CR, et al. Moran repair for inguinal her-
Shouldice technique. nias. Am Surg. 1997;63:430-433.
In summary, it is thought that this technique is an excellent op- 10. Moran RM. Local anesthesia for inguinal-femoral hernia repairs. In
eration for large indirect inguinal hernias (Gilbert III), all direct Schumpelick V, Wantz GE (eds): Inguinal hernia repair. New York: S.
inguinal hernias (Gilbert IV and V), and most recurrent inguinal Karger AG; 1995:85-88.
hernias.
of inguinal hernioplasty. Surg Clin Nmh Am. 1993;73:751-781.
12. Read RC. The proper anatomic location for groin herniorrhaphy. Con-
temp Surg. 1993;43:99-102.
13. Gilbert AI, Felton LL. Infection in inguinal hernia repair considering
biomaterials and antibiotics. Surg Gynecol Obstet. 1993;177:126-130.
14. Gilbert AI. An anatomic and functional classification for the diagno-
sis and treatment of inguinal hernias. Am] Surg. 1989;157:331.
Commentary
Spermatic Con~--I-+
Robert Bendavid
Given the particular interest of Robert Moran's group in the dis-
cipline of hernia surgery, I wonder whether the success is due to
the method or to their expertise.
I do agree that there is no need to resect the cremaster muscle,
FIGURE 55.2. Insertion of polypropylene mesh 4 by 1 inch (10 by 2.5 cm) which results in a drop of the scrotum and testicle that becomes
into the space of Bogros; extent of mesh indicated by dashed line. more marked with the passage of time. Resection of the cremas-
390 R. lIendavid
ter muscle does, however, results in a generous exposure of the fascia. More importantly, the rigidity, bulkiness, and elevation of
posterior wall of the inguinal canal, the division of which allows the "new inguinal ligament" cannot be denied, nor can the ten-
confident verification of the absence of concomitant hernias that sion resulting from approximation and imbrication, or overlap-
might otherwise show up later as "missed hernias." ping, of myoaponeurotic layers in the inguinal region.
A common objection by surgeons is that two out of three re- The good results reported by Robert Moran (10 year span with
currences following the Shouldice procedure are femoral hernias. 0.39% recurrence overall on 90% follow-up) are impressive. I have
Because Shouldice surgeons routinely check for femoral hernias personally attempted to follow up 400 patients after 10 years, with
at the original surgery, it is not likely that these femoral recur- the dismal showing of only 10%! The accuracy and significance of
rences are missed hernias. Moran observes that the surgical "truss- our statistics depends crucially on follow-ups in terms of numbers,
ing" of all pure tissue repairs distorts the femoral angle to varying years, and the personal re-examination of each patient: This is the
degrees, putting tension on the femoral sheath and transversalis mandate of every surgeon.
56
The Nyhus Preperitoneal Repair of
Groin Hernias
Jose F. Patino
Introduction intestinal loops, a phenomenon that usually does not occur when
the prosthesis is placed in an extraperitoneal position. In the pos-
In the opening chapter of the fourth edition of Hernia, edited by terior preperitoneal approach espoused by Uoyd M. Nyhus,7 the
L.M. Nyhus and RE. Condon, in a review of the history of the material is an undisputed blessing.
treatment of hernia, this statement appears: "Apparently it was Amid8 notes that Billroth's dream was realized in 1959, when
Thomas Annandale of Edinburgh who first presented the concept polyethylene was introduced as a synthetic prosthetic material by
of the preperitoneal approach in 1876."1 Annandale did not, how- Francis Usher and describes how in the decades since there has
ever, perform a fascial repair. Meade traces the preperitoneal ap- been a transition to polypropylene and other biocompatible syn-
proach back to 1913, when Bates, of Seattle, advanced the concept thetic materials of varied physical and structural properties. Poros-
of a fascial repair through an abdominal incision lateral to the rec- ity and pore size are characteristics of paramount importance.
tus muscle. Cheatle, in 1920, perhaps under the influence of ear- Our group in Bogota, Colombia, preferentially uses Prolene®,
lier English writers, described an operation for the radical cure of a knitted polypropylene monofilament mesh that is easy to han-
inguinal and femoral hernias through a median abdominal sec- dle, appears to be biologically inert, and induces adequate fibro-
tion, without entering the peritoneal cavity. In 1921, Cheatle re- genesis and angiogenesis leading to rapid incorporation into the
ported on the use of the Pfannenstiel incision, but "advised against host's tissue in a manner that is relatively free of inflammatory re-
the use of this approach for direct hernias." According to Read, action. Being a totally macroporous prosthesis with pores larger
the preperitoneal approach lay dormant until rediscovered by than 75 #Lm, it allows for the proper deposition of fibrous tissues
Henry in 1936; in 1942, Jennings and Anson revived it in the and, most important, for the free passage of macrophages, gran-
United States. Read and McVay are among the authors who have ulocytes, fibroblasts, blood vessels, and collagen fibers. This bio-
reported on this approach, but it was Nyhus and associates who logical process of penetration of the prosthesis by fibroblasts, new
established it firmly as an operation based on detailed anatomical vessels, and collagen determines the solidity of the repair. We have
and clinical studies. In their 1959 paper, Nyhus and colleagues de- encountered no adverse reactions or infections with the use of
scribed for the first time the use of a synthetic (Ivalon®) sponge the Prolene mesh in the preperitoneal position according to the
to buttress the posterior wall repair of a recurrent hernia. 2 In a Nyhus approach.4 Nyhus uses Marlex®, also a macroporous poly-
subsequent paper, Nyhus et al. 3 described and illustrated the sur- propylene mesh. 9
gical anatomy of the transversalis fascia and its analogues. The fundamental anatomical defect in an inguinal hernia is the
The decade of the 1990s has witnessed a true revolution in the failure of the transversalis fascia: "A direct inguinal hernia is a weak-
treatment of inguinal hernia. There is a worldwide trend toward ening of the transversalis fascia in the Hesselbach triangle (the
repairs using prosthetic materials in preference to pure tissue re- posterior wall of the inguinal canal). An indirect inguinal hernia is
pairs, which involve suturing, often under tension, native tissues a weakening of the transversalis fascia lamina at the margins of
that evidently had suffered structural defects that led to the de- the internal abdominal ring resulting in widening of the ring. It
velopment of the hernia in the first place. 4 may also involve the posterior wall of the inguinal canal. A femoral
On page 271 of his collected Surgical Papers, William Stewart Hal- hernia is a dilatation of the femoral ring above and the femoral
sted refers to Czerny, whose classic Beitriige zur Chirurgie appeared orifice below the femoral canal, with distortion of the overlying
in 1878, dedicated to Theodor Billroth. Czerny quotes Billroth as weakened transversalis fascia. In every setting of inguinofemoral
saying: "If we could artificially produce tissues of the density and hernia, then, the basis of repair must be an anatomic restoration
toughness of fascia and tendon, the secret of the radical cure of of the altered transversalis fascia lamina. The structures used in
hernia would be discovered."5 repairing a hernia are a group of ligamentous and aponeurotic
According to Bendavid,6 "the introduction of prosthetic mate- structures closely associated with the transversalis fascia; these
rials in hernia surgery has been a mixed blessing." He is referring structures are termed transversalis fascia analogues. These ana-
to their use in incisional herniorrhaphy, where visceral adhesions logues are capable of retaining sutures and provide the strength
and fistula formation may result from contact of the material with required for the reapproximation and restoration of the trans-
391
392 J.F. Patino
FIGL"RE 56.l. Polypropylene mesh. Anterior and posterior

approach. In the anterior approach, the repair is executed
through an oblique inguinal incision, and the mesh is placed
in front of the repair. The posterior approach is through a
low right lower quadrant (RLQ) abdominal incision, and the
mesh is placed behind the repair. (Reprinted from Patino,l1
with permission.)
versalis fascia. The distinction between transversalis fascia proper arch of the transversus abdominis muscle, is identified, and the
and transversalis fascia analogues is made to help clarity the con- lower, corresponding to the iliopubic tract, can now be identified
cept of laminar repair."10 by deep palpation, although it is not yet visible at this stage of the
The efficacy of the posterior approach has distinct advantages, procedure. A useful maneuver is the use of an Allis clamp to hold
the major one being that it achieves the restoration of the trans- the strong, firm, and well-defined edge of the iliopubic tract. It
versus abdominis layer and the reconstruction of the internal ring may be necessary to clear the iliopubic tract by sharp dissection,
under direct and easy visualization. Reconstruction of the poste- especially in obese individuals.
rior wall at the level of the inguinal canal is readily executed by Direct hernias are seen protruding through Hesselbach's trian-
suturing the aponeurotic arch of the transversus abdominis (com- gle, whereas indirect hernias are seen entering the dilated inter-
monly misnamed "conjoined tendon") above to the iliopubic tract nal ring along the spermatic cord. The cord structures are freed
below or, alternatively, by means of a preperitoneal prosthetic but- and retracted by means of a Penrose drain placed around them.
tress. The posterior placement of a mesh has clear mechanical ad- Indirect sacs are dissected, ligated, and resected (Fig. 56.5),
vantages comparable with the method that engineers use to seal whereas direct sacs are merely invaginated. Very large inguina-
a leak in a large dam (Fig. 56.1). The posterior approach also scrotal hernias with scarred sacs may occasionally be treated by
avoids the risk of ilioinguinal, iliohypogastric, or genitofemoral transection, leaving the excess distal sac in situ. This is not the
neuralgia, which may occur after an anterior inguinal repair. usual or preferred procedure, but the risk of developing a post-
The posterior preperitoneal approach provides superb visualiza- operative hematoma or hydrocele in the residual sac may be
tion of the hernia region for an adequate management of complex preferable to extensive dissection needed for its mobilization,
sliding hernias and incarcerated or strangulated hernias or to per-
form concomitant procedures such as incidental appendectomy. 7
Technique of the Preperitoneal

Approach and Iliopubic Tract Repair
The Approach to the Preperitoneal Space
A skin incision is made about two fingers' width above the sym-
physis pubis, about 7 to 8 cm in length (Fig. 56.2). The dissection
is carried through the subcutaneous tissue to reach the muscular
layer. The rectus sheath is partially incised (Fig. 56.3), the rectus
bundle mass is retracted medially, and the transverse incision is (
extended laterally through the full thickness of the muscu-
loaponeurotic layers formed by the external oblique aponeurosis
and the internal oblique and transversus abdominis muscles to ex-
pose the flimsy transversalis fascia, which is now incised trans-
versely to open the preperitoneal space (Fig. 56.4). The inferior
epigastric vessels are preserved intact, but they can be sectioned
if necessary. The hernia becomes immediately evident, be it indi-
rect, direct, or femoral. Combined blunt and sharp dissection ex- FIGURE 56.2. The transverse skin incision is placed about 2 to 3 em above
pose the posterior inguinal wall an the area of herniation. The the upper border of the symphysis pubis. (Reprinted from Patino,l1 with
upper border of the internal inguinal ring, formed in part by the permission. )
56. The Nyhus Preperitoneal Repair 393
FIGURE 56.3. Transverse incision of fascia, starting over the rectus abdom-
inis, and extending laterally. (Reprinted from Patino, II with permission.)
FIGURE 56.5. An indirect sac has been dissected out of the deep inguinal
which may result in damage to the spermatic cord, vessels, or testis. ring. The sac is being ligated with a purse-string suture, and the excess sac
We resect large and bulky omental segments (usually 100 to 500 will be resected. (Reprinted from Patino,ll with permission.)
g) found within the hernial sac, under the assumption that the in-
traabdominal pressure is reduced and that the "piston" effect of
the protruding omentum is eliminated. Of course, this incidental but in some cases it may be advantageous to place some sutures
step does not imply a radical resection of the greater omen- also medial to the cord. We prefer monofilament nonabsorbable
tum. 4•11 •12 The dilated internal ring is repaired with interrupted sutures, usually 0 polypropylene (Prolene®) (Fig. 56.6).
sutures placed lateral to the cord, between the arch of the trans- Femoral hernias are treated by high invagination of the sac and
versus abdominis above (upper border of the internal ring) and repaired by placing sutures between the anterior margin of the
the iliopubic tract below (lower border of the ring), which is held hernial defect formed by the iliopubic tract and the posterior mar-
by an Allis clamp. The sutures are best placed lateral to the cord, gin formed by Cooper's ligament.
FIGURE 56.6. The dilated deep inguinal ring is closed, medially or later-
FIGURE 56.4. The fibers of the external oblique, interior oblique, and trans- ally, by interrupted sutures between the upper border formed by aponeu-
versus abdominis muscles are separated; the transversalis fascia appears be- rotic fibers of the transversus abdominis muscle and the inferior border
low. The transversalis fascia is incised to allow entry into the preperitoneal formed by the iliopubic tract. The stump of the closed hernial sac is shown.
space. (Reprinted from Patino, II with permission.) (Reprinted from Patino,ll with permission.)
394 J.F. Patino
FIGURE 56.8. The lower border of the buttress is sutured to the ligament
of Cooper. Note the vertical incision in the mesh to allow passage of the
FIGURE 56.7. Diagram showing the inguinal canal and deep inguinal ring. spermatic cord. (Reprinted from Patino,ll with permission.)
The fibrous longitudinal structure forming the lower border is the ili<r
pubic tract. (Reprinted from Patiiio,ll with permission.)
In all direct hernias and in all adult large indirect hernias, rect hernias forming years after a Cooper ligament repair (McVay
namely types II, III (except femoral), and IV of the Nyhus classi- procedure) of an indirect hernia. At the second operation the re-
fication (Table 56.1), we favor the use of the inlay mesh buttress paired ring appeared intact, but the progressive debilitation of the
repair. 4,lI,12 The polypropylene mesh (Prolene or Bard mesh®), posterior inguinal wall had produced the new direct hernia. 4
about 15 X 10 cm, or trimmed to fit the individual case), is su-
tured to Cooper's ligament medially and inferiorly. The mesh is
partially cut vertically to provide passage for the cord structures Conclusion
and then is resutured below the passage for the cord structures
(Fig. 56.8). Further fixation, above and laterally, is done using a We have been largely satisfied with the preperitoneal approach.
few interrupted sutures to musculoaponeurotic structures. The absence of mortality, very low morbidity, low recurrence rate,
Although we would not generally use the mesh prosthetic re- and rapid return to usual activities reported recently by the Bo-
pair in young men with simple type II indirect hernias, we feel gota group have continued in the current series, which more than
that the "prophylactic" use in middle-aged men, even when the doubles the number of cases published in December of 1998. 4
posterior inguinal wall appears intact, is warranted, considering Although we recognize the value of new approaches to hernia
the risk of developing an ulterior direct hernia. Our experience repair, particularly the laparoscopic extraperitoneal method and
with the use of herniography in selected patients has revealed re- the tension-free mesh plug hernioplasties, we strongly believe that
current hernias that are really new ipsilateral hernias, that is, di- the posterior preperitoneal buttress operation remains the gold
standard repair of large hernias in middle-aged and elderly males
with predisposing factors, in large and complicated hernias, and
TABLE 56.1. Classification of groin hernias
above all in recurrent hernias.
Type I-Indirect hernia
Internal inguinal ring normal (e.g., pediatric hernia)
Type II-Indirect inguinal hernia
Internal inguinal ring dilated but posterior inguinal wall intact; References
inferior epigastric vessels not displaced
Type III-Posterior wall defects 1. Patino JF. A history of the treatment of hernia. In Nyhus LM, Condon
A. Direct inguinal hernia RE (eds): Hernia, 4th ed. Philadeiphia:J.B. Lippincott; 1995.
B. Indirect inguinal hernia 2. Nyhus LM, Stevenson JK, Listerud MB, et al. Preperitoneal hernior-
Internal inguinal ring dilated, medially encroaching on or rhaphy: a preliminary report in fifty patients. West] Surg Obstet GynecoL
destroying the transversalis fascia of the Hesselbach triangle (e.g., 1959;67:48-54.
massive scrotal, sliding, or pantaloon hernias) 3. Nyhus LM, Condon RE, Harkins HN. Clinical experience with preperi-
C. Femoral hernia toneal hernial repair for all types of hernia of the groin. Am] Surg.
Type IV-Recurrent hernia 1960; 100:234-244.
A. Direct 4. Patino JF, Garcia-Herreros LG, Zundel N. Inguinal hernia repair. The
B. Indirect Nyhus posterior preperitoneal operation. Surg Clin North A"~ 1998;
C. Femoral 78:1063-1074.
D. Combined 5. Halsted WS. The radical cure of inguinal hernia in the male. In Hal-
sted WS (ed) : Surgical Papers. Baltimore: Johns Hopkins Press; 1924.
Commentary 395
6. Bendavid R. Composite mesh (polypropylene-ePTFE) in the preperi- Today, however, with polypropylene as a prosthesis, the pros-
toneal position. A report of 30 cases. Hernia. 1997;1:5-8. thetic buttress repairl5 has indeed become classic. Ironically, many
7. Nyhus LM. The preperitoneal and iliopubie tract repair of inguinal of today's repairs, whether suprapubic, transinguinal, or laparo-
hernia. In Nyhus LM, Condon RE (eds): Hernia, 4th ed. Philadelphia: scopic, lead back to the same site: the space of Bogros, the ideal
J.B. Lippincott; 1995. place for a tension-free repair.
8. Amid PK. Classification ofbiomaterials and their related complications
in abdominal wall hernia surgery. Hernia. 1997;1:15-21.
and prosthetic buttress repair for recurrent hernia. The evolution of
a technique. Ann Surg. 1988;208:733-737.
References
10. Nyhus LM, Klein MS, Rogers FB. Inguinal hernia. CUrT Frobl Surg. 1991;
1. Nyhus LM, Condon RE, Harkins HN. Clinical experience with preperi-
XXVIII(6):403-450.
toneal hernial repair for all types of hernia of the groin. Am] Surg.
11. Patino]F. Operacion de Nyhus: hernioplastia preperitoneal. Trih Med.
1960; 100:234-244.
1992;86:62-73.
2. Nyhus LM, Klein MS, Rogers FB. Inguinal hernia. CUrT Frobl Surg.
12. Patino JF, Garcia-Herreros LG, Zundel N, et al. Hernioplastia preperi-
1991;XXVIII(6):403-450.
toneal con protesis. Rev Colomb Cir. 1992;7:74-80.
3. Greenburg A Revisiting the current groin hernia. Am] Surg. 1987;
154:35-40.
4. Ljundhal I. Inguinal and femoral hernia. An investigation of 502 own
operated cases. Acta Chir Surg. 1973;439:81-84.
Commentary 5. Read RC. Recurrence after preperitoneal herniorrhaphy in the adult.
Acta Surg. 1975;110:666-671.
Robert Bendavid 6. Borgeskov S, Skeie E. Preperitoneal herniorrhaphy. Acta Chir Scand.
1973;139:45-47.
The retroinguinal space has become an anatomical, if not a po- 7. Robertson HT. Preperitoneal approach in the repair of inguinal her-
litical, powder keg. Described successively, directly or indirectly, nias. Am] Surg. 1966;112:627.
8. Gaspar MR, Casberg MA An appraisal of preperitoneal repair on in-
anteriorly or posteriorly, by Retzius, Bogros, Bates, Annandale,
guinal hernia. Surg Gynecol Obstet. 1971;132:207-212.
Cheatle, Henry, and McEvedy, it proves the old axiom that victory
9. Blaisdell FW, Adams DR, Hall AD. Preperitoneal hernia repair. Expe-
has many fathers and defeat is an orphan. Those who know Pro- riences in 101 consecutive cases. Am] Surg. 1964;30:623.
fessor Nyhus admire him for his exceptional qualities as a speaker, 10. Lindholm A, Nilson 0, Tholin B. Inguinal and femoral hernia. Arch
teacher, and author, but especially for his selfless devotion as a Surg. 1969;98:19.
mentor to many surgeons beginning themselves to make their 11. Nyhus LM, Harkins HN. Hernia, 1st ed. Philadelphia:J.B. Lippincott;
mark. Enough praise, and now facts. 1964.
The Nyhus preperitoneal, suprapubic, iliopubic tract repair, as 12. Nyhus LM, Condon RE, Harkin HN. Preperitoneal hernioplasty: a
published in 1960,1 was impeded by a major drawback: It was an technique for the repair of all groin hernias. III th Annual Meeting
operation whose time had not yet come. It was not for lack of try- of the American Medical Association, Chicago, 1962.
13. Bagot-Walters GA A retropubic operation for femoral hernias. Br]
ing. At a time when the technique was perhaps not yet well per-
Surg. 1965;52:678-682.
formed, failure rates ranged from 3.2 to 21 % for primary repairs
and for recurrences, 9.5 to 27%.2-10 Results were best for femoral and prosthetic buttress repair for recurrent hernia. The evolution of
hernias, where recurrence rates were from 0.0 to 0.9%.8,11-13 The a technique. Ann Surg. 1988;208:733-737.
use oflvalon® in 195914 was a daring attempt doomed by the short- 15. Nyhus LM, Stevenson JK, Listerud MB, et al. Preperitoneal hernior-
comings of the material, which deteriorated with time and did not rhaphy: a preliminary report in fifty patients. West] Surg Obstet GynecoL
fare well in the presence of infection. 1959;67:48-54.
57
Unilateral Giant Prosthetic Reinforcement
of the Visceral Sac: Preperitoneal Hernioplasties
with Dacron®
George E. Wantz and Eva Fischer
Unilateral Giant Prosthetic with the contraction of the investing scar tissue. Gore-Tex® is con-
forming but intolerant of early infection and, rather than being
Reinforcement of the Visceral Sac rapidly integrated, is only slowly encapsulated in the tissues.
Unilateral giant prosthetic reinforcement of the visceral sac
(GPRVS) is the descriptive term for a preperitoneal hernioplasty
with a large unfixed piece of the polyester mesh Mersilene®. It is Techniques of Unilateral Giant Prosthetic
the Stoppa procedure, applied to a single groin. The preperitoneal Reinforcement of the Visceral Sac
mesh in unilateral GPRVS may be implanted through a lower quad-
rant transverse abdominal incision or through an anterior groin Transverse Abdominal Incision
incision either transinguinally or subinguinally.l-6 Ugahary and
Simmermacher6 have described the technique for unilateral The preperitoneal space is reached by a transverse incision ex-
GPRVS performed through a short gridiron abdominal incision. tending from the midline laterally for 8 to 9 cm. It is made 2 to 3
Originally, unilateral GPRVS was developed for the treatment of cm below the level of the anterior superior iliac spines and should
complex hernias of the groin (for example, recurrent hernias) in be well above the deep ring and any hernias that might present
an ambulatory setting, with local anesthesia and a minimal chance (Fig. 57.1). The rectus sheath and oblique abdominal muscles are
of complications, testicular atrophy, or chronic neuralgia. Cur- incised the length of the skin incision. The rectus muscle is bluntly
rently, the chief indication for unilateral GPRVS is when the dissected from the rectus sheath and the lower abdominal wall re-
Stoppa operation is unnecessary or inapplicable and when an tracted (Fig. 57.2). The transversalis fascia will be seen adjacent to
unanticipated complex hernia is encountered during a hernio- the lateral border of the rectus muscle. It is thin, covers the infe-
plasty with an anterior groin incision or for the repair of the groin rior epigastric vessels and the yellow preperitoneal fat, and passes
after removal of a previously implanted prosthetic device. Unilat- deep to the rectus muscle. Incising the transversalis fascia along
eral GPRVS via an abdominal incision or via Ugahary's gridiron the border of the rectus muscle frees the muscle, permits entrance
incision are the hernioplasties we use for primary and recurrent into the preperitoneal space, and exposes the inferior epigastric
groin hernias whenever regional or general anesthesia is used. vessels, which do not necessarily require division.
The preperitoneal space is cleaved in all directions, medially
and superiorly, behind the rectus muscle and the oblique muscle
Permanent Prostheses for Unilateral of the abdominal wall, and inferiorly and deeply into the pelvis,
exposing the space of Retzius, the superior ramus of the pubis,
Giant Prosthetic Reinforcement of the obturator foramen, iliac vessels, and iliopsoas muscle.
the Visceral Sac Hernial sacs are dealt with in conventional ways. The sacs of di-
rect, femoral, or other rare hernias, such as obturator, are easily
The permanent prosthesis for unilateral GPRVS must conform to identified and teased from adjacent tissues. If the sacs are large,
the complex curves of the pelvic cavity and should therefore be they are amputated or inverted beneath a purse-string suture in
soft, elastic, supple, and conforming. It must also be rapidly inte- order to smooth the external surface of the visceral sac. In simple
grated and tolerant of infection, have a surface texture that will indirect inguinal hernias, the pedicle is divided and the proximal
grip the tissues, and be available in large pieces. To date the only peritoneum oversewn. The distal peritoneal sac is left in place,
prosthetic mesh meeting these criteria is Mersilene, which is com- undissected and attached to the cord. Of course, all sliding indi-
posed of polyfilamented fibers of the polyester Dacron®. Meshes rect hernial sacs require dissection from the cord. An incision in
of other materials are not suitable. Polypropylene meshes currently the anterior inguinal canal may be required to release voluminous
available are semirigid and nonconforming. Moreover, intra- incarcerated hernias.
abdominal pressure may be insufficient to prevent unfixed poly- The vas deferens and the testicular vessels are freed from the
propylene mesh inside the preperitoneal space from deforming peritoneum from the level of the deep ring proximally at least
396
57. Unilateral CPRVS with Dacron 397
FIGURE 57.3. The complete dissection of the preperitoneal space showing

parietalization of the vas deferens and testicular vessels. (Reprinted from
Wantz,3 Atlas of hernia surgery. Philadelphia: Lippincott Williams and
Wilkins; 1991, with permission.)
FIGURE 57.1. The location of the abdominal incision for preperitoneal uni- mesh was incorrectly shaped and too small. Currently the pros-
lateral CPRVS. (Reprinted from Schumpelick V, Wantz CE. Inguinal her- thesis is shaped like a diamond (Fig. 57.4). It is important that the
nia repair. Basel: S. Karger; 1995, with permission.) bottom edge be wider than the top and that the lateral side be
longer than the medial side. The width of the superior edge of
the prosthesis equals the distance from the midline to the ante-
10 cm. This technique, first described by Stoppa, is called pan-
rior superior iliac spine minus 1 cm. The vertical distance medi-
etalization of the elements of the spermatic cord (Fig. 57.3).
ally is 14 cm plus or minus. The inferolateral corner is extended
The defects in the abdominal walls are not closed. If necessary,
2 to 4 cm. This elongates the lateroinferior corner of the mesh
the dead space created by the hernia sac can be eliminated by in-
and ensures a solid prosthetic grip on the lateral visceral sac.
verting the transversalis fascia that envelops the peritoneal sac in
In lieu of the diamond-shaped mesh, a square of Mersilene 15
the abdominal wall and suturing it to the abdominal wall. In this
by 15 cm may be used. In this case the lateral absorbable suture
process the spermatic cord should not be withdrawn. Surplus
attaching the mesh to the anterior abdominal wall should be omit-
preperitoneal fat should be cleared away from the abdominal wall.
ted and instead implanted with a long clamp because the width
The Mersilene is arranged so that the material stretches trans-
of the mesh will exceed the distance from the midline to the an-
versely. In the developmental stages of the operation, the mesh
terior superior iliac spine.
was shaped as a square or rectangle and was considerably smaller
The prosthesis is drawn into place under the rectus muscle and
than is used nowadays. Experience (recurrence) showed that the
the superior abdominal wall by three absorbable synthetic sutures
appropriately placed along the upper border of the mesh (Fig.
57.5). The sutures secure the mesh to the abdominal wall 2 to
Distance between ASIS and midline

minus 1 em - usually about 12 em
if----12 em --~~
15 em
114 em
J
Lateral Medial
FIGURE 57.2. The rectus sheath has been dissected from the rectus muscle
and the abdominal wall lifted, revealing the rectus muscle and lateral to
it the thin transversalis fascia covering the inferior epigastric vessels and
1 k Inferi~r- 2-4 em greater than
width at top
preperitoneal fat. (Reprinted from Schumpelick V, Wantz CE. Inguinal her- FIGURE 57.4. The dimensions of the Mersilene mesh for transabdominal
nia repair. Basel: S. Karger; 1995, with permission.) unilateral CPRVS.
398 G.E. Wantz and E. Fischer
grasping the lateral comer of the mesh slides the prosthesis up

into the iliac fossa and over the peritoneum facing the deep ring,
the parietalized spermatic cord, and the iliopsoas muscle. This
clamp is steadied by the surgeon. The retractors are removed; the
clamps are released and carefully withdrawn. Wrinkling and fold-
ing of the mesh will occur with removal of the clamps if the preperi-
toneal space is insufficiently cleaved. Closed suction drainage is
used when hemostasis is incomplete or there remains a large dis-
tal indirect hernial sac. The access incision is loosely closed with
continuous absorbable suture.
An important feature of GPRVS via a transverse abdominal in-
cision is that dissection or redissection of the inguinal canal and
its contents are avoided, thereby eliminating trauma to the sper-
matic cord and sensory inguinal nerves. Another advantage is that
in many cases the procedure can be done with local anesthesia
when necessary. Anesthetizing the peritoneum adjacent to the
FIGURE 57.5. The mesh in transabdominal unilateral GPRVS is fixed with pelvic wall, the vas deferens, and the testicular vessels may be dif-
successive sutures to the anterior abdominal wall 2 to 3 cm above the ac- ficult and incomplete. Supplementing the local anesthesia with in-
cess incision. (Reprinted from Wantz, 3 Atlas of hernia surgery. Philadelphia: travenous sedation is advisable. Drugs that may cause abdominal
Lippincott Williams and Wilkins; 1991, with permission.)
breathing such as fentanyl can severely restrict exposure and
3 cm above the incision. The medial comer suture is near the linea should not be administered.
alba, the middle suture is in the semilunar line of Spieghel, and
the lateral comer suture passes through the oblique abdominal
muscles near the anterior superior iliac spine. A Reverdin suture Transinguinal Giant Prosthetic Reinforcement
needle facilitates the placement of the sutures. Lacking this in-
strument, very large curved needles can be used. of the Visceral Sac
The inferior portion of the mesh is implanted with the aid of
three long clamps, which grasp the two comers of the middle lower Transinguinal GPRVS is similar to the Rives hernioplasty and dif-
edge (Fig. 57.6). Retracting the abdominal wall opens the preperi- fers from it in that the mesh is not sutured circumferentially and
toneal space, enabling the clamps to unfold the mesh and slide it the vas deferens and testicular vessel are parietalized. The main
into place. The clamp, grasping the medial comer, is placed in indication is for unexpected complex hernias of the groin and
the space of Retzius and unfolds the mesh behind the rectus and to repair the groin after painful polypropylene patches and de-
in front of the bladder. It is steadied by an assistant. Next, the vices previously implanted by the anterior approach have been
clamp that grasps the middle of the inferior edge is pushed deeply removed.
into the wound to unfold the mesh over the peritoneum facing The preperitoneal space is reached by division of the posterior
the superior ramus of the pubis, the obturator foramen, and the wall of the inguinal canal in exactly the same way as in the classic
iliac vessels. This is also steadied by an assistant. Finally, the clamp hernioplasties and repairs. Division of the cremaster muscle, cre-
master vessels, and genital nerve assists exposure but is not es-
sential. Wide cleavage of the preperitoneal space is easily
accomplished bluntly with the index finger or sponge stick in all
directions. Division of the inferior epigastric vessels faclitates this
dissection and the implantation of the prosthesis, but is not always
necessary.
Parietalization eliminates the need for a slit in the mesh to ac-
commodate the spermatic cord; it is done exactly as described
above. If parietalization is not done, the operation can be com-
pleted in the Rives manner. A lateral slit is made in the mesh to
accommodate the cord. The lateral bisected tails of the mesh are
sutured around the cord and circumferentially to Cooper's liga-
ment and the abdominal wall.
The Mersilene prosthesis should be as large as possible and not
less than 10 by 10 cm. It should be arranged so that it stretches
transversely. The prosthesis is drawn into the preperitoneal space
underneath the superior abdominal wall by three to five sutures
of permanent or slowly absorbable synthetic suture (Fig. 57.7).
The sutures that suspend the prosthesis are placed medially,
superiorly, and laterally far beyond the borders of Fruchaud's
FIGURE 57.6. The distal mesh is implanted with three long clamps. The myopectineal orifice. The sutures not only expedite the correct
mesh envelops the visceral sac. (Reprinted from Wantz,3 Atlas of hernia placement of the prosthesis superiorly, but also ensure its position
surgery. Philadelphia: Lippincott Williams and Wilkins; 1991, with permis- during the manipulation required to insert the inferior portion of
sion.) the prosthesis. The inferior border of the prosthesis is implanted
57. Unilateral GPRVS with Dacron 399
FIGURE 57.7. Unilateral GPRVS can be done through an anterior groin in-
cision. In this case, the floor of the inguinal canal is completely incised,
the preperitoneal space is bluntly dissected, and the cord is parietalized.
The mesh is fixed to the anterior abdominal wall with 3 or 4 sutures. (By FIGURE 57.9. The appearance of the implanted mesh in transinguinal
permission of Surgery, Gynecology and Obstetrics, now known as the Journal GPRVS. The transversalis fascia and aponeurosis are loosely approximated
of the American College of Surgeons.) to complete the procedure. (By permission of the Journal of the American
College of Surgeons.)
with long curved clamps (Wiley or Rochester Pean) that grasp the
prosthesis on the corners and in the middle of the distal edge (Fig. Subinguinal Giant Prosthetic Reinforcement
57.8). The long curved clamps push the prosthesis medially deep of the Visceral Sac
into the space of Retzius and laterally far up into the iliac fossa.
The clamp in the middle edge aids implantation of the prosthe- Subinguinal GPRVS is used when unanticipated perivascular
sis over the peritoneum facing the obturator canal. The clamps femoral hernias are encountered in frail elderly women during
are then carefully removed and the position of the prosthesis femoral hernioplasty and in patients with perivascular femoral her-
checked to make sure that it has not been dislodged (Fig. 57.9). nias following successful prosthetic inguinal hernioplasty. It is eas-
The posterior wall of the inguinal canal is closed without tension ily done with unassisted local anesthesia. The need for subinguinal
and with a permanent monofilament synthetic suture. A formal GPRVS is rare, yet knowing the technique is important.
hernioplasty is not essential. The hernioplasty is finished in a con- The technique of subinguinal GPRVS resembles the other meth-
ventional way. ods of unilateral GPRVS. The femoral region is reached through
an anterior groin incision. The femoral hernia sac is dissected from
adjacent tissues and from the edge of the parietal defect. The sac
may be ligated and amputated or merely inverted if empty. The
preperitoneal space is entered through the parietal defect and
cleaved by gentle blunt finger dissection in all directions. The dis-
section, however, is limited on the anterior surface of the iliac ves-
sels by the origin of the inferior epigastric vessels. A square of
Mersilene mesh approximately 6 to 8 cm2 is arranged so that the
stretch is transverse. A larger piece of mesh is not needed because
the parietal defect is relatively small compared with the size of the
mesh. It is placed in the preperitoneal space and secured to the
anterior abdominal wall 3.0 cm above the inguinal ligament with
three sutures (Fig. 57.10). A demitasse spoon is a useful instru-
ment to retain and protect the peritoneum during suturing.
Reverdin needles facilitate the placement of the sutures. These su-
tures, which need not be permanent, are very useful because they
maintain the position of the superior portion of the mesh during
the implantation of the distal border. The distal mesh is implanted
with two long clamps that grasp the far edge of the mesh at the
corners. The clamps push the mesh in place, medially deep in the
space of Retzius and laterally up into the iliac fossa (Fig. 57.11).
FIGURE 57.8. The distal mesh in transinguinal GPRVS is implanted with The inferior epigastric vessels prevent deep implantation of the
long clamps to envelop the visceral sac. (By permission of the Journal of midportion of the mesh. Injury of the inferior epigastric vessel
the American College of Surgeons.) does not occur because the Mersilene is elastic and pliant and can
400 G.E. Wantz and E. Fischer
FIGURE 57.10. Subinguinal GPRVS to repair the parietal defect offemoral FIGURE 57.12. The soft, pliable Mersilene mesh bunches up around the in-
hernias. The mesh is fixed to the anterior abdominal wall with three su- ferior epigastric vessels. (By permission of the Journal of the American Col-
tures. (By permission of the Journal of the American College of Surgeons.) lege of Surgeons.)
bunch up around them. Closure of the parietal defect is not nec- myopectineal orifice occurred due to twisting of the mesh as it
essary (Fig. 57.12). accommodated to the curves of the pelvis. When the mesh was
elongated at the inferolateral corner to correct this fault, no re-
currences occurred in the subsequent 328 repairs.
Results of Transabdominal Unilateral
Giant Prosthetic Reinforcement of Recurrence after Unilateral Giant
the Visceral Sac Prosthetic Reinforcement of the
Unilateral GPRVS via a transverse abdominal incision has been
Visceral Sac
used to manage 455 complex and recurrent hernias of the groin
Recurrent herniations after GPRVS are due to technical errors.
with an overall recurrence rate of 1.8% in the period 1986 to 1997.
For success, the pitfalls of the procedure must be avoided. These
It was not recognized until six recurrences appeared among the
are inadequate cleavage of the preperitoneal space, closure of the
first 127 repairs that the rectangular shaped mesh did not ensure
defect in the abdominal wall, and incorrect sizing, shaping, and
against recurrence. Draping the mesh in the preperitoneal space
placement of the mesh. Buckling of the mesh indicates inadequate
of Bogros in a cadaver revealed that inadequate coverage of the
cleavage or poor placement of the mesh. When implanting the
mesh, the surgeon should picture the mesh enveloping and re-
taining the peritoneum rather than being applied to the defective
abdominal wall. Probably too small a piece of mesh is the most
common cause of recurrence. Hematomas and seromas prevent
rapid integration, may displace the mesh, and provide a rich
medium for bacterial growth. They can be prevented by closed
suction drainage when hemostasis is incomplete.
References
1. Stoppa RE, Rives JL, Warlaumont CR, et aI. The use of Dacron in the
repair of hernias of the groin. Surg Clin North Am. 1984;64:269-285.
2. Munshi lA, Wantz GE. Management of recurrent and perivascular
femoral hernias by giant prosthetic reinforcement of the visceral sac.
J Am Coil Surg. 1996;182:417-422.
3. Wantz GE. Atlas of hernia surgery. New York: Raven Press; 1991.
necol Obstet. 1989; 169:408-417.
5. Wantz GE. The technique of giant prosthetic reinforcement of the vis-
ceral sac performed through an anterior groin incision. Surg Gynecol
FIGURE 57.11. The distal mesh is implanted with two long clamps. The me- Obstet. 1993;176:497-500.
dial clamp places the mesh in the space of Retzius, and the lateral clamp 6. Ugahary F, Simmermacher RKJ. Groin hernia repair via a gridiron in-
puts the mesh deep into the iliac fossa. (By permission of the Journal of cision: an alternative technique for preperitoneal mesh insertion. Her-
the American College of Surgeons.) nia. 1998;2:123-125.
58
The Rives Technique: Treatment of
Groin Hernias with Mersilene Mesh
by an Inguinal Approach
Jean Bernard Flament, Claude Avisse, Jean-Piene Palot, and]. Rives
The term groin hernia, as used by Fruchaud, l expresses the fact Technique
that all hernias of this anatomical region result from a single ba-
sic defect, a defect of the transversalis fascia. All groin hernias In 80% of our cases, the Rives operation was performed under
pass through this "myopectineal orifice." When the quality of the spinal anesthesia. Local anesthesia is also valuable, but we have
local structures is adequate, the use of a prosthesis is not indi- had little experience with it. Except in cases with strict medical in-
cated, but when the local structures are weak, especially in the dications for local or regional anesthesia, the choice is generally
case of recurrent hernias, it is mandatory to replace or reinforce left up to the patients.
the transversalis fascia with a prosthesis placed in the preperi- Performed through an inguinal incision, the dissection does not
toneal space, as described by Rives et al. 2 as early as 1965. The differ from classic hernioplasties. When the posterior wall of the
prosthesis is not simply sutured to the edges of the defect, but inguinal canal is completely exposed, an assessment can be made
placed behind the abdominal wall; the prosthetic material is to determine the final choice of a prosthetic repair.
cut larger than the orifice, and its adherence to the posterior The transversalis fascia is then divided longitudinally from the
surface of the abdominal wall is guaranteed by intraabdominal internal ring to the pubic tubercle, taking care to avoid the infe-
pressure. rior epigastric vessels (Fig. 58.2). A thorough blunt dissection re-
In 1965, one of us focused attention on the interesting possi- veals the inguinal ligament, the femoral sheath, and the Cooper's
bilities of the preperitoneal midline approach according to the ligament. The fibers of the transversus arch are retracted, and the
publications of A.K. Henry,3 H. Mahorner and G.M. Goss,4 and posterior aspect of the abdominal wall is separated from the peri-
L.M. Nyhus et al. 5 (Fig. 58.1). This procedure was later developed toneum by blunt dissection. The site for implantation of the mesh
and popularized by others in France and more recently in the is now ready.
United States. At the same time, one of us described and devel- A sheet of Mersilene (about 10 by 10 cm) is prepared using a
oped an original technique of hernioplasty using a Mersilene® metal pattern, with an indentation for the external iliac vessels
mesh placed in the preperitoneal space, through an inguinal in- (Fig. 58.3).
cision, as a substitute for the transversalis fascia. This technique is The ligament of Cooper is exposed, with a spoon retracting the
described in detail below. preperitoneal fat tissue. Crossing tributaries of the epigastric and
obturator vessels, well studied by Bendavid,14 are ligated and
divided.
The inferior edge of the prosthesis is folded over like a hem and
Patients and Methods the pleated portion anchored to Cooper's ligament with four or
five nonabsorbable sutures (Fig. 58.4). The sutures begin close to
FromJanuary 1970 to December 1994, 2065 hernias in 1758 pa- the pubic tubercle and progress laterally to the femoral vein (Fig.
tients were treated in our department. Nine percent had a re- 58.5). One or two transitional sutures are placed through the trans-
current hernia. Previous surgeries numbered one to four. Three versalis fascia and the femoral sheath to avoid a prevascular re-
percent of hernias were strangulated. The average age was 55 currence. The hem of the mesh is then turned down beyond the
years, with a range of 16 to 89 years. The sex ratio was 4.5 males level of the iliopubic tract, and the spoon is removed (Fig. 58.6).
to 1 female. The upper edge of the mesh is then slipped deep to the rectus
We inserted prostheses, using Rives's technique with Mersi- muscle and the transversus arch. Four or five U sutures are in-
lene,6--13 through an inguinal approach in 694 hernias, a midline serted through the muscles as far as possible beyond the upper
approach in 179 hernias (in 104 patients), and a laparoscopic ap- margin of the myopectineal orifice (Figs. 58.7 and 58.8).
proach in 12 hernias (12 patients). We also performed 342 McVay A slit is made in the lateral part of the prosthesis for the emer-
and 838 Bassini-Shouldice repairs. gence of the spermatic cord. The two legs of the prosthesis are
401
402 J,B. Flament et al.
FIGURE 58.3. Preparation of the mesh from a metal pattern. A to B = fix-

ation on Cooper's ligament; B to C = shape cut for the passage of the ex-
ternal iliac vessels; D to E = site of lateral slit to accommodate the
spermatic cord.
FIGURE 58.1. Posterior aspect of the Mersilene mesh in the preperitoneal

space. The prosthesis is anchored beyond the margins of the myopectineal Results
orfice.
Transversalis fascia replacement was used in 694 of 2065 hernias
treated during the past 20 years. The follow-up was 60% before
fixed by two U sutures through the abdominal wall as far laterally 1983, 90% during the past 10 years, and 100% during the past 4
as possible, creating a new internal ring deep to the muscles. This years.
new ring should be snug to prevent an indirect recurrence. Fi- The overall infection rate was 1.2% (9/694). In most cases
nally, the prosthesis is fixed more laterally along the inguinal lig- (7/9), the sepsis was superficial and had no further consequence
ament. The inferior fixation of the mesh is not fundamentally after appropriate treatment. Two (0.3%) deep infections in Con-
different from the suture of the McVay repair (Figs. 58.9 to 58.11). tact with the prosthetic material led to two recurrences. These two
When all the sutures have been tied, the mesh will bulge slightly cases occurred before 1980.
without excessive protrusion, free of folds and irregularities. The overall recurrence rate was 1.6% (11/694) after at least a
In most cases, it is possible to cover the prosthesis by approxi- 2-year follow-up. This result can be considered very good, consid-
mating the two edges of the transversalis fascia and the transverse ering that we have treated the most difficult cases with this tech-
muscle to the inguinal ligament as in the Bassini repair. Suction
drainage is usually not necessary. The external oblique aponeu-
rosis is closed over the spermatic cord to re-create the inguinal
canal (Fig. 58.12). The operation ends with the closure of the su-
perficial layers (fascia and skin), and patients are generally dis-
charged 2 or 3 days after the operation.
FIGURE 58.2. The transversalis fascia is opened longitudinally after removal FIGURE 58.4. The inferior edge of the mesh is anchored to Cooper's liga-
and high ligation of the sac. ment with nonabsorbable sutures.
58. The Rives Technique 403
FIGURE 58.5. The inferior edge is turned down, beyond the level of the il-
iopubic tract.
FIGURE58.7. Suture of the upper edge through the rectus muscle and the
nique. The recurrence rate was formerly 1.2% for primary repairs muscular arch of the flat muscles.
but 0.6% (1/161) during the past 6 years.
Two recurrences before 1980 were the consequence of postop-
erative infection. In the nine other cases, the recurrences appear by a single suture of chromic catgut. However, we have had to treat
to have been the consequence of technical errors. our own Shouldice or prosthetic recurrence.
The preperitoneal space is the only logical site for a prosthesis.
This space may be entered through an abdominal incision (mid-
line, supra inguinal or Pfannenstiel incision) or through an in-
Discussion guinal incision. 14-19
In our original procedure, a prosthesis was placed in the preperi-
Emphasis should be placed, when considering the pathology of toneal space through the classic anterior approach to hernia
groin hernias, on the importance of repair of the transversalis fas- repair. The prosthetic mesh was not "giant" but must not be con-
cia. In 64% of our indications we have used a classic approach, re- sidered a patch, for it extends beyond the limits of the myo-
sorting to the Bassini procedure until 1983 and the Shouldice since pectineal orifice and is held in place by intraabdominal pressure.
1984. Confidence in the Shouldice repair (less than 1 % recur- Furthermore, it must be perfectly spread and firmly sutured to the
rence rate in our hands) led us to reduce the number of pros- peripheral structures in order to prevent slippage during the first
thetic procedures. In cases of giant hernia, there was no choice postoperative weeks and to facilitate the early ingrowth of con-
but to use prostheses. nective tissue.
The treatment and approach in recurrences depend on the pro- As early as 1965, one of us (J.R.) chose Mersilene because of its
cedure used by the previous surgeon. Sometimes nearly nothing very good physical characteristics: It is a very light, nonabsorbable
had been done: We have seen a recurrence from a hernia treated material, supple, and with a certain degree of elasticity. Its bio-
FIGURE 58.8. Creation of the "new internal ring." A lateral slit is made, and
FIGURE58.6. Mesh in place, kept spread out by preperitoneal fat and peri- the two limbs of mesh are sutured as far laterally as possible, deep into the
toneum lying against it. muscles.
FIGURE 58.11. Remnants of the transversalis fascia are sutured over the
FIGURE 58.9. Transitional sutures are placed through the femoral sheath
prosthesis. This suture may include the transversus abdominis muscle and
and, more laterally, through the inguinal ligament, as in the McVay repair.
the inguinal ligament.
logical tolerance is excellent, inducing a very good fibroblastic re- tion because the latter relates to the size of the prosthesis and poor
action and a minor inflammatory response, demonstrated in ex- integration by connective tissue. In our experience, the risk of
perimental studies. When correctly spread, the prosthesis is postoperative infection was no higher after inguinal prosthetic re-
infiltrated by connective ingrowth within a few weeks. During the pairs than after pure tissue repairs. With some simple additional
past 20 years, we have never observed intolerance or rejection of measures, we have not observed septic complications during the
this type of mesh, and Mersilene remains for us the most appro- past 12 years. These precautions include double-gloving and use
priate material available. lO of a clean, secondary set of instruments for implantation of the
The inguinal incision, as used in our procedure, presents many mesh, prophylactic antibiotics before and during the procedure,
advantages: The dissection and regional preparation are not dif- use of a mesh soaked in Betadine® before implantation, and per-
ferent from "classic procedures" and do not need special training. fect hemostasis.
When the sac has been dissected and removed and the spermatic The recurrence rate is very low with this technique, and the risk
cord properly freed, an assessment oflocal structures can be made of recurrence can be minimized with strict attention to technical
and the surgeon can choose, with objectivity, the most appropri- details: As in any procedure, the sac of indirect hernias must be
ate repair (prosthetic or not) in each individual case. dissected high and completely removed. More specifically, the
If a prosthetic repair is chosen, the preperitoneal space can be mesh must be sutured to Cooper's ligament as close as possible to
easily entered after division of the transversalis fascia as in the the external iliac vein, and transitional sutures must be placed on
Bassini, Shouldice, and McVay repairs. the femoral sheath (as in the McVay repair) at the point where
The prosthesis used is of small dimensions and is perfectly the prosthesis bridges from Cooper's ligament to the inguinallig-
spread without wrinkles, two factors that guarantee against infec- ament. The surface of apposition of the mesh must be enlarged
FIGURE 58.10. Final appearance of the prosthetic repair. The myopectineal

orifice is closed, and the prosthesis extends beyond the margins of the ori- FIGURE 58.12. The external oblique aponeurosis is closed over the cord to
fice in all directions. re-<:reate the inguinal canal.
58. The Rives Technique 405
by an inferior hem below the level of the iliopubic tract, and the 6. Rives J, Nicaise H. A propos des hernies de l'aine et de leurs recidives.
lateral slit for the spermatic cord must be as narrow as possible to Semin Hop. 1966;31:1932-1934.
prevent indirect recurrence. With strict attention to these details, 7. Rives J. Surgical treatment of the inguinal hernia with Dacron patch.
we have had only 1 recurrence out of the last 120 cases operated Int Surg. 1967;47:361-361.
8. Rives J, Stoppa R, Fortesa L, et al. Les pieces en tulle de Dacron et
on (0.9%).
leur place dans la chirurgie des hernies de l'aine. Ann Chir. 1968;22:
In our experience, the prosthetic repair of groin hernias should
159-171.
have selective indications. Our overall rate of prosthetic repair 9. Rives J, Lardennois B, Flament JB, et al. Utilisation d'une etoffe de
through an inguinal approach is 34% of 2065 groin hernias oper- Dacron dans Ie traitement des hernies de l'aine. Acta Chir Belg. 1971;
ated on during the past 20 years. In our opinion, indirect hernias 70:284-286.
in young adults do not require prosthetic repairs and are correctly 10. Rives J, Lardennois B, FlamentJB, et al. La piece en tulle de Dacron,
treated by classic pure tissue hernioplasties. Direct hernias can also traitement de choix des hernies de l'aine de l'adulte, a propos de 183
be managed in the same way if the transversalis fascia can be ade- cas. Chirurgie. 1973;99:564-575.
quately sutured. In other situations, such as with older people, weak 11. Rives J, Lardennois B, Hibon J. Traitement moderne des hernies de
transversalis fascia, chronic increase in intraabdominal pressure, as- l' aine et de leurs recidives. Encycl Med Chir Techniques Chir. 1973; 1 (40-
110):1-12.
sociation of indirect, direct, and/or femoral hernias, we use a Mer-
12. Rives J, Flament JB, Palot JP. Treatment of groin hernias with a Mer-
silene mesh according to Rives's technique.
silene mesh via an inguinal approach: the J. Rives' technique. In Ben-
Femoral hernias are also a very good indication for this tech- david R (ed): Prostheses and abdominal wall hernias. Austin: R.C. Landes
nique, especially in men, because a McVay repair imparts too much Company; 1994;435-440.
tension. 13. Rives J, Fortesa L, Drouard F, et al. La voie d'abord abdominale sous-
Recurrences are usually treated with prosthetic repairs through peritoneale dans Ie traitement des hernies de I'aine. Ann Chir. 1978;
an inguinal approach, and our remaining indications for the ex- 32:245-255.
traperitoneal midline approach are the large bilateral hernias in 14. Bendavid R. The space of Bogros and the deep inguinal venous cir-
the aged and in multiple recurrent hernias when a new dissection culation. Surg Gynecol Obstet. 1992;174:355-8.
through an inguinal approach could increase the risk of ischemic 15. RivesJ, FlamentJB, DelattreJF, et al. La chirurgie moderne des hernies
de l'aine. Cah Med. 1982;7:1205-1218.
orchitis.
16. Stoppa R, Rives J, Warlaumont C, et al. The use of Dacron in the re-
Last, but not least, prosthetic repairs must be strictly avoided
pair of hernias of the groin. Surg Clin North Am. 1984;64:269-285.
when there is a risk of infection, particularly in the emergency re- 17. Stoppa R. Technique de cure de certaines hernies de l'aine par voie
pair for strangulated hernias, in the presence of an infected lesion mediane extraperitoneale. Film 16 mm, 71 erne Congres Fran<;ais de
of the skin, or when the operative field has been contaminated. Chirurgie, Paris, 1969.
18. Stoppa R, Warlaumont C. The preperitoneal approach and prosthetic
repair of groin hernias. In Nyhus LM, Condon RE (eds): Hernia, 3rd
Conclusion ed. Philadelphia: J.B. Lippincott; 1989:199-221.
19. Wantz CE. Ciant prosthetic reinforcement of the visceral sac. Surg Gy-
necolObstet. 1989;169:408-417.
The transversalis fascia replacement by the inguinal approach as
described by Rives is a simple and very safe procedure. Widely
placed in the preperitoneal space, the mesh allows a solid artifi-
cial insertion of the flat muscles of the abdomen on Cooper's lig-
ament. In this technique the mesh is sutured to adjacent structures Commentary
and perfectly spread, avoiding folds for good integration. This op-
eration can be done under local anesthesia. Robert Bendavid
In keeping with the pathophysiology, all types of hernias can be
treated by this procedure, especially when the local structures are The use of prosthetic meshes was introduced at the Shouldice Hos-
too weak to be sutured directly. For all these reasons, the Rives pital in 1983 for the treatment of all forms of abdominal wall her-
technique is the method of choice for the treatment of recurrent nias. As of August 1992, 1017 instances were recorded where mesh
or large groin hernias. had been used. The transversalis fascia replacement was carried
out in 339 cases. These were patients with an inguinal or in-
guinofemoral hernia (Table C58.1). The technique was first re-
References ported in 1989,1 at a time when little was known of the French
1. Fruchaud H. Traitement chirurgical des hernies de l'aine. Paris: Doin,

1957. TABLE C58.1. Use of transversalis fascia replacement in inguinal and
2. Rives J, Nicaise H, Lardennois B. A propos du traitement chirurgical inguinofemoral hernias
des hernies de l'aine. Orientation nouvelle et perspectives therapeu-
Hernia No. of cases Recurrence
tiques. Ann Med Heims. 1965;2:193-200.
3. Henry AK. Operation for femoral hernias by a midline extra peritoneal Primary 49 0
approach. Lancet. 1936;19:531-533. First time recurrence 103 2
4. Mahorner H, Goss CM. Herniation following destruction of Poupart's
Second time recurrence 96 4
and Cooper's ligaments: a method of repair. Ann Surg. 1962;155:741-
Third time recurrence 47
747. Fourth time recurrence 25
5. Nyhus LM, Condon RE, Harkins HN. Clinical experience with preperi- Fifth time recurrence 19 0
toneal hernia repair for all types of hernia of the groin. Am] Surg. Total 339 Recurrence rate 2.36%
1960; 100:234-244.
59
The Gridiron Hernioplasty
Franz Ugahary
Introduction ance and allows tissue ingrowth, while its rough surfaces prevent
migration.4 For a unilateral hernia, a 10 by 15 cm or 15 by 15 cm
Some techniques in surgery are derived from those of other pro- piece of polypropylene mesh will suffice, depending on the size
fessions; placing a piece of material between two layers as rein- of the patient or abdominal wall defect.
forcement and stiffening is a technique well known to engineers,
carpenters, dressmakers, wallpaper hangers, and many others, who
call it "laminating." Thinking about how to perform the unilateral Instruments
Stoppal and Wantz2,3 operation with an open, minimally invasive
approach instead of the total extraperitoneal laparoscopic ap- In addition to the instruments used for conventional hernia re-
proach, the author remembers his grandmother. She repaired a pair, two long, thin retractors (115 by 18 mm) with a slightly curved
worn jacket by removing one or two stitches in the armhole seam base and smooth ends, anatomical forceps (300 mm), and a de-
and then inserting between it and the lining a piece of cloth rolled pressor (a spoon-like device, 250 mm) are required. The forceps
around a pair of sticks. With the two sticks the "mesh" was then must be able to grasp the full length of the mesh to its distal end.
unfurled and positioned. It is often said that the treatment of her- A head-light or a retractor with a light source will give extra illu-
nia must be as simple as possible. Modifying the instruments and mination. Sometimes, for teaching purposes, we use the endo-
using a 2.5 to 3 cm gridiron incision, the author used the same scope for the preperitoneal view.
technique to reinforce the weakened layer of the abdominal wall
in the treatment of groin hernias. The mesh is rolled up and in-
serted in the prepared space with forceps and spread out with
long, thin specula or retractors. The technique has been used in
Determination of the Skin Incision
over 500 operations in our department.
Anatomical landmarks and the proposed incision are marked on
the skin for a better visual orientation during the procedure. One
of the features of this technique is the skin incision. The inguinal
Preoperative Management ligament is marked by drawing a line between the anterior supe-
rior iliac spine and the pubic tubercle. The femoral artery and lat-
Day surgery is planned under local or spinal anesthesia. Antico- eral border of the rectus muscle are identified. A line is then drawn
agulation medications are stopped 4 to 7 days earlier. The patient perpendicular to the inguinal ligament, along the iliofemoral axis.
is asked to urinate. At operation, an intravenous line is kept open, This line indicates the position of the inferior epigastric vessels.
and a single dose of antibiotic prophylaxis is given; basic moni- The internal inguinal ring should be above the inguinal ligament
toring consists of continuous electrocardiography, oxymetry, blood and lateral to the line marking the inferior epigastric vessels. The
pressure, and pulse readings. skin incision is made about 3 cm above and lateral to the position
of the internal ring, which is normally located in the softest part
of the affected lower abdomen and parallel to Langer's line. The
Operative Technique incision must not cross the lateral rectus border (Fig. 59.1).
The Prosthesis
The Gridiron Incision
The execution of this technique requires a soft, pliable, elastic
prosthesis with plastic "memory," because the mesh must be rolled The gridiron incision is a muscle splitting incision. A 3 cm inci-
up and unfurled to conform to the curves of the abdominal wall. sion is made in the indicated skin line. This is carried through the
A monofilament polypropylene (Prolene®) with the larger weave aponeurosis of the external oblique in the direction of its fibers,
is the material of choice. This material has a high infection toler- exposing the internal oblique; the ilioinguinal nerve will be seen
407
408 F. Ugahary
preperitoneal space is further expanded to the spaces of Bogros

and Retzius. In primary repair, most of the direct hernias and peri-
toneal protrusions medial to the epigastric vessels are easily teased
from their confining envelope of transversalis fascia. Femoral and
obturator hernias are also reduced by gentle traction. Cooper's
ligament is identified as a shiny, firm structure and can be used
as a landmark. This thorough medial and posterior dissection is
needed for smooth placement of the mesh between pubis and
bladder. Care should be taken not to injure the bladder, especially
when it is full. Mter all hernia content has been reduced and
all potential hernia sites inspected, the mesh is prepared for
insertion.
Mesh Placement
Step 1
FIGURE 59.1. The skin incision is located normally in the softest part of the
affected lower abdomen. Markings of the surface anatomy: (a) inguinal A polypropylene mesh (10 by 15 cm) is trimmed in shape by round-
ligament, (b) femoral artery, (c) lateral border of the rectus muscle, (d) ing off the corners, and its center is marked by a colored suture.
line perpendicular to the inguinal ligament from the femoral artery be- With the 300 mm anatomical forceps, the mesh is rolled so that
fore it becomes the iliac artery (indicates the surface projection of the in- the visceral side of the mesh will be inside and the future caudal
ferior epigastric vessels), (e) the internal ring should be lateral to the margin of the mesh at the tip of the forceps (Fig. 59.2).
epigastrics and above the inguinal ligament, (f) place of the skin incision
will be about two fingers laterocranial from the internal ring.
Step 2
passing caudally. With the edges of the external oblique well re- The preperitoneal space is held open by the two long, narrow
tracted, the internal oblique and the transversus abdominis mus- retractors and a Langenbeck retractor. The retractors hold the
cles are separated in the direction of their fibers. The incision is peritoneal sac back anterocephalad and posterocephalad, and
continued through the underlying transversalis fascia, carefully the Langenbeck retractor protects the inferior epigastric vessels
avoiding adherent peritoneum. (Fig. 59.3).
Cleavage of the Preperitoneal Space Step 3

The peritoneum is loosened, and cleavage of the preperitoneal The rolled up mesh is introduced into the preperitoneal space,
space is begun, using a peanut sponge or a finger. The operation centered behind the myopectineal orifice. The distal end of the
table is tilted slightly head-downward and toward the opposite side. mesh should be behind the pubis, the marked center of the mesh
This will move the peritoneal sac and its contents away from the
affected lower abdomen.
Blunt dissection is continued on the anterior abdominal wall,
where the inferior epigastric vessels, covered by the transversalis
fascia, are identified, both for their protection and to serve as a
reference point. These vessels are followed to their junction with
the iliac vessels; lateral to this point lies the internal ring and cord
structures. Normally the peritoneum smoothly covers the upper
surface of the internal ring. In an indirect inguinal hernia, the
peritoneum bulges into and through the internal ring. The lateral
preperitoneal space should be developed first, using a teasing,
blunt technique. The pedicle of the sac is then dissected. Large
indirect sacs may be transected at the level of the internal ring
and the proximal opening in the peritoneum closed with ab-
sorbable suture. The cord should be separated from the peritoneal
sac for at least 7 to 10 cm from the internal ring to facilitate later
parietalization of the cord structures. During this procedure care
should be taken not to damage the filmy membrane connecting
the vas deferens and the testicular vessels. At the end of a correct
dissection the cord structures should lie smoothly against the FIGURE 59.2. The preparation of the prosthesis. With an anatomical for-
pelvic wall. ceps the prosthesis is rolled up, the visceral site with the colored stitch be-
With a sweeping motion, using the two long, thin retractors, the ing inside the roll.
59. The Gridiron Hernioplasty 409
FIGURE 59.3. Insertion of the mesh. The cleaved preperitoneal space is

held open with the pair of thin, curved base retractors and one retractor, FIGURE 59.5. Drawing of the initial positioning of the mesh, as if viewed
which is also protecting the epigastric vessels. The mesh must be placed from within the preperitoneal space.
dorsal and cephalad to these vessels.
erally to spread out the upper part of the mesh. Using the curved
medial to the inferior epigastric vessels, and the lateral end at portion of the retractor with a stroking, slightly rotating motion,
wound level (Fig. 59.4). the surgeon positions the mesh between the peritoneal sac and
abdominal wall (Fig. 59.6).
Step 4
Step 5
While the retractors are carefully removed, a clamp is placed on
the anterolateral border of the mesh, holding it at wound level. With the upper retractor now holding the mesh against the ab-
One retractor is then reintroduced in the center of the rolled up dominal wall near the pubis, the caudal part of the mesh is stroked
mesh in such a way that the mesh is pushed against the superior out with the lower retractor. Following the contours of the iliac
ramus of the pubis. The second retractor is then carefully inserted fossa, the mesh is smoothed out with the distal end of the retrac-
cephalad to the first, behind the upper layer of the rolled up mesh tor, placed medially deep in the space of Retzius, between the pu-
and not in the center of the roll (Fig. 59.5). During the careful bis and bladder and inferomedially, over the obturator foramen
insertion of this second retractor, the upper part of the mesh will and iliac vessels, and finally laterally, parietalizing the vas deferens
partially open out. Then the retractor is turned cranially and lat- and testicular vessels over the iliopsoas muscle (Fig. 59.7) .
FIGURE 59.4. As the lateral part of the prosthesis is grasped by a clamp and
a retractor is holding the mesh against the pubis, a second retractor is be- FIGURE 59.6. Drawing to show use of both retractors, one to hold the mesh
ing carefully inserted beneath the outer layer of the roll. and the other to spread the mesh flat, smoothing out folds.
410 F. Ugahary
of all patients is performed at 1 week, 6 weeks, 3 months, 6 months,

and 1 year after the operation.
Patients and Results

From September 1995 to December 1998, 427 hernias in 364 pa-
tients were repaired with this technique: 10 in 1995, 79 in 1996,
147 in 1997 and 191 in 1998. Three hundred sixty-nine of the her-
nias were primary and 58 recurrent; there were 11 sliding hernias,
4 hernias with bowel incarceration and resection, 29 scrotal her-
nias, and 7 femoral hernias. There were 349 men and 15 women
aged 20 to 90 years. The duration of an average procedure was ap-
proximately 20 to 25 minutes, whether for primary or recurrent
hernias. In the beginning, only the author used this technique,
but after 1996, when the procedure was refined and the instru-
ments modified, the three other surgeons in the department
joined in.
There were seven recurrences, an overall recurrence rate of
FIGURE 59.7. Drawing illustrating the final position of the mesh in the
preperitoneal space behind the myopectineal orifice. 1.7%. Four of these were identified in the first week after the ini-
tial operation, and all were immediately corrected through the
same incision; one was a missed indirect hernia, one mesh dis-
placed in the inguinal canal after a scrotal hernia repair, one mesh
We can also use a depressor, instead of the retractor, to smooth displaced in front of the anterior epigastric vessels, and one mesh
out the distal ends of the mesh. While placing the mesh, it must was incompletely deployed. Detaching the former mesh and re-
be remembered that the peritoneal sac must lie on the visceral placing it with new and larger prostheses proved easy. Three re-
side of the mesh. The abdominal wall should not be lifted during currences were repaired through an anterior approach; one
spreading of the mesh, because, when it is allowed to drop back, Lichtenstein repair, one plug repair, and one with the Prolene her-
it will cause the mesh to fold when the retractors are withdrawn. nia system for a medial parapubic defect. Most recurrences oc-
curred in the first 10 patients of a surgeon, during the learning
period. Before 1996, the mesh used was smaller (8 by 10 cm), and
Step 6 a slit was made to accommodate the cord. During the manipula-
tion to accommodate the cord, the medial side of the prosthesis
When the lateral part of the mesh is not fully unfurled, it can be might be dislodged, resulting in recurrence. We now parietalize
eased into proper position using two forceps. the cord and use a larger mesh.
Because most of the operations are performed under regional Most patients were operated on under spinal anesthesia. Recov-
or local anesthesia, the repair can be tested by asking the patient ery has been rapid, with early return to daily activities, and patient
to cough or strain. The peritoneal sac will be seen to compress satisfaction has been high. There were no serious complications or
the mesh against the abdominal wall. There should be no bulge infections.
at the original hernia site.
Discussion
Step 7
Covering the myopectineal orifice with a nonabsorbable pros-
Finally, the transversus abdominis and internal oblique muscles thesis in the preperitoneal space is a well-established method for
are closed with one or two absorbable sutures, one of which se- the repair of groin hernias. This technique accomplishes the
cures the lateral anterior part of the mesh to the abdominal wall. same objective as the totally extraperitoneal laparoscopic ap-
During closure, the ilioinguinal nerve must be carefully avoided. proach while avoiding the difficulties of endoscopy and general
The aponeurosis of the external oblique is closed with absorbable anesthesia. This is not only of benefit to the patient but also of
sutures. The skin is closed with a subcuticular suture. great interest to those concerned with managing health-care
costs. 5 The preperitoneal dissection and preparation are accom-
plished with regular instruments and a relatively short operative
Postoperative Management procedure. When perioperative difficulty or complication occurs,
no conversion is needed; it can be easily managed by lengthen-
If dislocation of the mesh or local complication is suspected, ex- ing the incision. The approach is simple, inexpensive, and ap-
ploration is recommended as soon as possible following ultra- plicable not only to primary and recurrent hernias but also to
sonography, especially if a recurrence is suspected. Postoperative the treatment of complex hernias. The Stoppa-Wantz repair
analgesia consists of ibuprofen. All patients are contacted the fol- for groin hernias, with their giant prosthetic reinforcement of
lowing day. There are no specific restrictions regarding the re- the visceral sac (GPRVS) technique, has proved an effective
sumption of work or other activities. For study purposes, follow-up weapon against recurrence. 1,2,6 Combining the gridiron mesh in-
59. The Gridiron Hernioplasty 411
sertion technique with the valid principle of the GPRVS, we could References
say that this is an open minimally invasive GPRVS procedure
(OMI-GPRVS). 1. Stoppa RE. The preperitoneal approach and prosthetic repair of groin
hernia. In Nyhus LM, Condon RE (eds): Hernia, 4th ed. Philadelphia:
J.B. Lippincott; 1995:188-210.
Summary 2. Wantz GE. Giant prosthetic reinforcement of the visceral sac: the Stoppa
groin hernia repair. Surg Clin N(ff(;h Am. 1998;78(6):1075-1087.
This technique of repair is simple, open, minimally invasive, 3. Wantz GE. Atlas of hernia surgtfry. New York: Raven Press; 1991.
tension free, anatomical, and elegant to perform for the treat- 4. Berliner SD. Biomaterials in hernia surgery. In Maddern GJ, HiattJR,
Phillips EH (eds): Hernia repair: open vs. laparoscopic approaches, 1st ed.
ment of nearly all kinds of groin hernias. As with any technique,
New York: Churchill Livingstone; 1997:199-214.
this method of hernia repair must be carefully studied and
5. Liem MSL, Steensel Cj, Boelhouwer RU, et al. The learning curve of
clearly understood before it can be executed. Good knowledge totally extraperitoneal laparoscopic inguinal hernia repair. Am] Surg.
of and respect for the regional anatomy is mandatory. This pro- 1996;171:281-285.
cedure is a viable alternative to accepted techniques for groin 6. Ugahary F, Simmermacher RKJ. Groin hernia repair via a grid-iron in-
hernia repair. When correctly performed, there should be no cision: an alternative technique for preperitoneal mesh insertion. Her-
recurrence. nia. 1998;2:123-125.
60
Dynamic Self-Regulating Prosthesis
(Protesi Autoregolantesi Dinamica) (PAD)
G. Valenti, A. Testa, and N. Barletta
Introduction oblique at the point where it forms the anterior sheath of the rec-
tal muscle. Surgical preparation must be extended to the supra-
When treating primary inguinal hernias through an anterior ap- pubic level.
proach, it is our opinion that the prosthesis should be positioned Above the internal inguinal ring the internal oblique must be
anterior to the fascia transversalis. released from the aponeurosis of the external oblique muscle. The
This constitutes the rationale for the use of a Dynamic Self- fascia transversalis must not be opened, and the cremaster mus-
Regulating Prosthesis (Protesi Autoregolantesi Dinamica [PAD]), cle must be spared as far as possible. A routine search for associ-
a new therapeutic approach for the treatment of all primary inated hernias must be performed. Nerves should be spared if
guinal hernias and many recurrences. The PAD consists of two su- possible, but if they obstruct the implantation of the prosthesis or
perimposed layers of polypropylene, which are fitted and come in if there is a risk of nerve kinking, they must be first coagulated
one size, to support the inguinal region in a synergistic, comple- and then resected.
mentary manner. The deep and superficial layers of this dynamic In the case of an indirect hernia, the sac is dissected from the
prosthesis can move independently of each other because each internal orifice and then sectioned and reduced inside the ab-
side is fixed to a separate myoaponeurotic layer. Yet the prosthe- domen, whereas in the case of a sliding hernia the sac is always
sis remains flat and parallel to the myoaponeurotic plane. reduced inside the abdomen. When operating on a direct hernia,
the imbrication of the fascia transversalis is performed using a con-
tinuous absorbable suture. It is important to avoid suturing the
Methods genital branch of the genitofemoral nerve, which is superficial
between the internal inguinal orifice and the lateral fibers of the
The deeper prosthetic layer (Fig. 60.1A) is trapezoidal. It has a fis- cremaster.
sure C on its medial side AB through which the spermatic cord The PAD implantation may now begin.
may pass, leading to an orifice D, where it may be lodged. The To secure the deeper prosthesis, the spermatic cord and the cre-
two prolongations A and B are anchored to the anterior rectus master muscle are lifted and positioned perpendicular to the plane
sheath. The lateral side EF of the prosthetic layer is free and lies of the fascia transversalis at the exit of the internal inguinal ring.
flat, parallel to the inguinal ligament, without sutures. The deep prosthetic mesh is set in place and the cord released.
The superficial prosthetic layer (Fig. 60.IB) is similar in shape Each leg of the prosthesis is secured with a single, nonabsorbable
to the inguinal floor. The lateral margin GH presents a semilunar suture (polypropylene 2-0) at the point where the aponeurosis of
notch I for the passage of the spermatic cord from below. The the internal oblique muscle fuses with the rectus sheath. The lat-
spermatic cord takes a zigzag course between the two prosthetic eral margin of this layer lies parallel to the inguinal ligament, with-
layers. The medial side LM is positioned anterior to the rectus out sutures (Fig. 60.4A).
sheath. The superficial prosthesis is then secured, generally with three
The shape and the size of the two layers are the result of a plani- or four sutures (polypropylene 2-0) to $e inguinal ligament above
metric study of the inguinal canal conducted in 150 patients and below the notch created for passage of the spermatic cord.
(Valenti, 1998) (Figs. 60.2 and 60.3).1-3 The distal suture is positioned over the pubic tubercle, a second
suture is placed near the lower side, and a third is placed near the
upper side of the notch. Sometimes a fourth suture is needed be-
Surgery tween the first two. The surgeon uses a finger to smooth out the
prosthesis over the rectus sheath, medially, and under the aponeu-
The operative procedure is similar to any anterior approach re- rosis of the external oblique, to ensure the absence of tension or
pair. The inguinal canal structures and myoaponeurotic planes on folds; no suture is required (Fig. 60.4B).
which the prosthesis is to be implanted must be freed. Particular Lack of space for spreading the prosthesis indicates inadequate
care must be taken to release the aponeurosis of the internal preparation of the anatomical bed. The aponeurosis of the exter-
412
60. Dynamic Self-Regulating Prosthesis 413
FIGURE 60.1. (A) The deeper layer.

AB = medial side; D = orifice for A
the spennatic cord; AC to CB =
M
medial "legs"; EF = lateral side.
(B) The superficial layer. GH =
lateral side; I = semilunar notch E
for the passage of the spennatic c o
cord; LM = medial side.
G H
A 1,8=-----,1 F B
nal oblique is closed with a continuous suture over the spermatic Discussion
cord, thus recreating normal anatomy.
This elasticity and dynamism of the prosthesis is compatible The techniques involved in the application of a peripherally su-
with perfect stability. Figure 60.5 illustrates the relationship be- tured prosthesis, positioned above the fascia transversalis, that is,
tween the prosthesis and the inguinal canal structures. The deep the so-called tension-free techniques, guarantee immediate am-
prosthetic layer (PI) medially sutured to the rectus (S) follows bulation, swift recovery, and an early return to work, in addition
the muscle in its movements; its lateral margin is stabilized by to satisfactory postsurgical comfort and a next to zero rate of
the portion of spermatic cord placed between the two layers, and recurrence.
by the superficial prosthesis (PS), sutured to the inguinal liga- However, the problem of how to construct a prosthesis of the
ment (U). right shape and size still exists, as does the problem of how to mod-
The incision along the lateral margin of the upper prosthesis is ulate the tension of the suture so that the prosthesis is lax enough
not for containment, as would be the case with a newly formed to prevent tension and traction. This is what Amid et al.4-6 refer
orifice; its function is to lateralize the spermatic cord, so there is to when they say "this desirable laxity assures a true tension-free
no potential for entrapment (a in Fig. 60.6). The suprapubic por- repair." Tension and traction are the basis of postoperative pain
tion of the superficial prosthesis is in excess so that it may be po- and complications.
sitioned underneath the medial crus of the external oblique Analysis of our recent experience highlights the various prob-
aponeurosis to stabilize the prosthesis (b in Fig. 60.6). lems linked to the preperitoneal positioning of the prosthetic
We close the external oblique aponeurosis over the spermatic mesh and the risk of prosthesis migration. In fact, a plug may mi-
cord. Contact between the cord and the prosthesis has never been grate or cause decubiti and fistulize with intraabdominal organs
a problem in our experience; we preserve the cremasteric fibers or vessels.6-8 Fixing the plug does not resolve these issues, but
and the internal spermatic fascia as much as possible to protect merely limits the risk of migration. The distance between the in-
the vas deferens and the spermatic vessels. The cord, on the other ternal ring and the iliac vessels is approximately 1.0 cm; the size
hand, enveloped by the cremaster, has a stabilizing effect on the of some plugs is 2.5, 3.5, or 4.5 cm; a fibroblastic reaction creates
upper prosthesis as an "elastic pressure transducer" elsewhere de- dense fibrosis around the mesh that may cause partial· compres-
scribed by the authors. sion of the vein and the risk of venous thrombosis. Moreover,
preperitoneal fat is not an ideal tissue in terms of resistance to in-
fection and promotion of rapid fibroblastic response capable of
encompassing the prosthetic mesh.9-11
Placing a prosthesis in a preperitoneal site results in extensive
x y
fibrosis of the spaces of Retzius and Bogros and may constitute an
obstacle to subsequent surgery in the same area. 12
50· - 60·
1.6 em
o
c D
FIGURE 60.2. The deeper layer. (A) X = rectus muscle; Y = inguinal liga-
ment. (B) Distance between the internal orifice and the inguinal ligament.
(C) Common area of the minimum and maximum angles. (D) Definitive
shape. FIGURE 60.3. Dimensions of the superficial layer.
414 G. Valenti et al.
A B
FIGURE 60.4. (A) Deeper layer correctly positioned. a = rectus muscle; b = inguinal ligament; c = spermatic cord; d = transversalis fascia; e = internal
oblique muscle. (8) The two prosthetic layers correctly positioned.
In terms of chronic pain, cases of removal of the subfascial plugs well as the vas deferens, with or without the interposition of the
have been recorded as a solution to persistent neuralgia when lo- cremaster and the internal spermatic fascia, as is the case in the
cal and systemic pharmacological treatment is ineffective. lo Sub- suprafascial compartment?
fascial infections are difficult to treat and often require the We are proposing PAD because it offers all the advantages of
removal of the prosthesis. tension-free and sutureless techniques. It offers the excellent re-
In our opinion, the newer prostheses with a subfascial disc and sults of a "tension-free" technique in terms of recurrences, which
a suprafascial ellipsoid stabilized by a connecting cylinder create have not yet occurred in our experience of 800 cases treated since
more problems than those they try to solve. 1992. Furthermore, the sutureless technique provides a comfort-
Some authors state that once a prosthesis is placed on the trans- able postoperative phase, with cessation of analgesics within 24
versalis fascia it is preferable to close the external oblique aponeu- hours in 80% of patients and a mean consumption of 2.9 pain re-
rosis underneath the spermatic cord in order to avoid contact lief tablets for an average of 1.7 days. The routine use of local anes-
between the cord and the prosthesis. A question arises: Are not thesia and immediate mobilization have eliminated many general
the prostheses positioned under the transversalis fascia in direct complications, such as urinary retention and thrombophlebitis. Ta-
contact with vascular structures, that is, the spermatic vessels as bles 60.1 and 60.2 show early results of the 500 patients and 585
hernias (17% bilateral) .1-3
The PAD provides a single solution in all cases of primary in-
guinal hernia in adult males and in many cases of recurrent her-
Section 1
Section 2
Section 3
b
FIGURE 60.5. Three sections of the inguinal canal: Section 1 below, section
2 across, and section 3 above the internal inguinal ring. a = rectus mus-
cle; b = internal oblique and transversus muscles; c = spermatic cord; e =
external oblique aponeurosis; f = inguinal ligament; g = transversalis fas-
cia; PI = deeper prosthetic layer; PS = superficial prosthetic layer; S = su- FIGURE 60.6. The two prosthetic layers correctly positioned. a = semilunar
ture between the deeper layer and the rectus sheath; U = suture between notch; b = superficial inguinal ring, medial crus of the external oblique
the superficial layer and the inguinal ligament. aponeurosis.
60. Dynamic Self-Regulating Prosthesis 415
TABLE 60.1. Short-term complications in 585 hernioplasties
Complications Cases Percent
Hematomas 1 0.17
Seromas 2 0.34
Urinary retention 0 o
Orchitis 0 o a
Suppuration 0 o
Thrombophlebitis 0 o
Mortality 0 o
TABLE 60.2. Long-term complications in 585 hernioplasties
Complications Cases Percent
Recurrences o o
Prosthesis displacement o o b
Pain lasting over 4 days 30 5.12
Persistent neuralgia 2 0.3
Testicular atrophy o o
Complications linked to the prosthesis o o
nia. This precut, single-size prosthesis is the result of a study of

150 male patients affected by primary inguinal hernia (Valenti
1998), taking into consideration the average measurements of the
inguinal canal. 3
In the initial postoperative period, when the patient changes po-
FIGURE 60.7. Changing shape of abdominal wall with movement. (a)
sition from recumbency to orthostatism, the PAD adapts and mod-
Supine. (b) Erect ("sail effect"). (c) Overweight ("spinnaker effect").
els itself to the morphological variations of the inguinal area of
each individual patient. During this phase there is an important
variation in the relationship between the inguinal ligament and the
broad muscles of the abdomen. The distance between the inguinal
ligament and the rectus muscle increases; the wall, from a flat po-
sition, becomes convex, and in some cases the lowest portion of 2. Valenti G, et al. Le ernie inguina~ la terapia chirurgica da Bassini al day-
the abdominal wall may collapse (Fig. 60.7). In such cases, assess- hospita~ 3rd ed. Torino: UTET; 1998.
ing the correct tension to be applied to both the prosthetic mate- 3. Valenti G, Testa A, Capuano G. Misure antropometriche del canale in-
rial and the sutures, while the patient is supine, can be difficult, guinale maschile. Min Chir. 1998;53:715-718.
and there is a risk of creating folds, traction, and therefore pain. 4. Amid PK, Shulman AG, Lichtenstein IL. The Lichtenstein open "ten-
The preparation of anatomical planes for the application of PAD, sion-free" mesh repair of inguinal hernias. Surg Today. 1995;25:
619-625.
far from being a limiting factor in the operation, is a crucial ther-
5. Amid PK, Shulman AG, Lichtenstein IL. Simultaneous repair of bilat-
apeutic step; moreover, it represents a technical and cultural ad-
eral inguinal hernias under local anesthesia. Ann Surg. 1996;223:249-
vantage: The technical advantage stems from the fact that a lesser 252.
dissection would pose the risk of missing an associated hernia and 6. Amid PK, Lichtenstein IL. Long term results and current status of the
therefore a "false" recurrence. This way a minimally invasive oper- Lichtenstein open tension-free hernioplasty. Hernia. 1998;2:89-94.
ation would result in a minimally therapeutic intervention. The cul- 7. Cristaldi M. Femoro-popliteal by-pass occlusion following mesh plug
tural advantage derives from the obligation of the surgeon to be for prevascular femoral hernia repair. Hernia. 1997;1:197-199.
familiar with the inguinal region and to use a standardized proce- 8. Danielli PG. Le complicanze dei plugs: infezioni e recidive. Hernia.
dure that guarantees anatomical integrity before the application of 1997;1 (suppl 1):85.
the prosthesis; this is crucial in complex cases in which knowledge 9. Greco DP. Valutazione morfologica. In Greco DP, Forti D (eds): Le
protesi nella chirurgia erniaria rrwderna. Milano: Medical Economics;
and experience ensure the efficacy of the intervention.
1996:23-28.
We are therefore promoting this technique as first-line therapy
10. PalotJP, et al. The mesh plug repair of groin hernias: a three-year ex-
in all cases of primary inguinal hernia, representing a complete perience. Hernia. 1998;2:31-34.
and extremely comfortable solution that is both simple to use and 11. Pelissier EP, Blum D. The plug method in inguinal hernia: prospec-
easily replicated. tive evaluation of postoperative pain and disability. Hernia. 1998;1:185-
189.
12. Stoppa R, et al. Some problems encountered in re-operation follow-
References ing repair of groin hernias with pre-peritoneal prosthesis. Hernia.
1998;2:35-38.
1. Valenti G, Testa A, Capuano G. Protesi Autoregolantesi Dinamica 13. Valenti G, et al. Dynamic self-regulating prosthesis (Protesi Autore-
(PAD.), una nuova metodica per il trattamento delle ernie della regione golantesi Dinamica): a new technique in the treatment of the inguinal
inguinale: note preliminari su 153 casi. Min Chir. 1997;52:1247-1253. hernias. Hernia. 1999;3:5-9.
61
Ventral Hernias: Use of the Kugel Patch
Robert D. Kugel
The high risk of recurrence in large ventral hernia repairs has for tiseptic scrub is performed that extends several centimeters be-
many years induced the use of prosthetic materials. 1- 3 Although yond the likely extent of the hernia.
there has been some confusion and difference of opinion about
the proper site for mesh in these hernias, a consensus appears to
be evolving. 4 As greater attention focuses on the speed of post- Operative Technique
operative recovery in addition to the risk of recurrence, interest
in the use of mesh in the repair of ventral hernias is on the A small incision is made directly over the hernia. The hernial sac
increase. is identified and dissected free from the surrounding subcutaneous
The Kugel Patch™ (Ethicon, Inc.) is a double-layer mesh patch tissue down to the fascial edge (Fig. 61.2). The attenuated fascia at
initially developed for use in a virtually sutureless groin hernia re- the edge of the defect is incised by sharp dissection or electro-
pair, as described in Chapter 75. The patch was later used to ad- cautery, opening the preperitoneal space. The hernial sac, unless
vantage in the repair of ventral hernias. very large, is simply inverted. Large redundant sacs can be resected.
In ventral hernia repairs, the patch is placed preperitoneally, or The edge of the defect is elevated with clamps, and the preperi-
retromuscularly, where intraabdominal pressure and strong hy- toneal space is developed (Fig. 61.3). If multiple previous surgeries
drostatic tissue forces tend to maintain its position,5,6 thus reduc- have made this difficult, a submuscular (retromuscular) dissection
ing the number of anchoring sutures needed. The repair is can be performed and the patch placed posterior to the rectus or
completely tension free. oblique muscles,7,8 with the posterior sheath and transversalis fas-
cia as a barrier between the patch and the hollow viscera. In some
cases it may be necessary to use the omentum as a barrier.
The Patch A pocket is created in the preperitoneal space large enough to
accommodate the mesh patch. The patch should extend at least
The patch is composed of two layers of a knitted monofilament 2 cm beyond the edge of the hernia defect in small hernias (2 to
polypropylene mesh material. It is reinforced near the outer edge 4 cm), but proportionately farther with larger hernias. The size of
by a single monofilament polyester ring. This gives the patch the defect will dictate the size of the patch (or combination of
added rigidity and holds it open. The patch is commercially avail- patches) needed to accomplish the repair.
able in several sizes, which can be used individually or in tandem The mesh is loosely folded or rolled for insertion into the
to repair most ventral hernias (Fig. 61.1). preperitoneal or submuscular pocket (Fig. 61.4). It is allowed to
open to its full dimension and then anchored to the edge of the
fascial defect with interrupted mattress sutures (heavy absorbable
The Procedure or nonabsorbable monofilament) placed between the fascia and
the anterior layer of the patch (Fig. 61.5). The outer edge of the
Preparation patch is rarely anchored. Usually, no attempt is made to close the
fascia over the mesh. Closed suction drainage is used liberally in
Small hernias can be repaired under local anesthesia. Larger her- larger ventral hernias, and the patients are maintained on oral an-
nias or hernias in obese patients usually require regional or gen- tibiotics until the drain is removed, although the effectiveness of
eral anesthesia. this regimen is unproven. 9 ,lO
Prophylactic antibiotics may be used more liberally than in groin
hernia repairs, but not routinely. They are used for patients with
cardiac valve disease or artificial joints and for very obese patients Postoperative Management
with large hernias, as the risk of fluid collections, such as blood
or serum, and infection is greater. Even large ventral hernias can be treated on an outpatient basis
The operative site is prepared with a limited shave. A wide an- with this technique. Most patients are released 1 to 4 hours after
416
61. Ventral Hernias 417
FIGURE 61.4. The mesh patch is rolled or folded and inserted into the
preperitoneal pocket developed to accommodate it.
FIGURE 61.1. Mesh patch. (a = Outer "apron." b = Monofilament ring. c = the procedure. Pain control is achieved, in most cases, with hy-
Transverse slit. d = Tissue apposition hole and wedge-shaped tab.
drocodone and acetaminophen. With more extensive procedures,
pain is occasionally managed with a combination of oxycodone
and acetaminophen with oral hydroxyzine.
Patients are usually encouraged to resume normal activities
within 1 or 2 weeks. They are seen for follow-up in 1 to 2 weeks.
Drains are removed in 2 to 7 days.
Results
Between March 1, 1994, and May 1, 1999, 246 ventral hernia re-
pairs were performed in 172 patients. The hernias repaired in-
- ---::::---
cluded relatively small umbilical and epigastric hernias, but also
very large and complex recurrent incisional hernias requiring
more than one large patch. Two recurrences have been identified
in these patients (recurrence rate of 0.82%). One patch had to be
removed because of a chronic draining sinus that did not respond
to conservative treatment.
FIGURE 61.2. Ventral hernial sac dissected free down to the edge of the fas-
cial defect. Conclusion
The use of the preperitoneal patch allows the surgeon to approach
both ventral and groin hernias using similar methods and princi-
FIGURE 61.5. The anterior layer of the patch is anchored to the edge of
FIGURE 61.3. Elevated edges of the fascial defect of a ventral hernia. the hernia defect with a few interrupted sutures.
418 RD. Kugel
pIes. The patch and its deployment are completely tension free, 3. Bendavid R Prosthesis and herniorrhaphies. In Kurzer M, Kark AE,
using intraabdominal pressure and hydrostatic tissue forces to Wantz GE (eds): Surgical management of abdominal wall hernias. London:
maintain its position and reduce the need for anchoring sutures. Martin Dunitz Ltd.; 1999:73-85.
This means easier placement (particularly in ventral hernias) and 4. Stoppa R, Ralaimiaramanana F, Henry X, et al. Evolution of large ven-
less pain for the patient. tral incisional hernia repair. The French contribution to a difficult
problem. Hernia. 1999;3:1-3.
Use of the patch has enabled the surgeon to treat even very large
5. Rives J, Lardennois B, Pire JC, et al. [Large incisional hernias. The im-
ventral hernias on an outpatient basis. Operating time is reduced portance of flail abdomen and of subsequent respiratory disorders.]
because it is rarely necessary to anchor the outer edge of the patch, Chirurgie. 1973;99:547-563.
which is held open by its construction. Reduced postoperative pain 6. Wantz GE. Incisional hernioplasty with Mersilene. Surg Gynecol Obstet.
allows patients to return rapidly to normal activities. 1991;172:129-137.
7. FlamentJB, PalotJP, Avisse C, et al. Massive multirecurrent incisional
hernia prosthetic repair. In Kurzer M, KarkAE, Wantz GE (eds): Sur-
gical management of abdominal wall hernias. London: Martin Dunitz Ltd.;
References 1999:227-240.
8. Duce AM, Muguerza JM, Villeta R, et al. The Rives operation for the
1. Bendavid R Prosthetics in hernia surgery: a confirmation. Postgrad Gen repair of incisional hernias. Hernia. 1997;1:175-177.
Surg. 1992;4:166-167. 9. Condon RE. Incisional hernia. In Nyhus LM, Condon RE (eds): Her-
2. Beets GL, van Mameren H, Go PMNYH. Long-term foreign-body re- nia. 4th ed. Philadeiphia:J.B. Lippincott; 1995:319-328.
action to preperitoneal polypropylene mesh in the pig. Hernia. 1998; lO. White lJ, Santos MC, ThompsonJS. Factors affecting wound compli-
2:153-155. cations in repair of ventral hernias. Am] Surg. 1998;64:276-280.
62
Use of Vicryl Pads In
Inguinal Hernia Repairs
H.R. Willmen
From the Bassini l to the Shouldice,2 various techniques of differ- In direct hernia repair, the sac remains unopened. Indirect sacs,
ing viability have been developed to repair inguinal hernias, which however, are always resected except in sliding hernias. Mter liga-
are by nature prone to recurrence. These are the so-called pure tion of the hernial sac, we leave a stump of 1.5 to 2 cm, which will
tissue repairs, that is, they make use only of the often poor qual- adhere to the surrounding tissue. Under direct vision and with the
ity fascial and muscular tissue available in the groin. help of the index finger, we then secure all layers, including the
In 1986, we wanted to induce the human body to produce en- external oblique aponeurosis, with four, or at most five, inter-
dogenous collagenous connective tissue in Hesselbach's triangle, a rupted sutures placed at intervals of 1 to 1.5 cm. Laterally, the su-
region of particular weakness. To achieve this, we used an ab- tures incorporate the ligament of Cooper. The transversalis fascia
sorbable Vicryl® pad (Fig. 62.1), first in combination with a modi- is not included. We also deliberately avoid placing sutures in the
fied Bassini repair and now with a modified Kirschner technique.3-8 periosteum near the symphysis pubis.
The absorbable Vicryl pad we developed is a knitted Vicryl tube Mter inserting these nonabsorbable, monofilament sutures
(polyglactin 910) filled with Vicryl filaments and sealed at both (Prolene®, Ethicon, Inc.), we thoroughly rinse the surgical site
ends. Polyglactin 910, a copolymer of glycolides and lactides, is with iodine and prepare the Vicryl pad, injecting it with one am-
broken down by hydrolysis and absorbed. The catabolic products poule of gentamicin sulfate (Refobacin®, Merck). We lift the pre-
of glycolic and lactic acids are metabolized without affecting the placed Prolene sutures and put the pad beneath (Fig. 62.5). The
wound-healing environment. As the Vicryl pad is fully absorbed, pad is then adjusted so that it reaches the edge of the symphysis
the risk of later infections occasionally caused by nonabsorbable pubis but does not overlap it. Its opposite side lateralizes the sper-
mesh implants is largely eliminated. The Vicryl pad's dimensions matic cord. The Vicryl pad, now placed in Hesselbach's triangle
are 60 by 25 by 5 mm. It is fully absorbed in about 112 days (Fig. on the transversalis fascia and hernial sac, is secured to the inner
62.2). The regular formation of connective tissue has been proved abdominal wall by modified Kirschner sutures (Fig. 62.6).
in animal studies (with rats and miniature pigs) performed by The pad serves several purposes: in the early postoperative
Lierse and Brenner3 as well as in our surgical practice6 (Figs. 62.3 phase, the pad protects the sutures from the inside like a plug in
and 62.4). a sink. At the same time, it reinforces the transversalis fascia by a
factor of 5 to 10, without requiring extensive preparation (Fig.
62.7). The pad also shifts the deep inguinal ring laterally. Later in
the healing process, it induces the formation of connective tissue,
Technique thus providing more stability and minimizing the likelihood of re-
currence. The spermatic cord, however, remains subcutaneous.
Repair of Primary Direct and Indirect Hernias The additional suture lateral to the spermatic cord would only in-
crease the risk of ischemic orchitis.
A horizontal incision, usually 6 by 8 cm in length, is made along
The surgical field is rinsed with iodine again, before we insert
the skin crease, starting 2 cm lateral to the symphysis pubis. The
an iodized drain. Finally, we apply two 4-0 Vicryl sutures to ap-
larger subcutaneous veins are ligated with 4-0 Vicryl sutures;
proximate the subcutaneous tissues and close the skin with inter-
smaller ones are coagulated. The external oblique aponeurosis is
rupted 3-0 monofilament sutures.
split along the direction of its fibers to the superficial ring. The
spermatic cord is isolated and retracted with a rubber drain. The
cremaster is not resected. Up to now, this approach has never
caused any problems. To facilitate the eventual approximation of
Simplified Technique for Repairing
rectus, internal oblique, and transversus muscles to the inguinal Recurrent Hernias
ligament, we use the index finger to separate the structure as a
whole from the deep surface of the anterior rectus sheath, ren- Before surgery, the hernia site is marked with ink. The horizontal
dering unnecessary any relaxing incision in the rectus sheath. incision is the same as for primary hernias, but previous scars,
419
420 H.R. Willmen
FIGURE 62.1. Vicryl pad (60 X 25 X 5 mm).
FIGURE 62.3. Newly proliferated collagenous connective tissue induced by

which often reach down to the scrotum, are left undisturbed. We the Vicryl pad in the inguinal region of a miniature pig 5 months after
directly approach the marked hernia site and the underlying de- implantation. (Reprinted from Lierse and Brenner,3 with permission.)
fect, taking care to identifY the spermatic cord. After exposing the
defect, we dissect a surrounding margin of 1 cm to prepare an ap-
propriate suture base. The hernial sac remains unopened, if pos- sues with two interrupted 4-0 Vicryl sutures. Finally, we close the
sible. If accidentally opened, we close it with a running 3-0 Vicryl skin using interrupted nonabsorbable monofilament sutures.
suture after inspection.
Under direct vision and with the help of the index finger, we
then apply interrupted sutures of monofilament, non absorbable
material. Depending on the position and size of the defect, the Efficacy of the Vicryl Pad
sutures may include the external oblique aponeurosis, rectus
sheath, internal oblique muscle, transversus muscle, and trans- Since 1986, more than 30,000 Vicryl pads have been used, in Ger-
versalis fascia superiorly and, if preserved, the inguinal or Cooper's many and adjacent countries, particularly in France, in implanta-
ligament inferiorly. Any supporting scar tissue is included in the tions. Between 1986 and July 1992, we studied a total of 1431
sutures. Subsequently, we apply one to three (in exceptional cases patients undergoing primary hernia repair with the Vicryl pad in
up to five) interrupted sutures at intervals of 1 to 1.5 cm. our surgical department.4-7 During the same period, another 291
After injecting 1 ampoule of gentamicin sulfate into the Vicryl patients who had previously undergone up to seven hernia repairs
pad, we place it beneath the row of sutures and knot the Prolene were admitted to our hospital. All of them were treated with the
sutures over the pad. The pad now lies directly on the hernial sac simplified hernia repair technique outlined above. Between 1986
and parts of the transversalis fascia, protecting the row of sutures and December 1998, we implanted Vicryl pads in a total of 3619
from the inside. As in the primary hernia repair, the spermatic primary and 1611 recurrent hernia repairs.
cord remains subcutaneous. After rinsing the surgical field with
iodine, we insert a drain and approximate the subcutaneous tis-
eo 120
FIGURE 62.2. Absorption of the Vicryl pad, completed after approximately FIGURE 62.4. Collagenous connective tissue formed after implantation of
112 days. a Vicryl pad into an 82-year-old male patient; postmortem preparation.
62. Vicryl Pads in Inguinal Hernia Repairs 421
FIGURE 62.5. Vicryl pad placed beneath a suture onto the transversalis
fascia. FIGURE 62.7. Cross-sectional view of the inguinal region. Inguinal hernia
repair according to Kirschner. The Vicryl pad is placed anterior to the
transversalis fascia.
Results
Since August 1992, we have implanted the Vicryl pads using a
Results of Primary Inguinal Hernia Repairs modified Kirschner method, a technique that provides more sta-
bility through the approximation of the external oblique aponeu-
Among the 1431 patients undergoing direct and indirect inguinal rosis and Cooper's ligament.
hernia repair between 1986 and July 1992, 838 patients were
treated between 1986 and 1989, mainly with the modified Bassini
method. Of these, 727 (88.4%) were followed up after 2 to 6 years. Results Of Recurrent Hernia Repairs
The recurrence rate was 1.03%. None of the patients needed treat-
ment for postoperative hematoma. Two small series of three and As mentioned above, 291 patients who had previously undergone
two patients in a sample of 150 first-time implantations showed re- up to seven hernia repairs were treated with a simplified Bassini
jection responses within 4 to 6 weeks after the surgery. Neverthe- (260 cases) or Shouldice (31 cases) technique between 1986 and
less, no recurrences were noted. Subsequently, we started to inject 1992. We followed up 172 (91%) of the recurrent hernia repairs
all pads with gentamicin sulfate, as is done in hip surgery. No re- performed between 1986 and 1989 after 2 to 6 years. Only three
jections have been reported since. hernias recurred, a recurrence rate of 1.7%. All three patients were
treated in 1986 or 1987, when we still used absorbable 2-0 Vicryl
sutures to close the hernial defect. Hematoma developed in 0.6%
of patients but did not require treatment. None of the patients
undergoing recurrent hernia repair showed rejection responses to
the Vicryl pad implants. Neither primary nor recurrent hernia re-
pairs resulted in testicular atrophy or persistent pain in the groin.
Discussion
Vicryl pad implants, containing a large number ofVicryl filaments,
stimulate the body to gradually absorb not only a single thread or
a thin Vicryl mesh but also a large mass of foreign substance. An-
imal studies by Lierse and Brenner3 and our surgical practice have
proved that this process results in reproducible, directional col-
lagenous connective tissue that is of a much higher quality than
scar tissue, a benefit not only to patients but to surgeons as well.
Our repair technique for recurrent hernias enables surgeons to ap-
proach the defect directly without unnecessary extensive dissection.
Rejection responses were reported only in the early phase; all
of these occurred after primary hernia repairs. We cannot confirm
FIGURE 62.6. Prolene suture tied across the pad; no periosteal suture. that injecting the pads with gentamicin sulfate prevents rejections.
422 H.R. Willmen
It seems, however, that it has a positive impact on the wound-heal- References

ing process. This is particularly true for recurrent hernia repairs,
where previous surgeries often do not allow for "minimally inva- 1. Bassini E. Uber die Behandlung des Leistenbruchs. Arch Klin Chir.
sive" dissections. 1890;40:429-476.
Thus far, we have successfully prevented the postoperative de- 2. Bendavid R. The Shouldice repair. In Nyhus L, Condon R (eds): Her-
velopment of the so-called ilioinguinal syndrome by resecting the nia, 4th ed. Philadelphia: J.B. Lippincott; 1995:217-226.
ilioinguinal nerve. Placing the spermatic cord in the subcutane- 3. Lierse B, Brenner J. Die Implantation des Vicryl-Kissens bei der
ous tissue with the cremaster fibers intact has not resulted in any Hemiotomie-Induzierte Stabilitiit im Leistenbereich. In 1m Dienst der
complications. Chirurgie. Ethicon; 1991:2.
4. Willmen HR. Die "Wende" in der Therapie von Inguinal- und Hiat-
Today, we successfully prevent hematoma formation, even after
ushemien durch Induktion tragrahigen Narbengewebes. Chirurgie.
recurrent hernia repairs, by giving heparin injections into the con- 1987;58:300-302.
tralateral thigh rather than the abdominal wall. About 10 years 5. Willmen HR, Holste, Holscher j, et aI. Behandlung von Leisten-
ago, it was our practice to inject the heparin into the abdominal hemien. Reproduzierbare Bindegewebesaugmentation durch Im-
wall, but we discovered that, despite continuous careful hemosta- plantation eines Vicryl-Kissens. Chir Praxis. 1988;39:173-176.
sis, a large number of patients developed hematomas. We then 6. Willmen HR. Die "Wende" in der Chirurgie der Leistenhemie durch
changed our practice and started to i~ect heparin into the ex- Induktion einer tragtahigen Narbenplatte mit einem Vicryl-Kissen. Z
tensor side of the contralateral thigh. None of our patients has de- Bl Chir. 1988;113:56-58.
veloped a hematoma in the surgical field since. 7. Willmen HR. Vereinfachte und optimierte Chirurgie der Re- und
Recurrence and re-recurrence rates of 1.03% and 1.7%, re- Rerezidiv-Inguinalhemie durch adjuvante Vicryl-Kissen-Implantation.
Akt Chir. 1992;27:184-187.
spectively, as compared with rates of up to 50% given in the liter-
8. Willmen HR. Protheses and major incisional hemias (part II): The
ature,l1-14 strongly support the use of Vicryl pad implants.
Vicryl pad. In Bendavid R (ed): Protheses and abdominal wall hernias.
Austin: R.G. Landes Company; 1994:472-475.
Summary 9. Willmen HR. Schwierige Reparation von Re-Rezidivhemien. In Kre-
mer, Lierse B, Plautzer W, et aI. (eds): Chirurgische operationslehre 7, Teil
Between 1986 and December 1998, we used the absorbable Vicryl 1. Stuttgart: Thieme-Verlag; 1994:124-127.
pad implant in 3619 primary and 1611 recurrent hernia repairs. 10. Willmen HR, Mies B, Nacken M. Vereinfachte Therapie der Re- und
A survey of patients who underwent primary (88.4%) and recur- Rerezidiv-Leistenhemie-iiber 10 jiihrige Erfahrung. Akt Chir. 1988;33:
34-36.
rent (91.0%) hernia repair between 1986 and July 1989, with a
11. Arlt G, Schumpelick V. Hernien. Stuttgart: Enke; 1987:269-274.
follow-up of 2 to 6 years, yielded recurrence rates of only 1.03% 12. Guthy E, van der Boom H. Das Mehrfachrezidiv beim Leistenbruch.
for primary hernias and 1.7% for recurrent hernias. These results Langenbecks Arch Chir KongrejJbericht. 1983;381:315-318.
show that the absorbable Vicryl pad implants help to reduce sig- 13. Kirschner M. Die praktischen Ergebnisse der freien Faszien-Trans-
nificantly the recurrence and re-recurrence rates. The pad's suc- plantation. Arch Chir. 1920;72:671.
cess lies in its ability to induce the formation of endogenous 14. Schumpelick V. Leistenbruch-Reparation nach Shouldice. Chirurgie.
connective tissue in the weak region of the groin. 1984;55:25-28.
63
Lichtenstein Tension-Free Hernioplasty for
the Repair of Primary and Recurrent
Inguinal Hernias
Parviz K. Amid
Introduction choice, however, is a 50:50 mixture of 1% lidocaine (Xylocaine®)

and 0.5% bupivacaine (Marcaine®), with 1/200,000 epinephrine.
For more than a century, the measure of success of hernia repair Local anesthesia begins with intradermal injection, progressing to
was its recurrence rate. In 1966, for the first time, the importance deep subcutaneous and subaponeurotic injections.
of the postoperative disability period of hernia repair was brought
to the attention of surgeons by Lichtenstein. l With the goal of de-
creasing postoperative pain, recovery period, and recurrence rate, Technique
the tension-free hernioplasty project was started at the Lichten-
stein Hernia Institute in June 1984. The concept is based on (l) A 5 cm skin incision, which starts at the pubic tubercle and ex-
the degenerative etiology of inguinal hernia and destruction of tends laterally ~thin Langer's line, affords excellent exposure of
the inguinal floor 2 and (2) the association of traditional tissue re- the internal ring. Mter the skin incision, the external oblique
pairs with undue tension at the suture line. aponeurosis is opened and its lower leaf freed from the spermatic
Today, an understanding of the role of the protease-antipro- cord. The upper leaf of the external oblique is then freed from
tease imbalance in the pathogenesis of groin hernias has shed new the underlying internal oblique muscle and aponeurosis for a dis-
light on the pathology of groin hernias and the causes of failure tance of 3 cm medially. The anatomical cleavage between these
of their surgical repairs. 2 There is morphological and biochemi- two layers is avascular, and the dissection can be done rapidly and
cal evidence that adult male inguinal hernias are associated with atraumatically. Generous separation of these layers has a dual ben-
impaired hydroxylation of proline, weakening the fibroconnective efit, as it allows visualization of the iliohypogastric nerve and cre-
tissue of the groin.2 To place this already defective tissue under ates sufficient space for insertion of a sheet of mesh wide enough
tension to effect a repair would seem counterintuitive. Further- to overlap the internal oblique by at least 3 cm above to the up-
more, approximation of the conjoined tendon to structures such per margin of the posterior inguinal wall.
as the inguinal ligament or iliopubic tract widens the femoral ring, The cord with its cremaster covering is separated from the pos-
inviting development of iatrogenic femoral hernias. terior wall of the inguinal canal and the pubic bone medially for
In tension-free hernioplasty, instead of suturing anatomical a distance of about 2 cm beyond the pubic tubercle. The anatom-
structures that are not normally in apposition, the entire inguinal ical plane between the cremasteric sheath and the aponeurotic tis-
floor is reinforced by the insertion of a sheet of mesh. The pros- sue attached to the pubic bone is avascular, so there is no risk of
thesis, which is placed between the transversalis fascia and the ex- damaging the testicular blood flow. When lifting the cord, care
ternal oblique aponeurosis, extends well beyond Hesselbach's should be taken to include the ilioinguinal nerve, external sper-
triangle in order to provide sufficient mesh/tissue interface. In- matic vessels, and the genital nerve with the cord. This ensures
traabdominal pressure on one side of the mesh and the counter- that the genital nerve, which is always in juxtaposition to the ex-
pressure of the external oblique aponeurosis on the other favor ternal spermatic vessels, is preserved (Fig. 63.1). The present au-
the repair. The procedure is both therapeutic and prophylactic: It thor found this method of preserving the genital nerve safer and
protects the entire susceptible region of the groin from future me- easier than the originally described "lesser cord" method, in which
chanical and metabolic adverse effects. the genitofemoral nerve is freed and held aside from the cord to
The procedure is performed under local anesthesia, our choice avoid injury.4 Cutting or ligating the genital nerve can cause long-
for all reducible adult inguinal hernias. 3 It is safe, simple, effec- term incapacitating neuralgia. The iliohypogastric nerves should
tive, economical, and free of side effects such as nausea, vomiting, also be preserved.
and urinary retention. Furthermore, local anesthesia administered To explore the internal ring for indirect hernial sacs, the cre-
before the incision is made produces a prolonged analgesic effect masteric sheath is incised transversely (if thick) or longitudinally
by inhibiting the build-up of local nociceptive molecules. 3 Several at the level of the deep ring (see Fig. 63.1). Preservation of con-
safe and effective anesthetic agents are currently available. Our tinuity of the cremaster prevents dropping of the testicle and
423
424 P.K. Amid
A
B
FIGURE 63.1. Spermatic cord together with its cremasteric covering, the in-
FIGURE 63.2. A = External oblique aponeurosis; B = internal oblique mus-
guinal nerve, the external spermatic vessels, and the genital nerve are
cle; C = transversus aponeurosis; D = transversalis fascia; E = peritoneum;
raised, and the cremasteric fibers are cut transversely or longitudinally
F = inverted direct sac; G = Cooper's ligament; H = pubis; I = inguinal
(dotted line) at the level of the internal ring.
ligament; J = spermatic cord; K = mesh patch bridging defect. The mesh
is anchored to the ligament of Cooper for closure of the femoral ring (dot-
ted line).
would protect against dysejaculation if indeed dysejaculation is

secondary to kinks, scarring, distortion of the vas deferens, or cre-
masteric dysfunction. 5 Complete stripping and excision of the cre- ament 1 to 2 em below its suture line with the inguinal ligament
masteric fibers is unnecessary and can result in i~ury to the nerves, to close the femoral ring (Fig. 63.2).
small blood vessels, and vas deferens. A slit is made at the lateral end of the mesh, creating two tails,
Indirect hernial sacs are freed from the cord to a point beyond a wide one (two-thirds) above and a narrower (one-third) below.
the neck of the sac and inverted into the abdomen without liga- The upper wide tail is grasped with a hemostat and passed cepha-
tion. Because of mechanical pressure and ischemic changes, liga- lad from underneath the spennatic cord; this positions the cord
tion of the highly innervated peritoneal sac is a major cause of between the two tails of the mesh (Fig. 63.4). The wider upper tail
postoperative pain. 5 It has been shown that nonligation of the inis crossed over the narrower one and held with a hemostat (Fig.
direct hernial sac does not increase the chance of recurrence. 6 To 63.5). With the cord retracted downward and the upper leaf of
minimize the risk of postoperative ischemic orchitis, complete the external oblique aponeurosis retracted upward, the upper
nonsliding scrotal hernial sacs are transected at the midpoint of edge of the patch is sutured in place with two interrupted ab-
the canal, leaving the distal portion in place. However, the ante- sorbable sutures, one to the rectus sheath and the other to the in-
rior wall of the distal sac is incised to prevent postoperative hy-
drocele formation. 7
In large direct hernias the sacs are inverted with an absorbable
suture (Fig. 63.2). A thorough exploration of the groin is neces-
sary to rule out the coexisting intraparietal (interstitial), low lying
spigelian or femoral hernias. The femoral ring is routinely evalu-
ated from the space of Bogros through a small opening in the pos-
terior wall of the canal.
A sheet of 8 by 16 em mesh is used in the repair. We prefer
monofilament polypropylene meshes because their surface texture
promotes fibroplasia and their monofilament structure does not
harbor or perpetuate infection. 8 One end of the mesh is rounded
to the shape of the medial end of the inguinal canal. With the
cord retracted upward, the rounded corner is sutured with a non-
absorbable monofilamented suture material to the aponeurotic tis-
sue over the pubic bone, overlapping the bone by 1 to 1.5 em (Fig.
63.3). This is a crucial step in the repair because failure to cover
this bone with the mesh can result in recurrence. The periosteum
of the bone is avoided. The suture is continued to attach the lower
edge of the patch to the inguinal ligament up to a point just lat-
eral to the internal ring. Suturing the mesh beyond this point is
unnecessary and could i~ure the femoral nerve. If there is a con- FIGURE 63.3. Medial comer of the patch overlaps the pubic bone by 1 to
current femoral hernia, the mesh is also sutured to Cooper's lig- 1.5 cm.
63. Lichtenstein Tension-Free He rnioplasty 425
The excess patch on the lateral side is trimmed, leaving at least

5 cm of mesh beyond the internal ring. This is tucked underneath
the external oblique aponeurosis (see Fig. 63.6), which is then
closed over the cord with an absorbable suture. Fixation of the
tails of the mesh to the internal oblique muscle, lateral to the in-
ternal ring, is unnecessary and could result in entrapment of the
ilioinguinal nerve with the fixation suture.
Outcome Measures
Reported by more than 100 authors from Europe and the United
States, results of the open tension-free hernioplasty are as follows.
Postoperative Pain
Regardless of the approach, tension-free mesh repair of inguinal
hernias results in minimal postoperative pain, requiring only mod-
FIGURE 63.4. Spermatic cord is placed in between the two tails of the mesh. erate oral analgesic for a period of 1 to 4 days. Several prospec-
tive randomized studies including those by Horeyseck et al. 10 and
ternal oblique aponeurosis, just lateral to the internal ring. Occa- by Filipi et al. J I show no statistical difference in postoperative pain
sionally, the iliohypogastric nerve has an abnormal course and lies following open tension-free hernia repair compared with the la-
against the upper edge of the mesh. In those instances, a slit in paroscopic tension-free technique. In fact, a five-armed study by
the mesh will accommodate the nerve. Good retraction of the up- Ka\\ji et al. 12 comparing Lichtenstein repair under local anesthe-
per leaf of the external oblique during this phase of the repair is sia, Lichtenstein under general anesthesia, laparoscopic repair,
important to allow the appropriate amount of laxity for the patch. Shouldice, and open preperitoneal repair showed that postoper-
When the external oblique aponeurosis is released, the mesh buck- ative pain as well as the postoperative analgesic requirement were
les st~ghtly. This laxity ensures true tension-free repair; it is taken lowest after Lichtenstein repair under local anesthesia, followed
up when the patient strains on command during the operation or in order by Lichtenstein repair under general anesthesia, laparo-
resumes an upright position. More importantly, it compensates for scopic repair, Shouldice, and open preperitoneal repair. The con-
the future contraction of the mesh.8 clusion is that tension-free repair (regardless of the approach) is
Using a single nonabsorbable monofilamented suture, the lower associated with minimal discomfort, which results in a faster re-
edges of each of the two tails are fixed to the inguinal ligament covery and return to normal activities.
just lateral to the completion knot of the lower running suture.
This creates a new internal ring made of mesh (Fig. 63.6) . The
crossing of the two tails produces a configuration similar to that
Return to Work
of the normal transversalis fascia sling, which is assumed to be
Returning to work after hernia operation is a complex socioeco-
largely responsible for the normal integrity of the internal ring
nomic issue that largely depends on preoperative patient educa-
during strain. In addition, it results in buckling of the mesh in this
area and ensures a tension-free repair of the internal ring area.
FIGURE 63.6. The lower edges of the two tails are sutured to the inguinal
FIGURE 63.5. Crossing of the two tails. ligament for creation of a new internal ring made of mesh.
426 P.K. Amid
tion and patient motivation. In general, return to work after ten- ciated with the technique are chronic neuralgia and testicular at-
sion-free hernioplasty (regardless of the approach) can occur be- rophy, which occur in a fraction of 1%.
tween 2 and 14 days after surgery, depending on the patient's
occupation. According to several major series, return to work
after open tension-free repair for bilateral inguinal hernia is a max- Conclusion
imum of 2 days longer than unilateral repair. I 3-15 This is compa-
rable with return to work figures for laparoscopic repair of bilateral Since the introduction of the open tension-free hernioplasty in
inguinal hernia. 1984, the operation has been evaluated and compared with other
types of hernia repairs in several studies with regard to postoper-
ative pain, postoperative time off work, complications, costs, and
Recurrence Rate recurrence rate. Comparisons of data from different institutions
studying the same conventional herniorrhaphies are characterized
The reported recurrence rate of the procedure is less than 1%. by a considerable variation, whereas studies of the open tension-
Early in the evolution of tension-free hernioplasty, several patients free hernioplasty report remarkably uniform results, a fact that in-
operated on at the Lichtenstein Hernia Institute developed re- creases the validity of the individual studies.
currences as a result of technical errors. Three hernias recurred Published series, many from European centers, demonstrate
at the pubic tubercle because of failure to cover the bone with the that the open tension-free hernioplasty can safely be performed
mesh. One resulted from total disruption of the mesh from the under local anesthesia and allows the patients' immediate mobi-
inguinal ligament because the mesh was too narrow. Lessons lization, keeping hospital stay, costs, and patient discomfort to a
learned from these recurrences led to covering the pubic bone minimum. Furthermore, published recurrence rates are uniformly
with mesh, increasing the width of the mesh to approximately low, 1 % or less, after tension-free operation performed as de-
7.5 cm and keeping the mesh slightly wrinkled. These refinements, scribed above.
adopted by this author in the late 1980s,4 further decreased post- Fifteen years after the development of the tension-free hernia-
operative pain and recurrences through compensation for mesh plasty in 1984 and 10 years after the publication of the first series
shrinkage. 4,8 of open tension-free hernioplasty in 1989, the operation has been
thoroughly evaluated in large series and has been gaining increas-
ing acceptance with surgeons around the globe. A recent survey in
Repair of Recurrent Inguinal Hernias England showed that 70% of British surgeons are now employing
the Lichtenstein tension-free method of hernia repair.26
Our preferred method of repair for recurrent inguinal hernias was Large series and randomized studies indicate that excellent re-
the mesh plug technique. The concept of the mesh plug tech- sults from the open tension-free operation are less dependent on
nique was based on the assumption that recurrent inguinal her- the experience of the surgeon than are results from pure tissue
nias occur through a single defect in an otherwise intact inguinal repair and laparoscopic operation, an indication of the simplicity
floor, requiring minimal dissection limited to the area of the de- of the operation and short learning curve. 9,lO,15 The same tech-
fect for the repair. This assumption was proved wrong by Green- nique can safely be applied to all inguinal hernias, primary as well
burg's study, 16 which demonstrated that 10% of recurrent inguinal as recurrent. 22 ,23
hernias consisted of more than one defect. Furthermore, inser-
tion of a plug behind the transversalis fascia and into the small
space of Bogros places the plug in close proximity with the iliac References
vessels, and erosion by the plug into these vessels has been re-
ported. 17 Mesh plug repair fails for a variety of reasons: (1) miss- 1. Lichtenstein IL. Immediate ambulation and return to work following
ing a second defect as a result of inadequate dissection; (2) herniorrhaphy. Indust Med Surg. 1996;35:754-759.
shrinkage of the plugS,18 (depending on their looseness, mesh 2. Read RC. A review: the role of protease-antiprotease imbalance in the
plugs [Lichtenstein's cigarette plug, Gilbert's umbrella plug, and pathogenesis of herniation and abdominal aortic aneurysm in certain
Robin-Rutkow's Perfix plug] lose up to 75% of their diameter); smokers. Postgrad Gen Surg. 1992;4:161-165.
(3) infection of the plug requiring its explanation; and (4) seri- 3. Amid PK, Shulman AG, Lichtenstein IL. Local anesthesia for inguinal
hernia repair: step-by-step procedure. Ann Surg. 1994;220(6):735-737.
ous complications such as neuralgia,19 migration of a shrunken
4. Amid PK, Shulman AG, Lichtenstein IL. Critical scrutiny of the open
plug to the scrotum,20,21 and erosion of the plug into the bladder,8 tension-free hernioplasty. Am] Surg. 1993;165:369-371.
intestines,22,23,24 and femoral vessels. 15 Therefore, in 1996, the 5. Bendavid A. Dysejaculation: an unusual complication of inguinal
mesh plug was completely abandoned by the Lichtenstein group, herniorrhaphy. Postgrad Gen Surg. 1991;4:139-141.
and all recurrent inguinal hernias were repaired by the patch tech- 6. Smedberg SGG, Broome AEA, Glum A. Ligation of the hernia sac?
nique used in the repair of primary inguinal hernias. Surg Clin North Am. 1984;64:299.
In 400 patch operations performed for the repair of recurrent 7. Wantz G. Testicular atrophy and chronic residual neuralgia as risks of
inguinal hernias, there was only one recurrence in the parapubic inguinal hernioplasty. Surg Clin North Am. 1993;73(3):571-581.
region in a patient who had a previous open prostatectomy.21 The 8. Amid PK. Classification ofbiomaterials and their related complications
same incidence has been reported by other authors. 25 in abdominal wall hernia surgery. Hernia. 1997;1:12-19.
9. Bonwich JP, Johnson DD, Read RC, et al. Randomized trial of super-
ficial and preperitoneal prosthetic mesh placement in inguinal hernia
repair. Hernia. 1998;1 (1):S3.
Complications 10. Horeyseck G, Roland F, Rolfes N. Die "spannungsfreie" reparation der
Leistenhernie: laparoskopisch (TAPP) versus offen (Lichtenstein).
Complications such as infection, hematoma, and seroma occur in Chirurgie. 1996;67:1036-1040.
approximately 1 % of cases. The most serious complications assa- 11. Filipi Cj, Gaston:Johansson F, McBride PJ, et al. An assessment of pain
63. Lichtenstein Tension-Free Hernioplasty 427
and return to nonnal activity: laparoscopic herniorrhaphy vs. open 19. PalotJP, Avisse C, Cailliez-TomasiJP, Greffiern D, FlamentJP. The mesh
tension-free Lichtenstein repair. Surg Endosc. 1996;10:983-986. plug repair of groin hernias: a three year experience. Hernia. 1998;
12. Ka\\ji R, Feichter A, Fuch~ager, Kux M. Postoperative pain and return 2(1):31-34.
to activity after five different types of inguinal herniorrhaphy. Hernia. 20. Dieter Jr, RA. Mesh plug migration into scrotum: a new complication
1999;3:31-35. of hernia repair. Int Surg. 1999;84:57-59.
13. Amid PK, Shulman AG, Lichtenstein IL. Simultaneous repair ofbilat- 2l. Amid PK, Lichtenstein IL. Long-tenn result and current status of the
eral inguinal hernias under local anesthesia. Ann Surg. 1996;223: Lichtenstein open tension-free hernioplasty. Hernia. 1998;2:89-94.
249-252. 22. Danielli PG, Kurihara H, Montecamozzo G, et al. Le complicanze dei
14. Kark AE, Kurzer MN, Belsham PA Three thousand one hundred sev- plugs: infezioni e recidive. Hernia. 1997;1(1):55.
enty-five primary inguinal hernia repairs: advantages of ambulatory open 23. Chuback JA, Singh RS, Sills C, Dick LS. Small bowel obstruction re-
mesh repair using local anesthesia.] Am CoU Surg. 1998;186:447-456. sulting from mesh plug migration after open inguinal hernia repair.
15. Wantz GE. Experience with tension-free hernioplasty for primary in- Surgery. 2000;127:475-476.
guinal hernias in men.] Am CoU Surg. 1996;193:351-360. 24. Gilbert AI, Graham MF. The internal inguinal ring is Nature's window
16. Greenburg AG. Revisiting the recurrent groin hernia. Am] Surg. 1987; into the preperitoneal space-Why not use it? In: ChevrelJP (ed), Her-
154:35-40. nias and surgery of the abdominal waU, 2nd ed. New York: Springer-Ver-
17. Cristaldi M, Pisacreta M, Elli M, et al. Femoro-popliteal by-pass occlu- lag.
sion following mesh-plug for prevascular femoral hernia repair. Her- 25. Horeyseck G, Pohl C. Lichtenstein-patch repair of recurrent inguinal
nia. 1997;1:197-199. hernia. Hernia. 1998;2(1):S6.
18. Gai H. Hernienoperation nach Lichtenstein. Chir Praxis. 1998;54:183- 26. O'Riordan DC, Morgan M, Kingsnorth AN, et al. The surgical man-
195. agement of inguinal hernias in England. Hernia. 1998;2(1):SI7.
64
Reinforcement of the Visceral Sac by a
Preperitoneal Bilateral Mesh Prosthesis
in Groin Hernia Repair
Rene Stoppa
Efficacy is both an ethical and an economic obligation in the treat- Why Large Partial Wrapping
ment of hernia. Efficacy is not easily accomplished without mesh
in patients with weak inguinal tissues. A patient who is plagued by
of the Peritoneum?
recurrent hernias poses an additional challenge: a difficult repeat
The very large size of the prosthesis addresses two needs: (1) a
dissection, involving the risk of damaging regional nerves and cord
completely effective correction of the structural weakness of the
components often embedded in scar tissue. Some 30 years ago, in
groin and (2) a sutureless repair through self-stabilization. Cov-
the interests of effectiveness, safety, and ease of performance, we
ering the parietal peritoneum with a wide piece of mesh, making
assessed and introduced an original method that, making the most
it nondistensible, is an effective means of eliminating any possi-
extensive use of prosthetic mesh, creates a practically insur-
bility of herniation, no matter how damaged or weak the groin tis-
mountable barrier to recurrence, even in the most complex and
sues may be. Fruchaud's reliable conception of the anatomy of the
difficult cases. Through a posterior preperitoneal approach, the
inguinal region l includes a large weak area, devoid of voluntary
lower part of the visceral sac is partially wrapped with a wide piece
muscle fibers: the myopectineal orifice. This is a wide gateway be-
of nonabsorbable polyester mesh, which renders peritoneal her-
tween the abdomen and the thigh and genital areas, through
niation virtually impossible. As the parietal peritoneum and the
which pass the cord and the iliofemoral vessels and all groin her-
endoabdominal fascia are contiguous, this procedure reinforces
nias (indirect and direct inguinal, femoral) (Fig. 64.1). Within this
or replaces the transversalis fascia, the deeper layer of the groin
area only the transversalis fascia, which may be very thin, resists
that resists intraabdominal pressure. This method became the first
intraabdominal pressure. The most complete protection against
published tension-free and sutureless hernia repair.
herniation is a mesh prosthesis widely overlapping the limits of
the myopectineal orifice in all directions, like an artificial en-
doabdominal fascia. The larger the prosthesis, the safer the repair;
Technical Principles intraabdominal pressure forces the mesh against the waIl, in ac-
cordance with Pascal's hydrostatic principle. This encourages self-
Why Use a Prosthesis? fixation by surface-to-surface adhesion, which is stronger than
fixation by sutures. Avoidance of suturing the mesh also simplifies
Nowadays, the use of a nonabsorbable mesh prosthesis in the treat- the procedure and reduces the risk of injuring nerves and vessels.
ment of hernia is widely accepted as a way of ensuring a truly ten-
sion-free repair, particularly in cases at high risk for recurrence.
Even in the primary treatment of direct inguinal hernias it is cred- Why Use the Preperitoneal Approach?
ited with better results than pure tissue herniorrhaphy, which has
been associated in recent studies with such dystrophic herniation The preperitoneal approach was first described by Annandale. 2
factors as Peacock's "metabolic defect" and Read's "metastatic em- Tait,3 Cheatle,4 and especially Henry' discussed its advantages with-
physema." Modem fabrics are well tolerated biologically, and, even out sparking much interest in the surgical community until Ny-
more importantly, many exhibit macroporosity, which facilitates hus 6,7 achieved worldwide acceptance of the approach. There are
their penetration by connective tissue cells and consequent in- many advantages to the preperitoneal route, especially using a mid-
corporation. Polyester (Mersilene) mesh has been our preference line or Pfannenstiel incision: immediate easy entry to the retropari-
because it is supple (thus conforming to the irregular shapes of etal cleavage spaces, which are excellent routes for the exposure
the parietoperitoneal interface) and slightly sticky. It is also rela- of all relevant parietal structures without damage to inguinal
tively inexpensive. Less supple meshes (Prolene®, Marlex®), those nerves or cord vessels; easy discovery of hernial defects on both
that are microporous and impervious to fibrocytes (Gore-Tex®), sides, without risk of missing any (Fig. 64.2); adequate space and
and absorbable meshes (Vicryl®, Dexon®) are not recommended visibility for safe performance of surgical maneuvers; and access
for our procedure. to the neighboring spaces of Retzius and Bogros, which are ex-
428
64. Reinforcement of the Visceral Sac 429
X ------t~...f-J' 2cm
...........
FIGURE 64.3. Schematic plane representation of the retrofascial cleavable

space after anatomical measurements. The continuous line represents the
median size and shape of this space. The dashed line represents maximal
dimensions and the dotted line its minimal dimensions. X = Xiphoid
process; U = umbilicus; D = accurate line of Douglas; P = pubis.
cellent sites for placement of large mesh prostheses between the

peritoneum and the abdominal wall (Fig. 64.3). Especiallyappre-
ciated in complex recurrent hernias previously operated on using
an anterior approach, the preperitoneal route is most convenient
for our surgical procedure and much easier than the anterior ap-
FIGURE 64.1. Schematic representation from an anterior birdseye view of proach (Rives' operation) for the placement of preperitoneal
the anatomical structures of the groin, after artistic removal of the super- mesh.
ficial layers, including the external oblique aponeurosis. r = Rectus mus-
cle; ip = iliopsoas muscle; ct = conjoined tendon; t = transversalis fascia;
p = pubis; c = spermatic cord within its envelopes; v = femoral vessels; I =
inguinal indirect hernia site; D = inguinal direct hernia site; F = femoral
Indications
hernia site.
Hernias are diverse and therefore call for diverse methods of re-
pair. For simple hernias (Nyhus type I or II), nonprosthetic repairs
should be sufficient. We started using our method to repair mul-
tirecurrent hernias in which Poupart's and/or Cooper's ligaments
were destroyed. Then we extended its use to primary treatment of
all complex and difficult hernias: giant, sliding, multiple, prevas-
cular, femoral; and also to treat patients with special risks: obesity,
ascites, chronic bronchitis, collagenosis, heavy physical labor. We
no longer distinguish between inguinal and femoral hernias or be-
tween unilateral and bilateral hernias. Because it avoids the su-
perficial inguinal nerves and the distal testicular vessels, it is
recommended when there is a special risk for neuralgia or testic-
ular sequelae. At present we use this method in 15 to 20% of groin
hernias. Contraindications to the use of this method are primar-
ily septic risks: dermatoses, granulomas in recurrent hernias, and
emergency surgery. The presence of a midline subumbilical scar
or a history of iliocaval thrombosis is not an absolute contraindi-
cation for trained surgeons.
Technique
The regional preparation of the groin must be meticulous. In mas-
sive hernias that have "lost their right of residence" in the ab-
dominal cavity, and in patients with severe respiratory problems,
FIGURE 64.2. Schematic aspect from a posterior view of the anatomical
a preoperative progressive pneumoperitoneum, such as that de-
structures of the groin, after removal of the parietal peritoneum. The shape
of the myopectineal orifice is represented by the dashed line. 1 = Vas def- scribed by Goiii-Moreno,s may very occasionally be required. Gen-
erens; 2 = spermatic vessels; 3 = external iliac vessels; 4 = inferior epigas- eral or spinal anesthesia is recommended. Local anesthesia is not
tric vessels; 5 = obturator vessels; I = inguinal indirect hernia site; D = advisable. The operation is planned to be completed within 20 to
inguinal direct hernia site; F = femoral hernia site. 45 minutes.
430 R. Stoppa
FIGURE 64.4. 1 = routinely used midline subumbilical incision; 2 = low

horizontal skin incision of cosmetic interest; 3 = an associated separate in-
cision, which is eventually useful to free the adherent contents of a scro- FIGURE 64.6. Operator view of a right femoral hernia during its intraop-
tal hernia. erative reduction.
The vertical midline subumbilical standard incision divides all wall Direct hernial sacs (inguinal, femoral, or rarely, obturator) are in-
layers, including the endoabdominal fascia (Fig. 64.4). The verted with a purse-string suture. An interesting detail of surgical
preperitoneal space dissection begins in the center of the space anatomy of direct hernias is to be dealt with at this stage of the
of Retzius in front of the bladder and progresses downward to the operation: Mter the management of the peritoneal sac, another
prostate. The visceral sac is freed by finger dissection or a mounted fascial sac is visible, the herniated transversalis fascia, acting as a
sponge. The retroparietal cleavage is extended laterally on the side superficial lining of the reduced hernial sac; inverting this fascial
opposite the surgeon, behind the rectus muscle and inferior epi- sac and fixing it to the inner surface of the abdominal wall elim-
gastric vessels, in the space of Bogros as far as the iliopsoas mus- inates the dead space and prevents it from filling with serosan-
cle. The sac of a direct inguinal or femoral hernia is reduced by guinous fluid, which may give the appearance of an early
gentle traction and the spermatic cord drawn aside with a rubber pseudorecurrence.9 ,10
loop (Figs. 64.5 and 64.6). In an indirect inguinal hernia, the sac Indirect sacs are opened for the introduction of a finger to sim-
and the spermatic cord comprise a "pedicle" whose elements need plify their dissection; small sacs are managed by resection or in-
to be separated from each other (Fig. 64.7). The retroparietal vagination; after evacuation of their contents, larger sacs should
cleavage is then extended to expose the obturator wall below, the preferably be transected and closed at their proximal end and
external iliac vessels, and the psoas m.gor muscle laterally. There their distal part left undisturbed in the scrotum; it is important
is no need to extend the dissection upward beyond the arcuate not to dissect the sac below the level of the pubis, as this could
line of Douglas. In recurrent or multirecurrent hernias, it may be lead to ischemic orchitis due to trauma to the distal spermatic vas-
useful to use scissors to free the peritoneum from the scar. culature; the anterior aspect of the distal sac should be opened
as widely as possible to promote drainage into the surrounding
FIGURE 64.5. Operator view of a right direct inguinal hernia during its in- FIGURE 64.7. Operator view of a right indirect inguinal hernia before its
traoperative reduction. separation from the spermatic cord (represented by dotted lines).
tissues, and a suction drain placed within it, at the end of the 24 em
operation. I
The card components (vas deferens and spermatic vessels) are then
panetalized; this consists of separating them from the peritoneum,
being careful to leave them inside their sheath of areolar tissue,
-----------r~l~--
which is triangular in its lower portion (Fig. 64.S). This quick and
4 8
simple maneuver greatly simplifies the positioning of the pros-
E
thesis posterior to the parietalized cord and avoids the necessity u
co
of weakening the mesh by cutting it to allow passage of the cord.
These maneuvers are easily performed with a clear view of all
anatomical details, without risk of damaging nerves, cord, or blood 3 7
vessels and without further damage to the abdominal wall or un-
due bleeding. The surgeon and assistant now exchange places and carry 1
out the identical procedure from the other side. Once this step
has been completed, all hernial orifices are clearly visible, but these
defects should not be closed, as this can lead to bleeding and nerve
injury and is subject to tearing and subsequent bleeding due to
the tension introduced by suturing a large breach. This in turn
can cause prosthesis displacement. FIGURE 64.9. The chevron-shaped Dacron mesh prosthesis is cut with re-
The Dacron mesh prosthesis is then prepared and cut in a chevron gard to the mean dimensions (in centimeters) of the rectangular model
shape, with direction of m.yor stretch lying transversely. Its breadth (24 X 18 em) measured on the patient. The points marked 1 to 8 are seized
by the eight long-curve Rochester clamps, which are indispensable for cor-
is equal to the distance between the two anterior superior iliac
rect handling and positioning of the prosthesis. The numbers indicate the
spines less 1 or 2 cm (mean 24 cm); its height is that of the um-
order of the successive placement of the clamps during the positioning of
bilicopubic line (mean 17 cm) (Fig. 64.9). The mesh prosthesis is the prosthesis.
briefly soaked in povidone-iodine and then grasped by eight long,
curved clamps, one at each of its six angles and one in the mid-
dle of each of its two lateral borders. The use of these clamps is ward the external iliac vessels. The cephalad lateral clamp pulls
crucial for efficient no-touch handling of the prosthesis (Fig. the mesh as far as possible and posteriorly (Fig. 64.12). Finally, the
64.10). upper and middle clamps are slid underneath the umbilical fas-
The prosthesis is now put in position on one side (Fig. 64.11). With cia. At this point, the retractor and three lateral clamps are re-
the surgeon standing on the patient's right side, the preperitoneal moved, being careful not to disturb the position of the prosthesis.
cleaved space is opened up by lifting the abdominal wall opposite Now the surgeon and assistant once again exchange sides in or-
to the surgeon with a retractor, while the surgeon's left hand moves der to position the prosthesis on the other side, using the same
the visceral sac upward toward the umbilicus. The middle and maneuvers. Mter removal of all the clamps, a single suture is in-
lower clamps are slid downward, drawing the prosthesis between serted at the uppermost angle of the mesh to suspend it from the
the pubis and the bladder. The lower lateral clamp is introduced umbilical fascia like a curtain (Fig. 64.13). The aponeurotic layer
as far as possible behind the corresponding obturator wall. The is closed with a continuous slowly absorbable suture. Suction
middle lateral clamp, held almost vertically, is moved medially to- drainage is seldom used.
In summary, the operation consists of wide interparieto-
peritoneal cleavage on both sides, parietalization of the cord com-
ponents, treatment of the hernial sac(s), and wide partial wrap-
FIGURE 64.8. Intraoperative photograph. The right spermatic cord (into

its preserved sheath) is elevated by the surgeon's index and middle fin-
gers. Note the ease of the maneuver clearly shown with the help of a sin-
gle retractor. Also note the indirect sac at the tip of the middle finger and FIGURE 64.10. Intraoperative photograph. The chevron-shaped prosthesis
the lipoma retracted by a small forceps. is siezed by eight long-curve Rochester clamps.
432 R. Stoppa
FIGURE 64.13. Intraoperative photograph. The positioning of the bilateral

FIGURE 64.11. Operator view of the right part of the bilateral mesh pros- mesh prosthesis has been completed in both sides; the patient, under
thesis, which is being pushed with clamps Nos. 1to 5. The numbers show spinal anesthesia, is coughing to demonstrate that the prosthesis does not
the order in which the clamps have been used. Clamps Nos. 6 to 8 will be move after this large covering of the visceral sac.
used for the placement of the left part of the prosthesis.
incision, reported by Cheatle in his 1920 publication, has been pe-

ping of the visceral sac with a large piece of mesh (Figs. 64.14 and
riodically used in my experience and proposed for routine use by
64.15). There is no attempt to suture the defect(s), no direct fix-
Rignault et alJI The myoaponeurotic layers are divided vertically
ation of the prosthesis, and no split in the mesh to let the cord
in the midline and will require multiple retractors for adequate
pass through. Handling the prosthesis with long clamps ensures
exposure of the cleavage spaces and placement of the prosthesis.
easy positioning and the necessary scrupulous asepsis.
On occasion, an additional small incision at the neck of the scro-
Postoperatively, the patient is encouraged to quickly resume nor-
tum (Fig. 64.4) may be required to free the adherent contents of
mal activity, which is usually easy, given the comfortable postop-
a scrotal hernial sac. Pelvic pathologies can be dealt with at the
erative course. We do not routinely use antibiotics. Slow-acting
same time as the hernia repair provided that no septic procedure
heparin is used for patients with varicose veins for a few days. The
is involved. Occasionally we carry out this operation on patients
dressing and drains are removed on the second postoperative day
with a unilateral hernia, as we have observed that 20% of con-
for easy management of the wound. Most patients are discharged
tralateral hernias appear within 5 years of the repair for one-sided
between the second and fourth postoperative day.
hernias.
C. Wantz,12 following the same principles, has adapted the op-
eration for day surgery; he uses a suprainguinal incision and then
Variations
Variations on the above technique include a low horizontal inci-
sion of the skin, which has cosmetic advantages. The Pfannenstiel
FIGURE 64.14. Schematic representation from a birdseye view of the giant

FIGURE64.12. Intraoperative photograph. The right part of the bilateral bilateral mesh prosthesis surrounding the inferior part of the visceral sac.
mesh prosthesis is being pushed into the right side of the patient by the The mesh is placed deep to the spermatic cord components contained
Rochester clamps. into their sheaths.
FIGURE 64.15. Schematic representations of the giant prosthesis (dashed against the abdominal wall. ghl, gh2 = the locations of two groin hernias.
lines) at the end of the operation. (Left) Horizontal cross section show- (Right) Sagittal paramedian cross section of the inguinal wall showing the
ing how the intraabdominal pressure (iap), acting in all directions (ar- underlying position of the prosthesis (pr) between the peritoneum (p)
rows) and following Pascal's hydrostatic principle, pushes the prosthesis and the transversalis fascia (tf).
similar maneuvers as ours for positioning a 10 by 15 cm unilat- Splitting of the prosthesis to allow passage of the spermatic cord:
eral Dacron mesh prosthesis, without direct suture of the defect Defenders of this procedure say that it promotes a central fixation
or direct fixation of the mesh, under local or general stand-by of the prosthesis, but peripheral "instability" of the mesh is a
anesthesia. greater risk. Furthermore, a split in the mesh is counterproduc-
tive, unnecessarily weakening the mesh and eliminating the in-
terposition of the spermatic sheath between the prosthesis and
Some Corrupt Variations external iliac vessels, a point that we consider important.
Choice of different material: The choice of a semirigid mesh (Mar-
There are several corrupt variations. 13 lex®) results from misunderstanding of the essential principle of
Destruction of the retroparietal segment of the spermatic sheath:. This tri- wrapping the visceral sac, which requires a sufficiently large and
angular sheath contains the vas deferens and the spermatic vessels supple piece of mesh to carry out the task. Wantz,12 in his early
while the cord is separated from the peritoneum during its pari- experience with our method, attempted to use polypropylene
etalization. The preservation of this sheath is advisable for two rea- (Marlex®) mesh and soon after published his failures. He clearly
sons: (1) The preservation of the integrity of the vas deferens and advised against this less compliant material; its plastic memory
its vessels, for the partial or complete obstruction of the vas, can, extends to retract one edge of the prosthesis during the early post-
perimentally and clinically, lead to a hypoazoospermia by serum an- operative period, leading to recurrence. Microporous or impervi-
tibody elevation. 14 (2) The spermatic sheath protects the external ous materials cannot be infiltrated and thus do not become fixed;
iliac bundle from direct contact with the prosthesis. This is a wise absorbable meshes disappear by hydrolysis after a few weeks; and,
precaution as periprosthetic scarring would be a hindrance, should of course, such fabrics cannot form an artificial endoabdominal
a subsequent inteIVention require dissection of the iliac vessels. 15 fascia.
Resection of the distal part of a scrotal sac: In nonsliding hernia, dis-
section of the sac incurs the risk of testicular ischemia. In agree-
ment with Fruchaud1 and Wantz,16 we recommend that the distal Intraoperative Pitfalls I3
sac be left undisturbed in the scrotum and drained. In scrotal slid-
ing hernias, even a partial resection of the sac is not recom- Several intraoperative pitfalls can occur.13
mended; a reduction "en masse" after perisaccular dissection is a Difficult retroparietal dissection: Previous intraperitoneal surgery
safer way to avoid injury of the mesenteric vascular supply and dif- through the midline does not represent a real obstacle, as the scar-
ficulties of peritoneal closure. ring is limited. This is not the case with diffuse scarring following
Use of too small a prosthesis: Ideal dimensions for sutureless pros- traumatic lesions of the pelvic rim, or suppuration, or in infre-
theses were arrived at through research with my fellow, B. F. K. quent recurrences after a bilateral prosthesis.l 4 Thus solutions
Odimba, and coworkers (Fig. 64.3) P The use of smaller prosthe- vary. In the case of a clean non pathological scar, excision of the
ses in unilateral procedures or two independent small prostheses scar allows entry to the paramedian preperitoneal space and then
for bilateral hernias, requires more or less blind fixation in the in- to the usual cleavage. Facing more extensive scarring of the spaces
ferolateral area beneath the iliopubic tract, a neurological hazard. of Retzius and/or of Bogros, one must enter the peritoneal cavity
In addition, one small unilateral or two independent prostheses and identify the limits of the scarred peritoneum, which should
fail to protect the midline against a possible incisional hernia. Us- be circumscribed and left adherent to the wall, while the normal
ing our wide partial wrapping of the visceral sac in a single large peritoneum can be dissected outward from the central area as ex-
prosthesis, we have not encountered a single case of incisional her- tensively as possible and then securely closed either by a running
nia in our series. nonabsorbable suture or by a polyglactin mesh, as proposed by
434 R. Stoppa
Trivellini et al. IS ; the final steps consist of wrapping the visceral Management of suppurations includes early reopening of the
sac in the usual wide bilateral prosthesis. wound, irrigation, and allowing healing by secondary intention.
Inadvertent opening of the peritoneum: This may take place during This is to be carried out without removing the macroporous mesh,
the preperitoneal cleavage at sites where the peritoneum is which will be slowly but surely incorporated into the scar tissue.
adherent, as occurs normally at the level of the arcuate line of Prophylaxis must include the precepts of all good, clean surgery:
Douglas or at the scar of a previous incision. These openings re- local preparation, adequate operating room, team discipline, asep-
quire a tension-free closure, preferably by mattress suture. To avoid tic operative technique, and postoperative observation. In cases of
opening the peritoneum, a scalpel or scissors is preferred to the special risk, we recommend the use of a broad spectrum antibi-
aggressive use of a mounted sponge to separate the peritoneum otic by intravenous bolus as immediately as the septic risk appears.
from a parietal scar.
Identifying the curd is usually easy, but may be more difficult in
the presence of a voluminous direct hernia or scarring associated Hydroceles of the Tunica Vaginalis
with a recurrence. The external iliac vein and the inferior epi-
gastric vessels, two important landmarks, form an obtuse angle Hydroceles of the tunica vaginalis are rare in our experience
where the cord components converge. (0.5%), although Houdelette and Dumotier20 report several bi-
Problems with reduction of sac contents: Large and sliding hernias lateral hydroceles. They are caused by disturbances of microcir-
are difficult to reduce whatever the surgical approach. In all irre- culatory lymphatic and venous drainage of the tunica vaginalis.
ducible hernias, it is important to open the peritoneal cavity to as- They are treated simply by drainage and eventual resection of the
sess the viability of the herniated viscera and whether they adhere tunica. Prevention lies in minimizing manipulation of the sper-
to the neck of the hernial sac. It is also important to avoid force- matic cord.
ful traction on the adherent viscera in adhesive or sliding hernias.
When necessary, a small transverse incision on the neck of the
scrotum will facilitate the reduction of irreducible contents of the Delayed Complications
sac, often with surprising efficiency, by freeing the intrasaccular
adhesions or carrying out a perisaccular dissection of a sliding scro- In our 1982 and 1990 series, there were no cases of testicular at-
tal sac. rophy and no chronic neuralgia: an established advantage of the
posterior approach.
Postoperative Complications
Delayed Suppurations (Fistulas)
Postoperative complications can be divided into early and late
complications. 13•19 We have observed 14 fistulas in cases treated at other centers. They
appeared between the third and eighteenth postoperative months.
They were caused by either suppuration of an unsuspected, mildly
Early Complications infected deep serohematoma or by delayed reactivation of an at-
tenuated deep sepsis. A fistulogram is required to locate the fis-
Serohematomas tulous tract and the abscess that maintains it. The tract must be
completely excised; instilling a small quantity of methylene blue
There were 72 clinically detectable serohematomas out of 1438 solution helps to define the tract. A small part of the mesh may
patients (4.5%) in our 1982 series. Two sites are clinically impor- have to be excised along with the deep abscess, but no attempt
tant. Preperitoneal hematomas may be exceptionally large and should be made to remove the entire prosthesis, as this would be
give rise to symptoms of functional obstruction and urinary re- difficult, risky, needless, and illogical.
tention; they may also displace the sutureless prosthesis. Echog-
raphy will confirm the diagnosis and assist in the follow-up.
Prognosis is usually favorable; only one preperitoneal hematoma Recurrences
needed reoperation in our experience. Scrotal hematomas fol-
lowing surgery in large scrotal hernias are also of interest. Mter Recurrences must be considered complications. Review of our
drainage, they may recur or become infected. In intractable cases most recent series (1998) yields the following recurrence rates:
of chronic infected serohematomas, it may be necessary to per- global, 1.1%; in primary repair, 0.56%; and in recurrent hernia
form a partial resection of the scrotum. Careful hemostasis should
be carried out, together with suction drainage when justified; in
TABLE 64.1. Results in series' reviewed up to 1990
difficult hemostasis, fibrin suspension spray can be helpful.
Total number of reviewed patients 1992
Straightforward postoperative course 91.1%
Suppuration Septic complications 2.1%
Follow-up rate 79.2%
Follow-up duration 2-12 years
In a series of 1223 patients reviewed up to 1990, we reported 26
Recurrence rate: global 1.1%
septic complications (2.1 %). One must differentiate between su- 0.56%
In primary hernias
perficial and deep suppuration. Early diagnosis is essential; the In recurrent hernias 1.3%
dressing is removed on the second postoperative day for this rea-
son. Echography is of help in the early diagnosis of deep sepsis. ·Stoppa.35
TABLE 64.2. Recurrence rates after preperitoneal prosthetic repair
No. of hernias Follow-up Recurrence rate

Author operated on Control rate (%) duration (years) (%)
Blondiaux 91 52.7 0.5-3.5 0.0

(in Stoppa25 )
Detrie 50 0.5-4 0.0
(in Stoppa35 )
Stoppa31 529 1-12 1.1
Stoppa29 285 91.3 1-10 1.2
Mathonnet23 198 2-6 1.6
ChampauJt22 49 93 3 2
de Stjulien 309 63 0.5-6 2.9
(in Salinier24)
Stoppa28 168 88 1-7 3.3
Wantz lO 358 100 4.5
Rignaultll 658 86.3 4 4.6
repair, 1.3%. These recurrences all appeared during the first post- points: (1) preoperative identification of prostate and bladder
operative year; this rather short interval points to intraoperative pathology in the group of patients at risk, for whom our method
error. The mechanism was displacement of the inferior margin of is relatively contraindicated; and (2) careful preservation of the
the mesh, more often than its lateral margin, resulting in a direct spermatic sheath during the parietalization of the cord, as this
hernia with a solid prosthetic edge. This observation and the ex- sheath then lies between the iliac vessels and the prosthesis; more-
pected difficulties of reintervention through the midline lead one over, the latter must not be divided for passage of the cord, as has
logically to consider a different approach from that of the primary already been pointed out and illustrated.
repair. For a recurrence on the lateral border of the mesh, a
suprainguinal preperitoneal approach allows easy access to anchor
the prosthesis beneath the lateral abdominal wall near the ante- Long-Term Results
rior superior iliac spine with full-thickness sutures. If the recur-
rence is at the lower border of the mesh, an inguinal incision allows Tables 64.1 and 64.2 present the recurrence rates reported in di-
fixation of the prosthesis to the ligament of Cooper. Wherever dif- verse published experiences with preperitoneal prosthetic repair
ficulties are expected, it is best to use a suprainguinal approach of groin hernias. 21 - 35
and insert an additional preperitoneal piece of mesh.
Conclusion
Problems of Reoperation
This presentation of our method describes errors, difficulties, and
After a bilateral preperitoneal prosthesis, various situations may potential complications reported over time by many centers. The
arise. 14 An intraperitoneal jtrocedure may be carried out without any actual incidence of these problems is limited, and our method re-
technical modifications on account of the presence of the preperi- mains a simple and effective treatment of difficult hernias. It re-
toneal Dacron prosthesis, which can be cut with a scalpel and is quires no particular dexterity or exceptional experience and is
seldom noticed. easy to reproduce. Ease of performance and reliability are among
In surgery for benign jtrostatic hypertrophy, the transvesical approach the most important criteria for evaluation of a hernia treatment;
need not be technically modified. The retropubic approach our method meets these criteria. Because of its pleasing perfor-
(Millin) is hampered by the retropubic sclerosis, which can be mance, our proposition has been widely accepted. It also yields
freed only by the use of a scaler through the retropubic subperi- creative arguments vis-a-vis laparoscopic hernia repair. But that is
osteal space. another story.
Surgery for cancer of the jtrostate or malignant bladder pathology must
use a combined transperitoneal and retropubic subperiosteal
route. With respect to an eventual associated lymph node dissec- References
tion, one may envisage the following modalities.
In surgery of the external iliac vascular bundle, for lymph node dis- 1. Fruchaud H. Anatomie chirurgicale des Hernies de l'Aine. Doin, Paris,
sections, the real obstacle may be the distal perivenous sclerosis, 1956.
and dissection should begin around the proximal part of the ves- 2. Annandale T. Case in which a reducible oblique and direct inguinal
and femoral hernia existed on the same side and were successfully
sels and progress distally. For vascular procedures on the external
treated by operation. Edin Med] 1876:1087.
iliac artery (arteriotomy, bypass, heterotopic organ transplanta- 3. Tait L. A discussion on treatment of hernia by median abdominal sec-
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The prevention of these potential difficulties is based on two 5. Henry AK. Operation for femoral hernia by a midline extraperitoneal
436 R Stoppa
approach; with a preliminary note on this route for reducible inguinal 22. Champault G, Rizk N, Catheline JM, et al. Hernies de i'aine. Traite-
hernia. Lancet. 1936;1:531. ment laparoscopique preperitoneal versus operation de Stoppa. Etude
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65
A Combined Abdominoinguinal Approach
to Stoppa's Giant Prosthetic Reinforcement
of the Visceral Sac Procedure
Vincenzo Mandala
Stoppa's operation, a well-established procedure for the treatment TABLE 65.1. Survey of various approaches in 236 cases.
of complex groin hernias, involves the placement of a giant pros- Approach No. Percent
thesis by a preperitoneal approach through a midline infraum-
bilical, or horizontal Pfannenstiel incision. 1,2 Midline 201 85.16
In 28 cases (11.8%) out of 236 surgical repairs with this tech- Pfannenstiel 7 2.96
Double 21 8.89
nique over the past 9 years, it was deemed necessary to make a
Triple 7 2.96
second, and sometimes even a third, supplementary inguinal in-
cision (Table 65.1). This was done to facilitate mobilization oflarge
hernias in either or both groins simultaneously. This became the
procedure of choice in cases of voluminous and! or recurrent slid-
ing hernias with a large inguinoscrotal component bound by nu-
In our opinion, in the laparoscopic period, the combined ap-
merous and tenacious adhesions.
proach is also recommended in some cases of laparoscopy that are
During the later period of our experience, we used somewhat
characterized by extensive local changes (see Fig. 65.5).
less aggressive techniques such as tension-free repair for bilateral
Our experience has confirmed the combined procedure to
inguinal hernias and laparoscopic repair in some recurrences, es-
be expeditious, without an accompanying increase in local mor-
pecially for bilateral hernia with a unilateral first recurrence. We
bidity.
are of the opinion that Stoppa's technique should be used rarely
today. In recurrences of large unilateral or bilateral hernias asso-
ciated with parietal adhesions and sliding hernias and actual loss
of the posterior inguinal wall, a combined approach is appropri-
ate 3 (see Fig. 65.1). In our series, this procedure has always been
successful and has allowed the simplification of surgical proce-
dures, with the following advantages:
1. The combined approach allows, through an inguinal incision,

the safe handling and reduction of sac and contents. (See Fig.
65.2.)
2. Local complications are no more frequent, especially orchitis
and testicular atrophy (Table 65.2) .
3. It allows assessment of a posterior inguinal wall, particularly
when extensive dissection and tissue loss may provide a large
defect, resulting in outward convexity of the prosthesis even
when correctly placed and seemingly taut. When necessary, a
second prosthesis may be inserted through the inguinal inci-
sion. (See Figs. 65.3 and 65.4.)
4. Operating time is shortened.
5. There is no increased risk of sepsis despite a wider and more
extensive tissue contact with mesh (even during emergencies).
6. It does not give rise to troublesome pseudo recurrences
(hematomas, seromas) .
7. Despite the advanced degree of herniation in our modest se- FIGURE 65.1. Left-sided recurrent sliding inguinal hernia, with tenacious
ries, the recurrence rate has remained very low. adhesions that were lysed to free and exteriorize the sac.
437
438 V. Mandala
FIGURE 65.4. Bilateral sliding inguinal hernias exteriorized after lysis of ad-
FIGURE 65.2. The sac is exteriorized through the midline infraumbilical hesions through secondary and tertiary incisions.
incision.
TABLE 65.2. Complications in 28 cases
Complication No.
Infections 2
Seromas 2
Hematomas
Orchitis
Hypoesthesia o
Chronic pain o
Prosthesis removal o
FIGURE 65.5. Postoperative appearance of the combined abdominoin-

guinal approach.
References
1. Stoppa R, Warlaumont CR. The preperitoneal approach and prosthetic
hernia. In Nyhus LM (ed): Hernia, 3rd ed. Philadeiphia:J.B. Lippincott;
1989:199-221.
2. Rignault D, Dumeige F. Pose de 2 plaques par voie de Pfannenstiel pour
hernie bilaterale. ] ChiT. 1981;118:673-676.
FIGURE 65.3. Postoperative appearance with the secondary incision of the 3. Mandala V. L'accesso combinato nella tecnica di Stoppa. Atti del con-
combined abdominoinguinal ap,proach. gresso "Ernia nel 2000." Napoli, April 1992.
66
Open Techniques of Femoral Hernia Repair
Jean-Pierre Palot and Claude Avisse
Femoral hernias occur considerably less frequently than inguinal stated that the aponeurosis of the transversus abdominis muscle
hernias. A recent studyl shows that, among 680,000 groin hernias is the usual medial boundary, and Condon 13 considered that it is
operated on in the United States, only 25,000 (4%) were of the the recurved insertion of the iliopubic tract on the ligament of
femoral type. The same study reveals a higher frequency in women Cooper. The femoral ring is small in size, rigid, and inflexible, fea-
(75% vs. 26% in men) and an increasing frequency with age (42% tures most surgeons consider responsible for incarceration and
over 65 years). strangulation.
A good understanding of these hernias is important because of The lower end of the femoral canal ends blindly below the level
the problem of misdiagnosis and the great tendency to strangula- of the inguinal ligament. A true orifice, the femoral orifice, exists
tion, a frequent, and often the first, clinical manifestation. Early only when the femoral hernia exits through the canal, generally
diagnosis of strangulation is very important to avoid intestinal re- at the level of the fossa ovalis near the terminus of the long saphe-
section, which carries a high mortality rate, ranging from 6% to nous vein in the femoral vein.
more than 25%.2-4 Consequently, all femoral hernias are indica- Lytle l4 considers the distal orifice of the canal the true hernial
tions for surgical treatment. orifice and the inelastic ligament of Gimbernat as the strangulat-
ing structure at this level (Fig. 66.2).
What Is a Femoral Hernia?

Unusual Presentations
Usual Presentation
If the usual type of femoral hernia develops through the femoral
The classic, artificial description of inguinal and femoral hernias canal, unusual anatomical configurations or special weaknesses of
as two different entities was abandoned at the beginning of the the femoral sheath may produce other atypical varieties of
twentieth century. In Fruchaud's conception,5,6 all groin hernias "prefemoral" hernias (Fig. 66.3).
begin in the area of the myopectineal orifice and result from the Prevascular hernias l5 are of small size and are contained within
distension or the rupture of the transversalis fascia. Therefore, the femoral sheath lying anterior to the femoral vessels.
femoral hernias are direct hernias. In femoral hernias, the peri- Lateral femoral hernias l6 emerge lateral to the femoral vessels
toneal sac moves down into the femoral canal (Fig. 66.1) through and are found mostly in men. They have a short sac and a wide
the femoral ring, medial to the iliofemoral vessels and under the neck and appear beneath the iliofemoral tract.
inguinalligament. 7- 11 A dimple or simple depression at the level A retrovascular hernia was reported by Serafinil7 on a cadaver,
of the femoral ring should not be considered a femoral hernia. but the possibility of its existence has been questioned by
The femoral canal is the medial compartment of the space de- Moschowitz.1 8
limited by the inguinal ligament anteriorly and the iliopectineal Some internal femoral hernias may also have an exceptional
line posteriorly. The femoral sheath, which is an extension of the presentation, such as the bisaccular hernia of Astley Cooper and
transversalis fascia, invests the femoral vascular trunks as well as the diverticular hernia of Hesselbach, in which the principal sac
the femoral canal. The canal is conical in shape, approximately 2 is within the femoral canal and single or multiple secondary sacs
cm in length, and extends laterally to the femoral vessels. The en- appear through secondary orifices in the femoral sheath and the
trance of the canal is the femoral ring: Its lateral margin is the cribriform fascia.
femoral vein, the posterior margin is the iliopectineal line and the Other femoral hernias are medial to the vessels but follow aber-
ligament of Cooper, and the anterior margin is formed by the il- rant routes such as the hernia of Cloquet,19 which crosses the
iopubic tract (an inferior reinforcement of the transversalis fas- pectineal aponeurosis, the hernia of Laugier20 and Velpeau,21
cia) and, further anteriorly, the inguinal ligament. In classic which comes through Gimbernat's ligament, or the femorogeni-
descriptions, the medial boundary is formed by the lacunar liga- tal hernia of Cooper, which develops into the scrotum or the
ment of Gimbernat, but this conception is controversial: MCVayl2 labium major.
439
440 J.P. Palot and C. Avisse
FIGURE 66.1. Usual route of a femoral hernia into the femoral canal, me-
dial to the femoral vessels. (Reprinted from Houdard CL, Stoppa R Le
traitement chirurgical des hernies de l'aine. Monographie de l'AFC. Paris:
Masson; 1984, with permission.)
These unusual femoral hernias are anecdotal, but their dissec-

tion and the treatment of the parietal defect may be tedious and
prone to recurrence. FIGURE 66.3. Some unusual parafemoral hernias and their relation to the
femoral vessels. (Courtesy of P. Bocchi, MD, Parma, Italy,)
Operative Treatment: Techniques

of Repair and inconveniences of each method in order to make the best
choice for each individual case. Most general surgeons would see
There are conflicting opinions concerning how femoral hernias one or two cases in a year, given the relatively uncommon occur-
should be repaired. A great variety of operations have been de- rence of these hernias.
scribed, and every author claims for his or her own procedure Classically the surgical "open" treatment of femoral hernias can
different anatomical concepts and better results in terms of re- be achieved through three routes: the "low" femoral route below
currence rate. This situation leads to uncertainty, and the average the inguinal ligament, the "high" transinguinal route, and the
surgeon, faced with a femoral hernia, has to weigh the advantages "posterior" preperitoneal approach.
The Low Approach

A The low approach procedures have in common the approach to
the hernia and its repair from below the inguinalligarnent. This
Femoral Vein - -- approach was developed by Cushing and Bassini at approximately
the same time, around 1890, and has been revisited more recently
,,_ •. -1'o,mol'.1 Ring with the new concept of tension-free repair and the use of pros-
thetic material.
AIIi ... --~lio...cti.....1 line
The skin incision and its site are not crucial. It overlies the
"swelling" of the femoral hernia and may be vertical, transverse,
----Fascial part1 Gimbernat • or horizontal, in a skin fold. The sac is dissected free and mobi-
'
Tendinous Ligament lized from the surrounding fatty tissue and then opened to ver-
E.ternal - Pari )
Oblique ify the contents (usually fatty tissue from the greater omentum).
Pubic If the hernia is irreducible, a small incision is made with the knife
Tubercle
on the lateral margin of Gimbernat's ligament to facilitate the re-
duction of the sac, which is then tied, resected, and reduced into
the preperitoneal space. At the time of the repair of the parietal
defect, several choices are possible. Note that blind incision of
FIGURE 66,2. (A, B) The femoral ring, the femoral orifice, and the lacu- the ligament of Gimbernat is not recommended because of the
nar ligament of Gimbernat according to LytIe. possibility oflaceration of an aberrant obturator vessel. A preperi-
66. Open Techniques of Femoral Hernia Repair 441
toneal approach should therefore be chosen in the case of

incarceration.
Classic Herniorrhaphies
Anatomical Closure of the Femoral Ring:
The Bassini-Kirschner Operation
Mter reduction of the sac, the lower border of the medial leaf of
the external oblique aponeurosis is drawn upward with a retrac-
tor to expose the inferior aspect of the inguinal ligament, Cooper's
ligament, and sometimes the iliopubic tract reinforcing the trans-
versalis fascia. Closure of the femoral ring is achieved by placing
nonabsorbable sutures between the inguinal ligament and iliopu-
bic tract above and the ligament of Cooper below. Care must be
exercised to avoid tension. If in doubt, resort to a prosthesis
(Fig. 66.4). FIGURE 66.5. Closure of the distal femoral orifice according to Lytle, with
a purse-string suture. (Reprinted from Houdard CL, Stoppa R. Le traite-
ment chirurgical des hernies de l'aine. Monographie de l'AFC. Paris: Mas-
Simple Closure of the Hernial Orifice: son; 1984, with permission.)
Lytle's Operation
avoidable tension and an unacceptable recurrence rate. For these
reasons they developed a "tension-free" repair using a plug of Mar-
According to Lytle,14 the actual defect lies at the lower end of the
lex®. This repair can be easily done under local anesthesia and
femoral canal, 1.5 cm lower than the femoral ring. In his con-
has given good results.
ception, the repair should occlude this distal orifice, which is, for
The plug is made by rolling a strip of Marlex into a cylindrical
him, the source of strangulation. Mter removal of the sac, apurse-
shape based on the size of the defect. Mter dissection of the her-
string suture or interrupted sutures approximate Gimbernat's lig-
nia from below the inguinal ligament and reduction of the sac,
ament anteriorly and medially, the pectineal fascia posteriorly, and
the plug is simply inserted into the femoral canal and secured with
the femoral sheath laterally. This technique is valid for the small-
a few nonabsorbable sutures to the inguinal ligament, the
est of defects, less than 1 cm; otherwise, a prosthesis must be re-
pectineus fascia, and the lacunar ligament. Shrinkage of the
sorted to (Fig. 66.5).
polypropylene has recently caused surgeons at the Lichtenstein
Clinic to distance themselves from this technique (Fig. 66.6) .
Modern Hernioplasties
Lichtenstein's Plug Repair Trabucco's Plug Repair
According to Lichtenstein, Amid, and their co-workers,22-24 clas- With the Trabucco plug repair,25 the author uses a dart plug with
sic herniorrhaphies for femoral hernias are associated with un- a base. The operation is performed under local anesthesia through
an inguinal or a suprapubic incision. The femoral hernia is ap-
FIGURE 66.4. The Bassini-Kirschner operation performed through the low FIGURE 66.6. Lichtenstein's plug repair through the low approach: plug in
approach. (Reprinted from PonkaJL. Hernia of the abdominal wall. Philadel- place into the femoral canal. A = Inguinal ligament; B = pectineal fascia;
phia: W.B. Saunders; 1980, with permission.) C = femoral vein; D = great saphenous vein.
proached and dissected from below the inguinal ligament or seen from inside
spine
through a Nyhus approach. The plug is then approximated to the and above
defect, and the base is sutured to the inguinal, Cooper's, and la-
inguinal ligament
cunar ligaments so that the base overlaps the margins of the de-
fect from either side of the myopectineal orifice (Fig. 66.7). interior of pelviS
Bendavid's Umbrella
ant.sup.iliac spine
Bendavid26 reported the umbrella technique in 1987. In this pro-
cedure, an "umbrella" is made by cutting a circular piece of
polypropylene 8 cm in diameter. A Prolene® suture is inserted near
its center to facilitate handling. The mesh can be inserted from
below the inguinal ligament by direct approach of the femoral
hernia. After adequate treatment of the sac and identification of
the ligament of Cooper, the umbrella is pushed in the Bogros space
through the femoral ring and anchored with Prolene sutures to toward feel +
the ligament of Cooper first and then to the lacunar ligament (Fig.
66.8). Anteriorly two or three sutures go through the iliopubic
tract and the inguinal ligament. Laterally the umbrella lies on the
femoral sheath and is anchored with one suture to the femoral
fascia. The umbrella can also be inserted after incision of the trans-
seen from outside
and below
versalis fascia (transinguinal approach).
Modified Unilateral Giant Prosthetic Schematic representation of placement and

Reinforcement of the Visceral Sac attachment of umbrella mesh
(Wantz's Technique) FIGURE 66.8. The umbrella in place covering the femoral ring. The um-
brella has been pulled down from below the inguinal ligament.
In 1996, Munschi and Wantz27 described a new method of per-
forming a giant prosthetic reinforcement of the visceral sac pro-
cedure via a low subinguinal approach: An anterior groin incision tions by gentle blunt dissection. A piece of Mersilene mesh (ap-
is made and retracted inferiorly to expose the femoral area. The proximately 8 by 8 em) is then placed in the preperitoneal space
sac of the femor~l hernia is dissected from the edges of the ori- and its superior edge sutured to the anterior abdominal wall with
fice and then ligated and resected or simply inverted out of the three absorbable sutures above the inguinal ligament. The infe-
parietal defect. The preperitoneal space is dissected in all direc- rior edge of the mesh is pushed into place with two clamps me-
dially in the Retzius space and laterally into the iliac fossa. Repair
of the parietal defect is not necessary (Fig. 66.9).
The "High" or Inguinal Approach to

Femoral Hernia
The skin incision is made transversely 1 em above the inguinallig-
ament. Medially, the incision reaches the level of the pubic tu-
bercle. The external oblique aponeurosis is incised along the
direction of its fibers. The cremasteric muscle is divided, and the
spermatic cord is isolated with a tape. Division of the transversalis
fascia from the internal ring down to the pubic tubercle allows en-
tering the space of Bogros (Fig. 66. lOA). Extensive blunt dissec-
tion reveals the inguinal ligament, the femoral sheath and the
iliopubic tract, the medial border of the femoral vein, and, pos-
teriorly, the ligament of Cooper. The femoral sac entering the
femoral ring is well exposed by this approach and can be with-
drawn by traction from the femoral canal and converted into a di-
rect sac (Fig. 66.l0B).
In case of difficulty in reducing the sac, a combined approach
from above and below the inguinal ligament can be used (Fig.
66.1OC). Furthermore, in cases of strangulated hernia, the femoral
FIGURE 66.7. Trabucco's plug repair of a femoral hernia from the low route. ring can be enlarged by incision of Gimbernat's ligament under
A B
FIGURE 66.9. GPRVS through the low route (Wantz) . (A) The mesh has been sutured above the inguinal ligament, and its inferior edge is placed in
the preperitoneal space. (B) Mesh in place. (Reprinted from Munschi and WanlZ,27 with permission.)
A B
FIGURE 66.10. Approach of a femoral hernia by

the inguinal route. (A) The transversalis fascia
is divided. (B) The femoral sac is converted into
a direct sac. (C) Combined approach from
above and below the inguinal ligament. (D) The
femoral ring may be enlarged by section of its
medial border. c o
443
direct vision (Fig. 66.100). Mter verification of the intraperitoneal

content by opening of the sac and actual closure of the peri-
toneum, the ligament of Cooper is largely exposed and crossing
tributaries of the epigastric and obturator vessels are divided and
ligated. Repair of the defect can now be done in different ways.
Closure of the Femoral Ring:

The Moschowitz Repair
In the Moschowitz procedure,21 closure of the femoral ring is com-
pleted by placing interrupted sutures of nonabsorbable material
between the ligament of Cooper on one side and the iliopubic tract
and inguinal ligament on the other from the pubic tubercle to the
medial border of the femoral vein, which must be clearly identi-
fied. Mter closure of the femoral ring the posterior wall of the
inguinal canal must be repaired, for example, by suturing the trans- FIGURE 66.12. McVay operation. A generous relaxing incision is necessary
versalis fascia and the transversus arch to the inguinal ligament and to release the tension on the suture line. (Reprinted from Houdard CL,
Stoppa R. Monographie de l'AFC. Le traitement chirurgical des hernies
the iliopubic tract (Bassini-Shouldice repair) (Fig. 66.11).
de l'aine. Paris: Masson; 1984, with permission.)
Repair of the Entire Posterior Inguinal Wall: ally fibroses over a few weeks, re-creating a new anterior rectus
sheath (Fig. 66.12).
The McVay Procedure
Mter appropriate reduction of the sac and exposure of the liga- Prosthetic Repair: The Rives Procedure
ment of Cooper, a vertical relaxing incision is made on the rectus
anterior sheath. The repair is completed by approximating the su- In 1965, Rives described an original hernioplasty using a Mersi-
perior leaflet of the transversus arch to the ligament of Cooper lene® mesh placed in the preperitoneal space through an inguinal
and to the anterior femoral sheath. 29,so incision. This mesh acts as a substitute for the transversalis fascia
In detail, interrupted nonabsorbable sutures are placed every and repairs the entire myopectineal hole as advocated by Fruchaud.
0.5 cm from the pubic tubercle to the medial border of the femoral This procedure is suitable for treatment of femoral hernia. S2- S5
vein, far enough to accomplish effective occlusion of the femoral Mter exposure of the ligament of Cooper and the femoral vein,
ring. A transition suture is then placed between the anterior the arching fibers of the transversus arch are lifted upward with a
femoral fascia, the ligament of Cooper, and the femoral sheath. A retractor, and the posterior aspect of the abdominal wall (that is,
few additional sutures are placed in front of the vessels and ap- the transversalis fascia) is separated from the peritoneum by blunt
proximate the transversus arch, the iliopubic tract, and the in- dissection. A precut Mersilene mesh (10 by 10 cm) is inserted in
guinal ligament laterally. The relaxing incision can be secured in the space of Bogros and sutured to the ligament of Cooper (Fig.
position with interrupted sutures between muscle and sheath edge, 66.13A) , the anterior femoral sheath (Fig. 66.13B) , and the in-
or the triangular defect can be covered with a piece of mesh as guinalligament (as in the McVay operation). A large hem is then
advocated by Rutiedge. S! The defect left by a relaxing incision usu- turned down behind the iliopectineal line beyond the inferior
limit of the myopectineal hole. The upper edge of the prosthesis
is then slipped as far as possible (4 or 5 cm) behind the rectus
muscle and the transversus arch above and laterally. An external
slit is made in the mesh to maintain the spermatic cord in an up-
right and superior position (see Chapter 58).
Bendavid's Umbrella
As discussed earlier, the umbrella procedure can be done via a di-
rect low approach, but it can also be used via an inguinal approach
when the posterior wall of the inguinal canal has been divided for
the repair of a simultaneous inguinal hernia or even for the re-
pair of a femoral hernia.
In this situation, a Kelly forceps is inserted into the femoral de-
fect from below the inguinal ligament, and the stem of the um-
brella is pulled down. The inguinal approach allows the surgeon
to check good positioning of the mesh in the preperitoneal space.
FIGURE 66.11. Closure of the femoral ring by the inguinal route Then the umbrella is sutured as previously described, and the stem
(Moschowitz). (Reprinted from Ponka JL. Hernia of the abdominal walL is cut down. Repair of the inguinal floor is finally achieved ac-
Philadelphia: W.B. Saunders; 1980, with permission.) cording to the Shouldice procedure.
A B
FIGURE 66.13. Prosthetic repair by the inguinal route (Rives) . The mesh closes the femoral ring. (A) The mesh is stitched on the Cooper's ligament
close to the lateral border of the femoral vein. (B) Suturing the mesh to the iliopubic tract and inguinal ligament anterior to the vessels.
Plug Repair attention of French surgeons on the interesting possibilities of the

preperitoneal approach for prosthetic repair of groin hernia. This
A plug can be inserted into the femoral ring via an inguinal route. procedure was then developed and popularized by Stoppa 40 and
Rutkow and Robbins 36 use a conical Marlex plug fixed to the ad- more recently by Wantz41 in the United States.
jacent structures. The posterior wall of the inguinal canal is then It is apparent that repair of femoral hernias can be achieved by
closed and reinforced with a piece of Marlex mesh as an onlay. the preperitoneal approach with or without a prosthesis.
The "Posterior" or Preperitoneal The Iliopubic Tract Repair of Femoral

Approach of Femoral Hernias Hernia (Nyhus)
The term posterior approach is applied to repairs completed from In the procedure, the preperitoneal space is approached through
within the abdominal cavity. The posterior preperitoneal approach a horizontal incision 3 cm above the inguinal ligament. The an-
to the groin was first described by Cheatle 37 in 1920 for the cure terior rectus sheath is opened transversely above the level of the
of inguinal and femoral hernias. This author used first a midline internal inguinal ring. The rectus muscle is retracted toward the
and later a Pfannenstiel incision. In 1936, Henry38 from Cairo re- midline and the incision is extended through the flat muscles lat-
discovered it for the treatment of femoral hernias through a mid- erally. The next step is the opening of the transversalis fascia, tak-
line approach. In the late 1950s and early 1970s, Nyhus and ing care not to open the peritoneum. Blunt dissection of the
associates 39 adopted the concept and in several publications de- peritoneum exposes the posterior aspect of the abdominal wall
clared their conviction about the merits of this approach, espe- and the hernial sac is freed (Fig. 66.14).39
cially in dealing with femoral hernias. In 1967, Rives 32 focused the Mter reduction of the femoral sac, verification of its contents,
A B
FIGURE 66.14. (A, B) I1iopubic tract repair. The iliopubic tract is sutured to the ligament of Cooper medial to the iliofemoral vessels. (Reprinted from
Nyhus LM. The iliopubic tract repair. In Nyhus LM, Condon RE reds]: Hernia, 4th ed. Philadelphia:J.B. Lippincott; 1995, with permission.)
and closure of the peritoneum, the femoral ring and the iliac vein Which Repair to Do?
are exposed. In the case of incarceration, the medial aspect of the
femoral ring (that is, the insertion on the Cooper's ligament of Because there is no prospective randomized trial in the surgical
the iliopubic tract according to the Nyhus conception) can be in- literature about femoral hernia repair (the low incidence of this
cised to release the sac, carefully avoiding any aberrant obturator type of hernia does not permit such a trial), we do not have any
vessels. data to indicate whether a particular procedure is superior or not.
Obliteration of the femoral canal is completed by suturing the In addition, recurrence rates in the retrospective studies must be
iliopubic tract anteriorly and the Cooper's ligament posteriorly. regarded with circumspection because long-term follow-up is not
always clearly indicated. Nevertheless, comparison of retrospective
studies 43 ,44 does indicate the superiority of prosthetic repairs (re-
Prosthetic Repair currence rates ranging from 0 to 1.1 %) versus nonprosthetic re-
pairs (recurrence rate 2 to more than 10%). Actually, most of the
The preperitoneal approach can be through a midline incision, oldest records do not give data about postoperative pain, length
as recommended by Rives and Stoppa, or through a horizontal of hospitalization, and time off work, which are very important cri-
suprainguinal incision, as done by Wantz. After having dealt with teria in modern hernia surgery. Like many other surgeons,3,39,40,45
the sac, surgical cleavage is extended to clearly expose the entire we think that a selective method of repair should be preferred
deep surface of the abdominal wall. with regard to the size of the hernia, the patient's general condi-
Rives then inserts a Mersilene mesh in the angle between the tion, and his or her lifestyle. Some guidelines for the treatment of
abdominal wall and the iliac fossa. A slit can be made laterally in femoral hernias may be offered.
the mesh to accommodate the spermatic cord, or the cord can be
parietalized, that is, freed from all adherent connective tissues as
far laterally as possible. A few sutures anchor the mesh to psoas Uncomplicated Primary Femoral Hernia
muscles and to the posterior abdominal wall (Fig. 66.15A).
Stoppa uses a very great Mersilene mesh through a midline in- Uncomplicated primary femoral hernias may be treated by dif-
cision, enveloping all the anteroinferior area of the peritoneum. ferent procedures, which are all effective. Small femoral hernias
The basic principles of this technique are reinforcement of the may be treated through a low approach. In this situation, the op-
peritoneal sac, parietalization of the structures of the spermatic eration is simple and can be performed under local anesthesia.
cord, and no closure of the parietal defect (see Chapter 64). Lytle's operation is performed by many surgeons. Closure of the
Wantz called this technique GPRVS (giant prosthetic reinforce- femoral ring (Bassini-Kirschner operation) is no longer routinely
ment of the visceral sac) and advocated a unilateral GPRVS used because of the difficulties of placing the sutures on the liga-
through a horizontal suprainguinal approach for confirmed uni- ment of Cooper and the reported high recurrence rate. 46 If the
lateral hernias under local anesthesia (Fig. 66.15B). These three femoral ring is enlarged, prosthetic repair with an umbrella or a
procedures are essentially similar. plug is preferred.
Larger hernias are better treated through an upper approach
(transinguinal or suprainguinal). The transinguinal approach gives
Plug Repair an excellent view of the deep femoral ring and permits the sur-
geon to deal with any unexpected finding. The McVay procedure
Sealing of the femoral canal from inside through a preperitoneal is effective, especially in women, and gives good results if well ex-
approach has also been proposed by Trabucco 42 (Fig. 66.16). ecuted technically.24 Special attention is required near femoral ves-
A B
FIGURE 66.15. Unilateral prosthetic repair by the posterior approach. Alarge mesh covers all the orifices of the posterior abdominal. (A) Rives (1965).
(B) Wantz (1989).
talized because of strangulation. 2-4 The upper approach is manda-

tory in these cases in order to deal with the sac, to check the vis-
ceral content, and to perform an intestinal resection under
optimal conditions, if indicated. Inguinal or suprainguinal tech-
niques are available. In our opinion, prosthetic repairs should be
avoided if there is contamination or bowel resection is carried out,
despite recent reports47 ,48 suggesting that there is now no increase
in morbidity and mortality following the use of a prosthesis in these
conditions. A McVay procedure and the iliopubic tract repair seem
to be more reasonable solutions.
A particular case is the hernial abscess (bowel perforation within
oj
the hernial sac), which is very rarely seen nowadays. The most rad-
ical solution, advocated by Rudler,49 consists of an abdominal ap-
proach for division of the bowel and anastomosis, followed by a
direct inguinal approach to the hernia for removal of the necrotic
bowel and drainage. No attempt is made to repair the abdominal
wall.
Unusual Varieties of Femoral Hernias

FIGURE 66.16. Plug repair from the preperitoneal approach (Trabucco).
Unusual femoral hernias are more easily identified from above
and cannot be correctly treated from below, the dissection of the
sac around the vessels, especially in the prevascular type, being
sels, and sutures on the ligament of Cooper must stop before the very dangerous or impossible. These hernias are generally treated
medial border of the femoral vein to prevent venous constriction with a large prosthesis through a posterior approach.
and subsequent thrombophlebitis. A generous relaxing incision is
essential to prevent tension on the suture line. If the repair cannot
be done without tension, a prosthetic repair must be used. Other Conclusion
alternatives are sealing the femoral ring with an umbrella or a plug
and repair of the inguinal wall with a classic Shouldice technique. Femoral hernias are the least frequent type among the groin her-
The posterior approach is also a good choice in this situation: nias. Open surgery provides different techniques for successful re-
the procedure has the advantage of respecting the intact inguinal pair of such hernias, and the average surgeon, encountering only
floor. Iliopubic tract repair is routinely performed by Nyhus with
a few cases in a year, must be aware of the advantages and disad-
very good results. Another alternative is the prosthetic repair advantages of each method: Poor choice of a procedure and poor
vocated by Wantz.
execution of the technique lead invariably to high recurrence
rates. Herniorrhaphies can be made when the anatomical condi-
tions permit a suture without tension; in other cases more recent
Inguinofemoral Hernias techniques with prosthetic repair must be emphasized.
[Editor's note: The use of laparoscopic techniques for treating
The coexistence of an inguinal hernia of any type with a femoral femoral hernias is discussed in chapters in the laparoscopic section.]
hernia must be treated through an upper approach (inguinal or
suprainguinal) because the entire groin area has to be repaired.
The McVay procedure or prosthetic repair according to Rives are
possible through an inguinal incision. If the choice of the poste-
References
rior suprapubic approach is made, an iliopubic tract repair cannot
1. Rutkow 1M, Robbins AW. Demographic, classificatory and socioeco-
be recommended because of the high recurrence rates published, nomic aspects of hernia repair in the United States. Surg Clin North
and a prosthetic repair must be performed (see Chapter 56). Am. 1993;73:413-426.
2. PalotJP, FlamentJB, Avisse C, et al. Utilisation des protheses dans les
conditions de la chirurgie d'urgence. Chirurgie. 1996;121:48-50.
Recurrent Femoral Hernias 3. Stoppa R, Delval Y Hernies crurales, leur etranglement et leur traite-
ment chirurgical. Chirurgie. 1991;117:834-839.
As for all groin hernias, recurrences are best treated with a pros- 4. Thomas P. Decision making in surgery: operative management of a
thetic repair. The choice of approach (generally inguinal or pos- strangulated femoral hernia. Br J Hosp Med. 1993;49:432-433.
terior) is dictated by the type of the previous operation. 5. Fruchaud H. Anatomie chirurgicale des hernies de l'aine. Paris: Doin, 1956.
6. Fruchaud H. Traitement chirurgical des hernies de l'aine. Paris: Doin, 1957.
7. Amid PK, Shulman AG, Lichtenstein IL. The femoral canal: the key
to femoral herniorrhaphy. Int Surg. 1990;75:69-72.
Strangulated Femoral Hernias 8. Berliner SD. The femoral cone and its clinical implications. Surg Gy-
necoIObstet. 1990;171 :111-114.
Strangulation is a frequent complication. In our experience, 50% 9. McVay CB, Chapp JD. Inguinal and femoral hernioplasty. The evalua-
of our patients who presented with a femoral hernia were hospi- tion ofa basic concept. Ann Surg. 1958;148:499.
10. Nyhus LM, Donahue PE. Femoral hernia. Ann ltal Chir. 1993;64: 32. Rives J. Surgical treatment of inguinal hernia with a Dacron patch. lnt
157-162. Surg. 1967;47:361-371.
11. Ponka]L, Brush BE. The problem offemoral hernia. Arch Surg. 1971; 33. Rives], Lardennois B, Flament]B, et al. Utilisation d'une etoffe de
102:417. Dacron et leur place dans la chirurgie des hernies de l'aine. Acta Chir
12. McVay CB. The anatomical bases for inguinal and femoral hernio- Belg. 1971;70:284-286.
plasty. Surg Gynecol Obstet. 1974;139:131. 34. Rives], Nicaise H. A propos des hernies de l'aine et de leurs recidives.
13. Condon RE. The anatomy of the inguinal region and its relationship Sem Hop. 1966;31:1932-1934.
to groin hernias. In Nyhus LM, Harkins H (eds): Hernia. Philadelphia: 35. Rives], Stoppa R, Fortesa L, et al. Les pieces en tulle de Dacron et
J.B. Lippincott; 1964:34-35. leur place dans la chirurgie des hernies de l'aine. Ann Chir. 1968;22:
14. Lytle~. Femoral hernia. Ann R Coll Surg Eng! 1957;21:244-262. 159-171.
15. Teale T. A practical treatise on abdominal hernia. London: Longman; 1946. 36. Rutkow 1M, Robbins AW. Mesh plug hernia repair. A follow-up report.
16. Hesselbach FK. Anatomisch-chirurgische abhandlung uber den ursfrrung der Surgery. 1995;117:597-598.
leistenbrUche. Wlirzburg: Baumgartner; 1806. 37. Cheatle GL. An operation for the radical cure of inguinal and femoral
17. Serafini G. Sulle varieta dell'ernia crurale e particolarmente sull'ernia hernia. BMJ 1920;2:68.
crurale retrovasculare intravaginale e sull'ernia pettina. Policlinico Sez. 38. Henry AK. Operation for femoral hernia by a midline extraperitoneal
Chir. 1917;24:130, 264-273. approach. Lancet. 1936;1:531.
18. Moschowitz AV. Prevascular femoral hernia. Ann Surg. 1912;55:848. 39. Nyhus LM, Condon RE, Harkins HN. Clinical experiences with
19. Cloquet J. Recherches anatomiques sur les hernies de l'abdomen. preperitoneal hernial repair for all types of hernia of the groin: with
These Med, Paris, 1817. particular reference to the importance of transversalis fascia analogues.
20. Laugier S. Note sur une nouvelle espece de hernie de l'abdomen a Am] Surg. 1960;100:234-244.
travers Ie ligament de Gimbernat. Arch Gen Med. 1933;2:27. 40. Stoppa RE. The preperitoneal approach and prosthetic repair of groin
21. Velpeau AALM. Nouveau eTiments de medecine operatoire. Paris: Bailliere; hernia. In Nyhus LM, Condon RE (eds): Hernia. 4th ed. Philadelphia:
1839:4, 218-232. J.B. Lippincott; 1995:188-206.
22. Amid PI(, Shulman AG, Lichtenstein IL. Femoral hernia resulting from 41. Wantz GE. Giant reinforcement of the visceral sac. Surg Gynecol Obstet.
inguinal herniorrhaphy. The plug repair. Contemp Surg. 1991;39:19-24. 1989;109:408-417.
23. Lichtenstein IL. Hernia repair without disability (introducing tension-jree re- 42. Trabucco E. Preperitoneal plug hernioplasty. In Bendavid R (ed): Pros-
pairs), 2nd ed. St Louis: Ichiyabu Euro-America; 1986:15-37. theses and abdominal wall hernias. Austin: RG. Landes Company;
24. Lichtenstein IL, Shore ]M. Simplified repair of femoral and recurrent 1994:446-449.
hernias by a plug technique. Am] Surg. 1974;128:439. 43. Bendavid R Femoral hernias: why do they recur? Probl Gen Surg. 1995;
25. Trabucco E. Femoral plug hernioplasty. In Bendavid R (ed): Prostheses 12(2):147-149.
and abdominal wall hernia. Austin: RG. Landes Company; 1995:411- 44. Bendavid R Femoral hernias: primary versus recurrence. lnt Surg.
412. 1989;74:99-100.
26. Bendavid R A femoral "umbrella" for femoral hernia repair. Surg Gy- 45. Rives], Lardennois B, Flament]B, et al. La piece en tulle de Dacron,
necol Obstet. 1987;65:153-156. traitement de choix des hernies de l'aine de l'adulte, a propos de 183
27. Munschi lA, Wantz GE. Management of recurrent and perivascular cas. Chirurgie. 1973;99:564-575.
femoral hernias by GPRVS.] Am Coll Surg. 1996;182:417-422. 46. Butters AG. A review of femoral hernias with special reference to re-
28. Moschowitz AV. Femoral hernia: a new operation for the radical cure. currence rate of low operation. BMJ 1948;2:743.
NY State] Med. 1907;7:396. 47. Henry X. Prostheses in emergency surgery. In Bendavid R (ed): Pros-
29. McVay CB. Inguinal and femoral hernioplasty. Surgery. 1965;57:615- theses and abdominal wall hernias. Austin: RG. Landes Company; 1994:
625. 337-341.
30. McVay CB, Anson BJ. Inguinal and femoral hernioplasty. Surg Gynecol 48. Pans A, Plumacker A, Legrand M. Traitement chirurgical des hernies
Obstet. 1949;86:473. inguino-crurales etranglees par interposition de prothese en situation
31. Rutledge RH. The Cooper ligament repair. Surg Clin North Am. 1993; preperitoneale. Acta Chir Belg. 1991;91:223-226.
73:471-485. 49. Rudler. Phlegmon herniaire. Rev Chir. 1944;63:225.
Part VIII
Laparoscopic Techniques of
Groin Hernia Repair
67
Laparoscopic Intraperitoneal Onlay Mesh Repair
Morris E. Franklin, Jr., and Jose Antonio Dfaz-Elizondo
Introduction Clinical Setting

Different types of hernia repairs have been used in the past cen- The most critical requirement in the laparoscopic approach is
tury; however, modern hernia repair begins with Edoardo Bassini recognition of anatomical structures of the myopectineal area
in the late nineteenth century.l Many variations were developed from an intraperitoneal view.
following his original contribution, all of which were anterior ap- At the beginning of our experience, all patients with inguinal,
proaches for the solution of this old problem. Posterior or preperi- femoral, or obturator hernias underwent this procedure. Cur-
toneal approaches by Cheatle2 and HenryS appeared later and rently, it is used primarily for patients with recurrent, incarcerated,
were popularized by Nyhus et al. 4,5 Nonabsorbable prosthetic mesh and/ or strangulated hernias and for patients with previous lower
now plays a major role in hernia repair, allowing a tension-free re- abdominal surgery. Adhesions are commonly encountered in pa-
sult and providing a matrix for tissue ingrowth and replacement. tients with prior abdominal or open hernia surgery.
If the anatomy and physiology of the inguinal canal are under- This laparoscopic approach is contraindicated for patients who
stood to provide "shutter" and "sling" mechanisms, 6 it makes sense cannot undergo general anesthesia, have intractable bleeding
that, should those mechanisms fail, a posterior approach with a dyscrasias, or are under 18 years of age, as the body is still grow-
prosthetic reinforcement becomes a good option for the repair of ing and the fate of mesh in younger patients is unclear. Patients
all types of hernia and can be accomplished with conventional or who have had abdominal or hernia surgery (conventional or lap-
laparoscopic surgery. A sound basis for the approach has been pro- aroscopic) and obese patients should be assessed individually, as
vided by Stoppa et al. 7 they may well be suited for this type of surgery.
The operating room setup is the same as for any lower abdom-
inal laparoscopic procedure, with placement of monitors by the
patient's feet. The patient is secured to the surgical table with
Development shoulder and knee straps. Standard laparoscopic instruments are
used, including polypropylene mesh and hernia stapler.
Laboratory Setting
Porcine models were chosen to study the intraperitoneal place- Technique
ment of prostheses in the treatment of hernias by way of lap-
aroscopy.B When the hernias were identified, the defects were The procedure is performed under general anesthesia with en-
covered with polypropylene mesh, which was found to be the dotracheal intubation. A urinary catheter and nasogastric tube are
most manageable type ofprosthesis. 9 Defects were covered from inserted before surgery. The surgeon stands on the side opposite
2 to 5 cm beyond their borders, and the prostheses were held the hernia. Pneumoperitoneum is established using the Veress
in place with staples. The animals were sacrificed at 3 days, 1 technique in the contralateral pararectus area, at the level of the
week, 3 weeks, and 4 weeks, and the fate of the mesh was de- umbilicus. Previous abdominal surgery or the presence of an um-
termined. The mesh was completely "peritonealized" within 7 bilical hernia increases the risk of visceral or vascular laceration if
days. Minimal adhesions were noted. Mesh shrinkage was ob- the umbilicus is used for the blind insertion of the first trocar to
served, as reported by Lichtenstein et al. lO and Amid et al. ll ,l2 establish the pneumoperitoneum.
The width of the mesh required beyond the hernia defect mar- A 5 mm trocar is placed at the puncture site, and, if the um-
gin was 3 cm; less than this critical amount of overlap invited bilical area has no adhesions or incarcerated contents, a 5 to 12
recurrence due to mesh shrinkage. As no harmful effects were mm trocar is placed (Fig. 67.1). Additional trocars are placed as
observed in the animal model, the repair was performed in hu- necessary to perform lysis of adhesions before the placement of
mans in a controlled clinical setting. the umbilical cannula. With the camera at the umbilicus, explo-
451
452 M.E. Franklin, Jr., and J.A. Diaz-Elizondo
• • •
o
• •
FIGURE 67.1. Alternate sites for insufflation. FIGURE 67.3. Periphery of mesh being anchored with stapler.
ration begins with a search for direct, indirect, femoral, and ob- the mesh in this area, the stapler should be manipulated lightly
turator hernias. to prevent injuries to deeper structures. The mesh is then an-
Anatomical landmarks identified are the inferior epigastric ves- chored to Cooper's ligament with at least three staples (Fig. 67.4).
sels, vas deferens and cord structures, genitofemoral nerve, lateral Staples are then placed throughout the entire area of the mesh as
femoral cutaneous nerve, and iliac vessels. Cooper's ligament is needed, avoiding the epigastric vessels and the urinary bladder.
also identified. The sac is identified and inverted (Fig. 67.2). It Transabdominal polypropylene sutures are placed at the ante-
should be remembered that, in patients with incarcerated or stran- rior border of the mesh anteriorly to prevent migration. II This
gulated hernias, anatomical landmarks may be distorted. portion of the procedure is completed with a Keith needle and a
Any incarcerated or strangulated contents are reduced and in- 13 gauge hollow needle (Fig. 67.5).
spected. Resection of omentum or bowel is performed if needed. Omentum is interposed between mesh and bowel and fixed to
In the case of a bowel resection, the procedure may be continued the abdominal wall by several lightly placed staples. Closure of
if there has not been any contamination by bowel contents. ports greater than 5 mm in diameter is accomplished with a Carter-
Once the sac is inverted, it can be incised around its base, com- Thomason® suture passer, using "0" absorbable sutures. The ab-
pleting resection of the sac and any "lipoma" of the cord. domen is deflated under direct vision, and the skin is closed.
A prosthetic mesh is tailored to cover the defect, and a 12 by
15 cm piece is usually sufficient. The mesh is brought into the ab-
dominal cavity through the 5 to 12 mm trocar. Alignment of the Results
mesh is completed, with an overlap of at least 3 to 5 cm beyond
the edges of the defect and across the midline in the case of di- From January 1991 to February 1999, 413 patients, 332 males and
rect hernias. A stapler is introduced through the 5 to 12 mm tro- 81 females (average weight 180.31 lb), have undergone this pro-
car, and the periphery of the mesh is anchored (Fig. 67.3). Care cedure for a total of 520 repairs. Hospital stay was less than 23
should be taken to orient the stapler parallel to the genitofemoral hours in 94% of the patients; the reasons for prolonged hospital
nerve and the lateral femoral cutaneous nerve, and, while fixing stay are described in Table 67.1. Follow-up averages 68 months
FIGURE 67.2. Sac identification and inversion. FIGURE 67.4. Mesh anchored to Cooper's ligament.
67. Laparoscopic Intraperitoneal Onlay Mesh Repair 453
14G needle TABLE 67.2. Neuropraxia following intraperitoneal onlay mesh

12 cases (out of 497) = 2.4%
Genitofemoral = 3
Lateral femoral cutaneous = 9
Pain in distribution of a nerve = 3
Note: All resolved in 3 weeks except two: one resolved with cortisone in-
jection and one was permanent.
and for insertion of a polypropylene mesh for the intraperitoneal

onlay mesh herniorrhaphy.
Conclusion
Intraperitoneal onlay mesh is a simple, fast, and safe procedure. It
is easily reproducible. Most important of all, it is patient friendly,
allowing fast recovery and return to full activity earlier than con-
FIGURE 67.5. Polypropylene transabdominal sutures fixing mesh. ventional anterior open repairs. It is a tension-free procedure in-
volving less postoperative pain. The concern over mesh-viscera
juxtaposition is ever present, and we believe that omental inter-
position is important in the avoidance of possible enteral fistulas
(range 1 to 84 months). Return to full function was defined as the secondary to mesh erosion and transmigration. The intraperitoneal
ability to lift 30 lb or more, and patients were arbitrarily divided onlay mesh repair can be a good alternative for patients with mul-
according to their age. Patients less than 60 years old made up tiple previous hernia repairs and lower abdominal surgeries.
27% of the group and returned to full activity in 6.8 days, on av-
erage (range 1 to 45 days). The older group, over 60 years of age
(73%) returned to work in 7.2 days, on average (range 1 to 40 References
days).
The only intraoperative complication was a bladder laceration 1. Bassini E. Nuovo metodo operativo per la cura radicale dell'ernie inguinale.
Padova: Prosperini; 1889.
(0.20%). Early postoperative complications included seromas
2. Cheatle GL. An operation for the radical cure of inguinal and femoral
(3.01%), testicular pain (0.6%), and abdominal wall hematomas hernias. BM]. 1920;2:168.
(0.8%). Late complications were recurrences (1.0%) and neuro- 3. Henry AK. Operation for femoral hernias by a midline extraperitoneal
praxia (2.4%) (Table 67.2). There were no trocar site hernias. approach: with a preliminary note on the use of this route for reducible
Concern about the intraperitoneally placed mesh is always pres- inguinal hernia. Lancet. 1936;1:531-533.
ent. There has been an opportunity for a "second look" in several 4. Nyhus LM, Condon RE, Harkins HN. Clinical experience with preperi-
patients, during surgery for other reasons not related to the her- toneal hernia repair for all types of hernia of the groin. Am] Surg.
nia repair. Twenty-one such patients provided valuable glimpses of 1960;100:234-244.
what goes on after the abdomen is closed. Ten patients were con- 5. Nyhus LM, Pollak R, Bombeck CT, et al. The preperitoneal approach
sidered "clean," that is, free of adhesions between mesh and vis- and prosthetic buttress repair for recurrent hernia. The evolution of
a technique. Ann Surg. 1988;208:733-737.
cera; six patients had flimsy omental adhesions at the mesh edges.
6. Condon RE, Carilli S. The biology and anatomy of inguino-femoral
One patient showed dense adhesions between bowel and omen- hernia. Semin Laparvsc Surg. 1994;1(2):75-85.
tum that could not be lysed; in this case, Gore-Tex® had been used 7. Stoppa R, Soler M, Verhaeghe P. Treatment of groin hernia by giant
as the prosthetic material. A group of four patients showed mod- preperitoneal prosthesis repair. In Bendavid R (ed): Prostheses and ab-
erately dense adhesions from previous, nonhernia-related surg- dominal wall hernias. Austin: Landes Publishers; 1994:423-430.
eries; their adhesions were taken down in order to obtain exposure 8. Leyman ST, Bums RP, Chandler KE, et al. Laparoscopic inguinal
herniorrhaphy in a swine model. Presented at the Southwestern Sur-
gical Congress, Atlanta,June 2, 1992.
9. Gadacz T, Chase J. Technology of prosthetic material. Semin Laparvsc
TABLE 67.1. Causes of prolonged length of hospital stay (LOS) Surg. 1994;1 (2):123-127.
10. Lichtenstein IL, Shulman AG, Amid PI\, et al. The tension free hernio-
Reason No. Median LOS (days) plasty. Am] Surg. 1989;157:188-193.
Cardiopulmonary 8 3 11. Amid PI\, Shulman AG, Lichtenstein IL. Selecting synthetic mesh for
Urinary retention 7 the repair of groin hernia. Postgrad Gen Surg. 1992;4:150-155.
2
Bleeding abdominal wall 3 2.5 12. Amid PI\, Shulman AG, Lichtenstein IL. Critical security of the open
Ileus 7 3 "tension free" hernioplasty. Am] Surg. 1993;165:369-371.
Total 25 13. Rosenthal D, Franklin ME. Use of percutaneous stitches in laparo-
scopic mesh hernioplasty. Surg Gynecol Obstet. 1993;176:491-492.
68
Laparoscopic Transabdominal
Preperitoneal Hernia Repair (TAPP)
Michael S. Kavic and Sergio Roll
The success of laparoscopic cholecystectomy inspired many physi- in all of its aspects, Surgical attention, though, has been obsessed
cians to focus their attention on new applications of laparoscopy. with the hernia defect rather than with the mechanisms that per-
Using laparoendoscopic techniques, surgeons investigated com- mitted herniation to occur. Until recently, hernia repair efforts
mon surgical problems that involved disease of the appendix, have fixated on obliterating the hernia defect at its point of
colon, spleen, and gastrointestinal tract. I - 5 The underlying theme presentation rather than on correcting the hernia at its point of
of these investigations was to apply to other operations the proven origin.
benefits of laparoscopic cholecystectomy, that is, a reduction of There were those, however, who looked beyond the hernia de-
postoperative pain, decreased hospitalization, earlier resumption fect. Keith lO and Hammond ll early in the twentieth century ex-
of normal activity, improved cosmesis, and lessened metabolic de- plored normal groin physiology and suggested that contraction of
rangement. 6,7 It was acknowledged that for a laparoscopic proce- the transversus abdominis muscle caused a shutter-like approxi-
dure to be accepted, the procedure had to mimic its open mation of the muscle and its tendon to the inguinal ligament (Figs.
counterpart in efficacy and effectiveness. 68.1 and 68.2). This wall of strong musculotendinous tissue rein-
Inguinal hernia repair, which already had relatively minor mor- forced the transversalis fascia during exertion and protected the
bidity and a rapid return to normal activity, did not appear to be indirect and direct inguinal rings from herniation.
amenable to laparoscopic intervention. Operative results had to Henri Fruchaud12 further advanced the understanding of groin
be substantively improved for surgeons to accept a minimal access pathophysiology by underscoring the importance of a myopec-
approach for this disease. Complications such as postoperative tineal opening between abdomen and thigh (Fig. 68.3). The myo-
neuralgia, ischemic orchitis, and testicular atrophy also had to be pectineal orifice as described by Fruchaud is bound by the rectus
addressed and not exceed those of the open procedures. sheath medially, the internal oblique and transversus abdominis
In broad measure, laparoscopic access has improved the man- muscles superiorly, the iliopsoas muscle laterally, and the pubis in-
agement of abdominal wall hernias. The improvement with lap- feriorly. The opening is spanned and divided by the inguinal lig-
aroscopic repair of groin hernia, however, has not been as dramatic ament, traversed by the spermatic cord and iliofemoral vessels, and
an improvement as the advance of laparoscopic cholecystectomy covered on its inner surface by transversalis fascia.
was over open cholecystectomy. Improvements with laparoscopic Inguinal hernias traditionally have been defined by their point
repair of groin hernia, which have been more subtle, include in- of presentation, namely, femoral, indirect inguinal, or direct in-
creased diagnostic accuracy, an ability to widely expose the oper- guinal hernia. This terminology, perversely, has served to limit a
ative site, decreased postoperative pain, decreased postoperative surgeon's attention to the anterior abdominal wall. Fruchaud,12
morbidity, and a more rapid return to normal activity.B,9 contrary to the prevailing opinion of his day, emphasized the im-
In addition, a laparoscopic approach to hernia repair allows the portance of a hernia's point of origin, that is, its genesis at the
surgeon to address the entire myopectineal opening between ab- myopectineal orifice. He correctly stressed the necessity of ad-
domen and thigh and to visualize bilateral inguinal hernias. Now, dressing the entire myopectineal window during repair of inguinal
with the ability to evaluate the obturator, sciatic, and femoral hernia. Groin hernias begin in the abdomen and must traverse
canals, a laparoscopic reduce the possibility of "missed hernias."g the myopectineal orifice to present on the anterior abdomen. This
Finally, laparoscopic access has allowed recurrent abdominal wall incontrovertible fact must be addressed by the modem herniolo-
and pelvic hernias to be addressed from an entirely different as- gist when considering any technique for repair of groin hernia.
pect. A laparoscopic approach from within allows access to the
preperitoneal space without transgressing scarred tissue and
nerves from the initial hernia repair. Landmarks
A laparoscopic view of the groin area and its hernias is far differ-
Anatomy ent from that seen by the classically trained surgeon during open
The topographical anatomy of inguinal hernia sites has been stud- repair. Prominent laparoscopic landmarks are the right and left
ied by generations of anatomists and has been well documented medial umbilical ligaments, which are fibrous remnants of the um-
454
68. Laparoscopic Transabdominal Preperitoneal Hernia Repair 455
EXTERNAL OBLIQUE APONEUROSIS sage for the spermatic cord in the male and round ligament in
the female. The most inferior aspect of the external oblique
aponeurosis is the inguinal (Poupart's) ligament, which extends
-H-H----- INTERNAL OBLIQUE MUSCLE
from the anterior superior iliac spine to the pubic tubercle. The
inguinal ligament folds inward, forming a shelf that supports the
Ui------ TRANSVERSALIS FASCIA spermatic cord and bisects the myopectineal orifice (Fig. 68.1).
The inguinal ligament is not the solid, rigid base of past surgical
teachings; rather, the inguinal ligament is a modestly flexible shelf
TRANSVERSUSABOOMINUS
APONEUROSIS "SHUTTER UP"
of ligamentous tissue.
The next layer is the internal oblique muscle, which lies between
INGUINALUGAMENT
the external oblique muscle anteriorly and the transversus abdom-
\\"111------__ PERITONEUM inis muscle posteriorly (Fig. 68.1). It rarely joins with the trans-
SUPERFICIAL FASCIA
versus abdominis to form a true conjoined tendon medially. The
SPERMATIC CORD
internal oblique muscle is fused to the transversus abdominis mus-
SUPERIOR RAMUS cle and tendon in the groin.
OF PUBIC BONE
Innermost of the three flat abdominal muscles is the trans-
IUOPUBICTRACT
versus abdominis muscle (Fig. 68.1). It originates from the iliac
crest, lumbodorsal fascia, and lowermost six ribs to insert into
the linea alba of the rectus sheath and superior ramus of the
pubis. The origin of the transversus abdominis is muscular; how-
ever, its aponeurosis predominates in the groin. Inferiorly, the
FIGURE 68.1. Transversus abdominis, internal oblique muscles, "Shutter up." transversus abdominis ends in a free border that forms the su-
perior arch of the myopectineal orifice. Functionally, the trans-
versus abdominis arch behaves as a shutter that descends and
bilical (hypogastric) artery. Centrally, the somewhat less prominent approximates to the inguinal ligament during exertion (Fig.
median umbilical ligament represents the fibrous remains of the 68.2). Apposition of this strong musculotendinous wall of tissue
urachus, which connected the urinary bladder to the allantois to transversalis fascia reinforces the potential opening of the
(Fig. 68.4). myopectineal orifice and prevents herniation through the in-
guinal rings.
Lining the transversus abdominis muscle is transversalis fas-
Musculature cia, a part of the endoabdominal fascia that encloses abdominal
content (Fig. 68.1). The transversalis fascia is composed of two
There are three musculoaponeurotic layers that comprise the ab- lamellae that mayor may not be well developed in the groin.
dominal wall in the groin. The most superficial of these is the ex- Inferior epigastric vessels ascend between the two lamellae of
ternal oblique muscle, which is completely aponeurotic in the transversalis fascia. The transversalis fascia is composed of con-
groin. Near the pubic tubercle, an opening in the aponeurosis of nective tissue, not muscle or aponeurotic fiber, and therefore
the external oblique, the external inguinal ring, provides a pas- has little intrinsic strength. The inferior margin of transversalis
fascia forms the iliopubic tract that attaches laterally to the an-
terior superior iliac spine and medially to the pectineal line of
W-dI-lb-,fHt--- EXTERNAL OBLIQUE APONEUROSIS
the pubis.
~++I,----- INTERNALOBUQUEMUSCLE
Vasculature
.u..i - - - - - - - TRANSVERSALIS FASCIA
The external iliac artery and vein are major vessels of the "lap-
aroscopic" inguinal region (Fig. 68.5). The inferior epigastric
H I - - - - - - TRANSVERSUSABDOMINUS artery, which is girdled between two veins, arises from the exter-
APONEUROSIS "SHUTTER DOWN" nal iliac artery and courses superiorly between the two lamellae of
INGUINALUGAMENT the transversalis fascia. Superiorly, the inferior epigastric artery
forms an anastomosis with branches of the superior epigastric
~------ PERITONEUM
SUPERFICIAL FASCIA
artery, which is derived from the internal mammary artery. A pu-
bic branch of the inferior epigastric artery may be large and may
SPERMATIC CORD replace the obturator artery. This large pubic arterial branch,
SUPERIOR RAMUS
OF PUBIC BONE known as the "corona mortis," can partially encircle a hernial sac
IUOPUBIC TRACT
and may be injured during repair.
Nerves
FIGURE 68.2. Transversus abdominis, internal oblique muscles, "Shutter Nerves of significance during inguinal hernia repair include the
down." iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral
456 S. Roll and M.S. Kavic
RECTUS ABDOMINIS MUSCLE FIGURE 68.3. Myopectineal orifice.

INTERNAL OBLIQUE
ABDOMINAL MUSCLE
TRANSVERSALIS FASCIA
TRANSVERSUS
ABDOMINIS MUSCLE
ILiOPUBIC TRACT
ILIAC FASCIA
COOPER'S LIGAMENT
ILIOPSOAS MUSCLE
cutaneous nerves. The more superior iliohypogastric nerve sup- struction of the triple layer could not always be performed, and
plies the transversus abdominis and internal oblique muscles as American surgeons did not duplicate Bassini's operation nor did
well as the suprapubic and posterolateral gluteal skin. The ilioin- they duplicate his results. Inguinal hernia recurrence rates of 5
guinal nerve passes through the inguinal canal and lies below the to 10% after a "modified Bassini" procedure were common in the
spermatic cord. It exits with the cord through the external inguinal United States well into the current era. 14
ring and supplies branches to the internal oblique muscle and skin A better way was sought. Francis Usher, in the late 1950s, explored
of the superior medial thigh, penile root, upper scrotum, mons the use of plastic mesh, particularly polypropylene, in the manage-
pubis, and labium majus (Fig. 68.6). ment of groin and ventral hernias. 16,17 Shouldice championed short-
The genitofemoral nerve courses on the ventral surface of the stay hernia repair and rediscovered the Bassini operation. 18,19 Nyhus,
psoas major muscle and gives rise to femoral and genital branches along with others, re-explored the open preperitoneal approach of
(Fig. 68.7). Femoral branches pass underneath the iliopubic tract Cheatle and Henry for inguinal hernia repair. 2(}-22
and inguinal ligament to supply the skin of the upper thigh. Femoral Raymond Read suggested that smokers with chronic obstructive
branches may be compromised during laparoscopic hernia repair. pulmonary disease had an abnormal metabolism that led to ele-
Genital branches innervate the cremaster muscle and scrotal skin. vated circulating levels of the active enzyme compounds protease
The lateral femoral cutaneous nerve exits the abdomen near and elastase. These enzymes can cause destruction of elastin and
the anterior iliac spine and passes underneath or through the in- collagen in the rectus sheath and transversalis fascia, which,
guinal ligament. It innervates the skin of the anterior and lateral in tum, may result in a susceptibility to hernia formation. 23-26
thigh down to the knee and may also be injured during laparo- Rodriguesjunior et al. 27 reported a progressive weakening of elas-
scopic hernioplasty. tic and elastic-related fibers of the transversalis fascia with aging.
The above studies and others have reinforced the use of synthetic
materials in the management of hernia.28- 32
In the mid-1970s, the field of herniology was energized by the
Laparoscopic Hernioplasty: Rationale work of Irving Lichtenstein, who emphasized a "tension-free" ap-
Edoardo Bassini's 1890 report of a "new method" to treat inguinal
hernia ushered in the modem era of hernia management. 13 His
"triple layer" repair of the inguinal floor and reconstruction of the
inguinal canal was a logical, well thought out procedure to per-
form inguinal herniorrhaphy. It rapidly became widely accepted.
Bassini's operation was "radical" in that the patient did not have
to wear a truss after the repair. Operative intervention alone was
sufficient to cure the hernia.
The operation was effective-Bassini reported a recurrence rate
of only 3% for the 5 years of his 1884 to 1889 series. At that time
in Europe, hernia recurrence rates of 40% were common in the
first year after surgery,14
Unfortunately, Bassini's operation was not accurately described
in the medical literature of the United States. I5 Division of the
transversalis fascia was not emphasized. Most surgeons in the west-
ern hemisphere did not divide the transversalis fascia in prepa-
ration for a "triple layer" approximation of transversalis fascia,
transversus abdominis arch, and internal oblique muscle to the FIGURE 68.4. Right and left medial umbilical ligaments, median umbilical
inguinal ligament. Because of this oversight, an accurate con- ligament.
FIGURE 68.5. Vascular structures of the groin, laparo- TESTICULAR VESSELS

scopic perspective.
INFERIOR
EPIGASTRIC
VEINS INGUINAL
DEEP CIRCUMFLEX
INFERIOR
EPIGASTRIC
ARTERY FEMORAL NERVE
PUBIC BRANCH
~_ _- - - EXTERNAL ILIAC
OBTURATOR NERVE
DUCTUS DEFERENS
proach to hernia management. 33,34 Building on the work of Usher A laparoscopic approach to inguinal hernia was built on these ex-
and others, Lichtenstein advocated a hernioplasty that utilized periences and principles. The most common laparoendoscopic
synthetic material to bridge inguinal hernia defects. Rather than ap- techniques involve a laparoscopic transabdominal preperitoneal re-
proximating a patient's own tissues to repair groin hernias (hernior- pair (LTPR, TAPP) or a totally extraperitoneal repair (TEP) of groin
rhaphy), Lichtenstein suggested replacing them. He thought that hernia. 36,37 Laparoscopic intraperitoneal onlay methods (IPOM)
the approximation of a patient's tissue under tension was a mcyor have not been widely employed largely due to the potential for de-
factor in hernia recurrence. Lichtenstein's operation was simple and velopment of intraabdominal adhesions to exposed mesh. 38
effective; it quickly became the "gold standard" for hernia repair. A laparoscopic transabdominal approach for hernia repair has
The mantra of a "tension-free repair" was chorused worldwide. been advocated9 because it
Further supporting the use of synthetic materials, Stoppa et al. 35
advocated the use of a "giant prosthetic reinforcement of the vis- 1. Enables a thorough intraabdominal examination
ceral sac" (GPRVS) to repair recurrent abdominal wall hernias. 2. Provides visualization of both inguinal regions
He suggested that a very large portion of synthetic mesh be posi- 3. Allows for visualization of incarcerated hernias and evaluation
tioned preperitoneally to reconstruct the "visceral sac" for repair of strangulated tissue (nonviable tissue, omentum, or intestine
of complex and recurrent groin hernias. This approach has been may be resected laparoscopically)
successful, and Stoppa has reported a 1.4% recurrence rate in the 4. Permits thorough exploration of the myopectineal orifice de-
repair of large, frequently multiple, recurrent hernias. scribed by Fruchaud
ILIOHYPOGASTRIC NERVE
INGUINAL CANAL
ILIOINGUINAL NERVE
ILIOINGUINAL NERVE
CUTANEOUS NERVES OFTHE THIGH:

~7ER4L--------------~I~h
GENITAL BR4NCH
\~w~_~ ____ FEMOR4LBR4NCH
OBTURATOR NERVE
FIGURE 68.6. Nerves of the groin.

Indications
A laparoscopic transabdominal preperitoneal repair is indicated
for all hernias of the myopectineal orifice (unilateral or bilateral) ,
that is, femoral, indirect inguinal, and direct inguinal hernias. Ad-
ditionally, a laparoscopic transabdominal repair can be utilized for
treatment of Spigelian, sciatic, obturator, ventral, sport, and inci-
sional hernias. Laparoscopic access has also been shown to be of
value in cases of recurrent hernia after open repair; this approach
avoids scarred tissue of the original procedure and may reduce
the chances of iatrogenic injury to abdominal wall nerves (ilioin-
guinal and iliohypogastric) and structures of the spermatic cord.
Technique
FIGURE 68.7. Genitofemoral nerve and branches (cadaveric dissection). Laparoscopic transabdominal preperitoneal repair of groin her-
nias requires a general anesthetic. The patient is placed supine on
the operating table and adequately secured with arms tucked to
the sides. A right-handed surgeon stands on the patient's left side.
5. Permits use of mesh sufficient to cover the entire myopectin-
Ambidextrous use of both right and left hands obviates the shift-
eal orifice with adequate overlap
ing of the operator from one side to the other for bilateral repair.
6. Avoids extensive mobilization of the spermatic cord
A video monitor is positioned at the foot of the operating table.
7. Avoids scarred tissue encountered during repair of recurrent
A Veress needle or open Hasson access technique may be used
hernia
to establish a pneumoperitoneum. Towel clips are attached to the
8. Is easily taught and learned
skin of the abdominal wall and used for traction during the es-
Laparoscopic access allows the surgeon to approach a groin her- tablishment of the pneumoperitoneum and trocar insertion (Fig.
nia from its point of origin in the abdomen, not its point of pre- 68.9). This maneuver provides countertraction for trocar insertion
sentation on the abdominal wall. The entire myopectineal orifice, and reduces the risk of injury by allowing intraabdominal viscera
including the femoral canal as well as the direct and indirect in- to "fall away" from the anterior peritoneal surface. Two 5 mm can-
guinal rings, can be secured against herniation (Fig. 68.8). nulas are positioned bilaterally to the rectus sheath on a plane
An additional benefit of laparoscopic hernia repair may be the level with the umbilicus. One 10/12 mm cannula is placed cen-
avoidance of cord mobilization during repair. Extensive mobi- trally in the umbilical position (Fig. 68.10).
lization can cause operative trauma to cord structures and possi- Mter all cannulas have been inserted, a thorough intraabdom-
bly vein thrombosis. It has been suggested that thrombosis of the inal survey is performed to rule out additional pathological find-
testicular veins is the underlying pathology in the genesis of ings. Both groin areas are thoroughly examined and inspected for
ischemic orchitis and subsequent testicular atrophy.39-4I By not possible occult herniation.
requiring dissection around the cord, as in open repair, laparo- Following the abdominal evaluation, an incision is made in the
scopic hernioplasty may avoid the trauma to testicular veins im- peritoneum approximately 3 cm above the superior margin of the
plicated in the development of ischemic orchitis and subsequent inguinal hernia defect (Fig. 68.11). The incision is initiated me-
testicular atrophy. 9 dially at the medial umbilical ligament and extended laterally to
RECTUS ABDOMINIS Museu:

INTERNAL OBLIQUE
ABDOMINAL MUSCLE
TRANSVERSALIS FASCIA
TRANSVERSUS
ABDOMINIS MUSCLE
ILiOPUBLIC TRACT
ILIAC FASCIA
COOPER'S LIGAMENT
ILIOPSOAS MUSCLE
FIGURE 68.8, Myopectineal orifice with prosthetic

screen.
FIGURE 68.9. Towel clips are used to elevate the abdominal wall during in- FIGURE 68.11. Peritoneal incision approximately 3 em superior to superior
sertion of the Veress needle and trocars. margin of the hernia defect extending from medial umbilical ligament to
anterior superior iliac spine.
the anterior superior iliac spine. The incision is deepened through in the pre peritoneal space and allow accurate coverage of the myo-
the peritoneum to enter the preperitoneal space. This space is pectineal orifice.
continuous with the prevesical space of Retzius and easily cleav- The mesh is secured at its periphery to the rectus sheath, trans-
able. Careful dissection, however, is required about the inferior versus abdominis arch, Cooper's ligament, and, laterally, to the su-
epigastric vessels to prevent injury to these structures. perior margin of the iliopubic tract with endoscopic staples or tacks
A peritoneal flap is developed, and the indirect and direct in- (Fig. 68.13). It is important to place only one staple or tack in the
guinal hernia sacs are reduced as the dissection is continued in- superior margin of the iliopubic tract laterally to avoid underlying
feriorly. Long, indirect inguinal sacs may be divided at the internal branches of the genitofemoral and lateral femoral cutaneous nerve.
inguinal ring and the distal portion left in situ. This is done to The peritoneal incision is closed with a running continuous intra-
minimize dissection about the cord and avoid potential injury to corporeal suture of 2-0 absorbable Vicryl (polyglactin 910), endo-
the spermatic cord and testicular veins. scopic staples, or tacks (Fig. 68.14). In this manner, no portion of
Mter a complete preperitoneal dissection has been performed the mesh is exposed to intraabdominal content. Ten millimeter
exposing the iliopubic tract, arch of transversus abdominis mus- and larger port sites are closed with nonabsorbable sutures.
cle, and Cooper's ligament, prosthetic mesh is inserted to com-
pletely cover the myopectineal orifice. A single large piece of
polypropylene mesh (10 by 15 cm) or several smaller pieces (8 by Complications
13 cm) may be used to cover the orifice (Fig. 68.12) . The graft
must overlap the orifice by at least 2.5 to 3 cm circumferentially. Complications related to general anesthesia are in large measure
Frequently, smaller portions of mesh are more easily manipulated related to the overall health of the patient and presence of co-
1O/12mm CANNULA
5mmCANNULA
FIGURE 68.10. Trocar sites.

FIGURE 68.12. Prosthetic screen covering myopectineal orifice. FIGURE 68.14. Running continuous intracorporeal suture 0£2-0 polyglactin
910 to close peritoneal incision.
morbid factors. The complications of wound infection, hernia rein PaC0 2 and pH can generally be managed with controlled
currence, and neuralgia are common to both laparoscopic and ventilation. 45-48
open hernia repair. Laparoscopic access, however, can induce com- Hemorrhage associated with laparoscopic repair of groin her-
plications different from that of open surgical techniques. 42-44 nias is typically due to abdominal wall vessel transection during
Imaging technology is used to visualize the operative field. A trocar insertion. Hemorrhage from trocar insertion sites can or-
two-dimensional image of the hernia is projected on a video mon- dinarily be controlled with judicious application of monopolar
itor in color and in real time. Depth perception, however, is lim- electrical energy. More vigorous bleeding may require suture li-
ited by the two-dimensional video representation. Additionally, the gation, which is aided by devices such as the Carter-Thomason fas-
use of instruments far removed from the operative field incur a cial closure needle. Less common, but more serious, is large
penalty in "feel and touch." A classically trained surgeon requires intraabdominal vessel injury. The internal or external iliac artery
re-education in laparoscopic technique and skills. or vein may be lacerated, secondary to trocar insertion or manip-
Laparoscopic access involves risks inherent in traversing the ab- ulation of laparoscopic instruments. In this instance, rapid con-
dominal wall; these include skin infection, subcutaneous emphy- version to open laparotomy with control of the bleeding vessel is
sema, hemorrhage, visceral perforation, port site herniation, and usually the most appropriate course. 49-53
gas embolism. Visceral perforation can occur with Veress needle injury, lacer-
Skin infection has been an uncommon experience with lapa- ation secondary to trocar insertion, or trauma from laparoscopic
roscopic surgery and can be prevented with scrupulous attention instruments and energy sources. Veress needle perforation, in
to skin cleansing. Subcutaneous and genital emphysema is gen- many instances, can be managed expectantly, as these small punc-
erally well tolerated and does not require intervention. Carbon ture sites seal spontaneously with little peritoneal soilage. Larger
dioxide, however, is not an inert gas and can be absorbed across tears in the bowel or viscera should be repaired. Laparoscopic su-
the peritoneum, causing a rise in PaC0 2 and a fall in pH. Changes ture repair of visceral tears is a reasonable approach if the opera-
tor is skilled in laparoscopic suturing and knot tying. Otherwise,
open exploration and repair is indicated. 54-56
Port site hernias can be prevented by closing all cannula sites
10 mm and greater with nonabsorbable sutures. Smaller port sites
should be closed if they have been extensively stretched or ma-
nipulated. If a port site hernia is suspected, diagnosis may be aided
by ultrasonography or computerized tomographic scanning. Sim-
ple exploration of the port site with reduction of incarcerated con-
tent and fascial closure is usually all that is required to effect a
repair. 5 7-60
Gas embolization is a very uncommon experience in laparo-
scopic surgery and is caused by insufflation of gas into a major vas-
cular channel. Direct insufflation of CO 2 into a large vessel can
result in massive embolization with right outflow obstruction and
cardiovascular collapse. Management is directed at discontinuing
the insufflating gas and evacuating the pneumoperitoneum. The
patient should be placed in the left lateral decubitus position with
head down. A central venous pressure line may be inserted for
possible aspiration of the gas embolus; vigorous ventilatory sup-
FIGURE 68.13. Mesh secured with endoscopic tacks. port is required. 44,61
Complications related to the laparoscopic dissection and repair TABLE 68.1. Complications of 1944laparoscopic transabdominal
of groin hernia include bleeding in the preperitoneal space, nerve hernia repairs
i~ury, and hernia recurrence. Preperitoneal space bleeding is usu-
Complication No.
ally slight and controllable with monopolar electrosurgical desic-
cation. Seromas, however, can occur and must be differentiated Recurrence 19(1%)
from hernia recurrence. Ultrasonography is valuable in differen- Complications 141(7%)
tiating seromas from hernia recurrence. Many seromas will resolve Hematoma 45
spontaneously so that observation or simple aspiration may be all Neuralgia 35
that is required to manage these problems after laparoscopic her- Urinary retention 20
Testicular pain 11
nia repair.
Chronic pain 6
Nerve i~uries can occur in open and laparoscopic hernia repair. Small bowel obstruction 4
Branches of the genitofemoral nerve have been the most com- Bladder injury o
monly involved in laparoscopic injuries. Typically, the nerve is en- Colon injury o
trapped by a staple or tack during lateral fixation of the mesh to Vascular injury 1
the iliopubic tract. This injury can be avoided by placing only one Trocar site infection 3
staple or tack in the most superior margin of the iliopubic tract Transfusion 2
during lateral fixation and none inferior to this landmark. 43 ,62,63 Other 10
Hernia recurrence, the bete noire of the herniologist, has ranged Trocar site hernia 2
from 1 to 2% in the early laparoscopic experience with groin her- Death" 2
Total 160
nia repair. The reasons for hernia recurrence have included sur-
geon inexperience and negotiation of the "learning curve," 'Liver failure I, myocardial infarction 1.
inadequate mesh size with incomplete coverage of the entire myo- From Phillips et al. 43
pectineal orifice, and incomplete fixation, resulting in "roll-up" of
the mesh after repair.
These problems have been recognized and dealt with such that
current laparoscopic experience with hernia recurrence rivals that were due to bleeding from the inferior epigastric vessels. Hyper-
of open approaches. carbia and cardiac arrhythmias occurred in a small number of
patients.
The overall postoperative complication rate was 7.4%. The most
Results common was hematoma, which occurred in 17 patients, followed
by seroma in 12 patients. Patients were studied on an outpatient
Laparoscopic anatomy and normal physiological relationships basis. Other complications included fluid collections about the
were not well understood during the initial studies of laparoscopic cord in 17 patients and hydrocele in 5 patients. Seven patients ex-
hernioplasty. Classically trained surgeons had to relearn groin perienced transient neuralgia. Twenty-three patients had testicular
anatomy from a laparoscopic perspective. Complications occurred discomfort for more than 15 days postoperatively. The recurrence
that were corrected with experience and knowledge, often pain- rate in this series was 0.99%.
fully gained. Avoidance of genitofemoral nerve branches and the These findings are paralleled by a 5-year prospective study by
use of larger mesh screens were but two of the adjustments that Kavic 9 that extended from June 1991 through May 1996, in which
significantly decreased the incidence of laparoscopic hernia com- 274 patients underwent laparoscopic repair of hernia. There were
plications. 224 men and 50 women in this cohort. Ages ranged from 13 to
A multi-institutional survey was undertaken in 1995 to examine 88 years, with a mean of 49.1 years.
the incidence of complications associated with laparoscopic One hundred eighty-three patients had groin hernia (73.5%),
hernioplasty. This study included the participant's "learning curve" which involved one side, and underwent a unilateral laparoscopic
and was significant in leading to adjustments that improved lap- myopectineal hernioplasty. Sixty-six patients with bilateral groin
aroscopic hernia repair. These results are included in Table 68.1. hernia (26.5%) underwent bilateral laparoscopic myopectineal
A large series by Roll, Cohen and Rodrigues involved 1005 pa- hernioplasty.
tients who underwent laparoscopic transabdominal preperitoneal Four patients had operations for symptomatic femoral hernia
repair of groin hernia between March 1991 and March 1999 (per- (1.5%). However, an additional 25 femoral hernias were discov-
sonal communication). There were 927 males and 78 females who ered during exposure of the myopectineal orifice. These findings
underwent TAPP repair of 1279 hernias under general anesthe- suggest that a significant number of occult femoral hernias may
sia. The average age was 37 years (range 16 to 84 years). There be missed during open anterior repair and not appropriately ad-
were 731 unilateral inguinal hernias and 274 bilateral inguinal her- dressed.
nias in this group of patients. The classification according to Ny- There were 40 patients (14.5%) in this cohort who had under-
hus revealed 670 Nyhus type II and IIIb, 333 Nyhus type IlIa, 202 gone a previous open groin hernia repair. Of these cases of re-
Nyhus type IV, 63 mixed, and 11 type IIIc. current hernia, 37 patients had previously been repaired with an
The average operating time was 40 minutes for unilateral cases anterior groin herniorrhaphy procedure, and 3 patients had been
and 70 minutes for bilateral inguinal hernias. Most patients (975) repaired with an open groin hernioplasty technique and mesh.
were discharged within 24 hours following the operation and re- Complications noted during this study included four patients
sumed normal physical activity within 6 days. with paresthesias that persisted for more than 4 weeks (1.6%), uri-
Intraoperative complications occurred in 2.4%. Of 1005 pa- nary retention in two patients (0.7%), seroma in two patients
tients, 25 had intraoperative complications, the maJority of which (0.7%), urinary bladder suture injury in one patient (0.4%) who
had been repaired with an IPOM technique, vascular injury of the 4. Thibault C, Mamazza JL, Letorneau R, et al. Laparoscopic splenec-
inferior epigastric artery in one patient (0.4%), and hernia re- tomy: preliminary report. Surg Laparosc Endosc. 1992;2:257-261.
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vagotomy. Surg Endosc. 1992;6:90--93.
6. Schrenk P, Bettleheim P, Wayand WU. Metabolic responses after lap-
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7. Payne JH Jr, Griniger LM, Izawa MT, et al. Laparoscopic or open in-
guinal herniorrhaphy? A randomized prospective trial. Arch Surg. 1994;
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scribed by Lichtenstein or herniorrhaphy as described by Bassini laparoscopic transabdominal preperitoneal hernioplasty vs. Shouldice
and Shouldice are very effective procedures. These authors fo- herniorrhaphy. Surg Endosc. 1996;10:845-847.
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1206--1208.
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12. Fruchaud HR. Anatomic chirurgicale des hernies de l'aine. Paris: G. Doin;
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36. Kavic MS. Laparoscopic hernia repair. Surg Endosc. 1993;7:163-167. 51. Katz M, Beck P, Tancer ML. Major vessel injury during laparoscopy:
37. McKernanJB, Laws HL. Laparoscopic repair of inguinal hernia using anatomy of two cases. Am J Obstet GynecoL 1979;135:544-545.
a totally extraperitoneal prosthetic approach. Surg Endosc. 1993;7: 52. Lynn SC, Katz AR, Ross PJ. Aortic perforation sustained at laparos-
26-28. copy. J Refrrod Med. 1982;27:212-219.
38. Fitzgibbons Rj, Salerno GM, Filipi Cj, et al. A laparoscopic intraperi- 53. Peterson HB, Greenspan JR, Ory HW. Death following puncture of
toneal onlay mesh technique for the repair of an indirect inguinal her- the aorta during laparoscopic sterilization. Obstet GynecoL 1982;59:
nia. Ann Surg. 1994;219(2):144-156. 133-134.
39. Wantz GE. Testicular atrophy and chronic residual neuralgia as risks 54. Gray MR, Curtis JM, Elkington JS. Colovesical fistula after laparoscopic
of inguinal hernioplasty. Surg Clin North Am. 1993;73(3):571-581. inguinal hernia repair. BrJ Surg. 1994;81:1213-1214.
40. Wantz GE. Testicular atrophy as a risk of inguinal hernioplasty. Surg 55. Deshmukh AS. Laparoscopic bladder injury. Urology. 1982;19:306-307.
GynecolObstet. 1982;154:570-571. 56. Homberg R, Segal T. Perforation of the urinary bladder by the lap-
41. Baker jW, Evoy MM. Insult to the testicle in herniorrhaphy. Surg Gy- aroscope. Am J Obstet GynecoL 1978;130:597-60l.
necolObstet. 1942;75:285-288. 57. Soderstrom RM, Levy BS. Bowel irTIuries during laparoscopy: causes
42. Hanley E. Anesthesia for laparoscopic surgery. Surg Clin North Am. and medicolegal questions. Contemp Obstet GynecoL 1986;27:41-45.
1992;72(5):1013-1019. 58. Hogdall C, Roosen JU. Incarcerated hernia following laparoscopy. Acta
43. Phillips EH, Arregui M, Carroll BJ, et al. Incidence of complications Obstet Gynecol Scand. 1987;66:735-736.
following laparoscopic hernioplasty. Surg Endosc. 1995;9:16-21. 59. Reissman P, Shiloni E, Gofrit 0, et al. Incarcerated hernia in a lateral
44. Phillips JM. Complications in laparoscopy. Int J Gynaecol Obstet. 1977; trocar site-an unusual early postoperative complication of laparo-
15:157-162. scopic surgery. Eur J Surg. 1994;160:191-192.
45. Kent RB. Subcutaneous emphysema and hypercarbia following lap- 60. Williams MD, Swaim-Bowers S, Fenoglio ME, et al. Richter's hernia
aroscopic cholecystectomy. Arch Surg. 1991;126:1154-1156. following laparoscopy. Surg Rnunds. 1995(Feb):61-65.
46. Hodgson C, McClelland RMA, Newton jR Some effects of the peri- 61. Azurin DJ, Schuricht AL, Stoldt HS, et al. Small bowel obstruction
toneal insuffiation of carbon dioxide at laparoscopy. Anaesthesia. 1970; following endoscopic extraperitoneal-preperitoneal herniorrhaphy.
25(3):382-389. J Laparoendosc Surg. 1995;5(4):263-266.
47. Wittgen CM, Andrus CH, Fitzgerald SD, et al. Analysis of the hemo- 62. Mintz M. Risks and prophylaxis in laparoscopy: a survey of 100,000
dynamic and ventilatory effects of laparoscopic cholecystectomy. Arch cases. J Refrrod Med. 1977;18(5):269-272.
Surg. 1991;126:997-1001. 63. Fitzgibbons RJ, CampsJ, Cornet DA, et al. Laparoscopic inguinal hernior-
48. Smith I, Benzie RJ, Gordon NLM, et al. Cardiovascular effects of peri- rhaphy. Results of a multicenter trial. Ann Surg. 1995;221 (1) :3-13.
toneal insuffiation of carbon dioxide for laparoscopy. BMJ. 1971;3: 64. Tetik C, Arregui ME, DulucqjL, et al. Complications and recurrences
410-411. associated with laparoscopic repair of groin hernias. Surg Endosc. 1994;
49. Boswell WC, Odom MD, Rudolph R, et al. A method for controlling 8:1316-1323.
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69
Laparoscopic Totally Extraperitoneal
Hernioplasty (TEP): Part I
Edward L. Felix
Introduction extraperitoneal approach have advocated returning to visual dis-

section, eliminating balloon dissection in order to control the over-
Before the last decade of the twentieth century, most hernias were all cost of the procedure. 5 The question then arises whether
repaired using conventional anterior approaches. With the advent dissection without a balloon can be performed as quickly and safely
of laparoscopic techniques, however, surgeons began to look at by the average surgeon using the TEP approach. The answer
the problem of hernia repair in a totally new way. Because recur- to this question will come in controlled studies that are now
rent and complex hernias had been successfully approached in underway.
the past by Stoppa, Read, Nyhus, and others using a posterior mesh Although the laparoscopic approach to hernia repair has grown
repair, laparoscopic surgeons thought that it was reasonable to ap- in acceptance since its introduction in 1990, it is still utilized in
proach inguinal hernias using a laparoscopic modification of this only 15 to 30% of hernia repairs in the United States, depending
technique. It was hoped that patients undergoing a laparoscopic on geographic location. Laparoscopic repairs are considered more
hernia repair would recover faster and have less discomfort, as was difficult than open repairs and are generally performed only by
the case for patients who underwent laparoscopic cholecystectomy. surgeons skilled in advanced laparoscopic techniques. In addition,
At first, surgeons looked for a simple way to perform hernia re- most surgeons utilizing the laparoscopic approach will use it only
pairs laparoscopically. Plug and patch techniques and intraperi- in patients who are suitable candidates for general anesthesia, al-
toneal mesh repairs were easy, but fraught with failures and though there are some surgeons now utilizing the TEP approach
complications. It soon became apparent that the proven Stoppa under regional or local anesthesia. 6 Cost has also been a drawback
approach was the best model to follow. l The transabdominal for some surgeons, but recent data indicate that the laparoscopic
preperitoneal hernioplasty (TAPP) was the first such approach to approach can be performed at nearly the same cost as open re-
be utilized for groin hernia repair. 2 Some laparoscopic surgeons, pairs, especially when compared with open procedures in which
however, did not want to violate the peritoneal cavity in order to preformed plugs or patches are used. In fact, several studies have
reach the extraperitoneal space and developed a totally ex- shown that the overall cost of hernia repair, which includes the
traperitoneal (TEP) repair. 3 cost of recovery, is less for the laparoscQPic approach. 7,8
Initially the TEP approach was not well received by most avid The future of the laparoscopic hernioplasty and the factors in-
laparoscopic herniologists. It was thought to be more difficult, and fluencing its choice for particular patients will depend on the con-
there was some fear that patients would develop subcutaneous em- tinued evolution of the approach and the education of surgeons.
physema after insufflation with CO 2, Surgeons soon discovered, There is no longer any doubt that the approach is highly effec-
however, that the incidence of subcutaneous emphysema was no tive. In experienced hands, reported recurrence rates after lap-
greater than that encountered in conventionallaparoscopic pro- aroscopic hernioplasty have been reduced to between 0.4 and
cedures as long as low pressure insufflation was used. Thanks to 3.2%.9-11 Complication rates have also been shown to be compa-
the efforts of Aronoff, McKernan, and later Ferzli, surgeons who rable with those reported for open repairs. With proper educa-
were using the TAPP approach began to consider the advantages tion, surgeons will be able to advise their patients intelligently
of the TEP repair. As laparoscopic hernioplasty has gradually about the best type of hernioplasty for them: open, with or with-
evolved, the majority of laparoscopic general surgeons have now out mesh, or laparoscopic, TAPP, or TEP.
adopted the TEP over the TAPP repair.
Nevertheless, dissection of the extraperitoneal space was still dif-
ficult and time consuming for most laparoscopic surgeons. The Choosing the Right Approach
introduction of a balloon dissector was crucial in popularizing the
TEP approach (Fig. 69.1). The balloon allowed surgeons to ex- It is important that a surgeon be experienced in conventional an-
pose the preperitoneal space rapidly and safely, avoiding the con- terior approaches as well as both laparoscopic approaches, the
fusion that sometimes followed instrument dissection with a transabdominal and the totally extraperitoneal, to make a ratio-
laparoscope. 4 More recently, some surgeons highly skilled in the nal decision about which hernioplasty best fits an individual pa-
464
69. TEP Hernioplasty 465
Prior abdominal incisions, operations, or treatments may pre-

clude adequate or safe dissection of the extraperitoneal space. Rad-
ical prostatectomy or pelvic irradiation can prevent the surgeon
from separating the peritoneum from the abdominal wall. Balloon
dissection of the extraperitoneal space may result in injury to the
bladder or a rent in the peritoneum. A lower abdominal incision
crossing the rectus sheath can obstruct the safe passage of a bal-
Balloon Dissector loon dissector. Forcing the dissector through the resistant scars may
tear the peritoneum and possibly injure intraabdominal organs. A
transverse incision is not a contraindication to the use of the TEP
approach, but if resistance is experienced on passing the dissector,
the procedure should be converted to a TAPP approach. A lower
abdominal midline incision is usually not a problem when using
the TEP approach. The dissector slides toward the pubis parallel
to the old incision. The peritoneum along the midline will sepa-
rate from the abdominal wall when the balloon is inflated or can
be dissected manually after the trocars are placed. If bilateral re-
FIGURE 69.1. The balloon dissector. pairs are planned, however, there is a small chance that a previous
midline incision may hinder the surgeon's ability to dissect the op-
posite side at the same sitting, and this should be discussed with
the patient preoperatively.
Recurrent hernias are ideally suited for the laparoscopic ap-
tient and hernia. In general, patients who are not candidates for proach. The posterior, unscarred, and unobstructed view of the
general anesthesia should have an open hernioplasty under local inguinal wall allows identification of the recurrence and repair of
anesthesia. Although several centers have reported success with lo- the posterior wall. 13 Whether to use the TAPP or the TEP approach
calor regional anesthesia for the TEP approach, it has been our depends on the surgeon's expertise. The dissection of the recur-
experience that some patients will become anxious when CO 2 is rent indirect sac can be difficult using the TEP technique and re-
introduced into the peritoneal cavity. General anesthesia is then quires more skill than a primary repair.
required, and this may involve overriding the preoperative indi- The dissection of large scrotal hernias by the TEP route can be
cations. We therefore reserve laparoscopic repair for patients who quite difficult. Surgeons should use the transabdominal preperi-
are candidates for general anesthesia, even if the procedure is to toneal approach until they have mastered some of the special ma-
be performed using a local or regional anesthesia. An absolute neuvers required to deal with a long scrotal sac.
contraindication to laparoscopic hernioplasty is the presence of The patient's age influences the type of hernioplasty chosen. In
infection. Neither the TEP nor the TAPP approach should be used general, laparoscopic hernioplasty is reserved for adults. In a few
in the face of local or systemic infection because of the risk of in- cases a minor may be fully mature and have an adult-type hernia
fecting the mesh. or even a recurrent hernia. In these circumstances, the laparo-
Which laparoscopic approach to use depends on the surgeon's scopic approach may be chosen. At the other extreme are patients
level of experience, the type of hernia present, and the patient's over 70 years of age. Some surgeons have suggested that laparo-
history. I favor the TEP approach for most patients because it scopic repairs be limited to working younger adults; in our expe-
avoids entering the peritoneal cavity. In general, it takes less time rience, patients of all ages benefit from the laparoscopic approach.
and has less potential for complications than the TAPP approach. More than 300 patients over the age of 70 years have had suc-
There are, however, a few exceptions. If the patient has an in- cessful laparoscopic hernioplasties in our center over a 7-year pe-
carcerated hernia, a TAPP approach is usually preferred. It al- riod. Their rapid recovery and return to normal activity in an
lows for an accurate analysis of the structure that is incarcerated average of 5 days testifies to the value of the laparoscopic repair
and its viability, as well as safe and usually easy reduction of the for the older patient. We therefore do not restrict the laparoscopic
contents. Under these circumstances, the use of a balloon dis- approach according to age (Table 69.1 and Figure 69.2).
sector to develop the extraperitoneal space for a TEP repair
could lead to a large tear in the peritoneum or to an injury to
incarcerated omentum, bowel, or bladder. The extraperitoneal
approach, and especially the use of a balloon dissector, should TABLE 69.1. Laparoscopic hernioplasty
be avoided if the hernia cannot be reduced after the induction
Hernia TAPP TEP
of anesthesia. 12
In female patients with abdominal pain, the etiology of the pain Simple x
may be in question. To differentiate between a groin hernia and Bilateral X
other possible causes of the patient's symptoms, such as en- Large Scrotal X
dometriosis, a diagnostic laparoscopy should be performed, fol- Incarcerated X
lowed by a TAPP repair if warranted by the findings. For female Recurrent X X
patients whose diagnosis is certain, a TEP technique is preferred. Diagnostic X
Previous Pelvic Incision
The presence of a Pfannenstiel scar is common in many female
Transverse X
patients from a previous cesarean delivery or pelvic surgery, but Midline X
this need not interfere with the TEP dissection.
466 E.L. Felix
.--- Patient-----.
Poor Risk for Good Risk for
General Anesthesia General Anesthesia
/~ History of /\
Virgin Preperitoneal Space Radical Prostatectomy Virgin Preperitoneal Space
" - Pelvic Radiation
/ ~ Multi~OUS Pelvic Operations/ ~
Posterior Open Repair Anterior Open Repair / ~
Laparoscopic Experienced Laparoscopic Experienced

Surgeon Surgeon
Early in Learning Curve Late in Learning Curve
/~ ~~
Complicated Simple Complicated
Unilateral or Bilateral Unilateral or Bilateral Unilateral or Bilateral
Recurrent
/~~T
Incarcerated
1
Open Hernioplasty Laparoscopic Hernioplasty
FIGURE 69.2. Flow chart demonstrating choices of hernia repair according to the patient's presentation and surgeon's experience.
Preparing for Surgery of cases and can be set up if needed. A six-by-six (15 by 15 cm)
inch flat sheet of polypropylene mesh will be used for each her-
A full history and physical examination are essential to rule out nia and a single fixation device, stapler or tacker, to anchor the
medical problems that might preclude the use of the laparoscopic mesh. Endoloops are used in some cases to ligate the hernial sac
approach or favor one laparoscopic technique over the other. Be- or close a tear in the peritoneum.
fore the operation, each patient should be informed of the possi- We do not open a full laparotomy tray, but use a Mayo clamp
bility that the TEP approach may be converted to a TAPP or open to dissect the fat and muscle at the umbilicus. A No. 11 knife blade
repair. In addition, it is important to go over the major and mi- and "S" retractors facilitate this dissection. A Hasson-type blunt
nor complications that are seen with the different hernioplasties. trocar is used at the umbilicus, and two 5 mm or a 5 and a 10 mm
If the patient is prepared for the possible sequelae of the repair, trocar are used for instruments. A 3 mm trocar can be substituted
he or she will be better able to deal with them. This is especially for the lower 5 mm trocar. The extraperitoneal space is dissected
true for such minor problems as seromas, CO 2 in the scrotum, and with a balloon dissector, or bluntly without a dissector if the sur-
ecchymosis of the scrotum and penis, which may occur at day 2 geon is experienced.
or 3.
The monitor and video equipment should be placed at the foot
of the operating table in the midline or slightly to the side of the The Totally Extraperitoneal Technique
hernia. The surgeon stands on the side opposite the hernia. If
there are bilateral hernias, the surgeon should start standing on The procedure begins with a small transverse skin incision just be-
the side opposite the larger or more complicated hernia and switch low the umbilicus extending from the midline approximately 1
sides for the second repair. Usually the scrub nurse stands on the inch laterally on the side of the hernia or the dominant hernia if
side of the hernia to hold the camera and pass instruments. The bilateral hernias are present. Staying off the midline avoids en-
Mayo stand should be placed over the patient's legs so that both tering the peritoneal cavity where the anterior and posterior rec-
surgeon and nurse can reach the instruments. It is important for tus sheaths merge. We choose the side of the dominant hernia
both of the patient's arms to be draped at the patient's side to al- because the balloon dissector will dissect more completely on the
low room for the surgeon and nurse assistant to work comfortably. side where it is placed, making the rest of the dissection simpler.
The operating table can be flat or tilted slightly head downward. The anterior rectus sheath is identified by carefully spreading the
Having the proper laparoscopic equipment is essential to per- subcutaneous fat. If small vessels in the fat are tom at this point,
forming a safe and successful repair. Unipolar scissors and a bipo- the bleeding within the incision will make identification of the an-
lar coagulator should be set up on the field as well as two terior rectus sheath difficult. Two "S" retractors are placed in the
atraumatic graspers. A clip applier may be used in rare cases and wound and used as dissectors to expose the white fibers of the fas-
should be available. A suction irrigator is used in only 10 percent cia. A No. 11 blade is used to incise the fascia, exposing the rec-
tus muscle. One of the "S" retractors is placed under the muscle
to elevate it, and the posterior sheath is visualized. A finger is used
to dilate the space in preparation for the placement of a balloon
dissector.
Because the posterior rectus sheath ends at the line of Douglas,
an instrument such as the balloon dissector, passed on top of the
sheath, will automatically enter the extraperitoneal space. The dis-
sector is placed behind the rectus muscle with its tip on the pos-
terior rectus sheath. Aimed slightly anteriorly, it is gently slid on
top of the sheath toward the pubis until the bone is felt with the
dissector. If resistance is encountered, the dissector should not be
forced into the space because it will tear the peritoneum. After
the space has been dilated with a finger, a second attempt to pass
the instrument will usually be successful. (If this fails, the proce-
dure should be converted to a TAPP repair.) When the pubis is
encountered by the dissector, the balloon is inflated. With the
laparoscope in the dissector, the progress of the dissection can be
directly observed on the monitor. After the balloon dissection is FIGURE 69.3. The direct hernia seen after dissection is complete.
completed, the balloon is removed and replaced with a special-
ized Hasson trocar that seals the extraperitoneal tunnel. The dis-
sected space is then insufflated with CO 2 up to 12 mm Hg. Lower
pressures are used if the patient is thin or elderly. injure the small vessels that are present in the femoral canal. If
The anterior and posterior rectus sheaths create a tunnel that the hernia is incarcerated in the canal, an incision in the medial
opens into the dissected extraperitoneal space. If the tunnel is superior edge of the femoral ring should release the hernia.
short, it will not interfere with exposure or placement of the other The dissection of the lateral aspect of the posterior wall of the
midline trocars, but if it is very long, the available space will be inguinal canal begins with identification of the inferior epigastric
limited and vision impaired. In this case, a special Hasson trocar vessels. Fat and loose connective tissue are swept from the poste-
with a large inner balloon can be used to hold back the posterior rior abdominal wall just lateral to the vessels until the peritoneum
sheath, or, alternatively, the sheath can be cut back with en- is identified. If there is a lipoma of the cord, it should be drawn
doscissors. Either maneuver will open up the exposure, greatly fa- from the internal ring and left in the retroperitoneal space, out
cilitating the rest of the repair. of the operative field. The lipoma will be lateral to the peritoneal
Three trocars are placed in the midline: a 10 mm Hasson just sac and cord (Fig. 69.4). Sometimes only a slip offat will cover the
below the umbilicus for the camera, a 5 mm trocar in the middle, iliopubic tract, but it may lead to a very large lipoma in the scro-
and a 5 or 3 mm above the pubis. The second trocar should be as tum. It is therefore essential that the surgeon visualize the fibers
close to the subumbilical camera trocar as possible in order to of the iliopubic tract to avoid leaving such a lipoma behind. The
leave sufficient space between the lowest trocar and the pubis. The lateral femoral cutaneous nerve and femoral branch of the gen-
inferior trocar is positioned approximately three fingers' widths itofemoral nerve lie directly under the lipoma, and cautery should
below the middle trocar to prevent instrument sword fighting and be avoided in this part of the dissection.
still have the lowest trocar above the level of the mesh. The tro- Dissection of the cord and indirect sac is begun at this point. If
cars should be watched carefully as they enter the extraperitoneal there is no indirect hernia, the peritoneal edge will be found set
space to prevent laceration of a small branch of the inferior epi- back from the internal ring. The edge of the peritoneum should
gastric vessel or penetration of the peritoneal cavity. The trocars be grasped with atraumatic graspers and lifted off the testicular
should be anchored at the skin level to prevent them from slip- vessels. The peritoneal edge must be dissected as far cephalad as
ping in and out during instrument manipulation. possible so that the mesh used in the repair will be covered, not
Dissection of the posterior aspect of the anterior abdominal wall lifted, by the peritoneum when the CO 2 is evacuated. The peri-
is begun by sweeping any remaining tissue from the pubis to ex- toneum must also be dissected off the vas deferens as far laterally
pose Cooper's ligament. If a direct hernia is present (Fig. 69.3), as possible, as in the open posterior midline repair of Stoppa. This
it should be completely reduced at this point. This can almost al- "lateralization of the cord" will prevent the peritoneum on the me-
ways be accomplished with gentle traction on the peritoneal at- dial aspect of the cord from displacing the mesh.
tachments to the defect. The peritoneum will peel away from the If an indirect hernia is present, the sac will be found anterior
transversalis fascia, which will then bulge anteriorly. If the direct and lateral to the cord (Fig. 69.5). The sac may, however, extend
hernia is not reduced by the balloon and gentle traction, the fas- medially to involve the vas deferens if the sac is broad based. A
cial defect can be incised on the superior aspect to release the in- two-handed, hand-over-hand technique is used to dissect the sac
carcerated hernia. When the direct sac is reduced, it should not off the cord structures. It is essential that the peritoneum be dis-
be ligated. The bladder may line the medial aspect of the sac, and sected cephalad of the inferior edge of the mesh; if the peritoneum
ligation may injure it. or any of its attachments to the wall of the canal are left under
The femoral area should be examined after the dissection of the mesh, they may displace it, resulting in an early recurrence. A
the posterior wall of the inguinal canal. The iliac vein should be short or small sac is easily delivered out of the internal ring on the
visible just lateral to Cooper's ligament. If not, there is probably anterior surface of the testicular vessels and vas deferens, but a
an incarcerated femoral hernia. The vein will be under the her- very long sac that descends well into the scrotum may be difficult
nial sac. One must carefully reduce the hernia, taking care not to and traumatic to completely dissect off the cord. In such a case,
468 E.L. Felix
place before ligating the indirect sac, as this will equalize peri-
toneal pressure and extraperitoneal space pressure without com-
promising exposure. At the end of the procedure, the indirect sac
and any other tears in the peritoneum must be closed to prevent
development of an internal hernia and adhesions to the mesh. At
this point the CO 2 should be vented with an intracath or Veress
needle to prevent postoperative diaphragmatic irritation and
shoulder pain.
In the transabdominal preperitoneal approach, an indirect her-
nia is almost always obvious on inspection of the posterior wall of
the inguinal canal. In contrast, at the onset of a TEP repair, one
cannot tell whether there is an indirect component to a hernia
until the lateral dissection is completed. It is therefore mandatory
that the entire posterior wall be exposed in every TEP repair, even
if a direct or femoral hernia is immediately apparent. Up to 30
percent of patients will have an indirect hernia in addition to the
obvious direct or femoral hernia defect. 14 The advantage of the
FIGURE 69.4. Dissection of a lipoma lateral to the sac in a left indirect in-
laparoscopic repair, TEP or TAPP, is that it is possible to see and
guinal hernia. repair the complete posterior inguinal wall, eliminating missed
hernias that historically account for 14% of recurrent hernias in
most reviews.
After inspection of all potential hernia sites, the mesh repair is
the sac should be transected. The superolateral edge of the peri- begun. A 6 by 6 inch sheet of polypropylene is cut to fit the pos-
toneum should be incised first, because the testicular vessels and terior inguinal wall. At first most hernia surgeons used an oval or
vas deferens adhere to the undersurface of the sac. The vas def- rectangular mesh, but a shaped mesh is now preferred. Because
erens will be found on the medial and the testicular vessels on the the posterior inguinal wall is wider from top to bottom medial to
lateral side. Both structures must be identified before the inferior the iliac vessels, the medial half of the mesh is cut wider than the
peritoneal surface is incised, to avoid injury to them. Mass ligation lateral side so that it drapes over Cooper's ligament when it is
of the sac should be avoided, as the cord can be inadvertently in- placed in the space of Bogros. The overall shape is reminiscent of
corporated within the ligature. a free-form swimming pool. A suture should be used to mark the
When the proximal sac is divided from its distal portion, it is bottom of the medial side of the mesh before it is deployed in the
dissected off the cord structures and ligated with an endoloop. If extraperitoneal space to make laparoscopic orientation of the
CO 2 should fill the peritoneal cavity when the sac is dissected, an mesh simpler and quicker.
intracath needle, Veress needle, or intraperitoneal trocar can be Placing the polypropylene mesh in the extraperitoneal space
used to release the gas. This maneuver, however, is rarely needed. does not require any special instruments. The laparoscope is re-
If the intraperitoneal CO 2 causes the peritoneum to balloon into moved and the mesh is inserted into the extraperitoneal space
the operative field, obscuring the exposure, the surgeon needs through the camera port. The mesh is grasped with a 5 mm in-
only to dissect the peritoneum farther back to hold it out of the strument and is pulled into the space through the 10 mm port.
field of vision. It is probably better to wait until the mesh is in The laparoscope is reintroduced, and the mesh is gently pushed
into the pelvis with the scope. When the mesh is fully deployed in
the extraperitoneal compartment, it is rotated by means of two
graspers until the marked corner is in place below Cooper's liga-
ment or pubis. Using a two-handed technique, the smaller por-
tion of the mesh is placed over the indirect area and the larger
portion over the direct and femoral areas. It is important that the
mesh be large enough to cover all three potential hernia sites in
every patient. This means that the surgeon must tailor the total
size of the mesh to the size of the patient's myopectineal surface.
When the mesh is smoothed out, it should overlap the pubic bone
and cross the midline (Fig. 69.6). If the patient has bilateral her-
nias, the medial portions of the mesh from each side will overlap
each other. Surgeons should avoid leaving folds or wrinkles in the
mesh because these may lead to increased scar formation and
cause chronic pain.
Before anchoring the mesh to the abdominal wall and Cooper's
ligament, it is essential that the surgeon note the location of the
inferior epigastric vessels and the iliopubic tract as well as anyaber-
rant obturator vessels to prevent complications when anchoring
the mesh.
FIGURE 69.5. Dissection of the indirect sac from the lateral aspect of the The peritoneum and any lipomas of the cord must be well be-
testicular vessels. hind the inferior edge of the mesh before the mesh is secured in
pect of the anterior abdominal wall ensures that the mesh remains
in position. When the mesh is not fixed to the wall, fluid,
hematoma, or sharp movements such as coughing as the patient
emerges from anesthesia can elevate the mesh. Those who suggest
that stabilizing the mesh with staples or other fixation devices is
too dangerous base their attitude on early published reports of
nerve entrapment. 17 More recent data demonstrate that nerve in-
jury can be avoided by the proper placement of staples. 12 If the
surgeon understands that the nerves at risk (the genitofemoral,
lateral cutaneous, or femoral nerve) are all below the iliopubic
tract, injury due to anchoring is avoided. In addition, injury to the
ilioinguinal or iliohypogastric nerves, a rare complication, can be
almost completely prevented by avoiding staples above the ilio-
pubic tract in thin patients. The fixation-free approach is difficult
to justify because the major cause for recurrence in the past has
been inadequate fixation and mesh migration.
Recognizing the iliopubic tract is essential to a safe laparoscopic
repair. It is a white fibrous band running transversely at the lower
FIGURE 69.6. The mesh repair covering all three potential hernia defects edge of the internal ring. In some patients it is quite prominent
in a left groin repair. and evident, whereas in others it is subtle and barely visible (Fig.
69.7). When placing anchoring devices, one can confirm the lo-
cation of the tract by placing one hand on the abdominal wall
place. If any attachments of the sac to the distal cord remain un- while the other hand presses the stapler against the wall. If the tip
der the mesh after the mesh is positioned, the mesh may be lifted cannot be felt with the opposite hand, it is unsafe to place a sta-
laterally in the postoperative period, resulting in early failure. By ple or tack because the instrument is below the iliopubic tract and
creating a window between the vas deferens and the testicular ves- in an area where the nerves are exposed to injury. Pressing the
sels, one can ascertain that no sac projection has been left behind. opposite hand against the abdominal wall creates a more per-
Parietalization of the cord, as Stoppa 15 originally described, is also pendicular angle for the stapler, which improves its reliability.
essential. The peritoneum on the vas deferens must be completely When pressing against the abdominal wall, however, the surgeon
dissected from under the mesh. In some cases a large sac or lipoma should not press so hard as to force staples deep into the wall, pos-
can be placed on top of the mesh after the mesh is anchored and sibly injuring a more superficial nerve such as the ilioinguinal or
before the CO 2 is evacuated. Alternatively, if the mesh appears to iliohypogastric.
be too large, a portion of it can be cut away with an endoshears The first tacks or staples are placed through the mesh into
and removed through one of the ports. These maneuvers prevent Cooper's ligament. This stabilizes the mesh and allows the surgeon
the mesh from being lifted up by the peritoneal edge when the to spread the mesh out in a lateral direction, taking out any wrin-
CO 2 is released. kles or folds. Anchors are then placed into mesh and transversalis
If the mesh placed over the posterior inguinal wall is too small fascia medial to the inferior epigastric vessels. The mesh is again
to cover the whole area because the patient or the hernia is un- smoothed out in a lateral direction, making sure that the peri-
usually large, a second piece of polypropylene can be added in a toneum and lipoma of the cord are well cephalad of the mesh.
patchwork fashion to complete the repair. When a direct hernia
is extremely large, an additional mesh can be added, running in
a longitudinal direction and extending well above the defect and
below the pubic bone. This can be done to improve coverage of
a large femoral hernia as well.
Occasionally the testicular vessels will not lie flat against the pos-
terior inguinal wall. This occurs most often in very thin patients
or those with recurrent hernias. When this is observed, a double
buttress repair, originally described for the transabdominal
preperitoneal hernioplasty, can be utilized. In this technique, a
smaller mesh with a slit in the lower third for the cord is used to
secure the indirect defect. The slit is placed around the cord and
loosely reapproximated over Cooper's ligament. A second mesh
exactly like that previously described for the conventional TEP re-
pair is placed over the mesh with the slit. The second mesh pre-
vents reCUrrence through the slit and completes the repair of the
direct and femoral areas.
Fixation of the mesh is the next step. Although some surgeons
do not anchor the mesh to the wall or even to Cooper's ligament,
our standard approach still involves fixation. The number of points
of fixation, however, has decreased since our technique was first FIGURE 69.7. TEP view of a left indirect inguinal hernia, demonstrating
described.16 Fixing the polypropylene mesh to the posterior as- the landmarks.
470 E.L. Felix
Before the lateral fixation is completed, the mesh can be trimmed TABLE 69.2. Complications
and further dissection of the sac or lipoma performed to prevent
Year TAPP (%) TEP(%)
elevation of the lateral edge. The lateral anchors are inserted us-
ing a bimanual technique as described above to prevent damage 91-94 20/315 (6.3) 6/148 (4.0)
to the neural structures below the iliopubic tract. A final mesh an- 94-97 2/80 (2.5) 1/544 (0.2)
chor is placed into Cooper's ligament just medial to the iliac vein.
It is necessary to feel the pubic bone with the stapler when plac- Source: Surg Endosc (1999) 13:328-331.
ing this final fixation in order to avoid inadvertent laceration of
the iliac vessels. If aberrant obturator vessels are present coursing
over the pubic ramus, they must be avoided or serious bleeding ier than suturing a tear in the peritoneum. If the rent is large,
can result. The purpose of the fixation is to keep the mesh in place however, conversion to a TAPP repair and suture closure of the
until fibrous ingrowth takes place and to remove any slack in the defect is recommended.
mesh that would allow recurrence from beneath the polypropyl-
ene patch. The number of fixation points has decreased as our
understanding of the repair has grown. Complications
When the surgeon is satisfied that the hemostasis is effective and
the mesh is properly anchored, the CO2 is slowly evacuated Complications occur with every type of hernioplasty, but some are
through one of the 5 mm ports while a grasper in the other port limited to, or more common after, laparoscopic repairs. Seromas,
holds the lateral inferior comer of the mesh against the wall. This which frequently occur after laparoscopic repair of larger hernias,
procedure ensures that the peritoneum will cover the mesh rather are considered to be a minor problem, but they are important be-
than lift the inferior edge. The peritoneum should come to rest cause they can be confused with recurrence. They present as a
against the mesh, holding it in place. If the peritoneum lifts the mass that transmits an impulse when the patient coughs or strains.
polypropylene patch, the mesh can be manipulated or trimmed This fluid collection is usually spontaneously resorbed in 4 to 6
until the mesh is properly covered by the peritoneum. The 5 mm weeks. When not resorbed, it requires simple aspiration. There ap-
trocars are removed, and the rest of the extraperitoneal gas is evac- pears to be no relationship between seromas and the later devel-
uated through the umbilical port. If CO 2 is trapped in the peri- opment of hydrocele. 4
toneal cavity, it can be evacuated with a Veress needle or intracath. Nerve injuries after open or laparoscopic hernia repair are se-
This will prevent postoperative shoulder pain and abdominal dis- rious. The nerves most at risk during a laparoscopic repair are the
comfort. The fascia of the 10 mm port is approximated with ab- femoral branch of the genitofemoral nerve, the lateral cutaneous
sorbable suture. Gas trapped in the scrotum can be eliminated nerve of the thigh, and, rarely, the femoral nerve. Serious com-
with a small needle at the end of the procedure. plications from trauma to these nerves can be avoided in all but
rare instances if proper techniques of anchoring the mesh are fol-
lowed. As outlined earlier, placing tacks or staples above the il-
Technical Problems iopubic tract avoids injury to the nerves. In experienced hands,
the incidence of neuralgia is equal to or less than that reported
Although a balloon dissector facilitates dissection of the extra- for open repairs. 12 •18 Injury to the more anterior nerves, the ilio-
peritoneal space, three complications of balloon dissection can oc- hypogastric and ilioinguinal, may occur during open hernia re-
cur early in the procedure: takedown of the inferior epigastric pairs, but it is only occasionally seen in laparoscopic hernioplasty.
vessels, bleeding, and tearing of the peritoneum. When it occurs, it is due to staples penetrating too deeply into the
If the inferior epigastric vessels are stripped off the abdominal abdominal wall. The resulting neuralgia can usually be relieved by
wall by the balloon, they will hinder further dissection. They must removing the offending staple or tack.
be ligated with clips or endoloops, or cauterized with bipolar cur- Small bowel obstruction has been reported by several authors
rent, before dissection can proceed. after the TAPP approach, but rarely after a TEp repair. The key
Bleeding may occur from small vessels that come off the infe- to prevention of this complication is the closure of all tears in the
rior epigastric or pelvic vessels. When the surgeon first places the peritoneum.
scope, the extraperitoneal space will be dark because the light is Trocar injuries are extremely rare after TEP repairs. Because all
being absorbed by the blood. It is important to place the two op- trocars are placed in the extraperitoneal space under direct vision,
erating trocars quickly and carefully under direct vision to irrigate injuries to intraperitoneal viscera or retroperitoneal vessels are
and aspirate the field until it is clear. Usually the bleeding stops avoided. Blind insertion of a balloon dissector, however, can cause
spontaneously. If it does not, the bleeding points can be located damage if the precautions outlined previously are not heeded. If
and coagulated with bipolar cautery. it is likely that the extraperitoneal space has been obliterated by
A tear in the peritoneum can be the most difficult problem to
handle. Prevention is extreinely important because the incidence
TABLE 69.3. Complications by approach
of complications increases with conversion from a TEP to a TAPP
repair. The incidence of significant peritoneal tears can be Approach No. patients Complications %
markedly reduced by avoiding TEp approach in patients with an
TAPP 395 22 5.6
incarcerated hernia, a history of pelvic irradiation, or radical
TEP 692 7 1.0
prostatectomy. If a tear does occur, the surgeon can switch to a Totally TEP 678 5 0.7
transabdominal approach or proceed with the extraperitoneal TEP/TAPP 14 2 14.3
techniqu~, being sure to close the peritoneal rent at the end of
the case. A series of endoloops is usually sufficient and much eas- Source: Surg Endosc (1999) 13:328-331.
TABLE 69.4. Significant complications 7/91-8/97: 1,087 patients, alternative to the open approach in hernia repair. As surgeons be-
1423 hernias come more accomplished in advanced laparoscopy, it is certain
Complication
that the approach will be adopted by a larger number of surgeons
No. patients
because there remains little doubt that the approach achieves what
Intraoperative its originators had envisioned.
Trocar injury of bowel 2
Bleeding from trocar 1
Small bowel laceration References
Postoperative
Pain 1. Stoppa R, Rives JL, Warlaumont C, et al. The use of Dacron in the re-
Lasting> 6 months 8 pair of hernias of the groin. Surg Clin Narth Am. 1984;64:269-285.
Requiring surgical treatment 4 2. Schultz L, Graber J, PietrafittaJ, et al. Laser laparoscopic herniorrha-
Trocar hernia 6 phy: a clinical trial-preliminary results.] Laparoendose Surg. 1990;1 :98-
Small bowel obstruction 1 105.
Hydrocele requiring treatment 6 3. McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using
a totally extraperitoneal prosthetic approach. SurgEndosc. 1993;7:26-28.
Source: Surg Endose (1999) 13:328-331.
4. Felix EL, Michas C, Gonzalez M. TAPP vs. TEP laparoscopic hernio-
plasty. Surg Endose. 1995;9:984-989.
5. Ferzli G, Kiel T. Evolving techniques in endoscopic extraperitoneal
previous surgery, infection, or radiation, the TEP approach should herniorrhaphy. Surg Endose. 1995;9(8):928-930.
not be attempted. 6. Ferzli G, Sayad P, Huie F, et al. Endoscopic extraperitoneal hernior-
rhaphy. A 5 year experience. Surg Endose. 1998;12(11):1311-1313.
7. Heikkinen 1J, Haukipuro K, Hulkko A. A cost and outcome compar-
Results ison between laparoscopic and Lichtenstein hernia operations in a day
case unit. A randomized prospective study. Surg Endose. 1998;12(10):
1199-1203.
Early reports of laparoscopic hernioplasty were disappointing. 2 In 8. Ramshaw B, Frankum C, Young D, et al. 1000 total extraperitoneal
some recent reviews, recurrence rates, incidence of complications, herniorrhaphies: after the learning curve. Surg Endose. (in press).
and operative times have all been too high.19 As in conventional 9. Felix E, SCOUt S, Crafton B, et al. Causes of recurrence after laparo-
hernia repairs, experience is the key to improving results. scopic hernioplasty-a multicenter study. Surg Endose. 1998;12:226-
Laparoscopic hernioplasty, especially the TEP approach, has 231.
evolved dramatically over the past 8 years. Several centers report- 10. Leibl B, SchmidtJ, Daubler P, et al. A single institution's experience
ing on their experience, beyond the initial learning curve, have with transperitoneal laparoscopic hernia repair. Am] Surg. 1998;
demonstrated that laparoscopic TEP hernioplasty can be per- 175(6):446-452.
formed safely, quickly, and with an extremely low recurrence rate. 11. Liem M, Van der Graff Y, Van Steensel C, et al. Comparison of con-
ventional anterior surgery and laparoscopic surgery for inguinal her-
Our multicentered study with over 4800 TEP repairs achieved a
nia repair. N Engl] Med. 1997;29:336(22):1541-1547.
recurrence rate of less than 1%, despite the use of slightly differ- 12. Felix E, Habertson N, Varteian S. Laparoscopic hernioplasty: signifi-
ent approaches. 9 In a study by Ramshaw et al. s of 1000 TEP re- cant complications. Surg Endose. 1999;13:328-331.
pairs performed after the authors had become experienced with 13. Felix EL, Michas CA, Gonzalez M. Recurrent hernioplasty. Am] Surg.
the approach, the average operative time was shorter than that of 1996;172:580-584.
a consecutive series of open repairs, and recurrence for the lap- 14. Felix EL, Michas CA, Gonzalez M. Laparoscopic hernioplasty: why does
aroscopic group was less than 1%. it work? Surg Endose. 1997;11:36-41.
My own personal experience with the TEP approach began af- 15. Stoppa R. The treatment of complicated groin and incisional hernias.
ter I had completed over 300 TAPP repairs. In over 1300 TEP re- World] Surg. 1989;13:545-554.
pairs between 1991 and 1997, I have seen only 7 recurrences, and 16. Felix EL, Michas C. Double-buttress laparoscopic herniorrhaphy.
] Laparoendose Surg. 1993;3(1):1-8.
the complication rate has been similar to that published for open
17. Broin EO, Horner C, Mealy K, et al. Meralgia paresthetica following
repairs (Tables 69.2 to 69.4) .12 My TEP technique and indications
laparoscopic inguinal hernia repair. Surg Endose. 1995;9:76-78.
for its use have been modified over time. 18. Payne JH. Complications of laparoscopic herniorrhaphy. Semin Lafr
As with any surgical technique, modification or evolution of the arose Surg. 1997;4:166-181.
technique with lessons learned from experience are keys to its con- 19. Cooper S, McAlhany J. Laparoscopic inguinal hernia repair: is the en-
tinued success. The TEP approach is and should remain a viable thusiasmjustified? Am] Surg. 1997;63(1):103--106.
70
Laparoscopic Totally Extraperitoneal
Repair for Inguinal Hernias (TEP): Part II
Jonathan D. Spitz and Maurice E. Arregui
The repair of inguinal hernia is one of the most common proce- anatomy, indications, technical aspects, and complications of the
dures performed by general surgeons. However, there remains no procedure are presented. We also provide a summary of our ex-
consensus on the optimal approach. The anterior tension-free perience with laparoscopic TEP inguinal herniorrhaphy.
mesh repair popularized by Lichtenstein is perhaps the most
widely used technique, with a reported recurrence rate less than
1 %.1 However, the same level of success has not been universally
achieved. When one considers all current methods of hernia re-
Evolution of the Laparoscopic Totally
pair, the recurrence rate approaches 10%.1 Additionally, patients Extraperitoneal Repair
with open repairs have greater postoperative discomfort and a
longer interval until preoperative performance status is achieved, Inguinal hernias occur as a result of disruption or attenuation of
and a contralateral or femoral hernia may be missed. the transversalis fascia within the confines of the myopectineal ori-
In the era before laparoscopy, the open preperitoneal approach fice of Fruchaud. This is the space bordered medially by the rec-
to inguinal hernia repair, championed by Stoppa et al} Wantz,3 tus muscle, superiorly by the transverse aponeurotic arch and
and Nyhus,4 was considered primarily for recurrent, complicated, transversus abdominis muscle, laterally by the psoas muscle, and
and bilateral hernias. The more extensive approach by Stoppa5 inferiorly by the pubic bone (Fig. 70.1). Complete reinforcement
uses a giant piece of mesh placed into the preperitoneal space of the myopectineal orifice with a large mesh is the central prin-
through an infraumbilical midline incision. The mesh functions ciple behind current laparoscopic inguinal hernia repairs.
as an artificial endoabdominal fascia to definitively support the The introduction of laparoscopy for general surgery heralded
musculofascial layer. The recurrence rate of this unsutured the development of a variety of laparoscopic hernia repairs. Sim-
preperitoneal groin hernia repair of difficult hernias is 1.4%.5 ple closure of the hernia ring6 and plug and patch repair7 were
Since the introduction of laparoscopic inguinal herniorrhaphy, the first laparoscopic techniques, but because of unacceptably high
the preperitoneal approach has gained popularity. The laparo- early recurrence rates these techniques were abandoned. Cur-
scopic totally extraperitoneal (TEP) inguinal hernia repair com- rently there are three main methods oflaparoscopic hernia repair.
bines the benefits of the Stoppa procedure with the successful The simplest method is the intraperitoneal onlay mesh technique
principles of the anterior tension-free mesh repair. Specifically, the (IPOM).8 This repair involves minimal dissection as the mesh is
TEP repair uses a large (5 by 6 inch) piece of mesh to completely stapled directly on the peritoneum. Some have advocated a lim-
cover the myopectineal orifice. The large dimension of the pros- ited dissection to identifY Cooper's ligament for fixation. The ben-
thesis not only repairs the current hernia but also reinforces the efit of this technique is that it is easily performed and has a rapid
entire inguinal floor. The mesh is held in place within the preperi- recovery. However, the intraperitoneal placement of mesh and its
toneal space by the dynamics of intraabdominal pressure against exposure to bowel carries the theoretical risk of adhesion and fis-
the anterior abdominal wall. No fixation is needed, so risk of tula formation. Furthermore, because of the limited dissection,
injury to related nerves and vessels from staples or suture is lipomas of the cord and small hernias may be missed, and the sta-
eliminated. ple fixation has been associated with postoperative neuralgia.
Previously, the laparoscopic TEP was condemned for being too The transabdominal preperitoneal (TAPP) repair is the most
difficult, too costly, and associated with a higher complication and commonly performed laparoscopic technique. This is a tension-
recurrence rate than the anterior repair. As laparoscopic surgeons less repair with mesh placed through a peritoneal defect into the
gained a better understanding of the inguinal anatomy, the preperitoneal space. Briefly, the procedure involves carbon diox-
preperitoneal dissection became more complete, and today many ide insuffiation of the abdomen and inspection of the groin bi-
consider that the advantages of laparoscopic TEP repair make it laterally. An incision is made in the peritoneum at the orifice of
the technique of choice for the repair of inguinal hernia. In this the indirect hernia or internal ring. Peritoneal flaps are created,
chapter, the evolution of the laparoscopic extraperitoneal ap- and the cord structures are dissected free of the peritoneal mem-
proach, the rationale of the TEP repair, the inguinal preperitoneal brane. This "parietalization" of the cord structures is a key aspect
472
70. TEP for Inguinal Hernias 473
reevaluate current methods of herniorrhaphy. A key aspect to the

modem repair of inguinal hernia is the tension-free reinforcement
of the weakened transversalis fascia. At the onset of laparoscopy,
most surgeons were not performing Lichtenstein tension-free re-
pairs, and up to 20% of hernias repaired annually were for re-
currences. In our experience, 17% of repairs are for recurrent
defects following an initial open repair. Laparoscopic hernia re-
pair developed because surgeons and patients sought a less painful
and more effective method.
Now that the Lichtenstein approach has become "the standard,"
one has to question whether there is an advantage to the laparo-
scopic approach. Indeed, with a reported recurrence rate of 0.1 %
it is hard to imagine why there should be an alternative to the
open tension-free herniorrhaphy. Several authors have compared
laparoscopic hernia repair with standard anterior herniorrhaphy.
Payne et al.!1 compared TAPP with the Lichtenstein tension-free
mesh repair in a prospective randomized manner. The main out-
Iliopsoas
come measures were operative and discharge times, costs, recov-
muscle ery, and morbidity. Additionally, they attempted to better assess
"return to work" by evaluating responses to standardized exercise
testing. The operative times and the time to discharge were not
significantly different between the two groups. Overall, the rates
FIGURE 70.1. The myopectineal orifice of Fruchaud. Posterior right side.
of complication were 18% in the open group and 12% in the lap-
(Reprinted from Arregui ME. Transabdominal retroperitoneal inguinal
herniorrhaphy. In Macfadyen BY, Ponsky JL (eds): operative laparoscapy and aroscopic group. The complications were mostly minor, although
thuracoscapy. Philadelphia: Lippincott Williams and Wilkins; 1996, with per- there were two conversions to the open procedure. One of the
mission.) conversions was in a patient with a recurrent hernia, and the other
was required for control of intraoperative bleeding. One patient
in the laparoscopic group required a second laparoscopy 10 days
to allow placement of a large piece of mesh. The mesh is secured
following hernia repair because of inguinal pain and a mass in the
to the transverse abdominis muscle lateral to the internal ring and
groin. At surgery this patient had incarcerated omentum through
above the iliopubic tract. Sutures or staples are also placed on
inadequately closed peritoneum. No recurrences were detected in
Cooper's ligament and to the transversus abdominis medially and
either group at 10 months follow-up. The cost was higher in the
above the area of Hesselbach's triangle. The peritoneum is closed
laparoscopic group ($3093 vs. $2494), but there was a significantly
with either staples or a purse-string suture. The TAPP repair al-
quicker return to work among laparoscopic patients (9 days vs. 17
lows for tension-free fixation of mesh to cover all areas of poten-
days). Conclusions drawn were that there is a measurable benefit
tial groin herniation. There is, however, risk of visceral injury or
to laparoscopic TAPP repair in terms of both recovery and return
bowel herniation through a residual peritoneal defect if too much
to work.
space is left between the stapled closure.
In a multi-institutional study by Liem et al.,12 the laparoscopic
The TEP hernia repair represents the laparoscopic counterpart
extraperitoneal repair was compared with open herniorrhaphy. In
to the open preperitoneal mesh repair. Access to the preperitoneal
this series mesh was used in alilaparoscopic repairs, but was used
space may be obtained without violating the peritoneum. With our
at the discretion of the surgeon in open operations. The lengths
technique, we introduce a 5 mm laparoscope into the peritoneal
of surgery were similar, and operative complications were low in
cavity to inspect the groin bilaterally. Contralateral hernias are of-
both groups. In the laparoscopic group there was less postopera-
ten diagnosed. Additionally, the intraperitoneal view guides place-
tive pain and lower analgesia requirements. Recurrence rates at 1
ment of the extraperitoneal trocars into the correct space. A large
year were similar for both groups. Most of the recurrences in the
mesh is used to completely reinforce the myopectineal orifice,
laparoscopic group occurred early in the experience of the oper-
which is held in place by the intraabdominal pressure rather than
ating surgeon, and, when stratified, the recurrence rate during the
with staples. 9 ,10 Patients enjoy a more rapid return to preoperative
second year was greater in the open surgery group. The findings
performance status and less postoperative pain without restriction
supported laparoscopic herniorrhaphy, but the authors stated that
of activity compared with the open mesh repairs,Il The risk of neu-
results are dependent on the experience and the skill of the sur-
ralgia is eliminated because staples are not used. The complica-
geon.
tion and early recurrence rates have been favorable. However, t~e
Comparison of current laparoscopic methods has identified
technique has a longer learning curve than the other laparoscoplc
technical considerations that will help to prevent recurrences and
methods and is more costly than the open anterior mesh repair.
lessen the rate of complications. Ramshaw et aI.,13 in a retrospec-
tive series, compared 300 consecutive TAPP repairs with a subse-
quent 300 TEP repairs. They reported a 10.7% complication rate
Rationale for Totally among the TAPP group. This included 6 cases of thigh paresthe-
Extraperitoneal Repair sia, 4 inferior epigastric artery injuries, 1 enterotomy, 1 bowel ob-
struction, 1 bladder injury, and 14 urinary retentions. The
With the gaining popularity and decreasing controversy sur- complication rate in the TEP group was 3.7% and included two
rounding laparoscopic hernia repair, it becomes important to enterotomies, one bladder injury, one paresthesia, and six urinary
ReclUS Sheath
retentions. The technique of extraperitoneal dissection involved (Posterior Lart*1a
use of the balloon dissector, and staples were used in both groups Transversais Fascia)
to secure the mesh. Interestingly, in the TEP group, the enter-

otomies and the bladder injury occurred in patients who had prior
lower abdominal surgery, with the presumption of adhesions con-
tributing to the visceral injury. The bowel obstruction in the TAPP
group was secondary to a Richter's hernia at one of the trocar sites.
Theoretically, there will be a greater likelihood of visceral injury
in the TAPP group because of the intraabdominal placement of
ports. Because of the nonrandomized nature of the review, it is
difficult to draw direct conclusions, but the authors thought that
there were significant advantages to the extraperitoneal approach,
including fewer recurrences, fewer intraabdominal complications, Umbilical
Periloneun
PrevesicUar
and improved dissection of the preperitoneal space. Fascia
In another comparative study of laparoscopic extraperitoneal
hernia repair and transabdominal preperitoneal repair, Khoury14
evaluated his results of 120 laparoscopic herniorrhaphies. The op- Transversais
erative times were not significantly different, and all patients were Fascia
able to return to work within 1 week of discharge. The overall in-
cidences of complications were not different between the two FIGURE 70.2. Transverse view of the preperitoneal space and fasciae at the
groups, and most complications were minor. However, there was level of the internal inguinal ring. The posterior rectus space is separated
one Richter's hernia at the 10 mm trocar site in the TAPP group from the preperitoneal space by the posterior rectus sheath. (Reprinted
that required operative intervention. from Arregui ME. Transabdominal retroperitoneal inguinal herniorrha-
The TEP repair was associated with a shorter hospitalization phy. In MacFadyen BV, Ponsky JL (eds): operative laparoswpy and thura-
than the TAPP. Following TEP, 57% of patients were discharged coscopy. Philadelphia: Lippincott Williams and Wilkins; 1996, with
the same day, and 98% were discharged within 24 hours. In con- permission.)
trast, only 10% of patients were discharged the same day follow-
ing TAPP. The recurrence rates for the TAPP and TEP repairs were space is entered. This true preperitoneal space is continuous with
3.4% and 0%, respectively, with a follow-up of 1 to 27 months. This the space of Retzius below Cooper's ligament. The incorrect
report demonstrates the efficacy of laparoscopic hernia repair and anatomical presumption is that there is complete absence of the
preferentially supports the TEP. posterior rectus sheath below the arcuate line.
The main impetuses to laparoscopic extraperitoneal hernia re- Deep to the posterior rectus sheath lies the umbilical prevesical
pair remain (1) wider exposure of the myopectineal orifice, (2) fascia, which is a thin fascial layer that invests the bladder and me-
the ability to place a larger mesh, and (3) no peritoneal defect is dial umbilical ligament and laterally invests the indirect hernial
created. sac (if present), the vas deferens, and the other cord structures.
This fascial layer continues as the internal spermatic fascia and in-
vests the cord structures as they enter the inguinal canal. 15
Anatomy With the posterior rectus entry, access into the lateral inguinal
preperitoneal space is limited by the anterior attachments of the
There is a renewed interest in the preperitoneal anatomy because posterior rectus fascia. Hook scissors can be used to take down
of laparoscopic herniorrhaphy. Confusion abounds regarding the these fibers and access this space so that a large piece of mesh may
fascial layers and spaces of the anterior abdominal wall. With be placed. Once the anatomical dissection is completed, the di-
laparoscopy, surgeons gained a new perspective on the anterior rect, indirect, obturator, and femoral spaces are exposed.
abdominal wall that was not appreciated with open surgery. Suc- Contained within the triangle formed by the spermatic cord and
cessful laparoscopic TEP repair requires a comprehensive under- the spermatic vessels are the external iliac vessels and femoral
standing of the multiple fascial planes of the inguinal region. A nerve. Following the cord structures into the inguinal canal is the
key to successful dissection is the understanding that there is, in genital branch of the genitofemoral nerve. The femoral branch
fact, a true preperitoneal space that is distinct from the posterior of the genitofemoral nerve and the lateral femoral cutaneous
rectus space (Fig. 70.2). The posterior rectus fascia serves as the nerve are located lateral to the spermatic vessels and inferior to
anterior boundary of the preperitoneal space. Specifically, the pos- the iliopubic tract (Fig. 70.3). These structures are at risk of in-
terior rectus space, the umbilical prevesical fascia, the lateral injury from aberrant staples. Other nerves of concern in this area
guinal space, and the transversalis fascia are anatomical landmarks are the femoral, ilioinguinal, and iliopubic nerves.
that are used to guide the dissection. Complete dissection in the
correct plane allows wide exposure of the myopectineal orifice and
is mandatory if optimal results are to be achieved. Indications
The posterior rectus space is bordered anteriorly by the rectus
muscle and the inferior epigastric vessels. The posterior rectus The laparoscopic hernia repair is ideally suited to adult patients
sheath extends to the origin of the inferior epigastric vessels and with bilateral inguinal hernias or recurrences following anterior
to Cooper's ligament, but, while it is well developed above the repair. In the setting of hernia recurrence after an anterior
arcuate line, it becomes quite attenuated caudally. By breaking herniorrhaphy, the laparoscopic repair approaches the hernia
through these attenuated fibers posteriorly, the true preperitoneal through fresh tissue planes and avoids the scar from the previous
Femoral branches
of genitofemoral
nerve
Lateral femoral
Vas ----..:V cutaneous nerve
deferens
Psoas muscle FIGURE 70.4. Transperitoneal inspection of the groin. This patient has a
right indirect inguinal hernia.
Spermatic
vessels
and the patient is put in the Trendelenburg position. The ab-

domen is prepared and draped. The video monitor is placed at
the foot of the table, and the surgeon stands on the side opposite
the hernia. A single assistant stands opposite the surgeon to con-
FIGURE 70.3. Anatomy of the nerves and vessels of the preperitoneal and trol the camera. A pneumoperitoneum is established with a Ver-
retroperitoneal inguinal space. (Reprinted from Arregui ME. Transab- ess needle at the umbilicus, and through a 5 mm trocar the
dominal retroperitoneal inguinal herniorrhaphy. In MacFadyen BV, Pon- abdomen is inspected with as mm 30 degree angled laparoscope.
skyJL (eds): operative laparoscopy and thoracoscopy. Philadelphia: Lippincott Because the position of the trocars is slightly different for unilat-
Williams and Wilkins; 1996, with permission.) eral and bilateral repair, the inguinal area is first examined bilat-
erally (Fig. 70.4). If an unsuspected contralateral defect is
discovered, then bilateral repair is performed. If the patient was
thought to have bilateral hernias on examination and a peritoneal
procedure. Bilateral groin defects can be repaired during a single defect is not found, then bilateral exploration is performed be-
anesthetic through the same incisions. The advantages of unilat- cause a lipoma of the cord or small direct hernia could still be
eral TEP over open repairs is less clear. However, in patients of present.
working age or especially those engaged in physical labor, studies The intraperitoneal laparoscopic view is used to guide place-
have demonstrated a more rapid return to full preoperative per- ment of the first extraperitoneal trocar. This trocar is placed into
formance status with the laparoscopic repair. ll ,16 the lateral aspect of the posterior rectus space just cephalad to the
The only absolute contraindication to laparoscopic herniorrha- arcuate line on the index side (Fig. 70.5). Externally this corre-
phy is high risk patients not able to tolerate general anesthesia.
sponds to a point about 2 em inferior to the horizontal plane of
Consequently, for these patients we recommend an open anterior
mesh repair with local anesthetic. Additionally, although we per-
form the preperitoneal repair in patients who have had previous
lower abdominal surgery, we do so cautiously. In these patients
there may be scarring that makes the preperitoneal dissection dif-
ficult. Ramshaw et al. 13 ,17 found that complications such as blad-
der injury or peritoneal tears were more common among those
patients who had previous lower abdominal surgery. By using a
blunt instrument to create the preperitoneal pocket under direct
vision rather than the balloon dissector, we have avoided compli-
cations such as bladder and bowel injury and peritoneal tears.
These complications have been reported in cases in which the bal-
loon dissector was used.
Operative Technique
The patient is asked to void before transport to the operating
room, obviating the need for a urinary catheter. No preoperative
antibiotic prophylaxis is given. The patient is positioned supine FIGURE 70.5. Placement of the first extraperitoneal trocar into the poste-
with the arms tucked at the sides. General anesthesia is instituted, rior rectus space.
the umbilicus. We use a blunt instrument to dissect the posterior

rectus sheath from the posterior aspect of the rectus muscle and
the inferior epigastric vessels. Distally the dissection is extended
just across the midline for unilateral herniorrhaphy. In the pres-
ence of bilateral inguinal hernias, the posterior rectus space is dis-
sected bilaterally. Although some surgeons rely on the balloon
dissector to create this extraperitoneal pocket, we have found that
blunt dissection in this avascular plane less traumatically and more
precisely accomplishes the same task without the considerable ex-
pense.
Once completely dissected, the extraperitoneal space is insuf-
flated with carbon dioxide, and the pneumoperitoneum is evacu-
ated. This allows the posterior rectus space to fully expand. The
second extraperitoneal port is placed 2 cm inferior to the um-
bilicus. Through this port we place either a 5 mm 30 degree or a
10 mm 45 degree laparoscope. If a unilateral repair is being per-
formed, a 5 mm trocar is placed in the midline midway between FIGURE 70.7. Opening the umbilical prevesical fascia by teasing the fibers
the pubis and the umbilicus. For bilateral repair, this trocar is po- apart allows access to the indirect hernial sac.
sitioned above the arcuate line on the contralateral side.
Cooper's ligament is cleared laterally and medially by taking
down the areolar attachments of the posterior rectus sheath to en- tents (Fig. 70.7). The hernial sac may then be separated from the
ter the space of Retzius. Cautery is rarely needed in this avascular cord structures. The indirect hernial sac is ligated to eliminate the
space. The obturator foramen is visualized inferiorly within this possibility of an internal hernia.
space. To break out of the posterior rectus space laterally, the an- Parietalization of the spermatic cord is the important next step
terior attachments of the posterior rectus fascia are taken down for the laparoscopic TEP. The technique, developed by Stoppa et
with hook scissors. This provides entry into the lateral inguinal al,,2 facilitates implantation of mesh by eliminating the necessity
space for wide exposure of the inguinal floor needed for place- of a slit to accommodate the spermatic cord. By separating the
ment of a large mesh. peritoneum from the spermatic cord to a point proximal to the
Direct hernias are located medially and usually require reduc- confluence of the vas deferens and the spermatic vessels, these
tion before access to the internal ring is gained. Direct hernial sacs structures will lie against the retroperitoneum so the mesh can
are composed of the attenuated fibers of the transversalis fascia. cover them and the internal ring completely once the insuffiation
Large sacs may be a site for the development of a postoperative is released (Fig. 70.8). By avoiding circumferential mobilization of
seroma. We routinely reduce and ligate these sacs or suture the the cord, we avoid injury to the genital branch of the gen-
sac to Cooper's ligament to eliminate the dead space and lessen itofemoral nerve and constriction of the cord structures. If, in the
the risk of postoperative fluid collection. course of parietalization of the cord, a hole is made in the peri-
Posteriorly and laterally the umbilical prevesical fascia invests toneum, it is closed with a chromic tie. This maintains the preperi-
the vas deferens and spermatic cord as well as the indirect hernial toneal insufflation and eliminates the possibility of bowel
sac (if present) (Fig. 70.6). This fascial plane is opened by teasing herniation through the peritoneal defect. Once the dissection is
the fibers apart to expose the indirect hernial sac and cord con- complete, we inspect the cord for a lipoma. Anterior palpation
FIGURE 70.6. The umbilical prevesical fascia covers the bladder and ex-
tends laterally to cover the spermatic cord and indirect hernial sac. It fol- FIGURE 70.S. Parietalization of the spermatic cord by mobilizing the peri-
lows these structures into the inguinal canal as the internal spermatic fascia. toneum posteriorly. The vas deferens is being elevated by traction on the
(Reprinted from Arregui,27 with permission.) umbilical prevesical fascia.
FIGURE 70.9. Mersilene mesh (5 by 6 inches). The large dimension com- FIGURE 70.10. Transperitoneal inspection of the mesh, which is positioned
pletely covers the entire inguinal floor. between the peritoneum and the anterior abdominal wall. Inspection re-
veals that the mesh is lying flat and has not folded or migrated.
over the external ring and inguinal floor often reduces a clinically
significant lipoma so that it may be excised. One must be careful In a large multi-institutional retrospective study by Tetik et ai., 18
not to excise the normal fatty tissue surrounding the spermatic complications and recurrences were evaluated following laparo-
vessels. scopic repair of groin hernias. In this study, 1514 hernias were re-
To reinforce the myopectineal orifice, we prepare a piece of paired. The techniques used were 552 TAPP repairs (36.5%),457
Mersilene® or Prolene®mesh to 5 by 6 inches. The corners of the TEP repairs (30.2%) , 320 IPOM (21.1%), 102 ring closures
mesh are curved to make positioning the mesh easier. We make a (6.7%), and 82 plug and patch (5.4%). The total complication
curved cutout to overlay the cord. The medial superior corner is rate was 13.6%, with l.2% intraoperative complications. The com-
left square to help orient the mesh within the preperitoneal space plications consisted of hematoma/ seroma, subcutaneous emphy-
(Fig. 70.9). Bilateral herniorrhaphy requires two pieces of mesh sema, hydroceles, wound infections, and inguinal pain. The most
that overlap at the midline. The final position of the mesh widely common neurological complication was lateral femoral cutaneous
covers all sites of potential herniation of the inguinal floor. It ex- nerve pain. In two patients with intractable nerve pain, repeat lap-
tends across the midline and into the space of Retzius. It rests over aroscopy and staple removal was performed. The hernia repairs
the spermatic cord and extends into the lateral inguinal space. with the preperitoneal placement of mesh, namely, the TAPP and
Once the preperitoneal insufflation is released, the peritoneum TEP, had an 11 % and 12.2% local complication rate, respectively.
and intraabdominal pressure act to secure the mesh against the The higher complication rate associated with the TEP was attrib-
posterior inguinal floor and pelvis. Consequently, no fixation is uted to the more extensive pre peritoneal dissection and to the fact
needed, effectively eliminating the possibility of nerve or vessel that at the time of this study the TEP was less widely performed
injury. and experience was more limited.
The pneumoperitoneum is reestablished, and the mesh is in- In another multi-institutional study of outcome data, Phillips et
spected through the peritoneum to ensure that it has not folded ai. 19 considered the incidence of complications following laparo-
or migrated (Fig. 70.10) . The patient is taken out of the Trende- scopic herniorrhaphy. The conclusions drawn were that many com-
lenburg position so that the bowel will fall against the inguinal plications can be avoided with proper attention to technique. In
floor, further securing the peritoneum against the mesh, and the this study, 3229 laparoscopic hernia repairs were performed with
carbon dioxide insufflation is released. The fascial defect at the one of five laparoscopic methods. The techniques used were the
10 mm trocar site is closed with 00 Vicryl® and the skin incisions TAPP in 1944 (60%), the TEP in 578 (18%), the IPOM in 345
are re-approximated with a 000 Vicryl subcutaneous stitch. Collo- (11%), the plug and patch in 286 (9%), and simple primary clo-
dion® (Paddock Laboratories, Minneapolis, MN) is applied to each sure of the hernia defect in 76 (2%). The overall complication
wound and serves as the dressing. Patients are discharged follow- rate was 10%, and the overwhelming majority were minor.
ing a 1 to 3 hour observation period in the recovery area. Driving When each technique was individually evaluated, the TAPP had
is restricted for 3 to 4 days, but no restrictions are placed on ac- 141 (7%) complications. The most common complication was
tivity or lifting. hematoma, followed by neuralgia and urinary retention. There
were four small bowel obstructions through inadequately closed
peritoneum and two trocar site hernias. The IPOM had 47 (14%)
Complications complications. In this technique, hematoma and neuralgia were
the most common complications. There was also one bladder in-
There are many advantages to laparoscopic herniorrhaphy. De- jury and one colon injury. Interestingly, there were no cases of
creased pain, quicker return to full activity, and better cosmesis small bowel obstruction (a theoretical complication following in-
are all potential benefits. However, complications can occur, and, traperitoneal placement of mesh). The TEP repair had 60 (10%)
while most are minor and transient, serious complications have complications, none of which required intervention. Again,
been reported. hematoma and transient neuralgia were most common. The plug
and patch technique and simple closure of the hernia defect had aroscopic method is the ability to inspect the groin bilaterally at
8% and 13% complications, respectively. the time of initial repair and diagnose otherwise overlooked
One of the unexpected findings in several studies of laparo- femoral or obturator defects.
scopic hernia repair18,19 was that nerve injury and postoperative Critics of laparoscopic inguinal herniorrhaphy argue that little
neuralgia from mesh fixation was one of the most common com- is known of late recurrence rates. Admittedly, laparoscopic TEP
plications. Although many surgeons believe that fixation of the has been performed for less than a decade. However, the open
mesh is necessary with the TEP technique, we and others20 are preperitoneal repairs ofWantz3 and Stoppa5 for recurrent and re-
achieving excellent results without staple fixation. Our technique recurrent groin hernias after classic herniorrhaphy demonstrate
mimics the unsutured preperitoneal placement of mesh used by overall long-term recurrence rates of 3.7% and 1.4%, respectively.
Stoppa. With this technique, nerve entrapment and the resultant Additionally, the early results of laparoscopic TEP suggest that the
potentially disabling pain are avoided. The nerves at risk for in- repair offers an excellent outcome.
jury with staple fixation are the genitofemoral nerve, the lateral MacFadyen22 reviewed a series of 841 laparoscopic hernia re-
femoral cutaneous nerve, the femoral nerve, the ilioinguinal pairs by 16 surgeons. In this study, the recurrence rate of the TAPP
nerve, and the iliohypogastric nerve. If fixation is to be used, then group was 0.84%. The IPOM was associated with 3.2% recurrences.
careful placement and a complete knowledge of the anatomy will The extraperitoneal repair, with an average follow-up of 7 months,
decrease the incidence of nerve entrapment. Removal of the had no recurrences. The plug and patch technique and simple
offending staple or nerve ablation may be necessary if neuralgia closure of the hernia defect had 6.8% and 2.2% recurrences, re-
persists. spectively. These latter techniques have largely been abandoned
Bladder, bowel, and major vascular injuries can occur with any in favor of the methods with the preperitoneal placement of mesh.
laparoscopic procedure. These injuries have been described with Similarly, Tetik et al. 18 considered recurrence rates for each of
the use of either disposable or reusable trocars. Injuries may also five methods of laparoscopic hernia repair (TAPP, IPOM, TEP,
occur with the Hasson cutdown technique. These i~uries can also plug and patch, and ring closure). The overall recurrence rate,
occur in the course of the preperitoneal dissection and are more which varied drastically with technique, in this retrospective analy-
likely in patients who have had prior lower abdominal surgery.17 sis of 1514laparoscopic hernia repairs, was 2.2 %. The TEP method
Many surgeons have adopted the routine use of the balloon dis- had the lowest recurrence rate of 0.4%, whereas the plug and
sector to develop the preperitoneal space. This device is inserted patch technique had a recurrence rate of 22%. The improved re-
into the posterior rectus space and advanced to the pubis before sults seen with the TEP were attributed to a more complete dis-
the balloon is inflated. Complications such as peritoneal tears, in- section and better coverage of the inguinofemoral area with large
jury to the inferior epigastric vessels, bladder injury, and balloon mesh. Additionally, most of the TEP repairs were performed after
misplacement with inflation within the wrong fascial plane have re- a surgeon had gained experience with the TAPP method, which
sulted from this device. 21 We perform the extraperitoneal dissection may represent the benefits of the learning curve.
bluntly under direct vision and have avoided both the complica- In the multi-institutional series of 10,053laparoscopic hernia re-
tions and the expense associated with the balloon dissector. Unique pairs by Felix et al.,23 the recurrence rates for the TAPP and the
to the laparoscopic approach for hernia repair is small bowel ob- TEP were evaluated. In this series, the mean follow-up was 36
struction. This complication has occurred nearly exclusively with months, and the overall recurrence rate was 0.4%. The cause of
the TAPP method due to adhesions at the site of peritoneal viola- recurrence was determined in each case and was attributed to one
tion, herniation through inadequately closed peritoneum, or trocar of the following reasons: inadequate lateral fixation, too small a
site herniation (Richter's hernia). mesh, missed lipoma of the cord, inadequate medial fixation to
The TEP repair without mesh fixation has shown very promis- Cooper's ligament, or herniation through a keyhole in the mesh.
ing early results. Several recent prospective studies comparing The study also demonstrated that as the surgeon gained experi-
open and laparoscopic repair have shown no statistically signifi- ence the incidence of recurrence due to either missed hernia or
cant differences in complication rates.ll,12 As with open surgery, the use of too small a mesh decreased.
the successful repair of groin hernias is associated with the expe- It becomes apparent from these studies that there has been an
rience of the surgeon and mastery of the individual technique. evolution in the technique of laparoscopic hernia repair. Early in
the development of laparoscopy, simple methods such as primary
closure of the internal ring predominated. As there developed a
Recurrences better understanding of the preperitoneal anatomy, the tech-
niques of TAPP and TEP became favored. The size of the mesh
The vast number of differing operations for the repair of groin has also changed since the beginning of laparoscopic hernior-
hernias is evidence that there is little consensus on the optimal rhaphy. Initially, a 3 by 5 cm patch was placed over the inguinal
method of repair. Since Bassini ushered in the modern era of her- defect. Today we use a much larger mesh with minimal dimen-
nia surgery more than a century ago, the recurrence rate has not sions of 12 by 15 cm, and the recurrence rates have decreased.
appreciably decreased from approximately 10%. Causes of hernia The large size of the mesh obviates the need for fixation because
recurrence include intrinsic collagen deficiency, tension of the su- the mesh is held in place by the dynamics of intraabdominal pres-
ture line, technical error, and a "missed" hernia. The laparoscopic sure against the anterior abdominal wall. 10,24 Additionally, one au-
extraperitoneal herniorrhaphy is essentially an uncompromising thor (M.EA.) has used ultrasonography to examine patients more
copy of the Stoppa repair, and it, by design, functions to avoid than 1 year after laparoscopic sutureless TEP herniorrhaphy. He
these known causes of failure. Stoppa called this anterior midline has seen no evidence of mesh migration or contraction following
approach the "giant prosthetic replacement of the visceral sac," this repair. During this period of evolution, the TAPP repair was
and it was specifically used for the repair of groin hernias when the more commonly performed procedure. Gradually, as surgeons
ordinary techniques had failed. An added advantage of the lap- became comfortable with the technique, the TEP repair emerged.
Consequently, the TEP repair enjoys an apparent lower compli- TABLE 70.1. Short-term disability provided by employer for 30 days off
work in Indiana'
cation and recurrence rate than the TAPP in many initial re-
ports. 13,17,19 Income Disablity
Category (per year) payment
Professional $80,000 $3000

Our Experience Clerical $22,500 $1500
Skilled blue collar $31,000 $2148
Our current technique is the result of a gradual evolution in the
management of inguinal hernia that dates back to 1990. The TAPP The weekly income benefit in Indiana is 60% of earnings up to $500/per
repair was the initial approach. As experience and a greater un- week. Plan is assumed to be first day of accident, eighth day of sickness
derstanding of the preperitoneal anatomy developed, the TEP re- with benefits paid to a maximum of 26 weeks.
pair was adopted as our procedure of choice. Fixation of the mesh With permission from Arregui.27
to Cooper's ligament and the transversalis fascia was used early on.
However, with wide dissection and a large mesh, fixation is not
necessary. Hernia repair is the second most common operation performed
We have successfully used the sutureless extraperitoneal hernior- by general surgeons in the United States, numbering approxi-
rhaphy to repair 203 inguinal defects. Our operative time averages mately 750,000 annually. Because of such large volume, the in-
65 minutes (40 to 105 minutes) for unilateral repair and 84 min- dustry of hernia repair has a great impact on medical economics
utes (45 to 170 minutes) for bilateral repairs. The majority of these and the workforce.
repairs are performed by Fellows under attending staff supervi- Laparoscopic hernia repair does require specialized equipment;
sion. The hernial defects ranged in size from 0.5 to 7 cm (mean however, with the increased use of laparoscopy in general surgery,
2.4 cm). This consecutive series of 203 TEP repairs had a com- this equipment is readily available. Balloon dissectors used to de-
plication rate of 6.1 %, with all complications being minor. The velop the preperitoneal space, disposable trocars, and the hernia
length of follow-up for this group ranges from 4 to 60 months stapler used to fix the mesh represent unnecessary expenses. Rou-
(mean 22 months). tine use of these instruments inflates the cost of laparoscopic her-
Hematomas or seromas accounted for two complications. In one nia repair. We have used only nondisposable instruments without
patient with a persistent bulge in the groin, the fluid was percu- the need for the balloon dissector and without mesh fixation with
taneously drained without reaccumulation. Two patients experi- excellent results. At St. Vincent Hospital in Indianapolis, the bal-
enced urinary retention requiring a single catheterization before loon dissector costs $175, the stapler costs $163, and disposable
their discharge from the surgical short stay unit. Two patients de- trocars are $93 each. 25 If three trocars are used, this adds up to a
veloped localized umbilical wound infections that resolved with- total of $617. By using reusable instruments, the cost of laparo-
out involvement of the mesh. One patient experienced transient scopic extraperitoneal repair in minimized and more closely ap-
impotence that resolved spontaneously after several weeks, and proximates that of open anterior repair.
one patient developed thrombophlebitis in the popliteal space of A number of studies have consistently shown that, following lap-
the leg. Among this group we had not realized a single case of aroscopic herniorrhaphy, patients are able to return to work
mesh migration or hernia recurrence, although we recently ex- sooner than following open repair.I 1,12,26 The cost savings related
plored a patient with a recurrent bulge in the groin following a to decreased postoperative pain and earlier return to work com-
laparoscopic TEP repair in 1993. This patient had a lipoma of the pared with the Lichtenstein procedure may in part offset the
cord that had been reduced but not excised. This large lipoma higher initial cost of the laparoscopic method. For a skilled blue-
was allowed to drop into the pelvis. Over time it migrated into the collar worker in Indiana being off work for 30 days, the cost to the
previous direct hernia defect that had been covered by the mesh. employer for short-term disability and worker replacement is about
The mesh was well incorporated, and there was no peritoneal de- $5000. The loss of income to that employee for the same period
fect. Had we obliterated the bulging defect in the transversalis fas- of time is about $1200 (Tables 70.1 and 70.2).27
cia or excised the lipoma, this would not have occurred. By not The ability to perform hernia surgery safely on an outpatient
using staples to fix the mesh, we have eliminated neurovascular basis is known to reduce costs. 28 General anesthesia, while more
complications among this group. costly than local anesthetic with intravenous sedation, does not sig-
We have used both Prolene and Mersilene mesh. Prolene is a nificantly delay discharge and is safely administered on an outpa-
more rigid material with memory that makes it easier to manipu- tient basis. The overwhelming majority of our patients were safely
late into correct position within the preperitoneal space. However, and comfortably discharged following a short stay in the recovery
it requires a 10 mm trocar for insertion. Conversely, Mersilene area.
mesh is very flexible and can readily be introduced through a 5 The overall cost effectiveness of laparoscopic hernia repair is a
mm port. Initially, we found the Mersilene more difficult to work function of operative costs, speed of recovery with return to pre-
with, but, with experience, it has become our preferred mesh be-
cause it more completely conforms to the irregular configurations
of the inguinal floor. TABLE 70.2. Employee replacement costs
Category Cost per day
Cost Considerations Clerical $105
Skilled blue collar $145
One of the deterrents to the widespread application of laparo-
scopic inguinal herniorrhaphy has been the perceived high costs. With permission from Arregui.27
operative perfonnance status, complication rate, and the long- toneal onlay mesh technique. In Arregui ME, Nagan RF (eds): Inguinal
tenn recurrence rate. Further studies to include employer, patient, hernia: advances or controversies? Oxford: Radcliffe; 1994:245-250.
and insurance costs in addition to direct medical costs are needed 9. Wegner ME, Arregui ME. Laparoscopic totally extraperitoneal herni-
to completely understand potential savings of the laparoscopic orrhaphy. Probl Gen Surg. 1995;12;2:185-90.
procedure. 10. Hollinsky C, Hollinsky KH. Static calculations for mesh fixation by in-
traabdominal pressure in laparoscopic extraperitoneal herniorrhaphy.
Surg Laparosc Endosc. 1999;9:2;106-109.
Conclusions and Recommendations 11. Payne JH, Grininger LM, Izawa MT, Podoll EF, Lindahl PJ, Balfour J.
Laparoscopic or open inguinal herniorrhaphy? A randomized prospec-
tive trial. Arch Surg. 1994;129:973-981.
The laparoscopic extraperitoneal hernia repair adheres to the 12. Liem MSL, van der GraafY, van Steensel CJ, Boelhouwer RU, Clevers
same principles as described by Stoppa. This open repair was GJ, Meijer WS, Stassen LPS, Vente JP, Weidema WF, Schrijvers AJP, van-
specifically designed for complicated or bilateral groin hernias and Vroonhoven TJMv. Comparison of conventional anterior surgery and
has been a durable and reliable method for 30 years. The crucial laparoscopic surgery for inguinal hernia repair. N Engl] Med. 1997;
aspects of the laparoscopic extraperitoneal repair are complete 336:22.
preperitoneal dissection in the correct plane, wide parietalization 13. Ramshaw BJ, Tucker JG, Mason EM, Duncan TD, Wilson JP, Angood
of the spennatic cord, and coverage of the entire myopectineal PB, Lucas GW. A comparison of transabdominal preperitoneal (TAPP)
orifice with a large piece of nonabsorbable mesh. We have also and total extraperitoneal approach (TEPA) laparoscopic herniorrha-
phies. Am Surg. 1995;61:279-283.
found it useful to ligate large direct sacs to obliterate the dead
14. Khoury N. A comparative study of laparoscopic extraperitoneal and
space and lessen the risk of a postoperative fluid collection.
transabdominal preperitoneal herniorrhaphy. ] Laparoendosc Surg.
There remains controversy regarding the laparoscopic approach 1995;5:349-355.
to hernia repair. The advantages of decreased pain and earlier re- 15. Arregui ME. Surgical anatomy of the preperitoneal fasciae and poste-
turn to nonnal activity and work have been realized in some stud- rior transversalis fasciae in the inguinal region. Hernia. 1997;1:101-110.
ies. These benefits are clear when laparoscopic herniorrhaphy is 16. Tanphiphat C, Tanprayoon T, Sangsubhan C, Chatamra K. Laparo-
compared with the open tissue repair, but they are harder to scopic vs open inguinal hernia repair. Surg Endosc. 1988;12:846-881.
demonstrate in comparison to the anterior tension-free mesh re- 17. Ramshaw BJ, Tucker JG, Conner T, Mason EM, Duncan TD, Lucas GW.
pair. The incidence of complications related to laparoscopic TEP, A comparison of the approaches to laparoscopic herniorrhaphy. Surg
including nerve entrapment and postoperative neuralgia, has Endosc. 1996;10:29-32.
18. Tetik C, Arregui ME, DulucqJL. Complications and recurrences asso-
clearly declined with increasing experience and improved under-
ciated with laparoscopic repair of groin hernias: a multi-institutional
standing of the preperitoneal anatomy. The early recurrence rates
retrospective analysis. Surg Endosc. 1994;8:1316-1323.
of the TEP repair have been very favorable. Continued follow-up 19. Phillips EH, Arregui ME, Carroll BJ, et al. Incidence of complications
will likely confirm excellent results. following laparoscopic hernioplasty. Surg Endosc. 1995;9:16-21.
20. Van Steensel CJ, Weidema WF. Laparoscopic inguinal hernia repair
without fixation of the prosthesis. In Arregui ME, Nagan RF (eds):
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Part IX
Open Techniques of
Incisional Hernia Repair
71
The Shoelace Repair
Jack Abrahamson
Introduction Anesthesia
The shoelace operation is a simple but effective darn technique The operation is done under general anesthesia. Good relaxation
for the repair of ventral incisional hernias. l It is wholly ex- allows the flat muscles to return to their normal length.
traperitoneal, involves minimal dissection, and consists of only
two suture lines, making it especially attractive for elderly or de-
bilitated patients and those with concomitant cardiac, renal, or
The Incision
other diseases. It is suitable for hernias in vertical midline or
paramedian incisions and deals adequately with defects up to ap-
A vertical elliptical incision is used to excise the old scar. In
proximately 8 cm in diameter, especially long hernias involving
obese patients with a large apron of fat hanging below the pu-
most or all of the incision. Defects of 10 cm or more in diame-
bis, panniculectomy and abdominoplasty are combined with re-
ter as well as most transverse or oblique hernias,2 and especially
pair of the hernia. More usually, the skin and fat are dissected
where there has been a loss of abdominal wall, are best repaired
off the sac of the hernia and the rectus sheath on each side. Suf-
with prosthetic mesh.
ficient anterior rectus sheath should be exposed to allow for
splitting off a medial ribbon, as well as for suturing the shoelace
layer.
Anatomy
When a vertical midline incision fails to heal postoperatively, the The New Linea Alba
flat muscles of the abdominal wall lose their midline insertion;
their tonic contraction now shortens them, pulling the rectus mus- A vertical strip 1 to 1.5 cm wide is split off the medial edge of each
cles apart and creating a biconvex gap between them (Fig. 71.1). anterior rectus sheath (Figs. 71.2 and 71.3) for construction of the
The external oblique muscle, which arise from the thoracic cage new linea alba5 as follows: (1) The edge of the hernia opening is
and is inserted in the pelvis, is relatively short and difficult to defined; (2) an incision is made in each anterior rectus sheath
stretch. Because this muscle comprises most of the anterior rectus about 1 to 1.5 cm from the edge, to confirm the presence of rec-
sheath, it is relatively difficult to return the anterior rectus sheath tus muscle; (3) the incision is extended upward and downward to
to the midline, especially in the epigastrium. On the other hand, about 2 cm beyond the limits of the defect, keeping the incision
the posterior rectus sheath is made up of the internal oblique and parallel to the midline throughout; and (4) the two strips are sewn
transversus abdominis muscles, which have their origin in the lum- together from above downward by a continuous simple over-and-
bar region and are therefore relatively longer and more easily over stitch of 0 (metric 3.5) monofilament synthetic nonab-
stretched. This makes it possible to cover even large defects in the sorbable thread such as polyamide or polypropylene as a single or
abdominal wall with the strong aponeurotic layer of the posterior loop suture, incorporating the whole width of each strip. This not
rectus sheath when reconstructing the linea alba.3,4 only creates the new linea alba but also returns the unopened sac
and its contents to the abdominal cavity (Fig. 71.4). If the sac is
opened inadvertently, it is closed with a synthetic absorbable su-
ture. There is no need to open the sac unless dealing with an emer-
The Operation gency case of strangulation with bowel obstruction or a patient
with a recent history of bowel obstruction.
The shoelace operation reconstructs a strong "new linea alba," On completion of this step, the posterior rectus sheaths and the
straightens the rectus muscles to lie side by side at the midline rectus muscles have been approximated at the midline. The rec-
once more, reconstructs the anterior rectus sheaths, and fixes tus muscles have been stretched wide and thinned, with their fibers
them to the new linea alba. running in many different directions. A sometimes alarming gap
483
484 J. Abrahamson
FIGURE71.3. Transverse section showing the slit in the rectus sheaths and
the medial ribbons. (Reprinted from Abrahamson,3 with permission.)
side through the opposite comer and slipping through the loop.
The continuous suture is now passed to and fro in front of the
rectus abdominis muscles, between the cut edges of the anterior
FIGURE 71.1. The flat muscles have lost their midline anchor so that their
tonic contractions cause them to shorten and to pull the recti muscles lat-
rectus sheaths, and through the strong new midline anchor for
erally, widening the gap between them. (Reprinted from Abrahamson,3 the whole length of the hernia in the manner of a shoelace tight-
with permission.) ening a boot (Fig. 71.6). Each bite on the rectus sheath passes ver-
tically from above down, from outside in, and from inside out at
least 2 cm from the edge so that it crosses and pulls on the fibers
remains at the lateral cut edges of the rectus sheaths (Fig. 71.5), of the rectus sheath at a right angle, thereby preventing the su-
but this is narrowed or closed by the second suture. tures from cutting out (Fig. 71.7).
The sutures should be approximately 0.5 cm apart and fairly
tense to narrow the gap considerably between the cut edges of the
The Shoelace rectus sheaths. Each suture is fixed at its midpoint by passing
through the new midline, thus preventing bow-stringing and re-
For the shoelace suture, a 6 m length of No. 0 or 1 monofilament herniation between the sutures. At the bottom end of the repair,
polyamide is used, doubled to form a loop 3 m long. Alternatively, the thread is tied with a loop-in-the-Ioop (Aberdeen) knot.
two commercially available loops can be used, each starting at one With narrow or moderately wide hernia openings, the edges of
end of the incisions in the rectus sheaths and meeting in the mid- the anterior rectus sheaths may come together with this suture line
dle of the line of repair, where they are tied one to the other. The and lie up against each other and the new linea alba to restore the
suture begins at the top end of the incision in the rectus sheaths normal anatomy of the anterior abdominal wall (Fig. 71.8). In the
from inside the sheath and passes out on that side, returning in- usual case of a larger hernia, however, a gap of a few centimeters re-
FIGURE 71.2. The anterior rectus sheaths are slit to create the medial rib- FIGURE 71.4. The medial ribbons being sutured together to form the new
bons. (Reprinted from Abrahamson,3 with permission.) linea alba midline anchor. (Reprinted from Abrahamson, 3 with permission.)
71. The Shoelace Repair 485
FIGURE 71.5. Completed first suture line with hernial sac inverted.
(Reprinted from Abrahamson,3 with permission.)
mains, with the pliable continuous to-and-fro shoelace suture ad-

justing itself to the differing widths and tensions across the fascial
defect and thus functioning for the missing anterior rectus sheaths.
The excess skin and fat are excised, a vacuum drain is placed
on either side, and each is brought out through a separate stab
incision,6 and the skin is closed.
Hernias through paramedian or more lateral vertical incisions
are repaired in a similar manner. When other incisions with her-
nias exist on either or both sides of the main hernia, as after
colostomy closure or appendectomy, these can be dealt with at the FIGURE 71.7. The shoelace suture passing to and fro between the cut edges
same operation by extending the shoelace suture laterally to dam of the anterior rectus sheaths and through the new linea alba. (Reprinted
these lateral hernias as well. 3 from Abrahamson,3 with permission.)
Incisional hernias abutting on the costal margin or pubis may
have a triangular gap where the defect reaches the skeleton so
that it is not possible to approximate the rectus muscles. This can Results
be overcome by making the medial ribbon of the anterior rectus
sheath wider in this area and elongating the slit in the rectus In the author's series of over 800 cases, there has been no post-
sheath well up onto the chest wall or down onto the pubis. This operative death. The recurrence rate is in the region of 2%. Sev-
usually produces sufficient aponeurotic coverage for the gap eral of these patients have been reoperated on 1 to 5 years after
reinforced by the shoelace suture and further darning where the repair for reasons not related to the hernia operation. A stan-
necessary. dard midline incision was used for the reoperation. The smooth
FIGURE 71.6. The monofilament shoelace suture passing between the cut
edges of the anterior rectus sheaths and through the new linea alba and
in front of the recti muscles, drawing the flat muscles back to their former FIGURE 71.8. The completed shoelace suture. (Reprinted from Abraham-
length. (Reprinted from Abrahamson,3 with permission.) son,3 with permission.)
486 ]. Abrahamson
polyamide suture was easily extracted. No bare rectus muscle was Conclusion
seen alongside the midline; the defect in the rectus sheath had
apparently been filled by collagenous connective or scar tissue. We do not agree with those who adamantly insist that all postop-
There was little or no evidence of the inverted sac. The incisions erative ventral hernias, whatever their anatomical configuration,
were closed by continuous mass closure with a polyamide suture. must be repaired with prosthetic mesh. Applying the correct op-
There was no evidence of recurrence of the hernia 5 to 10 years eration appropriate to the type of ventral incisional hernia should
after the last operation. ensure a long-term recurrence rate of 2% or less. The shoelace
operation achieves these results in the majority of cases of prop-
erly selected incisional hernia.
Discussion
With the development of modern synthetic nonabsorbable pros-
thetic material, three basic methods have emerged for the closure References
of incisional hernias: (1) resuture of the original incision, (2)
shoelace darn repair, and (3) closure with a synthetic nonab- 1. Abrahamsonj, Eldar S. "Shoelace" repair oflarge postoperative ventral
sorbable mesh prosthesis. 7 These methods should not be viewed as abdominal hernias: a simple extraperitoneal technique. Contemp Surg.
1988;32:24-34.
being mutually exclusive. Each has its place in the armamentarium
2. Abrahamson]. Treatment of a giant abdominal incisional hernia by in-
of the modern surgeon. The method chosen in any particular case traperitoneal Teflon mesh implant. Postgrad Gen Surg. 1992;4:121-125.
depends largely on the size and shape of the hernial defect. 3. Abrahamson]. Hernias. In Zinner Mj (ed): Maingot's abdominal opera-
A small defect is one in which the musculoaponeurotic edges tions, 10th ed. Stamford: Appleton & Lange; 1997:479-580.
come together to meet in the midline of the abdomen or almost 4. Abrahamson]. Epigastric, umbilical and ventral hernia. In CameronjL
do so or are separated by one or two finger widths. This type of (ed): Current surgical therapy-3. Toronto: BC Decker, Inc; 1989:417-432.
narrow defect is suitable for closure by continuous mass closure 5. Dixon CF. Repair of incisional hernia. Surg Gynecol Obstet. 1929;48:
resuture. However, rather than open the abdomen, we prefer to 700-701.
repair these narrow hernias by our shoelace technique, which is a 6. Abrahamson]. Factors and mechanisms leading to recurrence. In Ben-
quick and easy extraperitoneal method that simply returns the un- david R (ed): Prostheses and abdominal wall hernias. Austin: RG. Landes
Company; 1994:138-170.
opened sac and its contents to the abdominal cavity. Hernias with
7. Eldar S, Abrahamson]. Ventra1-incisional hernia. Tissue repair. In
a wider defect, even up to 8 cm, especially long hernias involving Schein M, Wise L (eds): Crucial controversies in surgery, vol 3. Philadel-
most or all of the incision, can be conveniently repaired by our phia:].B. Lippincott; 1999:129-137.
shoelace darn technique. 8. Abrahamson]. Factors and mechanisms leading to recurrence. Probl Gen
Still wider defects, especially where abdominal wall tissues have Surg. 1995;12:59-67.
been destroyed, are best repaired with the use of a synthetic non- 9. Abrahamson]. Etiology and pathophysiology of primary and recurrent
absorbable mesh prosthesis. groin hernia formation. Surg Clin North Am. 1998;78:953--972.
72
Closure of Chronic Abdominal Wall Defects:
The Components Separation Technique
Oscar M. Ramirez and John A. Girotto
Introduction The basic premise of this technique was to mobilize the muscle,
keeping its origin or insertion intact, and to "slide" it toward the
Incisional hernias and abdominal wall defects are frequently iat- location of the defect requiring coverage, taking advantage of the
rogenic problems that have complicated up to 11 % of abdominal muscle's intrinsic elasticity. The motor innervation and the vascu-
operations. l The ideal reconstruction of the abdominal wall would lar pedicles were kept intact. This maximized preservation of mus-
fulfill four requirements as outlined by DiBello and Moore 2: (1) cle function, particularly in ambulatory patients.
prevent visceral eventration, (2) incorporate the abdominal wall, Success with this muscle stimulated anatomy laboratory investi-
(3) provide dynamic muscle support, and (4) provide a tension- gations, looking for other muscle units amenable to this sliding
less repair. Current techniques for closure of large, chronic ab- technique. s Clinically, the principle has been logically extended
dominal wall defects all have limitations. Primary repair can have to the muscles of the abdominal wall.
a recurrence rate as high as 45%,3 whereas the use of prosthetic The first patient to be treated with the "components separation"
materials carries the risk of infection, skin erosion, and enteric fis- technique presented in 1985 at The Johns Hopkins University
tula formation. 4 Both fail to fulfill all the requirements. School of Medicine. His case is unique. A 38-year-old male
Closure of abdominal wall defects can require the transposition presented after sustaining severe blunt abdominal trauma. He suf-
of remote myocutaneous flaps or free tissue transfers. Transferred fered a retroperitoneal duodenal rupture. During his hospitaliza-
tissues are usually denervated and consequently atrophy over time. tion, he required multiple complex operative procedures,
The use of local musculofascial flaps is preferable to fascial including the internal inferiorly based pedicle rotation of the right
patches, such as tensor fasciae latae, or synthetic material for the rectus abdominis muscle to cover the duodenal anastomosis and
repair of chronic abdominal wall defects. The superiority of in- prevent recurrent fistula formation. Because of gross peritonitis
nervated muscle flaps that provide dynamic abdominal support and a prolonged operative course, Marlex® mesh was required to
has been demonstrated. The use of tissue-expanded external close the abdomen. Subsequently, granulation tissue formed and
oblique muscle flaps has also been described. 5,6 However, this re- a split-thickness skin graft was applied.
quires an additional surgical procedure and a prolonged expan- Several months later, the skin graft began to erode and show
sion phase and can be complicated by local infection, erosion, or signs of infection, with Marlex exposed. The patient was taken to
expander failure. the operating room where the skin graft and all the mesh was ex-
This discussion focuses on patients with chronic abdominal wall cised. The resulting defect measured 18 by 35 cm. Separating the
defects in whom previous techniques have failed. In 1990, Ramirez anterior abdominal wall components successfully closed the ab-
et al. 5 presented a landmark paper describing the technique for domen. The patient's wound healed without incident, and he was
separation of the abdominal wall components to close abdominal able to return to work.
wall defects. This technique is first described in anatomical dis- Since description of this original case, many reports have been
sections, and then an algorithmic approach to planned clinical represented and published about cases using the principles of "com-
construction is presented, utilizing the "components separation" ponents separation."
technique as its basis (Table 72.1). An additional 48 patients who
have undergone abdominal reconstruction following this algo-
rithm are reviewed, and their clinical course is outlined. Anatomy and Cadaver Dissections
The anatomy of the abdominal wall is well documented in nu-
History merous texts. 9 The abdominal wall is composed of multiple layers
of musculature with differently oriented muscle fibers. Centrally,
As early as 1979, the senior author (O.M.R.) broached the feasi- the rectus abdominis muscles originate from the costal margins
bility of transferring muscle units to cover defects in a "sliding" and insert on the pubis. The lateral abdominal muscles include
fashion. The first of these units was the gluteus maximus flap.7 the transversus abdominis most posteriorly, the internal oblique,
487
488 O.M. Ramirez andJ.A. Girotto
TABLE 72.1. Clinical and radiological evaluation of abdominal dominal wall between the transversus abdominis and the internal
wall components oblique muscle, finally piercing the rectus just laterally to the mid-
Are any anatomical line. The lower five intercostal nerves innervate the rectus itself.
components missing? Before clinical application of the "components separation" tech-
A
YES NO - - - - - - STEP 1: Subcutaneous elevation to pubis,
nique, the abdominal wall musculature of 10 fresh cadavers was
dissected. Our laboratory investigations in 1984 yielded important
information regarding the vasculature, innervation, and muscle-
ribs, and bilateral iliac crest. Is to-fascia relationships. Two clear planes of separation were iden-
mobilization sufficient? tified. First, the external oblique is easily separated from the
YES
~ NO
underlying internal oblique in a relatively avascular plane. Second,
the rectus muscle may be elevated without difficulty from its pos-
terior sheath. The internal oblique muscle is adherent to the un-
I
STEP 2: Incision of posterior rectus
derlying transversus abdominis muscle, and it is within this plane
that the segmental neurovascular bundles of the rectus muscle
sheath and elevation. Is mobilization travel until they perforate centrally.s The most extensive mobi-
sufficient? lization can thus be obtained when the rectus is separated from
,,/1
YES NO
its posterior sheath and the external oblique is separated from the
underlying internal oblique.
Excessive tension at the edges of the abdominal wall defects dur-
I STEP 3: Incision of external oblique

ing closure has been widely discussed and implicated in the high
failure rates of some repair techniques. Advancing the individual
components of the abdominal wall with the "components separa-
aponeurosis and elevation. Is mobilization
sufficient? tion" technique reduces the tension of the closure. Nahas et aL 10
/'1
recently presented data to support this statement. They studied 20
fresh cadavers and documented the traction force necessary to
Free Tissue - - - NO YES draw the rectus to the anatomical midline. Measurements were
Transfer, tensor taken from various points along the rectus before dissection, fol-
fasciae latae, or covered lowing elevation of the rectus from its posterior sheath and then
mesh repair required. following separation of the external from the internal oblique.
The average of the mean traction indices was compared for each
and the external oblique (Fig. 72.1). The lateral abdominal wall
muscles all become aponeurotic medially to form the anterior and
posterior rectus sheaths and fuse in the anterior midline as the
linea alba. Superior to the arcuate line, the internal oblique di-
vides in the coronal plane; the posterior lamina fuses with the
transversus abdominis aponeurosis to form the posterior rectus
sheath, while the anterior lamina fuses with the aponeurosis of the
external oblique to form the anterior rectus sheath (Fig. 72.2).
The innervation and blood supply of the components of the ab-
dominal wall travel between the layers of the internal oblique and
the transversus abdominis. Superficial and deep vascular systems
are required to supply the abdominal wall. The skin and subcuta-
neous tissues are nourished by perforators from the deeper-lying
superior and inferior epigastric arteries and independently at a
more superficial level by the superficial epigastric artery. This su-
perficial system allows the first step in the "components separa-
tion" technique: wide elevation of the subcutaneous tissues from
the underlying muscles, with division of the perforating branches
from the superior and inferior epigastric arteries.
The superior and inferior epigastric arteries form the predom-
inant circulation to the rectus abdominis muscle. This blood sup-
ply travels along the posterior aspect of the rectus but anterior to
the posterior rectus sheath. Thus, elevation of the recti from their
posterior sheaths does not disturb their blood supply. The recti
receive innervation and additional blood supply from the inter-
costal nerves and vessels.
The intercostal, subcostal, and branches of the iliohypogastric
and ilioinguinal nerves all provide motor and sensory innervation FIGURE 72.1. Anatomical depiction of the anterior abdominal wall.
to the abdominal wall. These nerves travel around the anterior ab- (Reprinted from Clemente,9 with permission.)
72. Components Separation Technique 489
FIGURE 72.2. Anterior abdominal wall in

cross section. (Reprinted from Clemente,9
with permission.)
EJ{l. obit·
::s::::,~~~~ . que mu.lcl.
tnt ob ll.
que mUlde
TrI.MYtIIJUS
ebdomlnil _
stage of the dissection. Nahas et al. 10 report a statistically signifi-

cant reduction in the traction index with increasing dissection.
Thus, separating the abdominal wall components allows closure
of the abdominal midline with significantly less resistance.
Clinical Application
Hernia repair is one of the most frequently performed procedures A
in the United States and Europe.ll Following the cadaver studies,
our work proceeded into the operating room. Our algorithmic ap-
proach to the management of chronic midline abdominal wall de-
fects is proposed and outlined in Table 72.1. The first step in
repairing large abdominal wall defects is to assess the remaining
anatomical components of the wall and determine whether any
anatomical deficits exist by reference to past medical and opera- B
tive records, in conjunction with the physical examination. Radio-
graphic studies are obtained when necessary. If large portions of
abdominal wall musculature have been resected during tumor ex-
tirpation, destroyed by sepsis or trauma, or attenuated due to mal-
nutrition or disease, adequate functional reconstruction must
replace these deficits. Such situations may require the transposi-
tion of remote myocutaneous or fascial flaps, the placement of tis-
sue expanders, or the use of synthetic mesh. If most of the c
abdominal wall components remain, reconstruction of the hernia
defect is preferably accomplished utilizing autologous, contractile
muscle by the components separation method.
We have used this technique in progressive steps depending on
the extent ofthe defect and applied it to an additional 48 patients.
After the hernia defect or fistula is defined, the first step of the
components separation procedure involves elevating the skin and
subcutaneous tissue from the underlying muscles just lateral to the
o
border of the rectus abdominis muscle (Fig. 72.3A). If previous
FIGURE 72.3. "Components separation." Step A: Wide elevation of the skin
abdominal incisions exist, such as a prior subcostal or paramedian
and subcutaneous tissue from the underlying muscle and fascia. Step B:
incision, only limited undermining is performed. If the edges of Elevation of the rectus abdominis from the posterior rectus sheath. Step
the defect cannot be approximated at this point, the rectus mus- C: Separation of the external oblique muscles from the underlying inter-
cle with its anterior sheath is elevated from the posterior sheath nal oblique muscles. Step D: Final advancement for autologous closure of
(Fig. 72.3B) . If the abdominal defect cannot be closed or tension the abdominal wall.
490 O.M. Ramirez and J.A. Girotto
on the resultant closure would be too great, the external oblique ply a buttress of Vicryl® mesh over these areas to serve as a scaf-
muscle is mobilized. An incision is made through the aponeuro- fold for collagen ingrowth. In reported cases, this technique has
sis of the external oblique just lateral to the anterior rectus sheath, been used to close defects as large as 34 by 25 cm. 2 Additional ad-
and the external oblique muscle is separated from the underlying vancement can be obtained superiorly by detaching the rectus
internal oblique muscle. The contralateral external oblique is also from the rib cage if required. 12
elevated (Fig. 72.3C). The compound flap of the rectus muscle, The first patient to be repaired with the components separation
with its attached internal oblique and transversus abdominis may technique was treated in 1985. Since then, 48 patients have un-
be advanced up to 20 cm at the midline bilaterally (Fig. 72.3D). dergone similar abdominal wall reconstructions at our institutions.
Often the abdomen appears weak lateral to the rectus once the Patient data are given in Table 72.2. In all patients, earlier attempts
relaxing incisions have been made. We have found it useful to ap- at repair with either mesh or autologous tissues had failed (Fig.
TABLE 72.2. Patient group information

Patient ID Diagnosis Procedure Complication
2-1 Bladder CA with ileal cond CS None

2-2 Colon CA with ostomy CS None
2-3 Abdominal aortic aneurysm CS None
2-4 Colon CA CS Infection
2-5 TAH with exposed mesh CS None
2-6 Pancreatic CA with exposed mesh CS None
2-7 Pancreatitis CS None
2-8 TAH with exposed mesh CS Infection
2-9 Gastric bypass for obesity CS Infection
2-10 AAA CS None
2-11 DC with exposed mesh CS None
2-12 Colon CA with exposed mesh CS None
2-13 Esophageal hernia CS None
2-14 TAH CS None
2-15 Rectal CA with ostomy CS None
2-16 Blunt trauma CS Infection
2-17 MAA CS Infection
2-18 Bladder CA with ileal conduit CS None
2-19 Colon CA with ostomy CS 3 None
2-20 Trauma with exposed mesh CS 3 None
2-21 Pancreatitis CS 3 None
2-22 Colon CA CS 3 None
2-23 DC colectomy with ostomy CS 3 None
2-24 Pancreatitis CS 3 Hernia
2-25 TAH with exposed mesh CS Infection
2-26 Esophageal hernia CS None
2-27 Colon CA CS None
2-28 Colon CA with ostomy CS with mesh None
2-29 Colon CA CS 3 None
2-30 Cholecystitis CS with mesh Infection and hernia
1-31 GSW with EC fistulas CS Infection
1-32
1-33
Crohn's with EC fistulas
Crohn's with EC fistulas
CS 3
CS 3
None
.
Fistulas
1-34 Crohn's with EC fistulas CS rotation flap Infection
1-35 GSW with EC fistulas CS+TFLX2 Infection
1-36 Nec Fas with EC fistulas CS rotation flap Fistulas
1-37 Blunt trauma with EC fistulas CS rotation flap Fistulas and infection
1-38 TAH with EC fistulas CS 3 None
3-39 Infected mesh CS 3 None
3-40 Multiple internal abscesses CS None
3-41 Colon CA postop hernia CS 3 None
3-42 Necrosis following hip surgery CS rotation flap None
3-43 TRAM defect CS None
3-44 GSW CS None
3-45 Infected mesh CS 3 None
CA, cancer.
·Successfully repaired 1 year later through a midline laparotomy with small bowel resection and fis-
tulectomy.
A B
FIGURE 72.4. (A) Anteroposterior view of a 32-year-old male with skin graft applied to bowel. Evidence of frequent infection and local tissue break-
down. (B) Postoperative view of the same patient after components separation repair.
72.4). Excluded from this discussion are patients in whom ab- repaired with sliding myoaponeurotic rectus flaps. Their reported
dominal components were lost secondary to extirpation or trauma, technique mirrors the components separation technique as orig-
patients requiring emergent closure, and patients with less than 4 inally described by Ramirez. Even without elevating the rectus from
months' follow-up. its posterior sheath, they succeeded in closing abdominal wall de-
The reviewed patients ranged in age from 31 to 80 years, with fects as large as 875 cm 2 . However, nearly half (15/35) of their pa-
a mean age of 60.5 years. Follow-up ranged from 4 to 57 months. tients were buttressed with additional synthetic mesh applied as
Thirteen patients presented with exposed mesh from failed her- an overlay to the closure. We have not found this step necessary
nia repairs (27.1 %). Eight patients had active enterocutaneous fis- in our patients. DiBello and Moore's absolute recurrence rate over
tulas at the time of repair (16.7%). One-stage surgical repair of a mean follow-up time of 22 months was 8.5% (3 of 35). They did
all patients was undertaken using the described algorithm (Fig. not report or address any mesh-related complications. Postopera-
72.5). Two patients had recurrence of their hernia (4%). Other tive wound infections occurred in only 2 of 35 patients (5.7%).
complications were infrequent and included local infection,
seroma, and recurrent fistulas. Two of the 48 patients in this se-
ries were able to undergo repeat laparotomy through their autol- Rectus-Sharing Modification for
ogous abdominal repair for intraabdominal pathology unrelated
to their initial hernia. There were no complications secondary to
Abdominal Repair in TRAM
increased intraabdominal pressures (Fig. 72.6). Cumulative com- Breast Reconstruction
plications are listed in Table 72.3.
DiBello and Moore support these data. In 1995, they reported Four women required repair of their abdominal wall following the
on a series of 35 patients with recurrent abdominal wall hernias harvest of a unilateral rectus abdominis muscle for pedicle trans-
A B
FIGURE 72.5. (A) Preoperative lateral view of the same patient depicted in Fig. 72.4. (B) Postoperative lateral view of same patient after components
separation repair.
A B
FIGURE 72.6. (A) Anteroposterior view of a 32-year-old male with skin graft applied to bowel. Evidence of frequent infection and local tissue breakdown
is apparent. (B) Postoperative view of the same patient after components separation repair.
verse rectus abdominus myocutaneous (TRAM) flap breast re- Alternative Techniques
construction. Reported abdominal wall hernia or weakness follow-
ing such procedures varies from 1 to 16%.13 The use of autologous, Primary Repair
innervated tissues is desirable for a functional reconstruction.
When the TRAM flap is elevated, based on the rectus pedicle, there Traditional approaches to the elective repair of intraoperative ab-
is a significant defect, which often requires repair (Fig. 72.7). The dominal defects or postoperative herniations fail to meet all of the
components separation can be adapted to this unique reconstruc- DiBello and Moore criteria. Primary repair prevents visceral even-
tive situation. Similarly, the rectus-sharing modification may be pri- tration and restores dynamic muscle support, but is rarely tension
marily employed when performing a pedicle TRAM, to avoid the free, and reported recurrence rates for primary repair of abdom-
postoperative complication of herniation or bulge. inal wall defects are as high as 46%.3
The remaining contralateral rectus muscle and its anterior
sheath are separated from the linea alba. The linea alba and the
umbilicus are thus left intact in the midline. The rectus abdom-
inis is then elevated from its posterior sheath as in a standard
components separation repair. The muscle is advanced over the
linea alba and its anterior sheath sutured to the remaining con-
tralateral anterior rectus sheath. If required for mobilization, re-
laxing incisions on the external oblique aponeurosis may be
made, or the external oblique may be elevated from the internal
oblique bilaterally. In our experience, these steps are rarely re-
quired. Finally, the umbilicus is brought through the now cen-
tralized rectus with a blunt muscle splitting incision (Fig. 72.8).
A central umbilicus is thus achieved with dynamic abdominal wall 2
support. 14.l 5 A clinical example of this technique is presented in
Figure 72.9.
TABLE 72.3. Complications
Complication No. Absolute Percentage
Hernia recurrence 2/48 4.1

Fistula recurrence 3/8 37.5
Wound infection 11/48 22.9
Intestinal bleed 1/ 48 2.1
Hematoma 2/48 4.1 FIGURE 72.7. Elevation of planned TRAM flap with resulting abdominal
Bowel obstruction 2.1 wall defect. 1, 2, and 3 indicate planned relaxing of incisions through the
1/ 48
Seroma 1/48 2.1 aponeuroses of the external oblique and rectus abdominis bilaterally; 4
indicates the central linea alba.
Synthetic Adjuncts
Synthetic mesh does not provide dynamic contractile support. The
rate of recurrence and complication with synthetic mesh is signifi-
cant. Reporting long-term results with the use of mesh for hernia
repair, Voyles et al. 16 documented occurrence rates for the devel-
opment of enterocutaneous fistulas and mesh extrusion to be 22%
and 78%, respectively. Karakousis et alP confirmed these conclu-
sions, documenting a 23% rate of occurrence of fistulas following
abdominal wall reconstruction with unprotected mesh. White et aI. 1S
presented a direct link between the development of wound com-
plications following ventral hernia repair and the use of mesh.
Absorbable mesh products have been reported to provide an
adequate short-term solution to abdominal wall defects. Their ab-
sorption is advantageous in that it removes the persistent foreign
body and nidus of infection. However, it has been demonstrated
both clinically and in the laboratory that recurrent herniation is
practically inevitable.19
Synthetic mesh has a clear role in the staged repair of acute ab-
FIGURE 72.S. Closure with the rectus-sharing modification of the compo- dominal wall defects. 20-23 Temporary closure with prosthetic ma-
nents separation technique. Demonstrates the central linea alba with the terials has proved beneficial in many series. 12 .24-26 Subsequently,
umbilicus centralized through the contralateral rectus (3) ; planned re-
the delayed reconstruction as described here with the components
laxing of incisions are indicated by 1, 2, and 3.
FIGURE 72.9. (A) Photograph of patient

before TRAM flap breast reconstruction.
(B) Intraoperative picture after TRAM
pedicle rotation demonstrating the rec-
tus abdominis defect. (C) Centralization
of the contralateral rectus abdominis
muscle. Incisions in the aponeurosis of
the external oblique allow for easy "slid-
ing." (D) Postoperative results. C o
separation technique can be accomplished. These early advantages Livingston et al. chose to place the expanders in a subcutaneous
may, however, be offset by the long-term complications. 16 In par- pocket, superficial to the external oblique. Expansion was ac-
ticular, repeat laparotomy may be exceedingly difficult when syn- complished over 6 weeks. Neither of the patients experienced com-
thetic mesh is incorporated in the abdominal wall.27 plications from the expansion.
More recently, Jacobsen et a1. 4 reported four patients with ab-
dominal wall defects closed with expanded abdominal wall mus-
Tissue Expansion culature. They applied their technique only to individuals with
defects greater than 20 cm 2. Expanders were placed between the
Tissue expansion is a similar method for the staged repair of large internal oblique and the transversus abdominis muscles. Expansion
abdominal wall defects and hernias, providing autologous, inner- occurred over 6 to 8 weeks, and definitive repair followed without
vated muscle. When reconstructive options are limited by the avail- significant difficulty. The authors report one recurrence in the four
ability oflocal soft tissue, mechanical tissue expansion is sometimes patients over a 5- to 36-month period. One patient required hos-
an important adjuvant therapy. Living tissues respond dynamically pitalization for the last 10 days of tissue expansion, and one patient
to mechanical stress. Selective placement of a silicone prosthesis, experienced a rupture of the expander necessitating reoperation.
which is gradually percutaneously inflated with saline over time, There were significant complications in three of their four patients.
stimulates the development of "new" soft tissue that may be used The technique of tissue expansion provides an additional
to assist in hernia closure (Fig. 72.10). This technique was origi- method for reconstruction of an abdominal wall defect. The most
nally described by Byrd and Hobar28 for use in congenital ab- significant advantage is the creation of a tension-free closure that
dominal wall defects and applied to adult patients in 1992. They reestablishes normal anatomical relationships. The technique is
reported a case of a 57-year-old man who developed an abdomi- not without complication and associated morbidity and should be
nal defect after necrotizing pancreatitis and original closure with reserved for use in patients whose traditional repair has failed.
split-thickness skin grafting. Tissue expanders were placed be-
tween the internal oblique and the transversus abdominis muscles.
Mter a 12-week expansion phase, the abdomen was closed with- Distant Tissue Transfer
out complication. Nearly simultaneously, Livingston et a1. 27 re-
ported two patients treated in a similar fashion. Both sustained The defects created by extirpation of primary and secondary tu-
severe intraabdominal trauma and were closed with skin grafting. mors or the traumatic avulsion of components of the abdominal
A B
FIGURE 72.lO. (A) Anteroposterior view of a patient following 12

weeks of abdominal wall expansion. Tissue expanders were located
between the external and internal oblique muscles. Note the ex-
posed inflation port under the left breast. This did not complicate
the expansion process. (B) Lateral view of the same patient. The
exposed expander port is still evident. (C) Intraoperative photo-
graph demonstrating a tension-free abdominal closure with ade-
quate skin and soft tissue for coverage, following use of tissue
c expanders.
wall can be too extensive to permit closure with local tissue. The from its posterior sheath as in the standard open components sep-
traditional method of managing large defects in the abdominal aration technique. If this mobilization is insufficient to close the
wall has necessitated the use ofmyocutaneous flaps. With this tech- abdominal defect, then the endoscope is employed.
nique, a large volume of muscle, fascia, and skin can be safely in- The endoscope is inserted laterally, just superior and medial to
troduced into a defect in a one-stage procedure. In addition, this the anterior superior iliac spine. Balloon dissection develops a sub-
technique introduces an additional blood supply to a region dam- cutaneous pocket to the midaxillary line. Within this pocket, ad-
aged by trauma, radiation, chemotherapy, or persistent infection. ditional trocars are placed and the external oblique is elevated from
Ger and Duboys6 have emphasized the advantages of using in- the underlying internal oblique as originally described by Ramirez. 5
nervated and vascularized myoaponeurotic flaps to repair large The contralateral side is also elevated endoscopically if further mo-
hernia defects. There have been many reported cases of free tis- bilization is required. The authors state that the skin and subcuta-
sue transfer for the purpose of reconstructing the abdominal neous tissues advance with the fascia as it is released, thus avoiding
wall. 29-33 Commonly, the tensor fasciae latae or the rectus femoris wide undermining and communication with the hernia sac.
is utilized. However, as always, the utility of these flaps or others 29 When comparing 31 patients treated with open components sep-
is limited by marked donor site cosmetic and functional morbid- aration abdominal hernia closure to 7 patients treated with the
ity. Transferred free muscle flaps are denervated and consequently endoscopically assisted modification, Lowe et al. 37 report that an
fail to provide dynamic support. open components separation technique led to a higher incidence
Disa et al. 34 have recently published their clinical experience of postoperative wound complications and dehiscence. The oper-
with the tensor fasciae latae patch reconstruction of contaminated, ative time, blood loss, and hernia recurrence rates were similar be-
tissue-deficient wounds. Thirty-two patients were presented with tween the patient groups.
an average follow-up of 27 months (range 3 to 106 months). Of
these, 9% experienced recurrent herniation. This is somewhat
higher than our data using the components separation technique, Continuing Challenges:
in which we have observed only a 4% recurrence rate. Similarly, Enterocutaneous Fistulas
they noted local wound complications (infection, seroma, and
dehiscence) in 38 % of all cases. This is higher than our reported Eight of our patients presented with chronic enterocutaneous fis-
local wound complication rate (11/48 or 22.9%). This is under- tulas. Abdominal wall dehiscence with enterocutaneous fistula is
standable, given the contaminated nature of the wounds they ad- a severe complication with high associated morbidity and mortal-
dressed. They did not comment on the incidence of fistula ity. Mortality rates have been reported to be as high as 60%.38 Man-
recurrence following tensor fasciae latae patch reconstruction. agement traditionally includes antibiotic control of sepsis, bowel
Infection following incisional hernia repair has been reported rest, parenteral nutrition, and local wound care. 39 Our eight pa-
to range from 15 to 45%.35 In 1989, Houck et al. 36 analyzed the tients followed a similar protocol. Abdominal reconstruction was
incidence of wound infection after repair of incisional hernias and undertaken using the "components separation" technique. Three
compared it with the infection rate during all other elective "clean" of eight patients (37.5%) developed recurrent enterocutaneous
operations. All repairs of hernias were performed on completely fistula. Local wound complications were more prevalent, occur-
healed incisions without clinical signs of infection. During this pering in 50% (four of eight) of these selected individuals. None,
riod, Houck et al. demonstrated by culture 13 infections in 80 elec- however, experienced recurrent herniation.
tive incisional hernia repairs (16%). This contrasted dramatically Disa et al. 34 argue in favor of utilizing a tensor fasciae latae patch
with only 14 wound infections developing in the remaining 915 to reconstruct the contaminated, tissue-deficient abdominal wall.
other "clean" procedures (1.5%). They conclude that repair of any In that series, eight patients with enterocutaneous fistulas are in-
incisional hernia has a significantly higher rate of infection than cluded. The specific outcomes of these individuals are not docu-
other clean general surgical procedures. 36 This further emphasizes mented, and there is no mention of recurrent fistula formation.
the benefits of using vascularized autologous tissue when possible. Conter et al. 40 believe that it is essential to stabilize the fistulas
The presence of increased blood flow to a region that cannot be and delay repair longer than the traditionally recommended 6
considered "clean" is a theoretical advantage over synthetic or fas- weeks. Although the surgical method of repair was not specifically
cial grafts. addressed, they have recently reported 51 cases with a recurrence
rate of only 10%.
In the data presented here, two of the three patients develop-
Endoscopic Components Separation ing recurrent fistulas underwent initial surgical repair at approx-
imately 4 weeks. One of these was successfully repaired after nearly
The advent of surgicallaparoscopy has expanded the surgical hori- 1 year. The third patient, however, was delayed for over 4 months
zons. Recently, Lowe et al. 37 described an endoscopically assisted before initial repair and still developed a recurrence.
components separation technique designed to decrease postop- Perhaps it is this subset of patients with clearly contaminated
erative wound infection and dehiscence by minimizing operative wounds who could benefit the most from endoscopically assisted
damage to the superficial vasculature of the abdominal wall. They components separation closure. Clearly, the management of pa-
report seven patients in whom the endoscope was used to facili- tients with enterocutaneous fistulas continues to be problematic.
tate lateral dissections.
The technique of Lowe et al. 37 involves the routine open re-
duction of the hernia and excision of the scar tissue and sac. Skin Summary
and subcutaneous tissues only are undermined to clear a 1 cm fas-
cial margin to avoid interruption of the deep perforators from the Iatrogenic incisional hernias and abdominal wall defects may com-
anterior surface of the rectus. The rectus muscle is then elevated plicate up to 11 % of abdominal operations. 1 Many current tech-
niques for closure of large, chronic abdominal wall defects have 16. Voyles C, RichardsonJ, Bland KI, et al. Emergency abdominal waIl re-
unacceptable recurrence rates, whereas the use of prosthetic construction with polypropylene mesh: short term benefits versus long
materials carries the risk of infection, erosion, and enteric fistula term complications. Ann Surg. 1981;194:219.
formation,4 and free tissue transfer must deal with donor site mor- 17. Karakousis C, Volpe C, Tanski J, et al. Use of a mesh for muscu-
bidity, lack of recipient vessel access, and tissue limitations. loaponeurotic defects of the abdominal wall in cancer surgery and the
risk of bowel fistulas.] Am Coll Surg. 1995;181:11.
The algorithmic approach to planned and intraoperative re-
18. White TJ, Santos MC, Thompson JS. Factors affecting wound compli-
construction presented here uses the components separation tech- cations in repair of ventral hernias. Am Surg. 1998;64(3):276-280.
nique as its foundation. This provides a compound, innervated, 19. Dayton M, Buchele B, Shirazi S. Use of an absorbable mesh to repair
and vascularized muscle flap for dynamic support of the recon- contaminated abdominal waIl defects. Arch Surg. 1986;121:954.
structed abdominal wall. The experience documented here and 20. Usher F, Fries J, Ochsner J. Marlex mesh, a new plastic material for
by others 2,5,41 suggests that this technique is a safe and effective replacing tissue defects: II. Clinical studies. Arch Surg. 1959;78: 138.
method for reconstructing the abdominal wall in patients with re- 21. McLanahan D, King L, Weems C, et al. Retrorectus prosthetic mesh
current herniation. Enterocutaneous fistulas, however, continue repair of midline abdominal hernia. Am] Surg. 1997;173:445.
to present a challenge to the surgeon. Although the components 22. Marmon L, Vinocur C, Standiford S, et al. Evaluation of absorbable
separation technique can be an effective means of repairing her- polyglycolic acid mesh as a wound support.] Pediatr Surg. 1985;20:737.
23. Gray M, Caleel R, Sorg R Soft tissue sarcoma of the anterior abdom-
niation associated with fistulas in these difficult patients, it does
inal waIl: review of reconstruction techniques. ] Am Osteopath Assoc.
not confer a significant advantage over other staged methods. 34 1996;96:48.
24. Yeh K, Saltz R, Howdieshell T. Abdominal wall reconstruction after
temporary abdominal waIl closure in trauma patients. South Med J
1996;89:497.
References 25. Sleeman D, SosaJ, Gonzalez A, et al. Reclosure of the open abdomen.
] Am Coll Surg. 1995;180:200.
l. Mudge M, Hughes I. Incisional hernia: a 10 year prospective study of 26. Gottlieb J, Engrav L, Walkinshaw M, et al. Upper abdominal wall de-
incidence and attitudes. Br] Surg. 1985;72:70. fects: immediate or staged reconstruction? Plast Reconstr Surg. 1998;
2. DiBello J, Moore J. Sliding myofascial flap of the rectus abdominis mus- 86:281.
cles for the closure of recurrent ventral hernias. Plast Reconstr Surg. 27. Livingston D, Sharma P, Glantz A. Tissue expanders for abdominal
1996;98:464. waIl reconstruction following severe trauma: technical note and case
3. George C, Ellis H. The results of incisional hernia repair: a twelve year reports.] Trauma. 1992;32:82.
review. Ann R Coll Surg EngL 1986;68:185. 28. Byrd H, Hobar P. Abdominal waIl expansion in congenital defects. Plast
4. Jacobsen W, Petty P, Bite U, et al. Massive abdominal waIl hernia re- Reconstr Surg. 1989;84:347.
construction with expanded external/internal oblique and transver- 29. Dibbell D, Mixter R, Dibbell DS. Abdominal waIl reconstruction (the
salis musculofascia. Plast Reconstr Surg. 1997;100:326. "mutton chop" flap). Plat Reconstr Surg. 1991;87:60.
5. Ramirez 0, Ruas E, Dellon A. "Components separation" method for 30. Sensoz 0, Ustuner T, Taner O. Use of a sartorius myofasciocutaneous
closure of abdominal waIl defects: an anatomic and clinical study. Plast flap for reconstruction of a large, full thickness abdominal waIl defect.
Reconstr Surg. 1990;86:519. Ann Plast Surg. 1991;25:193.
6. Ger R, Duboys E. The prevention and repair of large abdominal waIl 31. Peled I, Kaplan H, Herson M, et al. Tensor fasciae latae musculocuta-
defects by muscle transposition: a preliminary communication. Plast neous flap for abdominal wall reconstruction. AnnPlast Surg. 1983;11 :141.
Reconstr Surg. 1983;72: 170. 32. Luce E, Hyde G, Gottlieb S, et al. Total abdominal waIl reconstruction.
7. Ramirez 0, Orlando j, Hurwitz D. The sliding gluteus maximus myo- Arch Surg. 1983;118:1446.
cutaneous flap: its relevance in ambulatory patients. Plast Reconstr Surg. 33. Iwahira Y, Maruyama Y, Shiba T. One stage abdominal wall recon-
1984;74:68. struction with oblique abdominal fasciocutaneous flaps. Ann Plast Surg.
8. Ramirez OM, Granick M. The sliding myocutaneous flap method: a 1987;19:475.
method of wound repair with preservation of function. In Hinderer 34. DisalJ, Goldberg NH, CarltonJM, et al. Restoring abdominal wall in-
U (ed): Transactions of the 10th congress of the international confederation tegrity in contaminated tissue-deficient wounds using autologous fas-
of the IPRAS, vol II. Amsterdam: Elsevier; 1992. cia grafts. Plast Reconstr Surg. 1998;101(4):979-986.
9. Clemente CD. Anatomy: a regional atlas of the human body, 4th ed. Bal- 35. Sampsel J. Delayed and recurring infection in postoperative abdomi-
timore: Lippincott Williams and Wilkins; 1997:502-503. nal wounds. Am] Surg. 1976;132:316.
10. Nahas FX, IshidaJ, Gemperli R, et al. Abdominal waIl closure after se- 36. HouckJ, Rypins E, Sarfeh I, et al. Repair ofincisional hernia. Surg Gy-
lective aponeurotic incision and undermining. Ann Plast Surg. 1998; necolObstet. 1989;169:397.
41 (6):606-617. 37. Lowe J, Garza J, Bowman J, et al. Endoscopic-assisted "components
11. Morton J. Abdominal wall hernias. In Schwartz S, Shires C, Spencer F, separation" for closure of abdominal waIl defects. Plast Reconstr Surg.
et al. (eds): Principles of surgery, 4th ed. New York: McGraw Hill; 1984. 2000;105:720.
12. Fabian T, Croce M, Pritchard F, et al. Planned ventral hernia repair. 38. Schein M, Decker G. Gastrointestinal fistulas associated with large ab-
Staged management for acute ·abdominal waIl defects. Ann Surg. dominal waIl defects: experience with 43 patients. Br] Surg. 1990;77:97.
1994;219:643. 39. Sitges-Serra A, Jaurrieta E, Sitges-Creus A. A management of post op-
13. Mizgala CL, Harftrampf CR, Bennett GK Abdominal function after erative enterocutaneous fistulas: the role of parenteral nutrition and
pedicle TRAM flap surgery. Clin Plast Surg. 1994;21:255. surgery. Br] Surg. 1982;69:147.
14. Ramirez OM. The rectus-sharing technique for repair of abdominal 40. Conter RL, Roof L, Roslyn lJ. Delayed reconstructive surgery for com-
wall following rectus abdominis breast reconstruction. Plast Surg Fo- plex enterocutaneous fistulas. Am Surg. 1988;54(10):589-593.
rum. 1990;13:167. 4l. Girotto JA, Ko M, Redett R, et al. Closure of chronic abdominal waIl
15. Ramirez OM. Invited discussion: abdominal waIl closure after selective defects: a long term evaluation of the "components separation"
aponeurotic incision and undermining. Ann Plast Surg. 1998;41:613. method. Ann Plast Surg. 1999;42(4):187.
73
The Components Separation Technique
Modified for Use with Enterostomies
Sylvester M. Maas, Tammo S. de Vries Reilingh, and Robert P. Bleichrodt
Introduction border of the rectal sheath is located by palpation. In our modi-

fied technique, the skin and subcutaneous tissue are not dissected
In 1990, Ramirez, Ruas, and Dellon l described the "components free from the anterior rectus sheath. Instead, transection of the
separation" technique for closure of abdominal wall defects with- aponeurosis of the external oblique muscle is done through two
out the use of prosthetic material. Their technique is based on separate incisions, just lateral to the rectus sheath (Fig. 73.2A).
translation of the muscular layers of the abdominal wall to enlarge The wound surface is significantly reduced, and the blood supply
its pure tissue surface. The method is of particular interest in the to the skin via the musculocutaneous perforators of the epigastric
reconstruction of abdominal wall defects with contamination, be- artery is preserved (Fig. 73.1A). The external oblique muscle is
cause the results of reconstruction with prosthetic material in these bluntly separated from the internal oblique muscle. A well-vascu-
circumstances are disappointing.2-4 However, the original tech- larized compound flap is thus created that can be advanced to the
nique has three major disadvantages. midline. Existing enterostomies can be left securely in place, and
First, the skin and subcutaneous tissue must be mobilized over the creation of new enterostomies is facilitated because shifting of
a wide area in order to reach and expose the aponeurosis of the the skin in relation to the rectus muscle does not occur (Fig.
external oblique muscle, which extends far laterally into the flank. 73.2B).
This creates a large wound surface that covers the whole ventral Recently, we further modified the method by transecting the
abdominal wall from the costal margin to the pubic bone and pre- aponeurosis of the external oblique aponeurosis through two small
disposes to hematoma and seroma formation and infection. horizontal skin incisions with the help of a rigid video endoscope.
Second, mobilization of the skin and subcutaneous tissue Through a 1 cm incision in the external oblique aponeurosis a di-
endangers their blood supply, which may lead to skin necrosis in lating balloon is introduced into the space between the internal
the midline if the collateral blood supply is interrupted. If these and external oblique muscles. The balloon is inflated to expand
branches are transected, the blood supply of the skin depends solely this space. Subsequently, the aponeurosis of the external oblique
on the intercostal arteries and the superficial branches of the infe- muscle can be transected under video-endoscopic control.
rior epigastric artery in the groin (Fig. 73.1B). Interference with the
blood supply from the intercostal arteries may thus result in skin
necrosis. In a series of 32 patients, we have seen this complication Results
in one patient who had a cholecystectomy through a subcostal in-
cision some years before abdominal wall reconstruction. 6 Similar To date, the technique has been performed in seven patients with
complications were seen in several patients with generalized peri- a large abdominal wall defect. In three patients, the endoscopic
tonitis in whom the abdomen was closed by approximation of the technique was performed under clean conditions. No postopera-
skin over the viscera after mobilization of the skin and subcutaneous tive complications occurred, and no recurrent hernias have been
tissue and the creation of relaxation incisions laterally. In these pa- found thus far, after a follow-up of 12, 4, and 2 months, respec-
tients, circulatory instability may have contributed to the problem. tively (Fig. 73.3).
Third, the technique destabilizes the outer layers of the ab- In four patients, reconstruction was performed in a contami-
dominal wall, allowing shifting of the skin in relation to the un- nated field (Table 73.1).5 In one patient (I), the defect was the re-
derlying myoaponeurotic tissues. This contributes to the risk of sult of recurrent wound dehiscence after Hartmann's procedure
contamination if used in patients with an enterostomy. for obstructive rectosigmoid carcinoma. In three patients (II, III,
To combat these disadvantages we modified the technique. 5 and IV) , the defect was a result of open treatment of intraabdominal
sepsis. Before reconstruction, three patients had enterostomies: a
colostomy (I), a uretero-ileo-cutaneostomy following Bricker (II),
Operative Technique and a left-sided colostomy and ajejunostomy (III). Patients III and
IV had multiple small bowel fistulas. In all patients, the abdominal
Mter entering the abdominal cavity through a median laparotomy, wall could be closed primarily without the use of prosthetic mater-
bowel is freed from the ventral abdominal wall, and the lateral ial and without undue tension. In patients I and II the stoma func-
497
FIGURE 73.1. Modified components separation technique. (A) Longitudinal
skin incisions are made at a distance of 10 to 15 cm from the median skin
border at both sides. The external oblique muscle (1) is transected just lat-
eral to its insertion in the rectal sheath and is separated from the underly-
ing internal oblique muscle (2). (B) A compound flap is created that can
be advanced to the midline. Existing enterostomies can be left in place, and
new enterostomies can be created in a conventional manner. The skin in-
cisions can be closed primarily in most cases. (Mter Taylor et al. 7)
FIGURE 73.2. Vascular anatomy of the skin of the

anterior abdominal wall. (A) The blood supply
of the muscular layers of the abdominal wall
comes from the superior (1) and inferior (2)
epigastric arteries, together with the intercostal
arteries (3). (B) The skin of the ven tral ab-
dominal wall is supplied by the periumbilical
musculocutaneous perforators of the superior
and inferior epigastric arteries (1) and the in-
tercostal arteries (2), but also by branches of the
superficial epigastric artery (3) and the super-
MUSCLE SKIN
B ficial circumflex iliac and external pudendal ar-
A
teries (4) . (Mter Taylor et a1. 7 )
FIGURE73.3. Appearance after repositioning of ostomy and repair

by modified components separation technique.
498
73. Components Separation and Enterostomy 499
TABLE 73.1. Characteristics of the four patients in whom an abdominal wall reconstruction was performed in a contaminated environment
Age Size Follow-up

Patient (yr) Sex Diagnosis (cm X cm) (months)
64 M Hartmann procedure for rectosigmoid carcinoma. Recurrent wound dehiscence 30 X 14 24

II 64 M Cystectomy and urostomy for bladder carcinoma complicated by intraabdominal sepsis 33 X 15 24
III 45 M Anastomotic dehiscence after sigmoid resection for diverticulitis 25 X 16 12
N 30 F Crohn's disease with perforation peritonitis 28 X 14 9
tioned well after reconstruction of the abdominal wall. In patient contaminated defects of the abdominal wall. Surg Gynecol Obstet. 1993;
(III) both enterostomies were dismantled, and the continuity of the 176:18-24.
bowel was restored during the same operation. In patient IV, an end 3. Simmermacher RKJ, Bleichrodt RP, Schakenraad JM. Biomaterials for
ileostomy was created after repair of the small bowel fistulas. Mter abdominal wall reconstruction. A review. Cells Mater. 1992;2:281-290.
a median follow-up of 18 months, there was no recurrent hernia- 4. Voyles CR, Richardson JD, Bland KI, et al. Emergency abdominal wall
reconstruction with polypropylene mesh. Short term benefits versus
tion, and all enterostomies functioned well.
long term complications. Ann Surg. 1981;194:219-223.
5. Maas SM, van Engeiand M, Leeksma NG, et al. A modification of the
"components separation" technique for closure of abdominal wall de-
References fects in the presence of an enterostomy.] Am Coli Surg 1999;189(1) (in
press).
1. Ramirez OM, Ruas E, Dellon L. "Components separation" method for 6. van Engeiand M, van Goor H, Rosman C, et al. "Components separa-
closure of abdominal wall defects: an anatomic and clinical study. Plast tion" technique for the repair oflarge abdominal wall defects. In prepa-
Reconstr Surg. 1990;86(3):519-526. ration.
2. Bleichrodt RP, Simmermacher RKJ, VanderLei B, et al. Expanded poly- 7. Taylor et al. The versatile deep inferior epigastric (inferior rectus ab-
tetrafluoroethylene patch versus polypropylene mesh for the repair of dominis) flap. Br] Plast Rec Surg. 1984;37:300--350.
74
Treatment of Incisional Hernias by
an Overlapping Herniorrhaphy
and Onlay Prosthetic Implant
J.P. Chevrel
Principles of Treatment of have to be removed. In deeper positions, there is greater risk of

contact between prosthesis and viscera and consequent fistula for-
Incisional Hernias mation.
The main principle of incisional hernia repair is the reconstruc-
tion ad integrum of the abdominal wall. An incisional hernia is more
than a defect in the abdominal wall. l -4 The flat muscles of the ab-
The Dnlay Mesh Repair:
dominal wall lose their insertion in the linea alba; in consequence, Surgical Procedure
respiratory mechanics are impaired/>-7 and visceral, cutaneous,
and postural problems develop. The disinserted flat muscles re- Preparation of the Patient
tract, further widening the defect and allowing extrusion and
adhesion of the viscera within the hernial sac; the cutaneous vas- A computed tomographic scan of the abdominal wall, at rest and
culature is compressed, and lumbar lordosis develops in the ab- under increased intraabdominal pressure, allows precise determi-
sence of normal muscular control of the spinal curvature. nation of the location and extent of the incisional hernia, as well
The anatomical and physiological reconstruction of the ab- as the condition of the flat muscles of the abdominal wall and the
dominal wall involves the reconstruction of the linea alba. Wide rectus abdominis muscles. In the presence of respiratory problems,
dissection and the use of prosthetic material and biological glues pulmonary function studies, preoperative respiratory physiother-
have made this reconstruction feasible in nearly 99% of 434 cases apy, and in some cases Goni-Moreno's pneumoperitoneum9 may
operated on between June 1979 and June 1998 at the Avicenne be necessary. Preparation is the same for midline and lateral in-
Hospital, Bobigny, France. Several prosthetic materials are avail- cisional hernias.
able, and our current preference is polypropylene (Prolene®), af- A careful skin scrub is performed with Betadine provided that
ter several years' experience with polyester (Mersilene®). there is no allergy to iodine products. Trophic ulcers must be
Prostheses may be inserted in six possible sites: treated before surgery or resected initially during the operation.
Antibiotics are routinely used.
1. In the peritoneal cavity (intraperitoneal) Preoperative bowel preparation will facilitate postoperative in-
2. In the preperitoneal space (Stoppa procedure), for low mid- testinal transit and avoid abdominal distension following surgery.
line, suprapubic, or iliac fossa incisional hernias Patients are sent to the operating room with an abdominal binder,
3. In the prefascial space, posterior to rectus abdominis muscle which will be used at the end of the procedure before the patient
(Rives procedure) (underlay) wakes.
4. Sandwich-like, between two muscular layers, for lateral inci-
sional hernias (interparietal)
5. Patch-like, bridging the gap when closure is impossible (inlay) Technique
6. In the premuscular aponeurotic space (Chevrel 1979), for all
types of abdominal incisional hernias (onlay) Midline Incisional Hernias
We have been using procedure No.6 since 1970. We have found The skin incision is usually vertical for incisional hernias above the
that dissection to undermine the skin and superficial fascia over arcuate line of Douglas. For lower abdominal hernias, where a der-
the musculofascial layer, together with Gibson or Clotteau-Pre- molipectomy is proposed, a transverse incision will allow resection
mont-type relaxing incisions,4,8 allows tension-free midline clo- of a wedge of skin and subcutaneous fat and easy access to the
sure. Other advantages of the procedure are the ease with which neck of the peritoneal sac as dissection proceeds from the pe-
tension may be regulated in the prosthesis and the immediate ef- riphery to the midline. When the skin incision is vertical, it is de-
ficacy due to use of biological glue. Infections are easier to treat sirable to dissect directly above the sac; oblique subcutaneous
in a premuscular than in a retromuscular prosthesis, which may dissection can cause postoperative skin necrosis. This dissection is
500
74. Treatment of Incisional Hernias 501
carried out with the electric scalpel, staying close to the sac until
its neck is reached.
Initially, this dissection can extend quite far laterally, on occa-
sion to the midaxillary line. The undermining may reach superi-
orly as far as the lower costal cartilages and inferiorly as far as the
iliac crest and inguinal ligament. The undermining of cutaneous
flaps has a double purpose: it allows the creation of an artificial
space in which the prosthesis will be placed while facilitating the
approximation of the edges of the fascial defect by freeing the
muscles from their lateral and anterior subcutaneous adhesions,
which have a retracting effect. As these adhesions are lysed, one
can feel the edges of the defect, when tested, return closer to the
midline.
FIGURE 74.2. Suture of the overlapped fascial strips. (From Bendavid R
The sac is always resected, an easy step unless intrasaccular ad-
Prostheses and abdominal wall hernias. Austin: RG. Landes Company; 1994.)
hesions are present. Returning a sac to the abdominal cavity with
adherent contents can be a source of postoperative pain and
episodes of parttal or complete obstruction. It would appear nec-
essary therefore to free all sac contents and to lyse all adhesions. surfaces from the recti, mainly at the fibrous intersections that
This will free the greater omentum as well as intestinal loops, which cross the recti at three or four levels (Fig. 74.1A,B). Several per-
might otherwise become adherent to the abdominal wall near the forating vessels will be identified, and careful hemostasis must be
site of repair. Mter dissection, a rim of peritoneum should be avail- observed.
able for closure with slowly absorbable sutures. Opening the sac Repair of the incisional hernia can now begin. 7 The peritoneum
allows exploration of the entire linea alba by means of palpation is closed with a continuous absorbable suture. The medial edges
from its deep aspect to verify the absence of any small defects un- of the defect are trimmed, carefully avoiding resection of the me-
recognized before the operation. dial hinge formed by the anterior and posterior rectus sheaths.
For tension-free midline suture, relaxing incisions are always The medial edges of the defect are now approximated with 2-0
needed, and several techniques may be used. Regardless of the re- nonabsorbable sutures. The lateral edges of the two medial strips
pair technique used, each relaxing incision must be reinforced of rectus sheath are then rolled toward the midline, with one over-
with a premuscular (onlay) prosthesis. In our procedure, the an- lapping the other. This new linea alba is then sutured with two
terior rectus sheaths are vertically incised 2 cm from their medial rows of interrupted nonabsorbable "U" sutures (Figs. 74.1C
borders, creating two medial strips that are freed on their under- and 74.2).
This plasty is then reinforced by a prosthesis that is anchored 3
to 4 cm lateral to the medial border of the remaining rectus sheath
to avoid a lateral recurrence (Figs. 74.1D and 74.3). This pros-
thesis is anchored with 2-0 absorbable sutures because it will rely
on fibrous tissue ingrowth for proper fixation. One criticism has
been, in the past, the lack of fixation of this prosthesis near the
midline, hence inadequate buttressing in case of a sudden increase
of intraabdominal pressure. In the past 5 years we have been us-
ing a fibrin glue (Biocol®, Laboratoire Fran(:ais de Fractionnement
et Technologie; or Tissucol®, Immuno) to secure the mesh near
the suture line, allowing a safe waiting period for granulation buds
to appear. 10 As these glues do not prevent seromas postoperatively,
FIGURE 74.1. (A) Incisions on the anterior rectus sheath. (B) Approxima-
tion offascial edges and turndown of the anterior rectus sheath. (C) Over-
lap and suture of the rectus sheath flaps. (D) Reinforcement with a
nonabsorbable prosthesis, in the premusculofascial position, sutured and
glued. (From Bendavid R Prostheses and abdominal wall hernias. Austin: RG. FIGURE 74.3. Placement and suture of only prosthesis. (From Bendavid R
Landes Company; 1994.) Prostheses and abdominal wall hernias. Austin: RG. Landes Company; 1994.)
502 J.P. Chevrel
two to four suction drains may be required. With the prosthesis in Difficult Cases
place, hemostasis is carefully secured, drains are inserted, the Be-
tadine wash is renewed, and the superficial fascia is approximated Rarely, it may be impossible to close the abdominal wall defect. In
with a continuous 3-0 nonabsorbable suture. The skin is closed our series, this was the case with only two midline and two lateral
with staples, a Betadine-soaked dressing is applied, and a binder incisional hernias. Midline hernias were always sub-xiphoid: In one
is wrapped around the abdomen before the patient is awakened case the defect was covered with a lateral anterior rectus sheath
and extubated. The wound is uncovered on the fifth day only, to flap, reinforced by an onlay mesh and a spray of fibrin glue. In
avoid accidental contamination of the wound. Drains are removed the second case, as well as in the two lateral incisional hernias, a
when no drainage has occurred for 4S hours. The abdominal truss patch of polyglycolic acid was used to fill the gap, reinforced by
is maintained day and night for 2 months. The advantage of the an onlay polypropylene mesh and fibrin glue. 8
immediate use of the truss is twofold: prevention in the first hours
and days of hematoma formation, which may be a nidus for in-
fection, and support for the abdominal muscles during the first Results
few months following surgery. Recurrences are most likely to oc-
cur during this period while the abdominal wall is not yet sound FromJune 1979 to June 1995, 426 major abdominal incisional her-
because the prosthesis has not yet been infiltrated and covered by nias were treated in our service. A reinforcing prosthesis was used
granulation tissue. on 273 occasions. Of these, 143 prostheses were reinforced by a
spray of fibrin glue, 9S Prolene®, 35, Mersilene®, 10 Dexon®, and
5 Vicryl®; a double prosthesis was used in 5 cases. The remaining
130 prostheses were used following incisional herniorrhaphies
Lateral Incisional Hernias with relaxing incisions or Welti-Eudel procedures,4 where the me-
dial portions of the two rectus sheaths are rotated, after longitu-
Viscera should be widely freed from the hernial sac to allow clo- dinal incisions, to be sutured at the midline and then covered by
sure of the peritoneum. A deep layer can almost always be created the approximation of the recti.
by approximation of the transversus abdominis and internal Of the 143 operations in which our technique was used, 93%
oblique muscles. Dissection allows creation of a space between this of patients have been followed up for between 1 and 20 years. The
deep layer and the external oblique muscle. A nonabsorbable overall morbidity rate was lO.4S%. There were two hematomas
mesh is then placed in this space interparietally and reinforced (1.39%), nine seromas (6.29%), and four superficial infections
with a spray of fibrin glue. The external oblique is sutured, and a (2.79%). Septic complications resolved with local treatment; no
second mesh can eventually be added in front of it if necessary. prosthesis had to be removed. Seroma formation was more often
This "sandwich-like" technique is the procedure of choice for lat- seen in our early experience, when suction drains were not used.
eral incisional hernias (subcostal, lumbar, iliac), as well as for We found also a relationship between the volume of fibrin glue
parastomal incisional hernias. However, our procedure of creat- employed and seroma formation: It is more likely to occur with
ing overlapping flaps of the external oblique fascia can also be use of more than 2 ml of fibrin glue.
used for lateral hernia repair, as in seven subcostal incisional her- Seven recurrences have been noted (4.S9%). Five of these were
nias and four iliac hernias in our series. successfully reoperated on with the same procedure. The only de-
FIGURE 74.4. Preoperative photograph of a giant multirecurrent incisional

hernia. FIGURE 74.5. Long-term postoperative result of the repair.
74. Treatment of Incisional Hernias 503
finitive recurrences were then one in a psychiatric patient who pre- 2. Loury IN, Chevrel JP. Traitement des eventrations. Utilisation simul-
sented with a history of 15 previous interventions for incisional tanee du treillis de polyglactine 9lO et de Dacron. Nouv Presse Med.
hernia (he had an absorbable mesh implanted and resumed stren- 1983;12:2116.
uous activities within 5 weeks) and the other in a patient suffer- 3. FlamentJB, Rives]. In: ChevralJP. Surgery of the abdominal wall, 2nd
ing from a chronic pulmonary obstructive disease who had had ed. New York: Springer-Verlag, 1998.
4. Clotteau JE, Premont M. Cure des grandes eventrations cicatricielles
multiple previous interventions. The final success rate is thus
medianes par un procede de plastie aponevrotique. Chirurgie. 1979;
98.6% (Figs. 74.4 and 74.5). 105:344-346.
The overlapping herniorrhaphy and premusculofascial mesh 5. Rives J, Lardennois B, Pire JC, et al. Les grandes eventrations. Impor-
provide a reliably stable abdominal wall. The more extensive pre- tance du volet abdominal et des troubles respiratoires qui lui sont se-
musculoaponeurotic and preperitoneal dissections for simple condaires. Chirurgie. 1977;99:547-63.
herniorrhaphies without prosthetic reinforcement have not 6. Rives J, Lardennois B, Pire JC. Physiopatho1ogie des eventrations. Act
evinced such striking results. In fact, simple suture without mesh Chir 75 e Congres Fran<;ais de Chirurgie. Paris: Masson, 1974.
reinforcement resulted in a 27% recurrence rate, and prosthetic 7. Chevrel JP. Traitement des grandes eventrations medians par plastie
reinforcement without fibrin glue led to a recurrence rate. en paletot et prothese. Nouv Presse Med. 1979;8:695-696.
8. FlamentJB, PalotJP. Prostheses and major incisional hernias. In: Ben-
david R (ed). Prostheses and abdominal wall hernias. Austin: R G. Lan-
References des Company, 1994:456-71.
9. Goiii-Moreno I. Le pneumoperitoine dans la preparation preopera-
1. Chevrel JP, Flament JB. Traitement des eventrations de la paroi ab- toire des grandes eventrations. Academie de Chirurgie 1948:481.
dominale. Encycl Med Chir Paris: Techniques chururgicales apparoil digestif lO. Chevrel JP, Rath AM. The use of fibrin glue in the surgical treatment
1995;40:165. of incisional hernias. Hernia. 1997;1:9-14.
75
The Kugel Repair for Groin Hernias
Robert D. Kugel
The relatively high risk of hernia recurrence associated with pure The Procedure
tissue repairs, as reported in the literature,I,2 has prompted a sig-
nificant increase in the use of prosthetic materials in the repair of Preparation
groin hernias.1h'l In addition, greater attention is now given to
speed of recovery after surgery and the cost and simplicity of var- The surgeon may choose the method of anesthesia after consid-
ious repairs. 9 ering the advantages and disadvantages of the various options. 12
The Kugel Patch™ (Surgical Sense, Inc.) started as a simple, Local anesthesia with sedation can be quite effective but more dif-
single piece of prosthetic material and evolved over a period ficult in patients with bilateral hernias or significant obesity. Gen-
of many months. The current patch, composed of two layers eral anesthesia has the advantage of simplicity and may be
with a reinforcing outer ring, was developed to facilitate per- necessary for some patients, but it does not allow the surgeon to
formance of an essentially sutureless and tension-free groin her- test the repair at the end of the procedure by asking the patient
nia repair. The patch was later found useful in the repair of to strain or cough. Spinal anesthesia can be very effective, but the
ventral hernias as well (see Chapter 61). The result is a uniform usual muscle paralysis precludes both testing the repair and re-
system of repair that can be applied in a similar manner to both dosing. Epidural anesthesia may be the most useful. It can be very
groin and ventral hernias. short acting, or, when a catheter is left in place, the patient may
In groin hernia repairs, the patch is placed in a totally preperi- be re-dosed for more prolonged procedures.
toneal position. Placing the patch deep to the hernia defect takes Prophylactic antibiotics are not routinely given except to pa-
advantage of intraabdominal pressure and strong hydrostatic tis- tients with specific problems, such as cardiac valvular disease. 13
sue forces to secure the patch in position.lO,n The operative site is prepared with a limited shave. A wide an-
tiseptic scrub is performed, which includes the lower abdomen,
groin, and scrotum. This allows for testing of the repair under ster-
ile conditions.
The Patch
The patch is composed of two layers of a knitted monofilament Operative Technique
polypropylene mesh material bonded together by a narrow "weld"
approximately 1 cm from the outer edge (Fig. 75.1). This creates An oblique skin incision is made 2 to 3 cm above the internal ring,
a 1 cm "apron" with multiple radial slits to allow it to bend and at a point about halfway between the anterior superior iliac spine
fold and conform to irregular surfaces, such as the iliac vessels. and the pubic tubercle (Fig. 75.2). One-third of the oblique inci-
Inserted between the two layers of mesh is a single monofila- sion lies lateral to this point and two-thirds medial.
ment polyester fiber stiff enough to contribute some rigidity to the Entrance into the preperitoneal space is accomplished using a
outer portion of the patch and hold it open. The fiber is held muscle splitting technique. The external oblique aponeurosis is
tightly in place between the outer weld and a second, inner weld. opened a short distance parallel to its fibers but not through the
Just inside the inner weld are a number of small holes to allow tis- external ring. The underlying internal oblique and transversus ab-
sue apposition through both layers of the patch, thus increasing dominis muscles are bluntly separated to expose the transversalis
friction once the patch is in place. In addition, two small cuts are fascia deep to them. The muscle should be split about 5 to 10 mm
made at each of these holes in the upper (or anterior) layer of lateral to the edge of the rectus sheath, taking care to avoid in-
the patch to create a wedge-shaped tab, a sutureless anchoring jury to either the iliohypogastric or ilioinguinal nerves.
mechanism that helps to secure the patch. The transversalis fascia is opened vertically (more or less paral-
A single transverse cut is made in the middle of the upper layer lel with the inferior epigastric vessels) (Fig. 75.3). This allows en-
of the patch. This allows a finger or instrument to be inserted in trance into the preperitoneal space (Fig. 75.4). The inferior
the pocket between the layers of mesh to aid in positioning the epigastric vessels are retracted anteriorly and medially. The plane
patch in the preperitoneal space. of dissection will be posterior to the inferior epigastric vessels.
504
75. The Kugel Repair for Groin Hernias 505
FIGURE 75.3. Transversalis incision.

FIGURE 75.1. Mesh patch. (a) Outer "apron." (b) Monofilament ring. (c)
Transverse slit. (d) Tissue apposition hole and wedge-shaped tab.
Special care should be taken at this point to stay behind the in-
ferior epigastric vessels. Working bluntly along Cooper's ligament
The peritoneum is identified, and gentle traction is placed on toward the pubic bone, a direct hernia may be encountered and
it with blunt forceps. With careful dissection and steady traction should be reduced at this time. Direct hernias can usually be re-
on the peritoneum, the cord structures will eventually appear lat- duced with gentle digital manipulation, but occasionally limited
erally in the wound (Fig. 75.5). With an indirect hernia, this trac- sharp dissection may be needed under direct vision. The pseudo-
tion will deliver the hernial sac through the internal ring into the sac formed by the attenuated transversalis fascia must be com-
wound. Large redundant sacs can be excised. Large sacs that do pletely separated from the peritoneum and preperitoneal fat to
not reduce into the wound easily should be divided near the in- allow proper positioning of the patch. Cooper's ligament must be
ternal ring and the resulting peritoneal defect closed with ab- clearly visualized, and the lower edge of Cooper's ligament will
sorbable suture. need to be cleared of any filmy fibrous attachments that would
The cord structures must be teased away from the peritoneum prevent the patch from completely covering Cooper's ligament.
to a point at least 3 cm posterior and superior to the internal ring. The preperitoneal pocket is now completed by making certain
This cleavage plane should be further developed along the lateral that the pocket is large enough to receive the patch, but not too
aspect of the peritoneum to a point about 2 to 3 cm superior to large. The goal is an oval-shaped pocket just slightly larger than
the upper edge of the transversalis incision. Working anteriorly
and medially, the dissection is directed toward the pubic bone.
FIGURE 75.4. Preperitoneal view of groin and pelvic structures. (a) Infe-
rior epigastric vessels. (b) Area of internal ring. (c) Direct space (Hessel-
bach's triangle). (d) Symphysis pubis. (e) Femoral canal. (f) Iliac artery.
FIGURE 75.2. Relation of incision to anatomical structures, between the an- (g) Iliac vein. (h) Vas. (i) Location of incision made to enter the preperi-
terior superior iliac spine and the pubic tubercle (black dots). (Reprinted toneal space. (Reprinted from Am] Surg 1999; 178:298-302, with permis-
from Am] Surg 1999; 178:298-302, with permission.) sion.)
506 R.D. Kugel
FIGURE 75.5. Dissection of the cord structures from the hernial sac.
FIGURE 75.7. The area of preperitoneal dissection and its relation to im-
the patch (Figs. 75.6 and 75.7). It should extend medially and in- portant anatomical structures. (Reprinted from Am J Surg 1999; 178:298-
feriorly along Cooper's ligament to the symphysis pubis and lat- 302, with permission.)
erally and superiorly to a point about 3 cm beyond the transversalis
incision used to enter the preperitoneal space. The long axis of
the pocket will lie parallel to the inguinal ligament; it will extend along Cooper's ligament. The finger is withdrawn, and the mal-
between the peritoneum and the posterior wall of the inguinal leable retractor is eased out from under the patch; it can be in-
canal and for a short distance over the external iliac vessels. serted into the patch to complete the insertion, if needed. The
An 8 by 12 cm patch is usually adequate, although in excep- lateral edge of the patch must be tucked up under the superior
tional cases a larger patch may be required. The patch is deployed edge of the transversalis incision.
in the left groin by inserting the right index finger through the When properly placed, the patch should be completely "open"
transverse slit in the anterior layer of the patch; the left hand will (Fig. 75.10). The patch should roughly parallel the inguinalliga-
be used for a right-sided repair. One end of the patch is folded ment, with about three-fifths of the patch above the level of the
over the palmar surface of the tip of the index finger in a cone inguinal ligament and about two-fifths below. The posterior edge
shape, for insertion. A narrow malleable retractor in the wound of the patch should overlie the iliac vessels. The medial edge of
keeps the peritoneum retracted out of the way and allows the patch the patch should extend over to the symphysis pubis, and the su-
to slide in smoothly. The assistant retracts the inferior epigastric
vessels anteriorly, while the surgeon inserts the patch, using the
index finger, palmar surface up (Figs. 75.8 and 75.9). The fin-
gertip should be directed toward the pubic bone sliding gently
FIGURE 75.8. At one end of the patch both sides are folded over the index
FIGURE75.6. View of the dissected preperitoneal pocket looking toward finger for insertion into the preperitoneal pocket. The direction of inser-
Cooper's ligament and the pubis. tion is toward the symphysis pubis. (Reprinted from Am J Surg 1999; 178:
298-302, with permission.)
75. The Kugel Repair for Groin Hernias 507
may be administered. Scarpa's fascia is closed with a single suture,

and the skin edges are approximated with an absorbable subcu-
ticular suture.
Postoperative Management
Patients are asked to cough at the end of the procedure to test
the repair. They are usually discharged within 1 to 2 hours, de-
pending on the anesthetic used. Postoperative pain is controlled
with hydrocodone and acetaminophen or acetaminophen alone.
Patients are advised to be guided by their own comfort level and
are usually able to resume most of their normal activities within 3
to 7 days, including heavy lifting. The postoperative evaluation is
carried out in 1 to 2 weeks.
FIGURE 75.9. Insertion of the patch is simplified by using a malleable re-

tractor as a shoehorn.
Results
Between January 1, 1994, and May 1, 1999, 882 inguinal hernia
repairs were performed in 758 patients using the preperitoneal
patch. Of these, 785 were primary hernia repairs (89%) and 97
perolateral edge should extend 2 to 3 cm beyond the transversalis were for recurrent hernias (11 %). The mean follow-up was 35
incision. When in this position, the patch should be between the months. During this time only five recurrences have been identi-
peritoneum and the cord structures (or round ligament) as a bar- fied and none in the past 2 years (recurrence rate of 0.57%). All
rier. It will completely cover the direct space, the internal ring, five recurrences were in primary repairs. Two wound infections
and the femoral ring. required drainage of purulent material; patch removal was not
The transversalis fascia is closed with a single suture, which is required.
used to catch the anterior layer of the patch in the closure. Ad-
ditional sutures into the patch are discouraged, as this creates two-
point fixation and buckling, which will interfere with the References
hydrostatic tissue forces helping to hold the patch in place. Al-
ternatively, with a large direct hernia, one or two sutures may an- 1. RAND Corp. Conceptualization and measurement of physiologic
chor the patch to Cooper's ligament, instead of the transversalis health of adults. Santa Monica: RAND Corp Publications; 1983:15.
fascia. 2. Lichtenstein IL, Shulman AG, Amid PK. The cause, prevention, and
treatment of recurrent groin hernia. Surg Clin North Am. 1993;73:529-
The external oblique aponeurosis is closed with a simple run-
544.
ning absorbable suture. At this point, a long-acting local anesthetic
3. Barnes ]P. Inguinal hernia repair with routine use of Marlex mesh.
4. Shulman AG, Amid PK, Lichtenstein IL. The safety of mesh repair for
primary inguinal hernias: results of 3,019 operations from five diverse
surgical sources. Am] Surg. 1992;58:255-257.
5. Amid PK, Shulman AG, Lichtenstein IL. Selecting synthetic mesh for
the repair of groin hernia. Postgrad Gen Surg. 1992;4:150-155.
6. Bendavid R. Prosthetics in hernia surgery: a confirmation. Postgrad Gen
Surg. 1992;4:166-167.
7. Beets GL, van Mameren H, Go PMNYH. Long-term foreign-body re-
action to preperitoneal polypropylene mesh in the pig. Hernia. 1998;2:
153-155.
8. Bendavid R. Prosthesis and herniorrhaphies. In Kurzer M, Kark AE,
Wantz GE (eds) : Surgical management of abdominal wall hernias. London:
Martin Dunitz Ltd.; 1999:73-85.
9. Rutkow 1M, Robbins AW. 1669 mesh plug hernioplasties. Contemp Surg.
1993;43:141-147.
10. Stoppa R, Petit], Abourachid H, et al. [Original procedure of groin
hernia repair: interposition without fixation of Dacron mesh prosthe-
sis by subperitoneal median approach.] Chirurgie. 1973;99:119-123.
11. Gilbert AI. Sutureless repair of inguinal hernia. Am] Surg. 1992; 163:
331-335.
12. Amado V\CJ. Anesthesia for hernia surgery. Surg Clin North Am. 1993;
73:427-438.
13. Gilbert AI, Felton LL. Infection in inguinal hernia repair considering
FIGURE 75.10. Preperitoneal view showing proper placement of the patch. biomaterials and antibiotics. Surg Gynecol Obstet. 1993;177:126-130
(Reprinted from Am]SurgI999; 178:298-302, with permission.) [published erratum appears in Surg Gynecol Obstet. 1993;177:528].
76
Treatment of Major Incisional Hernias
Jean Bernard Flament, Jean-Pierre Palot, A. Burde, Jean-Franc;ois Delattre, and Claude Avisse
Over the past 25 years, treatment of major incisional hernias by tion of our patients into three groups: those with acceptable pul-
prosthetic methods has evolved despite criticisms motivated by monary function studies on admission; those for whom operation
the rate of postoperative infection. Our publications, along with can be contemplated after preparation for weeks or even months;
those of other authors, contributed to this evolution. 1- 5 Con- and those, finally, who must be refused surgery because of irre-
versely, other surgeons have preferred to reconsider and improve versible respiratory insufficiency.
classic methods, and nonprosthetic methods have found new In addition, in patients suffering from major, chronically exte-
advocates.6-13 riorized viscera, the risks inherent to visceral reintegration such
The moment seems ripe for a more qualified and analytic atti- as increased intraabdominal pressure and diaphragmatic immo-
tude, which we would like to attempt by reviewing our acquired bilization must not be overlooked.
experience from 388 patients with large incisional hernias. The usual respiratory disturbances due to obesity are often
masked or made to look better by the mere existence of an inci-
sional hernia. A studY; of 90 obese patients revealed an increased
Our Statistics vital capacity and residual volume/total lung capacity ratio. Treat-
ment of the hernia removes the protective effect of the large ex-
We have treated more than 800 patients since 1970. The ratio of traabdominal hernial cavity and exposes them to postoperative
female to male was 2:1, and ages ranged between 60 and 79 years. respiratory disturbances that could not be foreseen by preopera-
We have been confronted by a wide variety of situations, ranging tive testing of respiratory function. 6
from a young, muscular man to an old, heavy, bedridden woman
with strangulated hernia requiring an emergency operation.
Our statistics have revealed midline supraumbilical hernias Preparation of the Patients
(30.1%), midline infraumbilical (29.3%), both supra- and in-
fraumbilical (26.9%), subchondral (4%), inguinal (8.1 %) and in- General preparation must include the search for and treatment
cisional hernias of the flank (1.2%). of associated visceral lesions. Active cooperation of the patient is
There has been a constant progression in the number of our indispensable.
interventions. Patients come from an ever larger area, suffering Respiratory preparation includes withdrawal of tobacco, pre-
from hernias that are increasingly difficult to manage. Some pa- scription of a mucolytic agent (cyclohexyl methylammonium chlo-
tients have even been refused surgery. ride), respiratory physiotherapy, coughing and expectoration by
posturizing and pummeling, and instrumental physiotherapy us-
ing a pressure breathing apparatus, which the patient can use at
Evaluation of the Operative Risk home. One of the most important aspects of this preparation is
the excellent and universally acknowledged pneumoperitoneum
We classify our patients according to the results of pulmonary func- technique of I. Coni-Moreno.
tion studies. We pay particular attention to the minute respiratory Disinfection of skin folds and treatment of associated dermato-
volume (MRV) and to the ratio of maximum expiratory flow rate logical lesions must also be carried out. In the case of skin ulcer-
to vital capacity (MEFR/VC), comparing the results obtained with ations, primary resection and closure of the ulcerated skin may be
expected values. Blood gas determination is mandatory: The mea- advisable.
sure of partial oxygen pressure (p0 2) , CO 2 partial pressure
(pC0 2), pH, and 02 saturation allow evaluation of pulmonary
function and identification of latent respiratory insufficiencies. Anesthesia and Postoperative Care
These results must be taken into account not only after the first
examination but at regular intervals during the preoperative pul- Anesthesia is facilitated by artificial preoperative ventilation. Op-
monary preparation of our patients. These data enable classifica- erative analgesia is obtained by administration of a morphi-
508
76. Treatment of Major Incisional Hernias 509
nomimetic drug, and anesthesia is induced with a narcotic drug.

Muscle relaxation is done with a curarimimetic (pancuronium
bromide 0.07 to 0.10 mg/kg). Immediate awakening must not be
sought, and artificial ventilation must be maintained until com-
plete recovery of muscular power and respiratory function. An
active physiotherapy program must be started immediately after-
ward. Finally, postoperative analgesia must not be overlooked. Par-
ticular vigilance must be maintained to detect the first signs of
respiratory insufficiency. These may consist of changes in blood
gas determination, especially hypercapnea (elevated pC0 2) asso-
ciated with normal p02'
Surgical Procedures
Classic Methods
The classic methods of repair are based on aponeurotic or mus-
cular reconstructive surgery using the anatomical structures of the
abdominal wall. Simple suturing of the aponeurotic margins after FIGURE 76.2. Gibson's operation: The generous relaxing incisions of the
reintegration of the herniated viscera and treatment of the her- anterior rectus sheaths allow approximation without tension at the mid-
nial sac may be useful when the hernial orifice is small, such as an line.
incisional hernia subsequent to drainage of an abscess. In such
cases, relaxing incisions of the anterior surface of the recti abdo-
minis may be of help, as Gibson proposed in 1920 (Figs. 76.1 and The procedure ofWelti and Eudel (1941) is used in France for
76.2). In Italy, Trivellini et al. 14,15 have used similar procedures. midline repair and consists of making two lateral incisions (par-
Suturing by Judd's technique (1912) requires that the aponeu- allel to the midline) through the anterior rectus sheath (Fig. 76.3).
roses be solid and that the margins of the orifice be brought into The two resulting medial aponeurotic flaps are then rotated me-
apposition without difficulty. This technique is mainly applicable dially and sutured together over the midline defect. Finally, the
to the treatment of lateral incisional hernia, although it can be muscular margins of the recti abdominis are sutured medially over
used in cases of midline hernia and consists of an overlap, that is, the aponeurotic repair.
approximating the full thickness of the abdominal wall on one The various procedures described above can be used to treat
side (skin and subcutaneous tissues excluded) onto the abdomi- relatively simple incisional hernias when there is no true loss of
nal wall on the other side of the defect. This repair emulated the abdominal wall substance or a hernia caused by a sclerotic re-
Mayo "vest-over-pants" technique of umbilical hernia repair traction of the muscles. The rate of recurrence is, however, rather
(1899). discouraging. Nevertheless, nonprosthetic repair must be done in
cases where there is an obvious risk of septic contamination.
Prosthetic Repair
Foreign materials must not be used routinely for the repair of ab-
dominal wall hernias, but prostheses allow for the repair of com-
plex herniations and can be used to treat formidable lesions, often
considered beyond the scope of surgical repair.
The ideal material should be as light and as solid as possible,
with a certain degree of elasticity and suppleness. It is also im-
portant that the material be a fairly open mesh structure so that
FIGURE 76.1. Gibson's operation: Mter closure of the peritoneum, the an- FIGURE 76.3. The Welti-Eudel procedure: The anterior flaps of the rectus
terior rectus sheaths are generously incised. sheaths are sutured in one layer with the peritoneum and fascial defect.
510 ].B. Flament et al.
the connective tissue response is able to invest the prosthesis. For

these reasons, we have chosen Dacron® over the past two decades.
Position of the Prosthesis

Intraperitoneal positioning of the prosthetic material has been car-
ried out (Fig. 76.4), and we believe that intraperitoneal implan-
tation has some advantages: The peritoneum rapidly envelops the
prosthesis and offers a good defense against infection or hema-
toma formation. However, it is true that the fibroblastic invasion
of the prosthesis is accompanied by adhesions of bowel loops: We
have observed two cases of intraintestinal migration of a mesh
placed intraperitoneally (Fig. 76.5). When possible, it is best to
put the mesh on a bed of omentum rather than in direct contact
with viscera.
Premuscular positioning (Chevrel's procedure) has also been FIGURE 76.5. Complications: intraintestinal migration of a prosthetic mesh.
proposed. 2 The author's personal experience has now been ex-
tended to include over 200 patients. The first steps are similar to
the Welti-Eudel procedure and are followed by implantation of a
large Mersilene prosthesis over the denuded recti and beyond. Al- Prejascial Retromuscular Prosthesis: the Rives
though precautions must be taken when this procedure is used,
especially in cases where cutaneous cover is less than satisfactory,
Incisional Hernia Technique
its major advantage over a deeper implantation is the absence of J. Rives and his co-workers described their incisional hernia pro-
grave complications for patients with infection. cedure as early as 1973 and have published extensively on the sub-
Preperitoneal implantation has been widely used by Stoppa et ject (Fig. 76.6).4-8,13 Most French surgeons l6 and some Americans l7
al. l6 The aim of the operation is to reinforce the peritoneum. Ac- have used this technique, inspired by our original work of 1976. 9
cordingly, the abdominal wall is closed over a large prosthesis In our practice, the prosthesis is always placed deep to the rec-
placed between the wall and the peritoneum: The prosthesis en- tus muscles, on the posterior rectus sheath, or in the preperitoneal
velops and reinforces the peritoneum. A biological glue is some- space below the arcuate line of Douglas.
times used to anchor the prosthesis in place. This procedure is The peritoneal cavity must be closed before implantation of the
not mandatory because intraabdominal pressure suffices to main- prosthesis. In most cases, apposition of the peritoneal margins can
tain the prosthesis in position. be achieved when the peritoneum has been adequately and widely
freed. In the midline, the peritoneum is much thicker because it
is covered by the posterior lamina of the rectus sheath in this re-
gion. When peritoneal closure cannot be achieved, a resorbable
mesh is sutured to the circumference of the hernial orifice.
In the case of midline incisional hernias, we place the prosthe-
sis in contact with the muscle fibers in the space between the rec-
Retromuscular tus abdominis and the posterior rectus sheath. The space for
implantation may differ for the upper and lower parts of the pros-
thesis. The upper part of the prosthesis is placed between the rec-
Intraperitioneal tus abdominis anteriorly and the thorax and internal oblique
posteriorly. For infraumbilical hernias the lower part of the pros-
thesis is fixed to Cooper's ligament in order to prevent its de-
Premuscular tachment; that is, the prosthesis is implanted anterior to the
posterior rectus sheath above the arcuate line and in the preperi-
toneal space below it.
Preperitoneal
FIGURE 76.6. The Rives procedure: transverse section showing the position
FIGURE 76.4. Various possible positions of the prosthetic mesh: intraperi- of the prosthetic mesh behind the rectus muscle and in front of the pos-
toneal, preperitoneal, retromuscular, onlay. terior rectus sheath.
In cases of lateral incisional hernias, the abdominal muscles sory disturbances reported in some cases is fully erased by the
may be seen along part of the circumference of the hernial ori- satisfaction of having alleviated a major lesion (sometimes of gi-
fice only. When a subcostal hernia is present it is often necessary gantic proportions) that up to that time had often been con-
to position the upper part of the mesh beneath the diaphragm sidered impossible to repair: One to six recurrences had been
and attach it to the rib cage using transfixing costodiaphragmatic sustained by 30 patients.
sutures. In the case of inguinal incisional hernias, it is necessary Poor results were seen in 4.8% of the patients (12 of 258 cases)
to position the prosthesis so that it envelops the peritoneum and and are discussed below.
extends into the iliac fossa and pelvis. The prosthesis is sutured
above to the deep surface of the muscles and below to Cooper's
ligament or the iliac crest. The patch of mesh should extend well Complications
beyond the area of the defect (in all directions) in the preperi-
toneal space. The mortality in our series was 0.8% (2 of 258 cases). In these
The area of insertion of the prosthesis must be as large as pos- cases, the repair of the incisional hernia was a complementary pro-
sible. Accordingly, the prosthesis should extend well beyond the cedure to the main operation, that is, intestinal resection in those
myoaponeurotic hernial orifice, with the intraabdominal pressure two cases. Death by respiratory failure was not observed.
ensuring its stability. The force of abdominal pressure holds the Superficial infection (20 cases) occurred around the cutaneous
prosthesis against the deep surface of the muscles, thereby achiev- sutures (14 of 20 cases), especially when a large dermolipectomy
ing "suture by apposition" as stated by Rives et al. 7 as early as 1973. was simultaneously performed, and around peripheral sites of at-
However, this pressure-induced apposition is not sufficient to tachment of the prosthesis (6 of 20 cases). In these patients the
maintain the prosthesis properly positioned during the first few superficial infection was uneventful, with full cure achieved after
postoperative weeks, and it becomes necessary to secure periph- a few weeks of local treatment.
eral stability of the prosthetic material. Traction sutures (re- Recurrence of aseptic herniation was seen in 6.2% of our pa-
sorbable or nonresorbable) are placed through the edge (folded tients (16 of 258 cases). In six of these patients definitive repair
or not) of the mesh. Each end of the suture is passed through the was achieved by reoperation. In the other 10 cases reoperation was
abdominal wall and then through a buttonhole skin incision. In not carried out due to the minor nature of the recurrence.
cases of midline incisional hernia, the semilunar (spigelian) line During the same period, we also treated 200 patients without a
is used as the site for peripheral attachment of the prosthesis. prosthesis. One hundred twenty-one patients were operated on as
Closure of the abdominal wall musculature in front of the pros- emergencies (strangulated incisional hernia or visceral emer-
thesis is possible in most cases because of the tension-sparing ef- gency) or for elective surgery, but with a septic component to the
fect of the prosthesis. We place two closed suction drains on top procedure in the abdomen. In these patients, the mortality was
of the prosthesis, beneath the abdominal wall, and, usually, two higher (10%). We had a 14% incidence of recurrence. Seventy-six
drains in the subcutaneous space. The skin is closed with staples. percent of the patients had a good result.
These surgical procedures must obey the rules of prosthetic im- Some of these patients presented with an enormous strangu-
plantation. The risk of infection can be minimized by operating lated hernia and were bedridden, and others were cases of visceral
under conditions of scrupulous asepsis: perfect hemostasis, ab- emergency associated with a major incisional hernia. The poor re-
sence of direct manipulation of the prosthesis, the use of laminar sults in this series were seen in unprepared patients, demonstrat-
flow when available, and generous use of Betadine. ing the importance of adequate local and general preparation and
the precautions that should be taken in cases of potentially septic
lesions.
Results In 79 patients with a small hernia, we performed a Judd opera-
tion. The recurrence rate was 10%.
Our experience with modem procedures for the repair of inci-
sional hernia dates back to 1964. During this period we have ob-
served and treated more than 700 cases. Discussed below are the Comments
results of 258 major incisional hernias treated between 1987 and
1992. These cases have been selected for presentation as they con- An incisional hernia may be defined with accuracy by the dimen-
stitute a homogeneous series with respect to the type of surgical sions and characteristics of the orifice in the abdominal wall. When
procedure performed and the surgical team performing the op- the hernia has matured, after a period not exceeding 2 years, it
eration. Five full-time surgeons have used, in every case, the Rives becomes stabilized in a definitive way: A balance is reached be-
technique. tween the sclerosis around the hernial orifice and the traction of
the flat abdominal muscles. The orifice becomes circular, sur-
rounded by a dense sclerotic ring; its diameter is equal or supe-
Long-Term Results rior to 10 cm. These dimensions allow the hands to be introduced
into the abdominal cavity to study the condition of the abdomi-
Excellent long-term results were seen in 95.2% of the patients nal wall and sometimes to discover secondary orifices. These fea-
(Fig. 76.7). These favorable results were often obtained from tures are important from a practical point of view because they
the onset of treatment in a few cases (6%): the definitive result motivate the choice of a therapeutic method. The importance of
was seen after a more or less long delay due to the need for lo- the hernia protrusion and the ratio existing between the volume
cal procedures (cure of superficial infection in 20 cases) or re- of the sac and the dimension of the orifice are data that prove
operation for recurrence of aseptic hernia (in six cases). The even more important with regard to the preparations that precede
discomfort of these complementary procedures and of the sen- the surgery.
A B
.~
c o
FIGURE 76.7. Results in three patients

(A,B, C,D, and E,F) with large incisional
hernias.
E F
Anatomy Hernias Without Loss of Parietal Tissue

The Envelopes of the Hernia Hernias without loss of parietal tissue constitute a few flank her-
nias and a large number of midline hernias. In these cases, mus-
Textbooks describe incisional hernias as peritoneal sacs protected cle fibers are not destroyed. The abdominal wall retains its integrity
by a cutaneous envelope. They dwell on the frequency of peri- despite functional disturbances and retractions caused by tendi-
toneal, omental, and visceral adhesions that encumber the sac and nous detachment of these muscles from the linea alba. This loss
may complicate dissection and hinder the reintegration of the her- of substance is more apparent than real, and closure and recon-
niated viscera. However, we place more emphasis on the detection struction of the wall may be contemplated without difficulty.
of the septic foci, because infection is the main cause of failure
with these interventions.
Small chronic abscesses developing in the omentum around su- Hernias with Loss of Parietal Tissue
tures are well known and several years after an intervention may
still contain organisms. There is a long-term correlation between Hernias with loss of parietal tissue develop within the proximity
an infection following a first intervention, the incisional hernia it- of the insertions of the muscles. The peripheral segments of the
self, and the infection that may complicate the treatment of the muscular fibers, once cut, retract and atrophy. They reveal the bor-
recurrence. Thus we can say that an incisional hernia is an "off- ders of the bones and cartilages on which the fibers are inserted;
spring of a postoperative infection" and that the infection of the the orifice is then bounded by this bony or cartilaginous border:
prosthesis is its "grandchild." The loss of substance is real, and no closure can be achieved. This
Second, it is common knowledge that heat and moisture lead situation is most frequent in subumbilical hernias, almost always
to maceration within skin folds and promote chronic infections found in women who have undergone sometimes five or six gy-
that are notoriously difficult to eradicate. necological interventions. The succession of closures deteriorates
Third, we emphasize another cause of infection, namely, trophic the rectus sheath, which is the only zone of resistance under the
ulceration, occasionally seen in large hernias. It is always located arcuate line. The muscular fibers themselves suffer deterioration
over the center and at the apex of the protrusion. It results from due to sutures. All these elements imply a veritable loss of parietal
the stretching and weakening of the subcutaneous cellular tissue tissue. Destruction and deterioration may extend down to the
and the flattening of blood vessels due to pressure from the vis- groin. Similar examples may be found in the subchondral and in-
cera. Our histological data confirm the thrombosis within small guinal areas. Cases of epigastric incisional hernias observed in men
vessels. The ulceration itself may be disinfected, but culture of the must always be classified in this group because of the importance
skin always reveals the presence of dangerous residual pathogenic of the retraction.
germs about it.
Muscles Physiopathology
A midline incisional hernia is not a consequence of a disinsertion Respiratory Disturbances
of the rectus muscles: The isolated contraction of these muscles
tends to bring them closer together. The hernia is due rather to Major but Reducible and Free-Moving
the disinsertion of the lateral muscles whose fibers are inserted at Incisional Hernias
the midline and span the rectus muscles. The flat lateral muscles
become sagittate. This disinsertion of the lateral muscles leads to Major reducible hernias often derive from operations involving
retraction, atrophy, and eventually fibroadipose degeneration, as the supra- and infraumbilical regions. In these cases, we may ob-
might be expected. These data have been confirmed histologically serve the respiratory disturbances described as "abdominal flap,"
by ourselves and others. Electromyographic studies in other cen- "paradoxical abdominal respiration," and "four phase curve of res-
ters 14,15 have yielded the same results. piration" (Fig. 76.8).7 These disorders underline the inefficiency
These observations led us to consider three different levels in of the diaphragm and abdominal muscles when their contraction
the abdominal wall according to the arrangement and especially acts on an open, extended, extraabdominal cavity. The diaphragm
the length of the muscular fibers: a superior level (costochondral does not contract against the abdominal viscera, which are no
insertions) with short muscular fibers, where retraction is irre- longer retained by the muscular abdominal wall. In most cases,
versible; ,a medium level (vertebral insertions), with long fibers the respiratory disturbances are not manifest. Their interest is
where retraction is at least partially recoverable; and an inferior more theoretical than practical because these types of hernia do
level corresponding to the groin and the line of Douglas, which not expose the patient to postoperative complications.
is a weak zone.
Irreducible Exteriorized Incisional Hernias

The Orifice in the Abdominal Wall
Irreducible hernias are quite different forms due to the presence
Our definition of major incisional hernias underlines the impor- of a voluminous sac outside the abdomen whose contents consti-
tance of this orifice and its dimensions. A more detailed analysis tute a "secondary abdomen." The relation between the two ab-
of its margins leads to identification of two groups of hernias. domens depends on the size of the orifice. In these situations, the
respiratory disturbances may remain hidden, especially with obese

patients, because a new balance may have been established in the
true abdomen that has become partially emptied. Complications
may occur during reintegration or in the postoperative period.
These risks have been extensively studied by Goiii-Moreno, whose
method provides the necessary means of prevention (Fig. 76.9).
Other Disturbances: Visceral, Vascular,

Muscular, and Articular
The weakening of the abdominal belt determines other distur-
bances: The viscera and the veins, which in normal conditions
work under weak but constant abdominal pressure (6 to 12 cm
H 20, with peaks rising to 80 cm during efforts and coughing), are
placed in an atmosphere of lowered pressure. They dilate and the
physiology of their waIl is altered. For example, such disturbances
have been recorded on the bladder. It can be supposed that caval
venous return may be affected for the same reasons. Finally,
the spine loses its anterior braces, and lordosis may be observed
(Fig. 76.10).
In this experience, we gave precedence to prosthetic surgery;
the classic pure tissue repairs were reserved for high risk patients.
Prostheses were preferred when there was no patient risk of in-
fection. We sometimes resorted to them when no other solution
could be contemplated. However, we did not consider that asso-
ciated cholecystectomy (without preoperative cholangiography)
was a contraindication. In three cases we implanted a prosthesis
even when the intervention included the resection of a cutaneous
ulceration, but generally we preferred to adopt a two-stage pro-
cedure. Classic pure tissue methods of repair were used in the
worst situations, including emergencies, strangulated incisional
FIGURE 76.8. Paradoxical abdominal respiration: the four phases of respi- hernias, discovery of a nidus of infection, or associated interven-
ration, in which the diaphragm is compromised by low intraabdominal tion on the gastrointestinal tract.
pressure. This is comparable to the paradoxical respiration seen in rib
fractures.
P\
·-0
FIGURE 76.10. Sequelae of large incisional hernias. 1, Respiratory; 2, vis-

FIGURE 76.9. When an incisional hernia is large, a second abdominal cav- ceral and vascular; 3, spinal (lordosis); v, bladder; vci, inferior vena cava;
ity is created; the abdominal contents are enucleated. cr, transverse colon; P, pressure.
on rectus sheaths. Relaxation of the suture line is obvious. Re-

currence is not to be feared if those incisions do not involve the
lower part of the abdomen. Adding an absorbable mesh may re-
lieve the suture tension during the period of scar formation. This
temporary prosthesis may be inserted within the peritoneal cavity
or in an anterior position on the abdominal wall. As with pros-
thetic procedures, all seats of infection must be eradicated.
Our Present Therapeutic Indications

Prostheses must be proscribed at the smallest risk of infection, and
the surgeon must abandon their use in the course of the inter-
vention. It must be resorted to only when absolutely indispensable,
in the following circumstances:
• Peripheral incisional hernias with muscular disinsertion of in-
FIGURE 76.11. Complication: loose mesh floating in a fluid-filled cavity. guinal, subchondral, and some midline subcostochondral or
suprapubic origins
• Some midline incisional hernias, including partial destruction
Prosthetic and Nonprosthetic Surgery of the rectus abdominis as a sequela of peritonitis or multiple
laparotomies
Resorting to a Dacron-Mersilene prosthesis enabled us to obtain • Major noninfected recurrences after failure of the classic pure
unexpected results in patients who were considered to be "beyond tissue repairs. The success of prostheses is essentially due to the
the resources of surgery." The 85% rate of success is progress, even failure of nonprosthetic procedures
if problems of recurrence and infection remain. Our experience
Nonprosthetic procedures are indicated for
suggests that the prosthesis must be placed deep under the skin
and, even more important, outside the peritoneal cavity. We have • Midline primary incisional hernias without muscular destruction
observed two major complications because an intraperitoneal pros- of retraction
thesis had migrated into the digestive tract, and we think that • Flank hernias with no evidence of neurovascular compromise
inserting the prosthesis inside the peritoneum must now be pro- or deficit
hibited. We also feel that a prosthesis must be inserted with a cer- • Incisional hernias with a risk of infection, recurrences includ-
tain tension to allow the reinsertion of the lateral muscles and the ing infected foci (sutures in omentum), strangulation, septic
closure of the abdomen whenever there is no real loss of parietal cutaneous risk (emergency, lack of preparation, trophic ulcera-
tissue. If the muscles are not closed anteriorly to the prosthesis, tion), or associated septic intervention
there is a risk of postoperative diastasis and discomfort.
Recurrences should not be considered catastrophic; they can be
remedied by a local intervention, and the surgeon may be satis- Conclusion
fied to have cured the patients even if two operations were re-
quired. Postoperative infections are not due to intolerance of The treatment of major incisional hernias implies the cooperation
mesh; they result rather from local contamination due to inade- of surgeons, anesthetists, and physiotherapists. Circumspection is
quate preparation of the skin or the neglect of a septic focus dur- necessary when approaching these patients without hasty com-
ing dissection. In such circumstances, prostheses must be mitment by the surgeon as to the operability and the choice of a
proscribed (Fig. 76.11). A review of the 32 infections shows that technique. Some patients must sometimes be refused operation
this complication was almost nearly early: 22 of 32 in the first few because of respiratory dysfunction or for technical reasons. Eval-
days and 6 of 32 within the first 6 months. Only four infections uation of the patient, especially for respiratory function, pneu-
occurred very late, 6 and 8 years after. The infection might have moperitoneum, cutaneous preparation, and postoperative care,
been avoided in 17 cases: It was predictable in 11 cases for the fol- are as important as the intervention itself.
lowing reasons: associated septic interventions (3 cases), emer- The choice of the procedure, with or without prosthesis, de-
gency (2 cases), premature treatment of the hernia after a septic pends on the experience of the surgeon and must take into ac-
intervention (3 cases), and persistence of micro abscesses (3 cases). count recent technical progress. Nonprosthetic procedures
It could have been prevented in six other cases: hematoma (3 cannot treat all cases; on the other hand, a prosthesis must be
cases) and mechanical disruption of the skin (3 cases). The 15 proscribed at the least risk of infection. By resorting to these
other cases were unforeseeable complications (3) and diabetes as- techniques eclectically and prudently, nearly 90% of cases can be
sociated with obesity (8 cases). In four cases no definite explana- cured. Failures must not prevent us from keeping abreast of the
tion can be given (possibly intraoperative contamination). major advances that have been taking place over the past 20 years.
Nonprosthetic Procedures References

Nonprosthetic procedures are being reconsidered and provide in- 1. Bendavid R. Incisional parapubic hernias. Surgery. 1990;108:898-901.
contestably good results. Our poor results obtained with the Judd 2. Chevrel JP. Traitement des grandes eventrations medianes par plastie
procedure compelled us to complement it with relaxing incisions en paletot et prothese. Nouv Presse Med. 1979;8:695-696.
3. Chevrel JP, Flament JB. Les eventrations de la paroi abdominale. nate Chirurgiche Internazionali di Roma, November 29 to December
Rapprnt au 923bne Congres Fran(ais de Chirurgie, A.F.G. Paris: Masson; 3, 1992. Edizioni Minerva Medica, Torino; 1992.
1990. 1l. RivesJ, PireJC, Flament]B, et al. Le traitement des grandes eventra-
4. FlamentJB, PalotJP. Prostheses and major incisional hernias. In Ben- tions. A propos de 133 cas. Min Chir. 1977;32:749-756.
david R (ed): Prostheses and abdominal wall hernias. Austin: R.G. Landes 12. Rives J, Pire JC, Flament JB, et al. Le traitement des grandes eventra-
Company; 1994. tions. Nouvelles indications therapeutiques a propos de 322 cas.
5. Palot JP, Deiattre]F, Burde A, et al. Le traitement des grandes even- Chirurgie. 1985;3:215-225.
trations. Est Med. 1981;9:611-637. 13. RivesJ, PireJC, PalotJP, et al. Major incisional hernias. In Chevrel
6. PireJC, Body C, FlamentJB. La capacite vitale, un piege dans Ie bilan JP (ed): Surgery of the abdominal wall. Berlin: Springer-Verlag;
des grandes eventrations. Nouv Presse Med. 1977;6:364l. 1987:116-143.
7. RivesJ, Lardennois B, PireJC, et al. Les grandes eventrations. Impor- 14. Trivellini G, Danelli PG, Cortese L, et al. L'impiego di due protesi in
tance du "volet abdominal" et des troubles respiratoires qui lui sont contemporanea nella riparazione delle grosse perdite di sostanza reale
secondaires. Chirurgie. 1973;99:547-563. della parete addominale. Chirurgia. 1991;4:601--606.
8. Rives J, Pire JC, Flament JB, Conyers G. Le traitement des grandes 15. Trivellini G, Danelli PG, Puerari R, et al. II nostro orientamento nel trat-
eventrations. A propos de 133 cas. Bordeaux Med. 1976;9:2115-2119. tamento chirurgico dei laparoceli. Chir GastroenteroL 1991;25:515-526.
9. Rives J, Pire JC, Flament]B, et al. Traitement des eventrations. Encycl 16. Stoppa R, Moungar F, Verhaeghe P. Traitement chirurgical des even-
Med Chir Paris. 1977;4.0.07:40165. trations medianes sus ombilicales. J Chir. 1992;129:335-343.
10. Flament]B, Palot JP, Mosca L, et al. Considerazioni su 235 biopsie 17. Wantz GE. Incisional hernioplasty with Mersilene. Surgery. 1991;172:
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Part X
Laparoscopic Techniques of
Incisional Hernia Repair
77
Repair of Incisional Hernias and Midline Defects
Guy R. Voeller
Background pair. A 30 or 45 degree angled view telescope is essential to view

both the anterior abdominal wall and the intraabdominal con-
The use of prosthetic materials in the treatment of incisional her- tents. Both 10 and 5 mm telescopes are useful. The newer 5 mm
nias is now well established, thanks to the efforts of J. Rives et al"l telescopes have excellent light transmission and field of vision, and
R Stoppa,2 and G. Wantz,3 who introduced these techniques in this allows all working cannulas to be 5 mm in size. It is important
North America. Rives popularized the space posterior to the rectus to have atraumatic bowel graspers to reduce incarcerated in-
muscle, first used for the insertion of a nylon sheet by D. Aquaviva testines as well as sharp scissors for dissection. Needlescopic-sized
and P. Mouret4 of France in 1948 for the treatment of incisional her- instruments (2 to 3 mm) can also be very helpful.
nias. Both techniques avoid the peritoneal cavity whenever feasible. Energy sources can be monopolar, bipolar, or harmonic type.
The approaches of Rives, Stoppa, and Wantz involve a long in- Whichever source the surgeon elects to use, its use should be kept
cision with the development oflarge skin and subcutaneous tissue to a minimum. Damage to viscera occurs quickly and may not be
flaps. A plane between the rectus muscle and the posterior rectus readily appreciated when cautery is used; a missed bowel injury
sheath can be developed on both sides of the incision. The pros- carries a high mortality rate.
thesis is inserted in this plane, and "U" sutures are placed around Fixation devices are both mechanical and manual. The 5 mm
the circumference of the mesh and through the entire thickness spiral tackers (Fig. 77.1) allow strong apposition of the prosthesis
of the abdominal wall. Multiple studies have shown this technique to the peritoneum to prevent viscera from slipping in between the
to lead to very low recurrence rates. 2-4 The problem with the pro- two layers. The strongest fixation is achieved with sutures placed
cedure is that it involves extensive dissection associated with a 20% through the entire thickness of the abdominal wall and the pros-
wound complication rate requiring further surgery for many pa- thesis. We have selected the Gore CV-O suture because it is non-
tients. 5 The average hospital stay ranges from 5 to 8 days, and re- absorbable and has no memory. Polypropylene suture material is
covery requires 6 to 8 weeks. In addition, Klinge et al. 6 have shown difficult to use videoscopically because of its memory. The suture
that when polypropylene mesh is used the compliance of the ab- is passed through the abdominal wall using a suture passer devel-
dominal wall is altered to a significant degree, and many patients oped by Toy and Smoot (Fig. 77.2). It is reusable and ideally suited
complain of this restriction and discomfort. to this technique.
At the University of Tennessee, Memphis, Eugene Mangiante in- The most extensive experience to date with respect to mesh
troduced and developed the Rives-Stoppa-Wantz approach, with placed laparoscopically for incisional hernia repair is with ex-
results similar to those mentioned above. In the early 1990s we, panded polytetrafluoroethylene (ePTFE). It is well documented
along with Toy and Smoot, Gagner, Parks, and others, began place- that intraperitoneal polypropylene and polyester meshes are as-
ment of prostheses laparoscopically for repair of incisional her- sociated with extensive and dense adhesion formation, with at-
nias. It soon became apparent that stapling the mesh without tendant risks of bowel obstruction and/or bowel fistulas and great
suture fixation would displace the prosthesis into the hernia de- difficulty in case of reoperation. 7 We use DualMesh Plus®, a dou-
fect and that suture fixation through the tissues bordering the de- ble-sided mesh developed by W.L. Gore (Fig. 77.3) for safer in-
fect would be required. Over the past several years techniques, traperitoneal placement. One surface has a pore size of 3 /Lm that
prostheses, and instruments have been developed that allow the prohibits tissue ingrowth-this is placed against the viscera. The
surgeon to mimic laparoscopically the Rives-Stoppa-Wantz ap- other side, whose expanded microstructure allows tissue ingrowth,
proach to incisional hernias with suture fixation of a large pros- is placed against the peritoneal surface. The prosthesis is impreg-
thesis behind the hernia defect. nated with an antimicrobial that dissipates over about 10 days.
Equipment Patient Selection

An up-to-date three chip videoendoscopic camera is absolutely We believe that any patient with an incisional hernia that requires
necessary for performance of laparoscopic incisional hernia re- mesh placement is a candidate for laparoscopy. Hesselink et al. 8
519
520 C.R. Voeller
FIGURE 77.3. DualMesh Plus®.

FIGURE 77.1. Spiral tacker.
showed that any hernia larger than 4 cm should be repaired with protective skin drape is used to avoid contact between skin and
mesh to avoid recurrence. However, we believe that hernias smaller the prosthesis. The mesh should be treated and handled like a vas-
than 4 cm, if recurrent or if occurring in obese patients, should cular graft.
also be repaired with mesh; these are ideal hernias for the lap- Gaining access to a virgin abdomen can be done with either a
aroscopic approach. Patients with evidence of "loss of domain" are Veress needle approach or Hasson technique, as the surgeon
not candidates for laparoscopic repair. In addition, if incarcerated prefers. In the often-operated-on abdomen, however, access for
viscera cannot be safely reduced, the laparoscopic approach pneumoperitoneum and visualization is challenging, but in our
should be abandoned. The surgeon's laparoscopic experience experience it can be done safely. In several hundred repairs to
should begin with the "easier" incisional hernias, leaving the more date we have never failed to gain access nor have we ever injured
complex recurrent, incarcerated hernias until adequate skills and viscera in the process.
confidence have been acquired. Our routine approach is placement of a balloon-tipped Hasson
trocar (Origin®) at the costal margin as far lateral as possible (Fig.
77.4). This is a muscle splitting approach to the abdominal cavity.
Technique The "S"-shaped Hasson retractors are used to retract each fascial
and muscle layer as it is incised and separated. The peritoneum
If extensive dissection or lysis of adhesions will be required, a Fo- is incised, and the abdominal contents protrude; the blunt-tipped
ley catheter, nasogastric tube, and sequential compression boots Hasson can be easily inserted.
are put in place. A first-generation cephalosporin is given intra- Pneumoperitoneum is created using a 15 mm Hg pressure limit.
venously. Many patients are overweight: If one or both arms can Accessory trocar placement depends on the size and location of
be tucked at the patient's sides this should be done. Otherwise, the hernia. In the example depicted (Fig. 77.5) a 5 mm port is
draping must allow the surgeon to move above the arm boards placed to begin lysis of adhesions. A second 5 mm port can be
without compromising sterility. Trocars must be placed far later- placed to allow countertraction with a grasper. Often it is easier
ally to avoid interference with mesh and mesh fixation. An Ioban® to perform adhesiotomy with scissors while applying counterpres-
FIGURE 77.2. Suture passer. FIGURE 77.4. Hasson placement.

77. Repair of Incisional Hernias and Midline Defects 521
FIGURE 77.5. Accessory trocars. FIGURE 77.7. Hernia borders drawn on abdominal wall.
sure on the abdominal wall with the nondominant hand, espe- to be the borders of the defect (Fig. 77.6). This is done in each
cially in markedly overweight patients. It is important to operate direction so the defect can then be drawn on the abdominal wall
in the direction of the camera, and trocars should be placed (Fig. 77.7). Three to five centimeters is added in all directions to
accordingly. this diagram to determine the size of the prosthesis to use (Fig.
If adhesions or incarcerated tissues are encountered, they are 77.8). The mesh may be cut to fit if necessary. A mark across the
taken down or reduced accordingly. It must be emphasized that top of the prosthesis will allow orientation, and "X's" are made on
the perception of depth is lost laparoscopically, and lysis of adhe- the mesh and on the skin at corresponding sites. These indicate
sions should be done both carefully and methodically. Minimal the location of the initial stay sutures that will be placed to hold
use of energy is important to prevent bowel injury; it is not re- the prosthesis against the abdominal wall when they are tied (Fig.
quired if correct tissue planes are exploited. We recommend tak- 77.9) . "U" sutures are placed at each "X" on the prosthesis and
ing down all adhesions to assess every potential defect needing tied, leaving the suture tails long enough to tie again once the
coverage to prevent future hernia development. If adhesiotomy or mesh is placed intraperitoneally. The tails should be held together
visceral reduction cannot be done safely, the procedure should be with a hemoclip and one tail left longer than the other; this will
abandoned. We have on occasion made a small incision to safely facilitate grasping the sutures with the suture passer (Fig. 77.10).
reduce incarcerated viscera, closed this limited skin incision, and For smaller patches, four stay sutures will suffice, whereas larger
continued with the laparoscopic procedure. patches will require five or six stay sutures. Any more than this we
The next step is to determine the borders of the fascial defect find cumbersome once the mesh is placed intraperitoneally.
so it can be drawn on the skin . This is a very critical step because The mesh is then rolled. Two opposite edges are rolled toward
it determines the correct positioning of the mesh. If the fascial the middle, as the mesh will be difficult to unfurl if it is rolled con-
borders can be palpated preoperatively, they should be drawn on tinuously from one side to the other (Fig. 77.11). Smaller pieces
the skin at this time. If not, a spinal needle can be passed during of mesh can be placed through the Hasson cannula directly, but
surgery through the abdominal wall at what the surgeon believes most pieces will require removal of the balloon-tipped Hasson. A
FIGURE 77.6. Spinal needle. FIGURE 77.8. Mesh size.

522 C.R. Voeller
FIGURE 77.9. Marking mesh. FIGURE 77.11. Mesh rolled.
grasper is placed opposite the Hasson port and then directed out this step will require placement of two additional 5 mm ports op-
through the Hasson cannula. The Hasson port is removed by de- posite the initially placed cannulas. One port is for the 5 mm tele-
flating the balloon, which allows the pneumoperitoneum to evac- scope and the other for the tacker. Counterpressure on the
uate. This leaves the tip of the grasper protruding through the abdominal wall is critical for firm, accurate tacking (Fig. 77.13) .
fascial defect of the Hasson port. The mesh is placed in the tip of The mesh should be stretched tightly so that when the pneu-
the grasper and then drawn into the abdominal cavity. Once the moperitoneum is evacuated there is a tension-free repair without
mesh is entirely in the abdominal cavity, the Hasson is reinserted protrusion of the mesh into the hernia defect. After tacking is com-
and pneumoperitoneum is reestablished. Two graspers are used plete, skin punctures are made at 5 to 7 cm intervals at the perime-
to unfurl the mesh and position the sutures. Turning the angled ter of the mesh. The suture passer is then used to place additional
telescope to look down on the viscera and mesh facilitates this sutures at these points, as in the Rives-type repair (Fig. 77.14).
maneuver. These sutures prevent slippage of the mesh and subsequent re-
Small skin punctures are then made at each "X" marked on the current hernia. Drains are not used, and all 10 mm fascial defects
skin. The Gore suture passer is used to puncture through the ab- are closed (Figs. 77.15 and 77.16).
dominal wall, and each suture pair is pulled out in succession. One
suture of a pair is pulled out and then the other. These sutures
come out through the same skin puncture, but the suture passer Results
is redirected to allow a fascial bridge of at least 1 cm between su-
tures. The sutures are then tied with the knots in the subcutaneous To date, the largest study of laparoscopic incisional hernia repair
tissues. This anchors the mesh to the entire thickness of the ab- using ePTFE mesh is a prospective study originated by Toy et al. 9
dominal wall (Fig. 77.12). at 12 study sites. The preliminary data were published in 1998 and
The 5 mm spiral tacker is then used to tack the mesh to the consisted of 144 patients. In total, 200 patients have been enrolled,
peritoneal surface around the circumference of the mesh. Because and 5-year data will be available soon. All types of incisional her-
the surgeon must tack in the same direction as the camera view, nias were repaired, with the majority being incisional (92) , epi-
FIGURE 77.10. Sutures in mesh. FIGURE 77.12. Sutures through abdominal wall.
77. Repair of Incisional Hernias and Midline Defects 523
FIGURE 77.15. Final result.

FIGURE 77.13. Tacking the mesh.
gastric (11), and umbilical (23). Thirty-eight of the hernias were Even the old subcutaneous space, after removal of the peritoneal
recurrent. The mean defect size was 98 cm 2, and the mean patch sac, can be a dead space where a seroma can form. It can be left
size was 215 cm 2. The mean operating time was 2 hours, and the to resolve on its own or, if bothersome, we have aspirated many
mean hospital stay was 2.3 days. Several of the investigators in the seromas without infection of the mesh. Among others, we have
study were from Canada, where patients are hospitalized longer had occasion to reoperate laparoscopically on study patients ei-
than in the United States. The hospital stay for our patients in this ther for a recurrence or for some other reason (cholecystectomy,
study was a little less than 1 day, and return to work occurred at appendectomy). It has been found that there are adhesions to the
16 days, on average. The mean follow-up at the time of the pub- ePTFE patch, but they are very filmy and easily taken down. They
lication in 1998 was 222 days, and the recurrence rate was 4%. are not at all like the dense, tenacious adhesions seen with
The mechanisms of recurrence varied according to the type of polypropylene (Fig. 77.17) .
defect, but a common theme was inadequate suture fixation. The Several studies 10-12 have compared laparoscopic with open in-
recurrences were mainly in people with occupations that involved cisional repair in a retrospective fashion . It is important to note
heavy lifting, and a corner of the mesh would pull loose where tis- that in most ofthese, the open approach studied was not the Rives-
sue quality was poor and/ or suture fixation not adequate. It is crit- Stoppa-Wantz approach, which is the best open technique with re-
ical that suture fixation be done at 5 to 7 cm or even more frequent spect to recurrence rates. In each study, the hernias were similarly
intervals with large defects. Such recurrences can be repaired lap- large in both groups, but hospitalization, complications, and costs
aroscopically in most situations. were all lower in the laparoscopic groups. In addition, the lap-
There were two infections that required patch removal and 23 aroscopic groups involved more patients with failed open hernia
clinically evident seromas, all of which resolved. The meshes that repairs. The recurrence rates in the laparoscopic groups were uni-
required removal due to infection were removed by open surgery. versally less than those of the open groups. Voeller et al. 13 pre-
These hernias were repaired months later. All patients will have sented a retrospective review of approximately 400 laparoscopic
some degree of seroma formation if the sac is left subcutaneously, incisional hernia repairs at the American College of Surgeons
regardless of whether it is connected to the main peritoneum. Meeting in October 1999. The findings in these 400 patients were
FIGURE 77.14. Additional sutures. FIGURE 77.16. Final result.

524 G.R. Voeller
the operation be converted at once to an open procedure to avoid

catastrophe. We do not recommend placing the mesh if the pa-
tient is opened for bowel repair. We simply repair or resect the
bowel and come back later to do a laparoscopic hernia repair. We
have placed DualMesh at the same time as the repair of small bowel
enterotomies as long as the contamination was minimal. These
few patients have done well, but we emphatically do not recom-
mend this unless the contamination is minimal, involving only the
small bowel. The surgeon must be comfortable with laparoscopic
suturing.
Preliminary evaluation shows laparoscopic incisional hernia re-
pair to be a safe technique that replicates a time-tested open re-
pair. Short-term recurrence rates are favorable and complication
rates lower than those for open incisional herniorrhaphy. The
main disadvantage is that like any advanced procedure it takes
time to master. The cosmesis is quite good. If there is a large
FIGURE 77.17. Adhesions to mesh.
amount of redundant skin, it may be necessary to excise this at a
later date. To date we have not had to do this because, once the
pressure of the viscera is removed, this tissue "regains" some of its
original form. We cannot reapproximate the midline as on occa-
very similar to the multicenter results described by Toy et al. 9 Typ- sion can be done with the open approach, but this has not been
ically, the patients were obese; 120 had recurrent hernias with an a major drawback to date.
average of 2 failed open repairs. The mean defect size was 99 cm 2,
and the average mesh size was 284 cm 2. Length of stay averaged
1.8 days. There were three conversions to open repair and 34 com- References
plications, the most major of which were three mesh infections,
two recognized enterotomies, and one unrecognized bowel injury. 1. Rives j, Pire jC, Flament jB, Convers G. Traitement des eventration.
There were no deaths and 10 recurrences (3.5%), with an aver- Mineroa Chir. 1977;32(11):749-756.
age follow-up of more than 18 months. 2. Stoppa RE. The treatment of complicated groin and incisional her-
The laparoscopic technique for incisional hernia repair can be nias. World] Surg. 1989;13:545-554.
3. Wantz GE. Incisional hernioplasty with Mersilene. Surg Gynecol Obstet.
applied to lumbar hernias 14 and parastomal hernias. The Sugar-
1991;172:129-137.
baker 15 technique for paras to mal hernia is ideal for the laparo- 4. Aquaviva DE, Mouret P. Cure des eventrations par plaques de nylon.
scopic approach. This technique (originally described for open Presse Med. 1948;73:892.
repair) utilizes mesh repair of the hernia, but no keyhole or slit 5. Sampsel J. Delayed and recurring infection in postoperative abdomi-
is cut in the mesh. The mesh is placed as described above with su- nal wounds. Am] Surg. 1976;132:316.
ture fixation, and the bowel of the ostomy is simply brought be- 6. Klinge U, Muller M, Brucker C, et al. Application of three dimensional
tween the mesh and the abdominal wall, with the mesh fixed on stereography to assess abdominal wall mobility. Hernia. 1998;2:11.
either side of the width of the bowel. Sugarbaker had no recur- 7. Hooker G. Taylor B, Driman D. Prevention of adhesion fonnation with
rences in seven open repairs over a 4- to 7-year follow-up. use of sodium hyaluronate-a randomized controlled study. Surgery.
1999;2:211-216.
The very high epigastric hernia and the very low suprapubic her-
8. Hesselink V], Luijendijk RW, de WiltjHW, et al. An evaluation of risk
nia can be difficult due to the absence of fascia for suture fixa-
factors in incisional hernia recurrence. Surg Gynecol Obstet. 1993;176:
tion. In lower hernias, Cooper's ligament must be identified and 228-234.
the prosthesis sutured to it. High epigastric or subcostal hernias 9. Toy FK, Bailey RW, Carey S, et al. Multicenter prospective study of lap-
may require suturing between ribs or to cartilage or bone. aroscopic ventral hernioplasty: preliminary results. Surg Endosc. 1998;
Finally, although wound and other complications are less com- 12(7);955-959.
mon with the laparoscopic approach, a missed bowel injury has 10. Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia
proved fatal in several cases. We have been contacted regarding repair: a comparison study. Surgery. 1998;124:816-822.
several cases in which enterotomies were not identified; the initial 11. Ramshaw Bj, Schwab j, Mason EM, et al. Comparison of laparoscopic
signs are so subtle on the first postoperative day that, while the pa- and open ventral herniorrhaphy. Am Surg. 1999;65(9):827-831.
12. Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral and
tient is "not right," he is not obviously extremely ill. On the night
incisional hernioplasty. Surg Endosc. 1997; 11 :32-35.
of the first postoperative day, however, or by the morning of the
13. Voeller GR, Park A, Ramshaw B, et al. Laparoscopic repair of ventral
second postoperative day, the patient becomes markedly ill, but hernias. Am Coli Surg. 1999;3.
by this time it is too late and the patient usually succumbs to sep- 14. Heniford BT, Iannitti DA, Gagner MG. Laparoscopic inferior and su-
sis. While a recognized enterotomy can be repaired laparoscopi- perior lumbar hernia repair. Arch Surg. 1997;132:1141-1144.
cally, it is critical in any situation where the bowel cannot be safely 15. Sugarbaker PH. Peritoneal approach to prosthetic mesh repair of
reduced, or the surgeon suspects an accidental enterotomy, that paraostomy hernias. Ann Surg. 1985;201:344-346.
Part XI
78
J.P. Chevre1
The loss of abdominal wall substance can be observed in particu- or with secondary conditions such as stress ulcers or intestinal
lar circumstances, fortunately rare, and can be classified into three necrosis. There is no major impediment to laparotomy through a
main categories: recent bum of the abdominal wall. The problem becomes more
difficult when the bum is no longer recent but has become in-
1. Pathological: loss of substance secondary to open trauma or ab-
fected; the abdominal closure will be less than ideal and presents
dominal wall infections
a major risk of burst abdomen, which may justify recourse to lap-
2. Therapeutic: loss of substance secondary to tumor resection
arostomy, as is discussed in the section on treatment.
3. Iatrogenic: loss of substance as can be seen in postoperative
burst abdomen
Parietal Infections
Pathological Causes
Postoperative Gas Gangrene
Shotgun Injuries
Gas gangrene generally complicates surgery on contaminated vis-
Shotgun injuries are due to hunting rifles fired at relatively close cera; in descending order of incidence the surgeries may be small
range. The lead pellets are high speed projectiles whose spherical bowel surgery (for occlusion, perforation, or necrosis), appen-
shape accounts for the sudden deceleration on skin contact with dectomy, colorectal surgery, surgery for bleeding gastroduodenal
a near total loss of kinetic energy. This leads to complex criss- ulcers, and hysterectomy for infected cancer of the cervix.
crossing of the shock waves of multiple projectiles and extensive
tissue destruction. To this ballistic tearing mechanism must be
added the presence of foreign matter: lead shot and fragments of Traumatic Gangrene
cartridge components and clothing. These projectiles can cross
the abdominal cavity and lacerate viscera, particularly the colon, More rarely, gangrenous abdominal wall may arise from an un-
causing fecal contamination. The latter can lead to the develop- recognized visceral insult, spreading from lesions in deep-seated
ment of parietal gangrene. Shotgun wounds are always poorly de- structures such as the extraperitoneal rectum or the retroperi-
marcated, making excision or clean resection difficult or toneal duodenum or colon. Even less commonly, the cause may
impossible; emergency treatment thus consists mainly of debride- be direct inoculation of the abdominal wall or muscular tears in-
ment and peritoneal and parietal drainage. curred in open trauma.
Major Lacerations Spontaneous Gangrene

Major lacerations are seen in war injuries or industrial accidents Infection from perineal, often perianal gangrenous abscesses can
resulting from heavy equipment such as farm combines. Explo- spread to involve the abdominal wall. The possibility of this com-
sion injuries are also seen in wartime or during insurrections; they plication requires the placement of an unavoidable colostomy at
create complex lesions combining avulsion, blast effect, and bums. the level of the transverse colon to avoid entering the peritoneal
cavity during a fulminating infection and running the risk of an
anaerobic peritonitis.
Burns Postoperative gangrenes manifest themselves 4 to 5 days after
surgery. Suspicion may be raised by the presence of vague, deep-
Bums do not present a specific problem other than their associa- seated, constricting postoperative pain; this justifies removal of the
tion with other traumatic lesions that may necessitate laparotomy dressing, examination of the wound, and release of some sutures,
527
528 J.P. Chevrel
which allows emergence of foul-smelling drainage associated with Therapeutic Causes

fatty tissue and gas bubbles. At this early stage, it is difficult to
distinguish between uninfected mechanical emphysema and Tumor Resections
anaerobic infection; the diagnostic signs are usually systemic and
often of late onset: fever, dyspnea, altered level of consciousness, Resection of abdominal wall tumors can create extensive loss of
jaundice. Septic shock may be the presenting clinical picture, abdominal wall substance, presenting a difficult problem of re-
sometimes associated with acute renal insufficiency, implying construction.
poor prognosis. This situation, in half the cases, leads to death
within 48 hours. On occasion, the lesion may be localized, with
moderate tissue loss and improvement in the clinical picture, Benign Tumors
which will allow eventual treatment of the loss of abdominal wall
substance. Benign tumors demonstrate no particular site preference in the
abdominal wall. Two types of lesions can, however, involve exten-
sive tissue resection. These are hydatid cysts and desmoid tumors.
Fournier's Syndrome
Fournier's syndrome manifests itself by the acute loss of skin cov-
Hydatid Cyst. Localization to the skin is a rare form of hydatid
disease. Presentation is that of a firm cyst, evolving within the der-
ering the genital organs. It is most often associated with the pres-
mis and capable of reaching a considerable size. Surgical resec-
ence of streptococci. It extends to the anterior abdominal wall,
causing a vast area of necrosis ("underpants" distribution), bright tion requires the usual precautions for hydatid disease.
red at first, sometimes delimited by raised edges, and subsequently
Desmoid Tumors. Desmoid tumors (Fig. 78.2) constitute 3.5% of
turning into a blackish eschar in 3 to 4 days if the patient lives
tumors of fibrous tissue and less than 0.03% of all malignant tu-
long enough (Fig. 78.1).
mors. They are nonencapsulated fibrous tumors of mesenchymal
Often confused with gangrenous infections of perineal origin
origin. About 35% of them are situated in the abdominal wall
where cutaneous involvement is never primary, Fournier's syn-
and, more notably, within the rectus sheath. They can be solitary
drome requires immediate medical treatment (electrolytes and an-
lesions or associated with familial polyposis (FAP) (15%)1,2 or
tibiotics); the surgical treatment is of secondary importance
Gardner's syndrome (35%).3-9 Families have also been reported
because tissue loss involves the cutaneous elements but not the
with hereditary transmission of desmoid tumors but without the
underlying aponeurotic layers.
colonic expression of FAP.lO,ll Desmoid tumors are seen more
often in women that in men (2:1), and more particularly during
Streptococcal Subcutaneous Cellulitis or after pregnancy, at the site of a cesarean incision. In associa-
tion with Gardner's syndrome, these tumors extend into the peri-
Streptococcal subcutaneous cellulitis differs from Fournier's syn- toneal cavity, invading the abdominal viscera, mesentery, and
drome because it does not initially affect the skin and from anaer- retroperitoneal space. The evolution of these tumors renders
obic gangrene because the causative organisms are essentially them unresectable at times, particularly when recurrent. They
hemolytic streptococci. Affecting more often the lower limbs, the can cause intestinal occlusion and necrosis beyond the reach of
infection spreads toward the anterolateral abdominal wall and the therapeutic intervention.
flanks. This results in a diffuse, necrotizing process in the subcu- Diagnosis is usually made from the discovery of a tumor of the
taneous layer which becomes the site of multiple abscesses, often abdominal wall. This tumor is painless, covered with normal skin,
associated with severe systemic changes such as septic shock and and, if large, may be associated with signs of nerve compression
gastrointestinal stress ulcers. Unlike Fournier's syndrome, it is leading to neurological disorders or venous compression. Medical
treated both medically and surgically, including subcutaneous de- imaging, whether ultrasound, computed tomography, or magnetic
bridement over large areas, which can unfortunately be followed resonance imaging scan, can only confirm the presence of a tu-
by further necrosis. mor and define its boundaries, and in practice only histological
study, whether immediate or of the operative specimen, allows con-
firmation of the diagnosis. The course of desmoid tumors is that
of a locally invasive tumor of low grade malignancy, with risk of
local recurrence estimated at around 45%.
Complete excisional surgery is the best treatment but does not
always prevent recurrence, which occurs in 20 to 40% of cases.
Such excisions may pose variably difficult problems of parietal re-
pair. 3,12,13,63 Nonsurgical treatments, such as the currently proposed
combination of hormonal 14 and nonsteroidal anti-inflammatory
agents,I5-18 are largely ineffective.
Malignant Tumors
Primary malignant tumors arising on the abdominal wall are es-
sentially cutaneous: spinocellular epitheliomas and fibrosarcomas.
The spinocellular epitheliomas occur on preexistent lesions: lap-
FIGURE 78.1. Fournier's syndrome. arotomy scars, burns, areas of radiodermatitis, psoriasis, or dysker-
78. Loss of Abdominal Wall Substance 529
A B
c D
FIGURE 78.2. (A) Preoperative computed tomographic (CT) scan of a revascular axis was protected with an ePTFE sheet after closure of the peri-
current desmoid tumor of the left inguinal wall in a 27-year-old woman. toneum. The inguinal wall was replaced by a polypropylene mesh folded
Tumor developed in a cesarean incision. The left iliac artery is visible, but in its lower edge to create a neoinguinalligament. Mesh fixation was com-
the vein is compressed by the tumor. (B) The operative specimen completed by a spray of fibrin glue. (D) CT scan obtained 1 year later. Note
prising the tumor and a full-thickness piece of abdominal wall. The his- the patency of the iliac vein. The ePTFE sheet covers the iliac vessels. There
tological examination allowed definitive assessment of the diagnosis of a are no signs of recurrence of the tumor.
desmoid tumor. (C) Operative view of the reconstruction: The iliofemoral
atosis. They require a wide excision. The fibrosarcomas of the ab- small bowel). They can be treated by block resection of the un-
dominal wall resemble the desmoid tumors in their clinical ap- derlying tumor and adjacent abdominal wall.
pearance and behavior. Inadequate resection can be the starting
point of a recurrence, distant metastases, or lymphatic spread. As
in all malignant tumors, the treatment rests largely on an exten- Iatrogenic Causes
sive, wide resection.
Secondary malignant tumors are the result of the spread of var- Postoperative Burst Abdomen
ious intraabdominal tumors. Prognosis is not encouraging when
the metastases are multiple or associated with pulmonary or he- Progress in surgery, anesthesia, and postoperative care has made
patic secondaries. These tumors are invariably secondary to gas- possible the treatment of older patients with extensive abdominal
trointestinal tract malignancies (transverse colon, sigmoid, and lesions, often through lengthy interventions. These are marred by
530 J.P. Chevrel
a higher incidence of complications among which is wound de- dominal pressures. 23 Other technical factors involved are single-
hiscence with a significant mortality. Incidence of dehiscence layer or double-layer myoaponeurotic closures3o or single full-
varies between 0.05% and 3.2% for primary closures and between thickness closure,47 closure in three layers, and retention sutures. 48
3 and 18% for reinterventions,19 Most prospective studies report Retention sutures seem to reduce the incidence of evisceration in
incidence rates of wound disruption of 1 to 3 %.20 It is an extremely patients at risk, but there is no consensus on it. 21 ,49-53
serious complication: Mortality varies between 9.4 and 43.8%, and An important topic is the choice of the suture thread. If all the
recurrent wound dehiscence is associated with 100% mortality. Al- materials available are well tolerated, the choice is determined by
though death is not caused by the dehiscence per se, it is always mechanical strength. However, clinical prospective randomized
an ominous finding.20 studies have failed to show a relationship between the type and
size of suture material and the risk of evisceration. Suture break-
down is most often seen with absorbable materials when an evis-
Clinical Aspects of Burst Abdomen ceration occurs,23 whereas nonabsorbable sutures cut the fascia in
cases of wound dehiscence. 20 Some authors report a statistically
A burst abdomen is characterized by the appearance of viscera more significant incidence of dehiscence following the use of
through a fresh abdominal incision, when all layers have given way. absorbable sutures than with nylon sutures (11.5% compared
Early burst abdomen occurs within 2 or 3 days of surgery, usu- with 3.8%).30 Conversely, another prospective randomized study
ally during a spell of coughing or retching. Part or all of the in- showed a greater incidence of evisceration with polypropylene
cision may open, allowing varying amounts of abdominal viscera than with PDS (6.4% and 0.7%, respectively).54 These studies in-
to escape. Such an evisceration involves significant respiratory dis- dicate that absorbable sutures, while holding long enough to avoid
tress and the risk of necrosis or fistulization of the herniated vis- dehiscence, do not hold long enough to prevent incisional her-
cera. It is therefore of the utmost importance to reintegrate the nias around the third and fourth month postoperatively. To pre-
abdominal contents and re-establish the abdominal wall. vent dehiscence, we have remained faithful to a layer by layer
Delayed burst abdomen occurs later, usually between the eighth closure, with a continuous peritoneal suture (slow absorption su-
and tenth days after surgery. The entire incision breaks down, but ture), an aponeurotic layer with slowly absorbed running sutures
the underlying viscera are adherent to each other and to the fas- if no risks are present, or interrupted 3-0 nylon in patients at risk.
cial edges by pseudomembranes and adhesions that prevent ex- The quality of postoperative care is of paramount importance in
teriorization. The problem is to protect the intestinal loops and these situations. Increased intraabdominal pressure significantly
to avoid a fistula due to exposure. increases the risk of evisceration21 ,23,25,26; it can be seen in the im-
In some cases, the cutaneous sutures remain intact while the mediate postoperative period, in patients emerging from anes-
myoaponeurotic layers have dehisced. This situation is referred to thesia, and in patients with respiratory distress due to chronic
as a "covered dehiscence." bronchitis and postoperative ileus.
Abdominal wound infections are encountered in more than
one-third of burst abdomen cases, reflecting the septic nature of
Factors at Work the intervention, as confirmed by the frequent presence of in-
testinal organisms. Wound dehiscence can be, on occasion, the re-
Several patient-related factors can favor the development of a burst sult of an intraperitoneal septic event such as an anastomotic
abdomen and were found to be significant risk factors in several fistula, the presence of which requires modification of the treat-
experimental and clinical studies: anemia,21 hypoproteinemia and ment of the abdominal wound.
malnutrition,21-24 jaundice (increasing up to 18% the risk of burst
abdomen22 ), steroid therapy, and chronic lung disease.21.23.25,26
Surgery-related factors play a major role in the genesis of the Treatment
burst abdomen. Surgical emergencies carry the maximum risk of
wound dehiscence and can be high as 40 to 48%.21,23,27-29 Most of Primary Treatment
the patients suffer from conditions that may delay wound healing
or lead to increased intraabdominal pressure, such as alcoholism, Treatment of loss of abdominal wall substance consists of the re-
malnutrition, and chronic bronchitis. construction of an impervious, solid, and cosmetically acceptable
Type and site of the laparotomy can also be important factors in abdominal wall. These reconstructions are rarely accomplished in
burst abdomen. Vertical incisions are more often associated with one session. In certain cases, it is the infectious process that de-
wound dehiscence than horizontal, although accurate figures are termines the prognosis, and the first measures are invariably the
difficult to obtain. Generally, vertical incisions are more frequently medical treatment of toxic and infectious components or the sur-
used in gastrointestinal surgery, particularly in emergency situa- gical treatment of the underlying cause. Parietal reconstruction
tions. However, prospective studies failed to demonstrate a signifi- thus becomes a secondary problem to be resolved once the pri-
cant difference between vertical and transverse incisions regarding mary causes have been eliminated. The treatment of major losses
the risk of wound disruption. 30-34 Among vertical incisions, mid- of abdominal wall substance varies with the etiology.
line repairs are stronger than paramedian repairs. 35-39 In open trauma (shotgun injuries, heavy machinery lacerations,
Technique of closure is often suggested as an etiological factor explosions), the first step consists of excision of all necrotic tissue
but is difficult to implicate. Many studies have compared inter- and the preservation of healthy edges of the abdominal wall de-
rupted and continuous sutures: In general, authors agree that fect. Burn injuries usually respect the aponeurotic layers, and the
there is no difference between them regarding the incidence of treatment is conventional: excision of eschar and skin grafting.
burst abdomen. 17,23,34,40-46 Recently, a double loop suture has been Infectious conditions require urgent medical attention: correc-
suggested to improve wound strength against increased intraah- tion of electrolyte imbalance; support for cardiac, pulmonary, and
renal functions; and antimicrobial therapy, keeping in mind aero- by tissue ingrowth, on which skin grafts may eventually be applied,
bic as well as anaerobic organisms. Clostridium (8 times out of 10) although the eventual sequela will be a herniation (Fig. 78.3C,D).
is associated with Bacteroides fragilis in 50% of the cases. Hyperbaric Certain rules must be observed: no peritoneal cavity that has been
oxygen therapy is controversial. To medical treatment, one must the seat of infection is to be reentered before 3 months have
add initial surgical measures consisting of resection of all necrotic elapsed unless absolutely necessary. Fresh adhesions would be en-
tissue (cutaneous, subcutaneous, and aponeurotic) and treatment countered that are difficult, if not impossible, to lyse, and visceral
of frequently associated peritonitis and any underlying visceral injuries are a real threat. Closure with or without prosthetic mesh
pathology. No gastrointestinal anastomoses are to be contemplated; should not be attempted before 6 months. Only then can a de-
stomas will be the rule. The initial emergency treatment often leads finitive treatment be considered.
to extensive losses of abdominal wall substance. Closure in the pres-
ence of such sepsis cannot be entertained, and one must rely on
laparostomy, such as that proposed for the severe forms of peri- Treatment of Loss of Abdominal Wall
tonitis. The abdominal wall defect remains patent, which allows reg-
ular surveillance of the viscera until an aseptic peritoneal cavity is
Substance Following Septic
obtained. The technique allows resection of necrotic tissue and Therapeutic Procedures
saucerization as needed until the infectious process is halted. Pro-
tection of the viscera is done with the help of sheets of polyurethane When treating a portion of the abdominal wall for a septic tumor
foam or Vaseline gauze (Fig. 78.3A,B) and dressings soaked in an- (i.e., invasion by an underlying visceral tumor), the situation is
tiseptic solutions. A mechanism of continuous irrigation can be in- analogous to tissue loss secondary to pathological processes such
serted using a plastic wound protector, the sides of which are as gas gangrene. Several possibilities exist, depending on the ex-
elevated by traction and ensuring noncommunication between the tent of tissue loss and the degree of sepsis of the field. In any case,
abdominal wall surface and its deeper aspect. 61 primary closure and the use of nonabsorbable prostheses must be
excluded. Certain measures can be taken to close the peritoneal
cavity.
Secondary Treatment Loops of bowel can be covered by a large sheet of polyurethane
foam, which can be changed every 4 to 5 days until enough gran-
On average, a laparostomy can be maintained for 1 to 2 weeks. ulation tissue has formed to accept skin grafts. The greater omen-
Subsequent treatment will assist scar formation, which takes place tum can be sutured along the edges of the fascial defect with slowly
A B
c D
FIGURE78.3. (A) Resection of the right half of the anterior abdominal wall following gas gangrene, a complication of a strangulated hernia. Polyglactin
mesh used. (B) Wound covered with a sheet of polyurethane foam. (C) Appearance on day 25. (D) Appearance 9 months after split-thickness skin graft.
532 J.P. Chevrel
absorbing sutures (Fig. 78.4) . Moist dressings should be applied ing can promote cicatrization, which should be completed in 2 to
and changed frequently until granulation tissue is obtained for 3 months. When coverage is complete, an incisional hernia will
skin grafting. become apparent.
Simple cutaneous closure can cover the loops of bowel. This is Internal containment with an absorbable mesh may be indi-
facilitated by deep cutaneomyoaponeurotic relaxing incisions cated when the defect is so large that viscera cannot be held in
made 10 em away from the midline, extending from the costal place, posing the risk of fistulization (Fig. 78.5). Internal swad-
margin to the level of the iliac crest. These relaxing incisions, dling can be achieved with an absorbable mesh (polyglactin 910,
which will result in hernias, can be repaired at a later date (10 to polyglycolic acid), with ePTFE (Gore-Tex®), or with the recent
12 months). composite polyglactin/polypropylene mesh (Vypro®). In either
External cutaneous containment can be carried out. This case, the prosthesis is anchored to the deep aspect of the peri-
method uses sheets of polyurethane inserted deep to the edges of toneum far lateral to the edges of the defect. The interrupted
the defect. A polyamide jersey covers the abdominal wall, glued sutures are placed through small cutaneous incisions and tied
to the skin with a surgical varnish and changed daily until, by the in front of the external oblique aponeurosis. When polyglactin
eighth or tenth day, a layer of granulation tissue appears. Subse- mesh is used, it must be covered with Vaseline gauze and
quently, the polyurethane foam can be replaced by high ab- changed daily. If ePTFE is used, in a septic wound, antiseptic
sorbency dressings such as Dextran® paste. Vaseline gauze should solutions must be used generously. Cutaneous closure will
be inserted between these dressings and the polyamide jersey. This be carried out at a later stage when the infectious process is
swaddling will last for 3 to 4 weeks. When indicated, thin skin graft- eradicated.
A B ~ ________________ ~~~ ____ ~~
c o
FIGURE 78.4. (A) Parietal extension of a tumor of the colon.

(8) Block resection of the abdominal wall and the tumor of
the colon. (C) Parietal closure with the greater omentum
covered with polyurethane foam sheeting. (Reprinted from
Chevrel JP. Defects of the Abdominal Wall. In JP Chevrel
(ed): Hernias and Surgery of the Abdominal Wall. Copyright
1998, Springer-Verlag Paris, with permission.) (D) Appear-
E ance on day 7. (E) Appearance 3 months later.
A B
c o
FIGURE 78.5. (A) Metastasis to the abdominal wall of a bron-

chogenic carcinoma. (B) Preoperative CT scan of the same
patient. (C) Block resection of the abdominal wall and right
hemicolectomy. (D) Parietal reconstruction with a double
thickness Dacron mesh. (E) Appearance on day 17. The ab-
dominal wall remains intact. The patient was dead 6 months
later. (From Bendavid R (ed): Prostheses in abdominal wall her-
E
nias. Austin: R.G. Landes Company; 1994.)
Treatment of Iatrogenic Loss of Abdominal When wound infection is present and the tissues of the fascial
defect are of poor quality, nonabsorbable prostheses are con-
Wall Substance traindicated, but it is possible to use an absorbable mesh. Cuta-
neous closure, if feasible, should be carried out, leaving the hernia
The treatment of burst abdomen will vary with the nature of the defect for repair in 6 months' time.
anatomical defect and the status of the peritoneal cavity. If a burst With intraperitoneal sepsis and peritonitis, or significant pathol-
abdomen is strictly a mechanical phenomenon, without sepsis, the ogy such as necrotizing pancreatitis, the abdominal wall defect
aponeurotic layers should be approximated with interrupted non- must be left open. Mter reintegration of the bowel loops within
absorbable sutures. The skin is loosely approximated, also with the abdominal cavity, polyurethane foam sheets or Vaseline gauzes
widely spaced interrupted sutures. If tension is too great, relaxing are used with a polyglactin mesh, the "method of laparostomy" re-
incisions may be made lateral to the rectus edge, extending from ferred to above in connection with burns. 58-6! When peritoneal
the costal margin to the groin. Alternatively, a prosthesis such as dressings and irrigation are no longer necessary, further treatment
ePTFE or its new substitutes (Soft Tissue Patch®, MycroMesh®, or can be undertaken, as in a delayed dehiscence.
DuaIMesh®)55 can be anchored to the edges of the defect or in- In delayed burst abdomen, 8 to 10 days postoperatively, the ma-
serted deep in an intraperitoneal position and anchored with in- jor problem is protection of the viscera, which may be exposed to
terrupted sutures; fistulization seems not to occur in this situation erosion and fistulization; this type of fistula is more difficult to
with these materials. 56 The combination of a deep ePTFE graft treat than the deeper ones. The greater omentum is used, if avail-
and a superficial polypropylene sheet has proved to be a safe al- able. In its absence, the ideal is simple cutaneous closure, with re-
ternative. 57 The more superficial layers of the wound can be closed laxing incisions where indicated. If the skin cannot be closed,
anterior to the prosthesis. sheets of polyurethane foam or Vaseline gauze are used for the
534 J.P. Chevrel
first 6 days, followed by high absorbency dressings from the sec- bowel with direct anastomosis and a simultaneous reconstruction
ond week on until, in 8 to 12 weeks, enough granulation tissue of the abdominal wall by one of the many procedures already de-
has covered the exposed viscera (Fig. 78.6). Iris then possible to scribed (Fig. 78.7).
perform a skin graft. Coverage is thin and of poor quality, but a
definitive treatment 6 months later will correct the situation.
Treatment of Aseptic Loss of Abdominal
Burst Abdomen and Fistula Wall Substance
Fistulas originate in the small bowel in 80% of cases. Burst ab- If the loss of abdominal wall substance results from clean, planned
domen secondary to anastomotic fistulas and peritonitis compels resections of parietal tumors or large incisional hernias, with no
the resection of the anastomosis and the creation of a double evidence of wound or peritoneal infection, repair of a large ab-
ileostomy. Abdominal wall reconstruction can then be realized by dominal wall defect can be done by pure tissue closure, by the use
various methods, such as cutaneous single layer closure with gen- of a prosthesis or a combination of both, or by a myoplasty.
erous relaxing incisions or the use of an absorbable mesh (poly-
glactin 910, polyglycolic acid) or containment with a polyamide
mesh and dressings, as already discussed. Simple Myoaponeurotic Closure
Closure of the fistula will result in failure. Only after lengthy
preparations (drainage of the fistula, lactic acid irrigations, hy- When the loss of tissue does not go beyond 10 cm in diameter and
peralimentation) can one attempt resection of that segment of if fascial edges seem adequate, pure tissue closure is feasible with
A B
c o
FIGURE 78.6. (A) Fixed burst abdomen on day 10. (B) Protection of the intestinal loops with microspheres of Dextran. (C) Appearance on day 30.
(D) Appearance 10 months later.
A B
c D
FIGURE 78.7. (A) Exposed intestinal fistula in a burst abdome n. (B) Setup for nutritional balance for 10 days. (C) Parietal reconstruction with relax-
ing incisions (Gibson 's operation) . (D) Appearance 6 months later.
the help of relaxing cutaneomyoaponeurotic relaxing incisions, ex- toneum. Thus, desmoid resections that do not invade peritoneum
tending from the costal margin above to the iliac crest level below. can leave a defect that will be corrected by the interposition of a
The suture must be nonabsorbable, and our preference is for in- large polypropylene mesh. Even if it is less strong, a Dacron mesh
terrupted rather than continuous sutures. Slowly absorbable sutures can also be used. Should peritoneum removal be necessary, an
will lose their strength by 8 weeks, when healing is far from having ePTFE patch may be applied against the viscera. The interposition
achieved its maximal solidity, and the repair may break down. of the greater omentum is a decided advantage. Skin closure may
be made easier by cutaneous relaxing incisions parallel to the lat-
eral edges of the recti.
Repair Using the Anterior Rectus Sheath An ingenious method is to create a circular defect in a pros-
thesis through which the greater omentum can be pulled and then
If tissue loss is medially situated, the anterior rectus sheaths may spread out to be sutured to the edges of the wall defect. Vaseline
be incised longitudinally 1 cm medial to the lateral borders of the dressings are applied until granulation tissue appears, upon which
recti and turned back toward the midline and sutured to each skin grafts can be applied.
other. Here again, our preference is for interrupted, nonab-
sorbable sutures. Relaxing incisions can also be used in these cases.
If the defect is lateral to the midline, the anterior rectus sheath Myoplasties
of that side can be incised longitudinally near the midline and
folded back laterally to cover the defect. Gracilis Muscle. The loss of abdominal wall substance near the mid-
line, below the umbilicus, can be corrected by a myopias tic rota-
tion of the gracilis muscle. This method, already well known,
Prostheses or Autografts consists of sectioning the distal end of the muscle at its myo-
aponeurotic junction, rotating the belly upward through a subcu-
When abdominal wall resection has been extensive (over half taneous tunnel, and suturing the muscle tissue to the fascial defects.
of the anterior wall), pure tissue repair is no longer possible.
Reconstruction can be planned with a prosthesis or autografts, de- Tensor Fasciae Latae. Certain authors have successfully used a myo-
pending on the availability of the greater omentum and peri- cutaneous flap of tensor fasciae latae rotated on a branch of the
536 J.P. Chevrel
2. Smith WG. Desmoid tumors in familial multiple polyposis. Proc Staff

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5. Goderey PJ, Moore AW, Clarke AM. Intra-abdominal desmoid causing
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7. Kitamura A, Kanagawa T, Yamada S, et aI. Effective chemotherapy for
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10. Eccles D, Van Der Luijt R, Breukel C, et al. Hereditary desmoid dis-
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11. Scott R, Froggatt N, Trembath R, et al. Familial infiltrative fibromato-
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13. Langlois P, Menegaux P, Lizina, et al. Utilisation couplee d'une plaque
de polyglactine 910 et d'un filet de polyester blanc apres excision
FIGURE 78.8. Myoplasty and skin grafting for secondary reconstruction of d'une tumeur desmoide de la paroi abdominale a extension viscerale.
loss of abdominal wall substance due to gas gangrene following laparo- Ann Chir. 1986;40:33-35.
scopic inguinal hernia repair. 14. Fadel C, Guimbaud R, Garat P, et al. Les tumeurs desmoides: tumeurs
benignes a malignite locale. Revue de la litterature; a propos d'un cas
c1inique. Cahiers OncoL 1998;7:169-173.
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tion will allow transposition to the level of the abdominal wall for delberg polyposis register. Chirurgie. 1995;66:997-1005.
total replacement. This technique has exceptional indications: No 17. McKinnon J, Neifeld J, Kay S, et al. Management of desmoid tumors.
other technique can be applied in young patients. Eventually, both Surg Gynecol Obstet. 1995;169:104-106.
18. Waddell W, Kirsch W. Testolactone, sulindac, warfarin, and vitamin K\
tensores fasciae latae could be used for large abdominal wall de-
for unresectable desmoid tumors. Am] Surg. 1991;161:416-421.
fects. Pedicled flaps are limited by the arc of rotation and size of
19. ChevrelJP. Postoperative burst abdomen. InJP Chevrel (ed): Hernias
the defect. Free flaps of the tensores fasciae latae are options for and surgery oj the abdominal wall. Berlin: Springer-Verlag; 1998: 118-128.
repair of abdominal wall defects for they are versatile in orienta- 20. Poole Gv. Mechanical factors in abdominal wound closure: the pre-
tion and long enough to be used for supraumbilical defects. 62 vention of fascial dehiscence. Surgery. 1985;97(6) :631-639.
Figure 78.8 shows a myoplasty and skin grafting for secondary 21. Makela JT, Kiviniemi H, Juvonen T, et al. Factors influencing wound
reconstruction. The rectus femoris muscle can also be used dehiscence after midline laparotomy. Am] Surg. 1995;170:387-390.
successfully.64 22. Ellis H. Wound healing. Ann R Colt Surg EngL 1976;59:382-387.
23. Niggebrugge AH, Hansen BE, Trimbos JB, et al. Mechanical factors
influencing the incidence of burst abdomen. Eur] Surg. 1995;161:
Conclusion 655-661.
24. Soisson AP, Olt G, Soper JT, et al. Prevention of superficial wound sep-
aration with subcutaneous retention sutures. Gynecol Oncol. 1993;51 :
Loss of abdominal wall substance is a major problem that requires
330-334.
patience, determination, awareness of the latest information, and
25. Baggish MS, Lee WK. Abdominal wall disruption. Obstet Gynecol. 1975;
willingness to call upon the various specialties for help critical to 46:530-534.
the well-being of the patient. 26. Sanders RJ, DiClementi D. Principles of abdominal wall closure. Arch
Surg. 1977;112:1188-1191.
27. Botella R. Les desunions parietales apres laparotomies. These Faculte
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79
Acute Loss of Abdominal Wall Substance and
Abdominal Compartment Syndrome
H. Harlan Stone
Among the most challenging of all scenarios faced by the surgeon depicted in Table 79.2, a retrospective condensation of 36 years'
is the realization that abdominal viscera cannot be returned to the experience with this particular set of issues.
peritoneal cavity because of the loss of an extensive area of full- 2. No bowel anastomosis should ever be made if likelihood of
thickness abdominal wall and/or massive visceral swelling as a re- healing is not certain. Suture line disruption creates a life-
sult of fluid sequestration following trauma, shock, or sepsis. The threatening infection for the wound and peritoneal cavity. In
tissue loss is usually due to an acute destructive injury requiring addition, there is an almost absolute contraindication to en-
debridement, a fulminant necrotizing infection requiring radical teral feeding for a protracted period of time unless the fistula
excision, or the unanticipated need to extend an en bloc tumor is quite distal in the small bowel and does not communicate
resection to include a sizable area of abdominal wall. A frequently with a major abdominal wound. Table 79.3 depicts the poten-
associated problem is bowel and mesentery edema that has pro- tially dire outcome.
gressed to the point that the swollen viscera have temporarily lost An anastomosis between bowel ends with a questionable
their right of domain within the peritoneal cavity proper. The clin- blood supply, with well-established inflammatory changes, or in
ical problem is the same whether abdominal wall substance has the presence of an advanced stage of peritoneal sepsis predis-
been lost or increased organ volume significantly exceeds the ca- poses to suture line failure. Massive contamination in the ab-
pacity of the peritoneal compartment. sence of one of the aforementioned features does not appear
The massiveness of the defect in abdominal wall, the overriding to exert an adverse effect. Data in Table 79.4 confirm the ob-
urgency to terminate the operative procedure, and/or the lack of servation that there is little difference between small bowel and
appropriate interposable tissue often precludes the performance colon in terms of the risk of anastomotic breakdown. An end
of a one-stage, definitive closure. stoma of proximal jejunum placed on the abdominal wall, with
suture closure of any more distal bowel wounds, is far easier to
manage with supplemented parenteral nutrition than is an in-
Loss of Abdominal Wall Substance testinal fistula located deep within recesses of the abdomen or
a discharge of intestinal contents into a suppurating wound,
Personal experience with 332 acute major defects in the abdomi- even if superficial.
nal wall as well as review of relevant published reports have led to 3. An end stoma is preferred to the vented bowel loop. Drainage
objective reconsideration of several tenets presumed to be cardi- bags fit more or less exactly over a Brooke-constructed en-
nal and inviolable (Table 79.1). Some axioms turn out to be less terostomy. Escaping contents can then be collected with little
infallible than one was led to believe, while others are truly invio- risk of spill into the wound, can be measured for appropriate
late and should never be defied. Among the principles that must intravenous replacement of fluid and electrolytes, and can be
always be heeded are the following. delivered into a more distal stoma to return otherwise lost in-
testinal juices. Even the blindly closed duodenum with a prox-
1. The surgical incision should never be closed under excess ten- imal decompressing Stamm gastrostomy, with threaded parallel
sion. Taut sutures will cut through fascia and allow bowel to tube passed into the duodenum, is a better alternative than the
protrude and impair blood flow to incision margins. These con- uncertain duodenal suture line.
ditions in turn foster wound sepsis, pressure necrosis in bowel 4. Exposed bowel must be kept moist; otherwise it will eventually
loops beneath tight strands of suture, compromised venous re- perforate, usually along its antimesenteric border. If the ab-
turn to the heart due to direct visceral pressure on the vena domen cannot be closed primarily, then saline-wet dressings
cava, renal venous hypertension progressing to oliguria and an and/ or covering mesh must be applied to the bowel to guar-
eventual cascade of renal ischemic complications, ventilatory antee a moist local environment. Once granulations have
embarrassment from the pressure of viscera against the di- appeared on a bowel surface, a modest protection against spon-
aphragm, or a combination of these adverse and potentially taneous fistula has been gained. Suture lines exposed to air
lethal events. As can be anticipated, closure under tension is present the greatest threat; they should be placed beneath over-
associated with high morbidity and mortality rates, which are lying loops of uninvolved segments of bowel or between the
538
79. Acute LAWS and Compartment Syndrome 539
TABLE 79.1. Causes of abdominal wall loss TABLE 79.3. Mortality of wound complications
No. of patients No. died Percent mortality No. of patients No. died Percent mortality
Necrotizing 224 46 21 Wound sepsis/ 116 13 11

infection necrosis
Traumatic 61 20 33 Peritoneal sepsis· 55 21 38
wound Bowel fistula 26 14 54
En bloc tumor 47 4 9 Total patients 116 48 41
excision
Total patients 332 70 21 "All patients with bowel fistula also had peritoneal sepsis; all patients with
peritoneal sepsis had wound sepsis.
mesenteric folds of more superficial intestinal segments that all future steps in management, although each of the various
have been approximated by sutures. Of seven exposed anasto- prostheses must initially be protected by a sterile dressing.
moses in a personal series, six disrupted. Immediate coverage with a pedicled flap of skin and subcu-
5. Wounds of questionable security demand close surveillance. Al- taneous tissue alone or with both subcutaneous tissue and mus-
though total white cell count, differential white cell count, and cle is relatively impracticable and generally contributes an
fever curve generally reflect the development and course of sep- additional risk of a complicating infection and/or necrosis.
sis, only frequent inspection of the wound will give early warn- Still, the important principles remain: Visceral protrusion is to
ing of a major infectious complication and impetus to intensify be prevented, wound edges cannot be allowed further retrac-
appropriate antiseptic measures. Areas of necrosis and/ or gross tion, and bowel must be maintained in a moist environment
infection demand almost daily debridement and cleansing. until definitive skin closure can be gained. To achieve these
Massive wounds cannot be redressed under sedation on the goals, various forms of mesh have been used as fascial substi-
ward, but instead should be changed in the operating room un- tutes.
der general anesthesia. Shortcuts only short-change the patient 2. Foreign bodies cannot be placed in an infected or contami-
and add to the amount of pain that must be endured. nated wound and should not be inserted without an overlying
tissue cover. Experience now indicates that the outcome is pri-
Certain rules long considered inflexible, however, have when
marily determined by the type of bacterial contamination that
challenged proved to be merely desirable goals rather than ab-
occurs before the time of complete wound closure (Table 79.5).
solute laws. Indeed, under certain circumstances, adherence to
Complicating infection is almost certain if gram-positive cocci
supposedly infallible principles may work to the disadvantage of
inoculate a prosthesis, whereas gram-negative rods do not rou-
wound healing and patient well-being.
tinely produce infection. Should the wound not immediately
1. The abdomen must always be closed in a watertight fashion. be closed over the fascial substitute, then colonization by hos-
This commandment appears to be absolute only for those pa- pital flora almost always includes gram-positive cocci. The one
tients with ascites. Clearly some mechanism to prevent visceral species of gram-negative bacteria that appears to be a constant
protrusion and its consequent circulatory embarrassment is factor is Pseudomonas aeruginosa.
necessary, but the completely closed abdomen is not the only Previously established infection and even massive contami-
way to handle the problem. A relatively small defect in the ab- nation does not necessarily lead to infection involving the at-
dominal wall can easily be plugged with a dressing that fits tached margin of the prosthesis. The incidence of local
snugly enough to fill the space without causing local tissue infection with or without associated tissue necrosis also varies
necrosis (Table 79.2). However, larger gaps in abdominal wall with respect to the cause of the abdominal wall loss (Table
continuity cannot be bridged by a mere dressing because the 79.6), type of synthetic material used (Table 79.7), associated
likelihood of bowel evisceration and/or dressing separation is disease states, organs injured or originally involved in the un-
too great. Instead, the wound is spanned by an inert prosthe- derlying process, intensity of the preexisting established local
sis that is sewn circumferentially to the wound edge. The spe- infection, and particularly both the severity and the specific
cific material used for fascial substitution accordingly dictates species of bacterial contamination (Table 79.5).
TABLE 79.2. Complications and deaths according to wound management

Died of Percent mortality
abdominal from abdominal
Wounds sepsis Peritoneal Bowel wound related wound related
Methods Patients and/or necrosis sepsis fistula complications complications
Primary closure 14 14 7 4 11 79
Gauze pack 18 4 2 2 1 6
Pedicled flap 32 3 4 1 3 9
Fascial prosthesis 263 85 42 19 33 13
Operative deaths 5
Total patients 332 116 55 26 48 15
540 H.H. Stone
TABLE 79.4. Fate of gastrointestinal anastomoses/repairs ceptable horizontal closure of any open wound that might cause
a metabolic drain, invite injury to bowel beneath, prevent pa-
Location Patients Disruption
tient discharge, or force patient placement into an extended
Stomach 6 care facility. Once the wound is mature (that is, once the healed
Gastroduodenal 4 wound no longer manifests any residual inflammation, as sug-
Duodenal 8 1 gested by scar hyperemia), final reconstruction of the abdom-
Small bowel 68 18 inal wall can be considered, with attention to an improved
Ileocolic 7 3 cosmetic appearance.
Colon 6 3
Rectum 2
Transient Visceral Swelling
Direct trauma, ischemia, and established inflammation account
3. Skin coverage for all wounds located on the abdomen must be for most cases of massive intestinal edema. Although the swelling
immediate. This concept is not only false, but it flies in the face is transient, it is refractory to all efforts to reduce bowel dimen-
of the repeated observation that any wound with potential for sions because the trapped fluid is aimost entirely an intracellular
subsequent infection or tissue breakdown must be left open sequestration. Osmotic diuretics fail to evoke even a partial re-
with appropriate protection by a sterile dressing. Because the sponse. Thus, a quick expansion of abdominal girth beyond nor-
majority of abdominal wound defects occur in patients who mal proportions is needed.
have had bowel entry or spill before or during the procedure, Prosthetic material offers a readily available patch that will allow
the converse to this dictum becomes mandatory: No attempt total visceral return to the peritoneal cavity. If bowel swelling is
should ever be made to approximate skin and subcutaneous tis- solely due to edema and can be expected to persist for a week at
sue when the risk of ensuing wound infection is great. most, nonabsorbable mesh can be used. Skin and subcutaneous tis-
The quandary then arises as to what prosthetic material sues are left open, and the bare area of spanning mesh is protected
should be used for the wound that is left open and almost cer- by an occlusive dressing. As edema subsides, the mesh is gathered
tain to be colonized by gram-positive cocci. Experience with in the midline until fascial edges can be closed definitively. At that
various fascial substitutes has demonstrated that an absorbable point, the mesh is removed and fascial margins are approximated
mesh not only is associated with a lower infection rate but also with interrupted monofilament sutures. Skin and subcutaneous tis-
never creates a problem for either immediate or delayed re- sues continue to be left open, for colonization of the superficial
moval (Table 79.7). Thus, in these circumstances, Vicryl® is the wound by hospital pathogens has undoubtedly occurred.
obvious prosthetic of choice. Expected delays beyond a week or 10 days before fascial closure
Once a wound has been stabilized (which may take as long can be achieved, dictate use of an absorbable mesh such as Vicryl
as 2 or 3 weeks), skin coverage can safely be obtained by rota- if the superficial wound is to be left open and there is little like-
tion of myocutaneous flaps, split-thickness skin grafts applied lihood of fascial edges ever being reapproximated. Skin closure is
to adherent and granulating bowel surface, or even final reap- later gained by split skin grafting of granulations covering the ex-
proximation of full-thickness abdominal wall if closure can be posed viscera, which have until now been held within the ex-
accomplished without tension. panded abdominal cavity by absorbable mesh. Many months later,
4. Small bowel continuity must be reestablished immediately. No any resultant hernia will be repaired.
premise is further from the truth. Proximal intestinal stomas If, however, skin and subcutaneous tissue can be closed at the
are well tolerated for long periods of time provided that par- initial procedure, a nonabsorbable mesh should be selected. M-
enteral alimentation is intelligently delivered and a distal stoma ter visceral swelling has subsided, the mesh may be removed and
has been created for the refeeding of bile and other intestinal the wound closed in layers, as would have been done if visceral
juices. Indeed, a distal stoma in the proximal small bowel can swelling had not prevented it.
be used for routine feeding and thereby eliminate the need of
a parenteral route.
5. Resultant hernias and exposed granulating bowel must be de- Compartment Syndrome
finitively corrected at an early date. Wrong! There is never a
rush. Split-thickness skin grafts can be used to provide an ac- The accelerated increase of pressure within a confined space to
such a degree as to interfere with microcirculatory perfusion and
threaten tissue ischemia and necrosis constitutes a compartment
TABLE 79.5. Infection consequent to mesh contamination- syndrome. The abdomen is by no means immune to this phenom-
primary closure enon. In addition, however, other adverse events usually occur when
the peritoneal cavity is so forcefully expanded. Direct pressure on
Patients with Marlex Prolene Gore-Tex Vicryl
the vena cava posteriorly obstructs venous return to the heart and,
Gram-positive 3 17 4 2 as a result, can so greatly diminish cardiac output as to cause shock.
coccal contamination The diaphragm is not a rigid structure and is subject to upward de-
Wound infection 3 16 3 1 formation by excessive pressure from below. This severely compro-
Incidence (%) 100 94 75 50 mises pulmonary function. Consequences are thus potentially much
Gram-negative more grave than a simple compartment syndrome.
rod contamination 11 34 3 3
Among the first to appreciate the dire consequences of a sud-
Wound infection 3 4 1 1
Incidence (%) 27 12 33 33
den increase in intraabdominal pressure were pediatric surgeons
charged with correcting a massive omphalocele or gastroschisis.
TABLE 79.6. Complications and deaths according to cause and defect (five operative deaths excluded)
Died of Percent mortality
abdominal from abdominal
No. of Wound sepsis Peritoneal Bowel wound related wound related
Cause of defect patients and/or necrosis sepsis fistula complications complications
Necrotizing infection 223 90 39 17 31 14

Traumatic wound 58 23 15 9 15 26
En bloc tumor excision 45 3 2 4
Total patients 327 116 55 26 48 15
The decision as to whether a ventral hernia should be created has When immediate reduction in intraabdominal pressure is vital,
usually been based on size of the umbilical defect, alteration in the incision is opened and a mesh gusset is inserted to afford the
heart rate and blood pressure upon forceful return of the viscera, necessary cavitary expansion. The consequent sudden escalation
and the difficulty of infant ventilation when primary closure is at- of venous return to the heart nevertheless demands that adequate
tempted. Essentially identical changes were later observed in PEEP be maintained. More life-threatening, however, is the acute
trauma patients when abdominal packing was used to tamponade reperfusion injury. Correction of acidosis and initiation of imme-
hemorrhage in cases complicated by coagulopathy or otherwise diate diuresis with some osmotic agent such as Mannitol are
uncontrollable bleeding. The effects of ischemia on specific in- equally important.
traabdominal organs as a result of impaired tissue perfusion were With a new baseline for intraabdominal pressure, the same pa-
not generally appreciated until acute renal failure resulted. rameters are followed as before. Further expansion of abdominal
Extraabdominal problems are primarily those due to inadequate capacity may still be necessary in another 12 to 24 hours; or, al-
filling pressure to the heart and insufficient lung volume to pre- ternatively, moderate mobilization of intracellular fluid may per-
vent hypoxemia. Controlled ventilation with increased positive end mit taking tucks in the mesh in stages until definitive abdominal
expiratory pressure (PEEP) is absolutely crucial and may require closure is possible.
airway pressures to the mid- to high 20s range (measured in em
H 20). Unfortunately, as PEEP is pushed, there is further reduc-
tion in venous return to the heart. Pulmonary artery pressures Staged Management
therefore become the dominant guide and may demand energetic
intravenous infusion of fluid to reach pressure levels in the mid- With these principles in mind, it is obvious that overall manage-
to high 20s (in mm Hg). ment of patients with large abdominal wall defects must be divided
Although these adjustments improve the pulmonary and cardiac into three separate stages. The initial phase is primarily concerned
dynamics, there must still be concern for the actual perfusion of with creation of an abdominal restraint so as to prevent prolapse
individual intraabdominal viscera. Urine flow and quality offer the of viscera, avoid traction or tension of mesentery that would com-
best guarantee of organ microcirculation. Unfortunately, patients promise blood supply, and create the potential for an early pro-
who have sustained a hypovolemic insult to their kidneys may have tective seal against overwhelming microbial challenge from the
another basis for their renal failure. Direct measurement of in- external environment. Associated organ injuries and/or patho-
traabdominal pressure should then be used as the most significant logical derangements of various systems must also be addressed.
index. An indwelling catheter in the bladder is ideal for such a An intermediate stage follows, which is primarily concerned with
monitor. Pressures below 20 em H 20 are at the upper range of nor- establishing a reliable skin cover without a break in body surface
mal. Recordings of 25 to 30 may cause concern, but generally these that might favor i~ury to contained organs or external pathogen
pressures are well tolerated if not allowed to persist for longer than invasion. The final stage is directed at both the functional and the
24 hours or so. However, an intraabdominal pressure above 30 em cosmetic end results.
H 20 demands urgent enlargement of abdominal girth. Each abdominal wall defect must be managed individually
according to magnitude of tissue deficit, bacterial challenge es-
tablished or recent, associated disease states regardless of in-
TABLE 79.7. Comparison of fascial substitutes
traabdominal or extracoelomic location, the need for subsequent
No. of therapy for malignancy with chemotherapy or radiation, and avail-
patients Marlex Prolene Gore-Tex Vicryl ability of tissues for either immediate or final abdominal wall re-
construction. The algorithm of treatment is therefore based on
Patients 27 193 24 19
the interaction of these several factors. The dominant considera-
Wound sepsis 14 54 12 2
Incidence (%) 52 28 50 11 tions are the massiveness of the abdominal wall defect itself and
Bowel fistula 6 9 4 presence or likelihood of significant infection recurring or evolv-
Incidence (%) 22 5 17 ing in the immediate postoperative period.
Skin grafted 15 53 16
Graft take >80% 3 40 14
Acceptable take (%) 20 75 88 Initial Management
Later removal 19 118 18
Difficult removal 18 19
16 If the defect is relatively small, that is, less than 5 or 6 em in di-
Incidence (%) 95 6
ameter, a pack may be inserted to fill the space. Ideally, a surface
542 H.H. Stone
of some inert material (such as Owen's gauze) should be placed struction. Any additional defect is then patched with another piece
at the depth of the pack so as to be the presenting surface that of mesh and basted with a similar suture. It is not uncommon for
comes into contact with the viscera below. The space within is filled a patient to require as many as three or four margin excisions with
with loosely packed gauze, such as a laparotomy pad, that will not corresponding additional patches of mesh.
shed fiber and lead to foreign body granuloma formation. A loose
dressing is followed by circumferential wrapping so as to avoid the
tape bum that often results from the shear oflateral traction. The Intermediate Management
pack within the Owen's gauze envelope can easily be changed daily
on the ward. At some time after 10 or 15 days, adhesions between As described, initial steps in managing the abdominal deficit in-
intraabdominal viscera are sufficiently strong to prevent organ pro- clude the small pack, mesh replacement of abdominal wall defect
lapse through the gap. From that point on, an external wrap is no with flap coverage, myocutaneous flap as the tissue used to re-
longer needed. The wound is then allowed to granulate for final construct abdominal wall, and application of absorbable polygly-
closure through tertiary intention. colic mesh followed by skin graft of granulations. In later stages,
For patients with a much larger defect, the choice to be made these may constitute the intermediate management of those par-
is between primary reconstruction by a designed tissue flap or de- ticular wounds. However, if the mesh used to span the defect is
fect spanning with synthetic mesh. The prime determinants are nonabsorbable, without any other tissue or skin cover, the inter-
whether infection was the reason for abdominal wall excision and mediate phase is more complicated.
whether there was contamination by gram-positive cocci during Mter 10 to 20 days, bowel often pulls away from the mesh as ad-
the procedure. Only cases free of such pathogens should be man- herent granulations between bowel contract. It may prove quite
aged by creation of a flap. This may consist of synthetic mesh in practical at this time to remove a strip of freed mesh from its cen-
place of fascia below with a skin and subcutaneous tissue rotation tral portion and then reapproximate the free edges with another
to achieve immediate final closure, or a planned myocutaneous running suture, much as one would cinch up any sort of fabric.
transposition of tissue to fill the fascial defect may be used. The By repeating this step at 2- to 4-day intervals, eventually the orig-
latter gains skin closure either by transfer of skin and subcuta- inal abdominal side walls can be approximated, one to the other.
neous tissue with the muscle flap or by an unexpanded 1.5: 1 This is often the case when the prosthesis had been needed be-
meshed split-thickness skin graft. It must be stressed, nevertheless, cause of extraordinarily edematous bowel that defied abdominal
that there should be absolutely no infection or significant conta- closure although there was no loss of wall substance. At this late
mination during the operation by gram-positive cocci if this form stage, the abdominal wall usually can be closed in a single layer,
of closure is chosen. leaving the skin and subcutaneous tissue open to heal by secondary
For most patients it is far more practical to span the larger de- intention. The enticement to gain a closure without fascial sub-
fect with a piece of synthetic mesh. If there has been contamina- stitute should be resisted, however, if significant tension on the su-
tion or infection by gram-positive cocci, a polyglycolic absorbable ture might result.
mesh must be used. It is fixed in place with a running suture of In most patients who require absorbable mesh as an open
similar material. The surface of the wound is dressed with lap- bridge, granulations grow from bowel and other viscera into the
arotomy pads, and an abdominal wrap is applied to give support mesh. Once these are solid, split-thickness skin grafts of unex-
and keep the dressing in contact with the mesh. Dressing changes panded 1.5: 1 mesh are applied in an open fashion. Healing will
are done on alternate days in the operating room. Mter a week be rapid and almost complete. A soft corset binder can then be
or two, a sufficiently healthy, but not exuberant, granulation bed used to give some protection to the thin skin. Small areas that fail
has usually developed. This can easily be converted to a closed to heal or later break down can be treated by application of some
wound by open grafting with unexpanded split-thickness skin, antiseptic agent that favors crusting, such as mercurochrome or
again meshed by 1.5. thimerosal (Merthiolate®).
Should infection or contamination by gram-positive cocci not Occasionally the skin and subcutaneous closure over nonab-
be present, then a nonabsorbable mesh should be selected. Ide- sorbable mesh fails or becomes infected and requires opening of
ally, a sheet of Prolene® fabric is applied and sewn to the margins the wound. In these circumstances, the mesh must be removed, and
with a running suture through both muscle and fascia. If the de- this event becomes the greatest challenge in wound management.
fect is too large for a single sheet of mesh, multiple pieces can be Certain techniques are crucial to avoid bowel injury as mesh is
sewn together in a patchwork fashion. As in the case with poly- separated from intestine. The attached margins of mesh are first
glycolic mesh, laparotomy pads are placed directly on the mesh, mobilized after removal of the running suture. With the patient
and a loose binder is used to hold the pads in place. Should a supine, traction on the mesh is maintained in the horizontal di-
bowel stoma or decompressing tube be required, the intestinal rection: Never should the mesh be raised verticaUy. Granulations grow-
vent should be located as far outside the field of mesh repair as ing through the mesh are scraped off with either a broad periosteal
possible. High subcostal, epigastric, lumbar, and even groin stomas elevator or the handle of a surgical scalpel. Once the surface of
work even if there is difficulty in confining the discharge to a bag. the mesh is completely clear of even the tiniest of granulations,
Without such a separation, wound and subsequent intraabdomi- then the mesh can be freed and separated from the granulating
nal sepsis become exceedingly difficult to manage and often pre- bowel below. While horizontal traction on the mesh is constantly
sent a major threat to life. As with the absorbable mesh, dressings maintained, a medium-sized periosteal elevator is passed beneath
should be changed in the operating room on either a daily or al- the mesh and gently thrust horizontally to clear granulating buds
ternate day schedule. Until the wound is stable, general anesthe- from the underside of the mesh. As long as the tip of the periosteal
sia is preferred because repeat excision of infected and/or elevator can be seen through the interstices of mesh, there is lit-
necrotic tissue may be required. To delay needed debridement an- tle likelihood of bowel injury or entry. This can only be guaran-
other day only leads to more massive infection and tissue de- teed if dissection is carried out by small segments at a time.
Whenever there is uncertainty, then one should move to another Once all skin has been removed, the hernia defect can be man-
area and address that particular troublesome adhesion from a dif- aged in one of many ways. A fresh piece of nonabsorbable mesh
ferent angle. Gradually the mesh is separated by working from the can be inserted and then skin and subcutaneous tissue flaps rotated
circumference of the wound toward the center. Mter all mesh has to provide appropriate soft tissue cover; one or two myocutaneous
been removed, it may then be advisable to delay skin grafting for flaps can be rotated in from their original bases of tensor fascia lata,
24 to 72 hours. Laparotomy pads are applied with counterpres- latissimus dorsi, or pectoralis major; or relaxing incisions in the fas-
sure against the abdominal defect and held in place by a circum- cia above and below (or on either side vertically somewhat lateral
ferential abdominal wrap. Delay avoids bleeding beneath the graft to wound margin) can be made so as to permit wound fascial clo-
and favors resolution of any contused area of granulations. About sure and subsequent skin graft of the superficial defect.
2 days later, the patient can be skin grafted with the same tech-
nique as described for wounds initially bridged by absorbable
mesh. References
1. Brown GL, RichardsonJD, Malangoni MA, et al. Comparison of pros-
thetic materials for abdominal wall reconstruction in the presence of
Late Management contamination and infection. Ann Surg. 1985;201:705-71l.
2. Feliciano DV, Mattox KL, BurchJM. Packing for control of hepatic he-
As described above, unless a wound complication develops, sel- morrhage.] Trauma. 1986;26:738-743.
dom are later procedures required when the small pack has been 3. Greene MA, Mullins RJ, Malangoni MA, et al. Laparotomy wound clo-
used or a flap was rotated to span the gap. However, for those pa- sure with absorbable polyglycolic acid mesh. Surg Gynecol Obstet. 1993;
tients with a resultant ventral hernia, later definitive repair is usu- 176:213-218.
ally required. 4. Gross RE. Surgery of infancy and childhood. Philadelphia: Saunders, 1953.
No attempt to correct the hernia should be made until the 5. Larson GM, Vandertoll DJ. Approaches to repair of ventral hernia and
full-thickness losses of the abdominal wall. Surg Clin North Am. 1984;
wound is mature. This phase is confirmed if there is no cutaneous
64:335-349.
hyperemia and only isolated segments of grafted skin are still fixed
6. Mathes SJ, Nahai F. Atlas of muscle and musculocutaneous flaps. St. Louis:
to bowel beneath. In most areas the skin with its new dermis can C. V. Mosby; 1979.
be rolled and separated from the intestine below. The few re- 7. MayberryJC, Mullins RJ, Crass RA, et al. Prevention of abdominal com-
maining pedicles of blood supply to skin are readily identified by partment syndrome by absorbable mesh prosthesis closure. Arch Surg.
thickened areas of firm skin fixation to bowel. 1997;132:957-961.
In areas where grafted skin can be folded and separated from 8. Morris JA Jr, Eddy VA, Binman TA, et al. The staged celiotomy for
intestine below, the skin is incised and dissected free from un- trauma. Ann Surg. 1993;217:576-584.
derlying bowel. It is important to use the same technique for dis- 9. Richards WO, Scovill W, Shin B. Acute renal failure associated with in-
secting bowel from neodermis as in separating bowel from creased intraabdominal pressure. Ann Surg 1983;197:183-187.
overlying mesh. In other words, horizontal traction is maintained 10. Saggi BH, Sugarman HJ, Ivatury RR, et al. Abdominal compartment
syndrome.] Trauma. 1998;45:597-609.
on the grafted skin while the bowel is being pushed away with a
11. Stone HH, Fabian TC, Turkleson ML, et al. Management of acute full-
medium sized periosteal elevator. Where fixation is firm, sharp thickness losses of the abdominal wall. Ann Surg. 1981;193:612-618.
dissection is required. It is generally preferred to leave buttons 12. Stone HH, Hester TRJr. Management of complicated omphaloceles.
of neodermis attached to bowel rather than risk enterotomy. Am] Surg. 1971;37:224-226.
Scraps of epidermis can later be shaved off the underlying neo- 13. Stone HH, Martin JD Jr. Synergistic necrotizing cellulitis. Ann Surg
dermis. 1972;175:702-706.
Part XII
Plastic and Reconstructive Surgery
80
Plastic Surgery of Abdominal
Wall Reconstruction
A. Berger and J. Liebau
Introduction fat tissue is followed by a hernia. Differential diagnosis is with di-

astasis recti, which involves separation of the rectus muscles with-
Abdominal wall reconstruction is dependent on the etiology and out hernia and for which conservative treatment is sufficient in
the site of the defect, the size of the defect, and the quality of the most cases. In epigastric hernia, however, surgical intervention is
surrounding tissue. Furthermore, the condition of the patient has recommended.
to be taken into account. Distinction should be made between the Spigelian hernias occur along a weak section of the abdominal
emergency and the elective situation. In an emergency situation, wall lateral of the rectus sheath at the intersection of the linea
the patient's condition is compromised by trauma, and the patient semilunaris and the linea semicircularis. They may be difficult to
is unprepared. In an elective situation, the informed consent of diagnose and require proper investigations. However, with incar-
the patient is required. The patient must be aware of the planned ceration and ileus leading to surgery, the diagnosis becomes clear.
operation, including the operative procedure and possible risks
and complications. There should be no acute inflammatory prob-
lem threatening to cause complications such as infection and Secondary Hernia
fistula.
The cooperation of a general surgeon will help to solve the prob- Abdominal wall hernias with a particularly high recurrence rate
lem of abdominal wall instability. The goal is to improve the qual- (27 to 57%3) are incisional hernias. Mter impaired wound heal-
ity of life for the patient with as few operative steps as possible by ing or premature resumption of heavy physical work after the op-
reconstructing abdominal wall function: support for the respira- eration (less than 3 months), incisional hernias may occur. Even
tory function, defecation, micturition, and childbirth. A variety of with omentoplasty and dermis plasty there is an 8% recurrence
surgical techniques are employed, beginning with conventional rate in incisional hernias. The therapy of choice for the healthy
techniques, use of autologous material like skin graft, creation of patient is the operative approach. In patients with impaired gen-
muscle flaps to allow free tissue transfer, and use of synthetic ma- eral condition, conservative management with tapes and bandages
terial. The background for these operations is knowledge of the must be performed. Careful planning of abdominal incisions con-
anatomy of the musculofascial system, blood supply, and innerva- sidering the blood supply and innervation of the abdominal wall
tion of the abdominal wall. l ,2 is important. l
Etiology of Abdominal Wall Defects Posttraumatic Defect

Primary Hernia Mter trauma such as a motor vehicle or industrial accident, tissue
loss can cause abdominal wall instability. The amount of damage
The origin of primary abdominal wall hernias lies in areas of weak- is visible after debridement of nonperfused, necrotic tissue. The
ness of the abdominal wall. Primary hernias are umbilical, epi- true demarcation of this tissue may be unclear until days after the
gastric, and spigelian. trauma, especially in blunt trauma, where intimal lesions of ar-
The umbilical hernia can be caused by persistence of the phys- teries may lead to perfusion problems and delayed tissue loss.
iological umbilical cord hernia, or it can be acquired. The hernia
is located in the area of the annulus umbilicalis. In the adolescent,
these hernias may easily cause incarceration; operative treatment Postinflammatory Defect
is thus mandatory. In the same operation, the contour of the um-
bilicus should be reconstructed for esthetic reasons. Following intraabdominal infection, closure of the abdominal cav-
The epigastric hernias occur at weak points in the linea alba be- ity can be difficult. The tissues of the abdominal wall may be in-
tween the xyphoid and the umbilicus. Prolapse of preperitoneal volved in the inflammatory process. Because of inflammation,
547
548 A. Berger and J. Liebau
edema, and fibrosis, reliable suture of the damaged tissue may be Suprapubic and Groin Region
impossible. Especially after multiple laparotomies with the neces-
sity of recurrent debridement and irrigation, abdominal wall clo- For the suprapubic and groin region a variety of reconstructive
sure can be problematic, as in acute pancreatitis, colitis, and procedures from the abdomen and the lower extremity may be
peritonitis. If there is no possibility of primary abdominal wall clo- employed. The rectus abdominis flap, groin flap, rectus femoris
sure, a temporary measure such as split skin graft or an absorbable flap, tensor fasciae latae, gracilis flap, and sartorius flap are valu-
mesh may be employed. Definitive reconstruction of the abdomi- able for defect reconstruction.
nal wall may have to occur at a later date.
Plastic Surgical Techniques of Abdominal

Irradiation Injury
Wall Reconstruction
Tissue repair following radiation is an especially delicate problem.
Radiation causes hypocellularity; impairment of cell function, The first step in a successful defect closure is careful debridement
mitosis, and blood supply; often followed by thrombosis and fi- of necrotic, traumatized, or infected tissue and of scar tissue to
brosis. The irradiated tissue is of inferior quality, and surgical in- ensure a healthy granulating tissue bed.
tervention is associated with a higher complication rate compared A variety of surgical techniques can find application in re-
with nonirradiated tissue. The only effective method of defect clo- construction of the abdominal walI. 3,5-8 Sometimes a combina-
sure is transfer of well-vascularized tissue with its own blood sup- tion of techniques is necessary. Generally, the aim is surgical
ply, including free tissue transfer. However, free tissue transfer after management with permanent and safe abdominal wall stabi-
irradiation can be difficult due to vascular problems, for the irra- lization. This aim should be achieved with as few operative steps
diated vessels are injured as well. as possible.
Tumor Surgery Conventional Techniques

Tumor surgery may cause defects in the abdominal wall. Especially Conventional techniques consist in suture and fascial duplication
in the lower abdomen, as in carcinoma of the bladder, the ab- performed with a particular suture material and technique. Non-
dominal wall is anatomically close to the neoplastic process, and absorbable suture material such as 2-0 prolene or 0 prolene is used,
radical tumor therapy includes resection of the infiltrated ab- with "Z"-shaped or "U"-shaped stitches.
dominal wall. In rare cases, a skin tumor, such as basal cell or squa- Especially in the umbilical region and the lower abdomen, du-
mous cell carcinoma localized in the abdominal region, can cause plication of the external oblique fascia can be achieved with the
an extensive defect. help of relaxing incisions in the external oblique aponeurosis. Re-
laxing incisions in the rectus sheath also facilitate approximation
of fascial tissue.
Sites of Abdominal Wall Defects
The choice of reconstructive procedure for an abdominal wall de-
fect depends on the location of the defect and may be aided by A utologous Tissue
division of the abdominal wall into regions. For all regions, omen-
toplasty can be performed. The components separation technique Skin Graft
described by Ramirez et al. 4 may be employed, as can the free tis-
sue transfer. In case of partial-thickness skin loss, split-thickness skin grafts
may be applied. Also, in postinflammatory or posttraumatic de-
fects, split-thickness skin grafts can be applied to the peritoneum
Epigastric Region or over the bowel for temporary closure of abdominal wall cav-
ity (see Fig. 80.10). Due to the shrinking effect of split-thickness
For the lower costal margin, the external oblique muscle can be skin grafts, the size of the defect area diminishes. A second op-
used, if available. The extended rectus femoris flap is an alter- eration for stabilization of the abdominal wall will have to be
native. If the rectus abdominis muscle is available, a turnover performed.
flap of the fascia can be performed. This is a region with lim-
ited possibilities for local coverage, as the rib cage offers little
for mobilization. Dermal Graft
For reinforcement of hernia repair, dermal graft as an autologous
Umbilical Region material can be used (Figs. 80.1 to 80.3).9 Dermal graft can be har-
vested from the upper leg, the groin, and, in fact, from any region
As in the epigastric region, the rectus fascia turnover flap may be of the body. The insertion of the dermal graft is attached under
used. Other choices for defect closure in this region are the an- drumhead-like tension to the wound margins to achieve a stabi-
terior thigh flap, the tensor fasciae latae, and the extended latis- lizing effect on the abdominal wall and to reinforce the direction
simus dorsi. of collagen fibers.
80. Plastic Surgery of Abdominal Wall Reconstruction 549
FIGURE 80.1. A 47-year-old patient with recurrent incisional hernia after

midline laparotomy. Treatment with dermal graft.
FIGURE 80.3. Postoperative view of patient in Fig. 80.1.
Fascia
Fascial tissue, taken mainly from the fascia lata, can be used for
chanical support is minimal. Also, a laparotomy is necessary and
defect closure reinforcement. For operative planning, the shrink-
carries its own risks and side effects.
ing effect of the fascia has to be taken into account.
Harvesting of fascia lata can be performed endoscopically to
minimize scar formation. A 5 cm incision is performed in the dis-
tal lateral upper leg region. With special knives and scissors and Muscle Flaps
the help of a suture inserted in the proximal margin of the fascia,
the fascia can be harvested. A variety of muscle flaps may be used, depending on the location,
the size of the defect, and the quality of the surrounding tissue
(see Figs. 80.4-80.6). The rectus abdominis muscle is, if available,
Greater Omentum a valuable donor muscle with multiple possible modes of applica-
tion. It can be used as a muscle or musculocutaneous flap. The
The greater omentum is used in any region of the abdominal wall. blood supply originates from the superior epigastric artery or the
The advantage is the good vascularization of the omentum. It is inferior epigastric vessels deep to the musculoaponeurotic layer.
useful for coverage of functional structures like nerves or vessels. Taylor et ai. 10 described the inferior epigastric artery as supplying
The disadvantage is the thin structure of the omentum; the me- a skin area in an oblique direction rising from paraumbilical per-
FIGURE 80.4. A 52-year-old patient with recurrent suprapubic hernia. Treat-

FIGURE 80.2. Intraoperative view of patient in Fig. 80.1, with dermal graft. ment with rectus femoris muscle.
FIGURE 80.5. Intraoperative view of patient in Fig. 80.4.

FIGURE 80.7. A 49-year-old patient with posttraumatic abdominal wall in- FIGURE 80.10. A42-year-old patient with postinflammatory abdominal wall
stability, unstable scar in lower abdomen. Treatment with dermal graft and defect, abdominal wall instability, and split-thickness skin graft in the right
free latissimus dorsi. lower, middle abdomen. Treatment with free latissimus dorsi.
550
80. Plastic Surgery of Abdominal Wall Reconstruction 551
forators . The skin portion of this flap is the thoracoepigastric flap.

The fascial turnover flap is one possible technique. Another tech-
nique is the components separation technique described by
Ramirez et a\.4 for closure of midline defects from 5 to 10 cm. In
this technique, a dissection of the anterior rectus sheath, the rec-
tus muscle, the internal oblique, and the transverse abdominal
muscles from the posterior rectus sheath and the external oblique
muscle is performed.
For the lower costal margin the external oblique muscle flap
can be used,ll although it is limited in its size and mobilizability.
In the umbilical region and in the upper and lower parts of the
abdomen as well, the transverse rectus abdominis musculocuta-
neous or the vertical rectus abdominis musculocutaneous flap can
be used. The extended latissimus dorsi is another choice in this
area. 12
The anterolateral thigh muscle is a possible choice for the groin
region and the lower part of the abdomen, as are the sartorius
muscle with segmental blood supply from the superficial femoral
artery, the gracilis muscle with blood supply from the medial
femoral circumflex vessels, and the tensor fasciae latae 13 with a
blood supply to the proximal pedicle from the lateral femoral cir-
cumflex artery. The tensor fasciae latae can be harvested distally
up to 5 cm proximal of the knee joint. This distal portion's per-
fusion is not reliable. The rectus femoris muscle with the same
blood supply as the tensor fasciae latae is another possibility for FIGURE 80.12. Postoperative view of patient in Fig. 80.10.
defect coverage, predominantly in the suprapubic region (Figs.
80.4 to 80.6). This muscle can be used like the extended rectus
the innervated abdominal wall muscles and the aponeurotic struc-
femoris flap for epigastric defects as well. Harvesting the rectus
tures are destroyed. In these cases, where conventional, autolo-
femoris has the disadvantage of reduction of quadriceps function
gous, or synthetic methods are not possible, the ultimate method
and impairment of knee extension and stability.
is free tissue transfer.l 4.15
A neurovascular tissue transfer is performed with the latissimus
dorsi muscle as a myocutaneous flap or a muscle flap.1 6 The latis-
Free Tissue Transfer
simus dorsi is harvested with a pedicle up to 15 cm long. For vas-
In rare cases, we have to cope with multiple recurrent hernias af-
ter surgery, or large defects due to radiotherapy, inflammation or
trauma (Figs. 80.7 to 80.12), or tumor (Figs. 80.13 to 80.15), where
FIGURE 80.13. A 64-year-old patient with ulcerating carcinoma of the blad-

d er and infiltration of the abdominal wall in the suprapubic area. Treat-
FIGURE 80.11. Intraoperative view of patient in Fig. 80.10. ment with free latissimus dorsi .
552 A. Berger and J. Liebau
cular anastomosis the inguinal or femoral vessels like femoral ves-

sels, external iliac vessels, or the inferior epigastric vessels end to
end or end to side to a side branch are possible. The thoracodorsal
nerve is coapted with 10-0 sutures end to end with a motor branch
of the femoral nerve (Fig. 80.16) after intraoperative function test
FIGURE 80.16. Anatomical preparation of the femoral nerve. Motor branch
by nerve stimulation.
marked with loop.
Reinnervation of the transferred tissue cannot be expected in
less than 6 to 8 months. For stability, a corset must be used at least
for this period of time. Mterwards the muscles of the abdominal
wall have to be trained with intense physiotherapy. cause minimal foreign body reaction and should be easy to
remove.
Prosthetic meshes made of polypropylene, e-polytetrafluoro-
Synthetic Materials ethylene, or the absorbable polyglycolic acid can be inserted. The
advantage is the absence of donor site morbidity. Disadvantages
A variety of synthetic materials are availableP The inserted ma- are the rigid structure of this material and possible infectious com-
terial should provide firmness and flexibility. The mesh should plications like chronic infection and intestinal fistulas. Prosthetic
meshes can be used in combination with other methods.
Conclusion
Abdominal wall reconstruction is a complex procedure and a chal-
lenge for the plastic surgeon. The cooperation of a general surgeon
should be obtained. Plastic surgery is needed in cases of recurrent
abdominal wall hernias, extended abdominal wall defects, or im-
pairment of abdominal wall function. A variety of surgical tech-
niques are used depending on size, etiology, and location of the
defect. Techniques range from skin grafts and myofascial flaps to
free tissue transfer and synthetic material. In some cases, several op-
erations are necessary, and sometimes a combination of techniques
will solve the problem. 18 Individual planning for each patient is nec-
essary in order to improve the patient's quality of life.
References
1. Cormack GC, Lamberty GH. The arterial anatomy of skin flaps. London:
Churchill Livingstone; 1986.
2. Stelzner F. Das Fascienskelett der Bauchhohle-Hernien und andere Stiirungen.
Kurzreferate DGCH, 110. KongreB: Demeter Verlag; 1993, Nr. 178.
3. Schildberg F-W, Vatankhah M, Nissen R. Chirurgische Behandlung des
Narbenbruches der Bauchdecken. Langenbecks Arch Chir. 1983;316:
319-323.
FIGURE 80.15. Postoperative view of patient in Fig. 80.13. 4. Ramirez OM, Ruas E, Dellon AL. Components separation method for
Commentary 553
closure of abdominal-wall defects: an anatomic and clinical study. Plast

Reconstr Surg. 1990;86:519.
5. Bendavid R. Experience in the Shouldice clinic in recurrent inguinal
hernia repair. Abdominal wall: function, defects and repair, St Moritz,
March 1998.
6. Klein P. Die Inlay/Onlay-Technik als funktionelle Rekonstruktion tier Bauch-
wand nach Naroenhernien und Naroenhernienrezidiven. Kursreferate
DGCHH, 110. KongreJ3: Demeter Verlag; 1993, Nr. 181.
7. Schumpelick V, Bleese N, Mommsen U. Chirurgie. Stuttgart: Enke Ver-
lag; 1989.
8. Wilker D. Narbenbruchoperationen. Breitner Chir OP-Lehre Band III.
Chir Abdomens. 1988:86--96.
9. Piza-Katzer H, Meissel G, Stachen G. Rekonstruktion von Bauch-
wanddefekten mit Coium. Chirurgie. 1979;50:775.
10. Taylor GI, Watterson PA, Zeit RG. The vascular anatomy of the ante-
rior abdominal wall: the basis of flap design. Perspect Plast Surg. 1991 ;5:1.
11. Hershey FB, Butcher HR. Repair of defects after partial resection of
abdominal wall. Am] Surg. 1964;107:586--598.
12. Houston GC, St Drew G, Vezquez B, et al. The extended latissimus
dorsi flap in repair of anterior abdominal wall defects. Plast Reconstr
Surg. 1998;81;6:917-924.
13. Wangensteen OH. Repair of large abdominal defects by pedicled fas-
cial flaps. Surg Gynecol Obstet. 1946;82:144-146. FIGURE C80.1. Diagrammatic illustration of transposed muscles, rectus
14. Berger A, Hierner R, Pallua N. New ways with reinnervated muscle femoris, and tensor fasciae latae.
transfer for abdominal wall reconstruction. Reconstr Microsurg Trends.
1993:67-68.
15. Berger A, Schneider W. Neue Wege mit mikrochirurgisch trans-
ferierten innervierten Muskellappen zur Rekonstruktion der Bauch-
wandbriIche. Langenbecks Arch Chir Suppl KongrejJbericht. 1993;276--281.
16. Tizian C, Berger A. Reconstruction of muscle function in extremities
after traumatic loss using free myocutaneous flaps. Proc 2nd Vienna
Muscle Symposion 6, 1985:1987.
17. Klinge U, Conze J, Klosterhalfen B, et al. Veriinderungen der Bauch-
wandmechanik nach Mesh-Implantation. Langenbecks Arch Chir. 1996;
381:323-332.
18. Schutter F-W, Kiroff P. Die netzverstiirkte Kutisplastik. Langenbecks Arch
Chir. 1995;380:249-252.
Commentary
Ralph Ger
The closure of abdominal wall defects by muscle transposition has
several advantages (Fig. C80.1). As the transposed muscle is a dy-
namic contractile tissue that responds to stimuli, it simulates the
action of the normal abdominal wall: An electromyograph of a
transposed rectus femoris contracts in response to coughing, un-
like an undisturbed muscle in the thigh.! Muscle is effective in
preventing a hernia; an abdominal hernia occurs through fibrous
tissue such as the linea alba, linea semilunaris, and fascia trans-
versalis of the inguinal canal, but rarely through healthy muscle.
There do not appear to be any problems of the lower extremi-
ties in terms of function, doubtless due to the action of the other
components of the quadriceps muscle. The only negative aspect
of the operative procedure is the creation of scarring on the thigh.
Indications for the Use of Transposed

Thigh Muscles for Abdominal Wall Defects
l. In congenital agenesis ofthe abdominal wall ("prune-belly syn- FIGURE C80.2. Illustrative operative procedure. The gracilis muscle is mo-
drome"), for which no alternative effective operative methods bilized and the inguinal dissection completed. The cord is depicted dis-
have been described placed inferiorly.
Part XIII
Emergency Surgery
81
Should Prostheses Be Used in
Emergency Hernia Surgery?
Xavier Henry and N. Bouras-Kara Terki
Currently, surgery of the anterior abdominal wall must meet high cular inguinal wall lined by the transversalis fascia, offers an ex-
expectations of excellent-and permanent-results. In prophetic cellent approach to the trouble spot and an ideal site for the de-
mode, Billroth envisaged in the 1870s the artificial "tissues of the ployment of a large reinforcing prosthesis. 3
density and toughness of fascia and tendon" used today as the In incisional hernias, there is, in addition to the need to rein-
treatment of choice for abdominal wall defects. force the parietal defect, the problem of reintegrating, inside a
This recourse to a prosthetic material is not recent: Many reduced abdominal cavity, a sometimes considerable mass of her-
varieties of materials proposed and tried marked the progress of niated viscera that constitutes, at worst, a second abdomen. Here
abdominal wall surgery in the twentieth century. Mter the aban- also the use of a plane of cleavage posterior to the muscu-
donment of metal prostheses, the appearance of synthetic poly- loaponeurotic wall will permit the insertion of reinforcing pros-
mers on the scene offered surgeons a solid, stable, more or less thetic material largely overlapping the edges of the parietal defect.
supple material that molds itself to the anatomical surfaces to be In all these situations, the use of a prosthetic material is often
reinforced. Mersilene®, introduced in France by Rives et al.,l has indispensable because it is porous, supple, nonbiodegradable, ca-
been used for hernia repairs in our service by Stoppa since 1965. pable of matching the convexity of the area to be reinforced, and
Many experimental trials and clinics have confirmed the place of rapidly colonizable by young connective tissue. This material must
these prostheses in the surgery of the abdominal wall. reconstitute an artificial endoabdominal fascia and not merely
The unquestionable success of prosthetic repair of large inci- function as a patch whose durability lies essentially in the me-
sional hernias and the relative rarity of septic complications, and chanical resistance of the structures to which it is attached.
above all, the possibility of healing infection without removing the Can the unarguable success of prosthetic repairs and a septic
prosthetic material, are additional arguments for the use of these risk that has become less prohibitive permit after all the use of this
materials. material in emergency situations and even in cases involving po-
These days, laparoscopic hernia surgery, so sparing of the struc- tentially contaminating procedures? To attempt a response to
tures of the abdominal wall (according to the statements of its these questions, we begin with personal experience and a review
originators), does not shrink from routine use of these prostheses of the literature.
in anatomical locations where the proponents of the materials
might not venture.
Can the considerable proliferation of techniques for prosthetic Our Experience
reinforcement in abdominal wall surgery make us forget the rules
laid down by Stoppa: that the procedure be carried out in an op- Having, in the course of 2000 prosthetic hernia repairs imposed
erating room reserved for the purpose, or in a rigorously prepared on ourselves the strict rules of asepsis, we needed to know whether
multipurpose operating room; adherence to "no touch" technique those rules could be respected in the emergency conditions of
and draping; repeated use of antiseptics during the procedure; complicated hernias. Betw~en 1970 and 1991, 264 complicated
and maintenance of a sterile operating field by the avoidance of hernias of the groin were operated on in emergency conditions;
all associated septic events, which automatically rules out use of of these, 148 were inguinal hernias and 116 were irreducible
this technique in emergency conditions? (strangulated or incarcerated) femoral hernias. This figure stands
Before answering this question, it is important to remember that beside 2907 ordinary hernias operated on during the same period
the goal of permanent hernia repair that every surgeon strives to (2756 inguinal and 151 femoral hernias). The predominance of
achieve can be reached only by understanding of two fundamen- inguinal hernias in men (115 vs. 33 in women) and of femoral
tal anatomical points: First, the large myopectineal orifice of hernias in women (89 vs. 27 in men) is here confirmed as well as
Fruchaud, 2 defended only by the transversalis fascia, constitutes a the greater frequency of strangulation in femoral hernias (43 % vs.
weak area through which all the hernias of the groin pass and 5% in inguinal hernias) (Table 81.1). In emergency conditions,
upon which the repair is built; and second, the existence of a bi- these patients were neither prepared nor selected. They were op-
lateral plane of cleavage between the peritoneal sac and the mus- erated on by surgeons who were not part of our team, which ex-
557
558 x. Henry and N. Bouras-Kara Terki
TABLE 81.1. Repair of hernias TABLE 81.3. Prosthetic repairs

Without Procedures No.
Hernias complications Strangulated" Male Female
Plugs 15
Inguinal 2756 148 115 33 Mersilene prostheses
Femoral 151 116 27 89 Unilateral 21
Total 2907 264 142 122 Bilateral 11
Absorbable prostheses
"or incarcerated? Unilateral 7
Bilateral o
plains the diversity of techniques employed. The hernia sac con-

tained small intestine in 148 cases, omentum in 47, sigmoid colon
in 17, appendix in 9, cecum in 3, and ovary in 1. Resections car- thetic materials. Stoppa et al. 4 proscribed the use of prostheses in
ried out involved the small intestine (35), omentum (22), sigmoid strangulated hernias, and Stoppa and Warlaumont5 elaborated
colon (2), appendix (9), and ovary (1) (Table 81.2). along the same lines: "The use of a prosthesis must be reserved
A musculoaponeurotic closure was carried out behind the sper- for cases in which the viability of the intestine is assured, where
matic cord in 190 cases (77%), with recourse to prosthetic mesh the operation takes place in an aseptic setting." In their own se-
in 54 cases (23%). Prosthetic repairs were divided between plugs ries, however, these authors admit the exceptional use of pros-
(15), nonabsorbable Mersilene prostheses (32), and absorbable thetic material, remarking, like Palot et al.,6 that the prosthesis was
prostheses ofVicryl® (7) (Table 81.3). In five cases, recourse to a put in place very soon after the onset of signs (less than 4 hours),
prosthesis was associated with a potentially contaminating proce- that is to say, in a situation where early removal of the cause of
dure (three small intestine resections, one enterotomy, and one strangulation made intestinal resection unnecessary.
appendectomy for localized appendicular peritonitis). Before such prudence, Pans et al. 7 prohibited the automatic use
In the early aftermath of this series of 54 prosthetic repairs, there of prosthetic material in the treatment of strangulated hernias,
was regrettably one death, following peritoneal carcinomatosis as- whether there was an intestinal resection or not. In this situation,
sociated with an irreducible femoral hernia. Other complications they carry out a median subumbilical laparotomy to explore the
were one infection requiring reoperation and limited excision of abdominal cavity and to treat the cause and the consequences of
the exposed prosthesis in a deep abscess, two scrotal hematomas the strangulation, while carefully protecting the operative field
that resolved, and one recurrence 2 years later in a patient with a from contamination. Then, after closing the peritoneum, they per-
unilateral Dacron® prosthesis. All of these patients healed. form a dissection of the preperitoneal space to insert the pros-
Between 1984 and 1995, we operated on 482 burst abdomens, thetic material (depending on the case, a unilateral prosthesis, a
44 of which were emergency cases due to strangulation or incar- double unilateral prosthesis, or a large bilateral prosthesis). In
ceration. We resorted in those situations to implantation of seven their series of 27 strangulated hernias treated in this manner, they
prostheses, five nonabsorbable Dacron, one intraperitoneal com- carried out 7 intestinal resections and 3 resections of necrotic ap-
posite (Vicryl-Mersilene), and one absorbable intraperitoneal pendices. 7
mesh. To these seven emergency prostheses, we add the placement While considering these extreme positions for or against the use
of a Vicryl prosthesis to treat one of our six peristomal ruptures. of prostheses in the treatment of strangulated hernia, one cannot
In these situations of risk, we encountered only one deep abscess, overemphasize the very great difference between inserting a large
which was treated successfully by local measures. reinforcing prosthesis into a widely dissected space, on the one
hand, and the occlusion of a narrow orifice with a prosthetic stop-
per, with hardly any dissection, on the other.
Review of the Literature
In strangulated hernias, the majority of authors prefer procedures Discussion
without prosthetic material because of the risk of infection. Thus
Rives et al.,l doubting the sterility ofliquid, no matter how clear, Nonabsorbable prosthetic materials have earned a place for se-
contained in the hernia sac, counseled against the use of pros- lected indications in regular open surgery of the abdominal wall.
TABLE 81.2. Contents of hernial sacs and resections

Condition
Hernial sac No. of
contents No. Healthy Ischemic Necrotic Perforated resections
Small intestine 148 25 92 28 3 35

Sigmoid" 17 2
Cecum 3 3 0
Appendix 9 2 4 3 9
Omentum 47 26 21 21
"Of which five had tumors.

81. Should Prostheses Be Used in Emergency Hernia Surgery? 559
From this brief review of the literature and our own personal ex- Conclusion
perience, it emerges that a certain number of strangulated her-
nias of the groin have been treated in emergency surgery with Prostheses have an important but nevertheless limited place in the
prosthetic material. Is this a case of imprudence to be condemned surgery of strangulated hernias of the groin. Reservations include
or of a calculated risk that gives the patient more of a chance to the following conditions: absence of identifiable infection, avail-
recover from a hernia at high risk for recurrence? It seems to us ability of a surgeon experienced in the identification and treat-
possible to establish reasonable limits for the use of prostheses in ment of hernias at high risk for recurrence and in the matching
this type of emergency surgery and to propose a certain number of adequate procedure with the correctly assessed operative risk,
of criteria not to be transgressed. the insertion of a unilateral prosthesis by an anterior approach,
The determination of a precise timetable for intervention is not rather than a bilateral prosthesis by the posterior approach, and,
always possible, and the rule that sets the borderline between asep- finally, a high quality technical environment.
sis and potential contamination of the operative site at 4 hours is
often of doubtful applicability. The operative conditions have to
be taken into consideration: Emergency surgery in a multiple-use
operating room, where operations routinely follow one another,
introduces a pejorative element that rules out the use oflarge pros-
References
theses. For elective operations, Stoppa insisted on rigorous asep-
1. Rivesj, Stoppa R, Fortesa L, et al. Les pieces en tulle de Dacron et leur
sis, a requisite in techniques involving heterologous implants.
place dans la chirurgie des hernies de l'aine. Ann Chir. 1968;22:159-171.
The favorable published results in these series (neither mor- 2. Fruchaud H. Anatomic chirurgicale des hernies de l'aine. Paris: Doin; 1956.
bidity nor mortality depended on the use of prosthetic material) 3. Odimba BFK, Stoppa R, Laude M, et al. Les espaces clivables sous-
bear witness to the quality of the macroporous material used and parietaux de l'abdomen. ] ChiT. 1980;117:621-627.
the respect for the septic risk by the experienced surgeons. Nev- 4. Stoppa R, Petitj, Abourachid H, et al. Procecie original de plastie des
ertheless, we do not recommend the routine use of parietal pros- hernies de l'aine: l'interposition sans fixation d'une prothese en tulle
theses in emergencies when an intestinal resection is required. de Dacron par voie mediane sous-peritoneale. Chirurgie. 1973;99:119-
Emergency surgery has as its goal the relief of a life-threatening 123.
strangulation. The evaluation of the risk of recurrence in the short 5. Stoppa R, Warlaumont C. The preperitoneal approach and prosthetic
repair of groin hernia. In Nyhus LM, Condon RE (eds): Hernia, 3rd ed.
term is also part of the ethical duty of the surgeon, particularly
Philadelphia: J.B. Lippincott; 1989:199-221.
for aged and fragile patients, but emergency circumstances rarely
6. PalotjP, FlamentjB, Avisse C, et al. Utilisation des protheses dans les
permit the rigorous preparation of safe conditions for the use of conditions de la chirurgie d'urgence. Etude retrospective de 204
prostheses. Suppuration in contact with foreign material remains hernies de l'aine etranglees. Chirurgie. 1996;121:48-50.
a grave complication, the healing of which is directly or indirectly 7. Pans A, Plumacker A, Legrand M, et al. Traitement chirurgical des
related to the volume of foreign material, the surgical approach, hernies inguino-crurales etranglees par interposition de prothese en sit-
and the complexity of the technique used. uation preperitoneale. Acta ChiT Belg. 1991;91:223-226.
82
Groin Hernias in the Adult
Presenting as Emergencies
David Watkin
Introduction and Definitions ter months as in the summer,15 suggesting that coughing may be
an important precipitating cause. The constriction results in ve-
A minority of patients with a groin hernia present as an emer- nous and lymphatic congestion, vascular engorgement, and edema
gency, with a painful and irreducible mass or with intestinal ob- of the contents. A progressive increase in the volume of the con-
struction. The terminology for the complications affecting a tents follows, so that they cannot be reduced, and further raises
hernia is confusing, as various authors refer to irreducibility, incar- the pressure at the neck so that venous and arterial flow is ulti-
ceration, obstruction, and strang;ulation. Each of these terms involves matelyarrested. Once that point is reached, the ischemic contents
irreducibility, for which incarceration is merely a synonym.l.2 of the sac will become gangrenous unless released: bowel within
Irreducibility is often of long duration and, in the absence of about 6 hours16 and omentum after a longer interval. Irreversible
acute symptoms, may be safely attributed to adhesions within the changes occur first at the constriction ring. The rate at which a
hernial sac. Occasionally it is due to inspissated feces or to the de- partial vascular occlusion progresses to completeness is quite vari-
velopment of pathology in the contained bowel. An asymptomatic able. A few hernias will, at operation after only 6 hours, be found
femoral hernia is often irreducible but, at operation, generally to contain irreversibly ischemic gut, while in others the contents
consists of an empty sac surrounded by a layer of extraperitoneal may be viable despite a 4-day history. It is impossible to know
fat3 contained in the stretched cribriform fascia. In Tasker's series whether, in those cases in which partially ischemic bowel is found
of 35 elective operations for femoral hernia,4 one sac contained at operation, this would have progressed to gangrene. The degree
bowel, three omentum, and the remainder were empty. Such her- of ischemia in a strangulated hernia cannot be assessed clinically
nias can safely await an elective repair, but irreducibility carries an unless there are infective changes indicating that the contents are
increased risk of strangulation so the operation should be sched- necrotic.
uled as soon as possible. When an irreducible hernia presents with These terminological differences all stem from the impossibil-
a history of hours, or a few days, there is concern that there may ity of determining, clinically, the state of the contents of a hernia
be impairment of the blood supply to its contents, with the po- presenting acutely. The clinical decision is that an emergency op-
tential to progress to gangrene. eration is required, hence the title of this chapter. Invariably, when
Most authors use incarceration to describe hernias that are irre- competing for priority in a busy emergency operating room, sur-
ducible but not acutely symptomatic.5-8 Others consider that the geons book such cases as "strangulated"! This is surely the appro-
word incarceration is confusing and is best avoided. 9 In the past it priate clinical term and also the most suitable description of the
implied intestinal obstruction without ischemia,1O but it is unlikely pathology found at operation when there is any degree of inter-
that the lumen of the contained intestine can be completely oc- ference with blood flow.
cluded without some impairment of blood flow.l 1.12 Conversely,
omentum or a partial enterocele (Richter's hernia) may become
gangrenous without intestinal obstruction. An obstructed hernia
Incidence of Strangulation
is therefore not a useful term, although intestinal obstruction may
The incidence of strangulation in groin hernias is not just of pass-
establish that an irreducible hernia is strangulated, and it is then
ing interest but is relevant to the indications for elective opera-
appropriate to describe the patient as having small bowel ob-
tion. The effectiveness of a policy of repair of all hernias may
struction due to a strangulated hernia.
be judged partly by its capacity to reduce the incidence-and
Strangulation of a hernia means compromise of the blood sup-
mortality-of strangulation. As the risk of strangulation varies with
ply to its contents; unrelieved, it will lead to necrosis. The hernia
the site, inguinal and femoral hernias are considered separately.
will generally be painful, and if it contains a loop of bowel the fea-
tures of intestinal obstruction will develop. The sequence of events
has been well described by Lauffman and Nora,13 Giles,14 and Inguinal Hernia
Mann. 9 A sudden increase in intraabdominal pressure forces such
a volume of contents into the hernial sac that it is a tight fit at the The incidence of strangulated inguinal hernia in large series from
neck. The incidence of strangulation is twice as high in the win- Western Europe varies from 3.25 to 7.16 per 100,000 population
560
82. Groin Hernias as Emergencies 561
TABLE 82.1. Incidence of strangulated inguinal hernias in adults TABLE 82.2. Strangulated inguinal hernias: type of hernia
Years of No. of No. per First author Indirect Direct

data Population strangulated 100,000 per
First author collection served hernias year Frankau19 559 14
McEntee 21 33 0
Quill17 1969-80 180,000 154 7.16 Williams26 43 5
Andrews 15 1975-80 250,000 66 4.65 Total 635 (97%) 19 (3%)
Hjaltason 1 1973-80 338,000 88 3.25
Watkin 18 1984-91 368,000 158 5.60
rarely strangulate.1 9,25 Unfortunately, few reports of strangulation

per annum (Table 82.1), the incidence being greatest in the sev- differentiate between the types of inguinal hernia, but, combin-
enth 19,20 and eighth21 decades. Of more relevance to the individ- ing three series, only 3% were direct (Table 82.2). Thus the risk
ual patient is the risk of strangulation if a hernia is not repaired. of strangulation for direct inguinal hernias is only about 10% of
This can be determined by reference to populations where elec- that for indirect hernias. This might justify a policy of not repair-
tive operation was unavailable. Berger22 in the 1890s asked 10,000 ing asymptomatic direct inguinal hernias, but for the difficulty
patients attending a truss clinic about previous episodes of incar- of distinguishing these clinically.27 The situation is different in
ceration and estimated the risk as 0.37% per year. Neuhauser23 re- West Mrica, where funicular direct hernias account for 15% of
ported a population study in Colombia, where elective surgery was strangulations. 28
virtually unobtainable, and found a similar rate of strangulation
of 0.29%. Gallegos and colleagues 24 reviewed the case notes of 439
adults having repair of inguinal hernias, including 22 with stran- Has a Policy of Elective Repair of
gulation. From the patients' lengths of history, they calculated the Inguinal Hernias Reduced the
cumulative probability of strangulation as 2.8% at 3 months, ris-
ing to 8.6% at 5 years (Fig. 82.1), but the confidence limits are
Incidence of Strangulation?
wide. Furthermore, approximately 10% of strangulated inguinal
There is no direct evidence that the incidence of strangulation has
hernias have no past history.19 The probability of strangulation for
been reduced by a policy of elective repair. However, strangula-
inguinal hernias thus appears to lie in the range 0.3 to 2.8% per
tion has a lower population incidence in the United States than
annum, with some loading of risk in the first few months.
in the United Kingdom, perhaps related to the greater frequency
of elective repair (280 vs. 100 per 100,000 per annum 29 ). Another
Type of Inguinal Hernia and Risk indirect measure is the proportion of cases of acute intestinal ob-
struction due to strangulated hernias. In 1932, Vick20 reported that
of Strangulation
they were responsible for 49% of 6892 cases. The proportion had
fallen to 24% in 197830 and to 20% in 1987. 31 However, these
At elective operation, 25 to 50% of adult inguinal hernias are of
the direct variety.18 It is widely stated that direct inguinal hernias changes may also reflect a relative increase in the prevalence of
postoperative adhesions. In Accra, from 1987 to 1988, inguinal
hernia still accounted for 47% of intestinal obstruction,32 re-
maining the most common cause.
50 Femoral Hernia
! '5 40
Femoral hernias comprise only 11 % of groin hernias,5 but account
for between 34%1 and 56%19 of strangulated groin hernias in
C)
c
g adults. The proportion of femoral hernias presenting with stran-
gulation averages 36% in 10 series (Table 82.3) compared with
(II 30
CD
C)
less than 10% of indirect inguinal hernias. 2,38 Gallegos and col-
~CD 20
~ TABLE 82.3. Proportion of femoral hernias presenting as emergencies
:. 10 No. of No. of Percentages of
elective emergency emergency
First author operations operations operations
McNealy33 179 225 56

o 12 24 36 48 60 72 84 96 Douglas34 45 51 54
Length of history (months) Rogers 35 1104 323 24
Waddington36 51 77 60
Wheeler3 7 36 44 55
FIGURE 82.1. Inguinal and femoral hernias: cumulative risk of strangulation Hjaltason 1 117 46 28
related to length of history. (Reprinted from Watkin,18 by permission of Tasker4 39 38 49
Martin Dunitz, adapted from Gallegos et al.,24 BrJ Surg., with permission.)
562 D. Watkin
leagues24 reviewed the records of37 patients with femoral hernias, strangulated groin hernia.39 Although some indirect left inguinal
including 12 that were strangulated, calculating a cumulative prob- hernias contain sliding sigmoid colon, it is rare for this to stran-
ability of strangulation of 22% at 1 month and 45% (confidence gulate, perhaps due to its large bulk and wide neck or because the
interval 23 to 67%) at 21 months. These rates are strikingly higher blood supply of a sliding hernia does not lie within a peritoneal
than for inguinal hernias (Fig. 82.1), emphasizing the need for ring.
prompt elective repair. Apart from the presence of a complete loop of bowel in a stran-
gulated hernia, there are other anatomical variations (Fig. 82.2) .
The most frequently encountered is a partial enterocele (Richter's
Anatomy of Strangulation hernia), but there are also the rarities of Littre's hernia, Maydl's
hernia, and proximal loop strangulation. Reduction en masse is also
The precise mechanism constricting the neck of a strangulated considered here. For convenience, their specific clinical and op-
hernia has been disputed, as between either muscular and liga- erative features are included in this section.
mentous structures, or the peritoneum and its immediate fascial
support. For inguinal hernias, Frankau 19 reported that over the
age of 10 years, 80% had the constriction at the internal ring and Richters Hernia
20% at the external ring. In infants the inguinal canal lacks obliq-
uity, so the constriction is at the external ring and the hernia is In 1606, Hildanus described a patient who, after apparent reduc-
almost always reducible after sedation and elevation, but some- tion of a groin hernia en masse, developed an abscess and then a
times, especially if incompletely descended, the testicle may in- fecal fistula; 2 months later the fistula had healed.4o He hypothe-
farct. It is not uncommon for an adult inguinal hernia to reduce sized that only part of the intestinal lumen had been involved.
once the patient is anesthetized, suggesting that muscle tone has During the eighteenth century, various authors reported cases of
been contributing to the constriction at the internal ring. For partial herniation of the small intestine, notably Richter41 in 1785.
femoral hernias, the lack of concomitant femoral vein occlusion In 1887, Treves 40 collected 50 cases of partial enterocele, defined
suggests that the constriction is caused by the neck of the sac rather as strangulation of part of the circumference of the intestinal wall
than the boundaries of the femoral canal. within a hernial orifice. He named the condition Richter's hernia
A strangulated groin hernia may contain bowel (80%), omen- to distinguish it clearly from Littre's hernia (of Meckel's divertic-
tum (15%), the appendix, or, rarely, another viscus such as an ulum), with which it had been confused.
ovaryB or even the pregnant uterus. lO Strangulated inguinal and Richter's hernia usually involves distal ileum, but any sufficiently
femoral hernias containing bowel are respectively three times and mobile part of the intestine may be implicated. Although such a
two times as common on the right 15 ; presumably the obliquity of hernia may be found at an elective operation, its importance is in
the base of the mesentery facilitates passage of distal small intes- strangulation. The majority are groin hernias, predominantly
tine into a right-sided hernia. Large bowel is rarely involved in a femoral. In Frankau's series of 1487 strangulated hernias,19
A B
c D
FIGURE 82.2. Anatomical variants in groin her-

nias. (A) Richter's hernia. (B) Maydl's hernia.
(C) Proximal loop strangulation. (D) Reduc-
tion en masse.
Richter's hernia was found in 77 (11.3%) femoral and 15 (2.2%) obstruction, a mobile cecum and terminal ileum lie in a right in-
inguinal hernias and in only two other hernias. If only a small pro- guinal hernia with a proximal loop of small bowel strangulated
portion of the circumference of the bowel is involved, there is no through the intraabdominal window behind them. 49 For this to
obstruction, and the effects are solely of strangulation. With happen, the cecum must be lying free, not sliding.
greater encroachment on the lumen, there is an increasing de- Tenderness, or a mass above the inguinal ligament, in the pres-
gree of obstruction. Scarpa,42 in an experimental model, demon- ence of a strangulated inguinal hernia, may suggest one of these
strated that the loss of two-thirds of the circumference resulted in diagnoses. Usually, however, such rare complications will be iden-
complete obstruction. tified only at operation. There is a risk that the contents of the
The clinical features derive from the presence of strangulation, hernia will be assessed as viable and returned to the abdomen,
with or without intestinal obstruction. The strangulated knuckle without the strangulated intraperitoneal loop being recognized.
of bowel may be painful, but some patients do not notice it. The The clues are, first, bloodstained or foul smelling fluid dispro-
local physical sign is a tender irreducible mass at the hernial ori- portionate to the condition of the bowel within the hernia; and
fice, but it may be missed if it is small and the patient is obese. If second, for Maydl's hernia, the presence of two or more loops or,
obstruction is partial or absent, presentation may be dangerously for proximal loop obstruction, the presence of the cecum in the
delayed for 2 to 4 days because the abdominal symptoms are not sac. In these circumstances, it is essential to examine bowel prox-
impressive. 43 ,44 Complete obstruction has the typical clinical fea- imal to the neck of the hernia; in the case of proximal loop ob-
tures, but there may still be delay if the mass in the groin is not struction, there may be a length of normal bowel between the
recognized. There is distension and borborygmi, and plain radio- hernia and the strangulated loop.
graphs show dilated loops. A Richter's hernia may be suggested in These hernias are rare in Europe and North America. Frankau19
a patient with a strangulated femoral hernia and incomplete small found only four (0.6%) MaydI's hernias in his series of strangu-
bowel obstruction, but the diagnosis is generally made at opera- lated inguinal hernias, but Bayley5° had 5 among 26 in Ghana and
tion. The essential is to diagnose strangulation and operate once Cole 28 had 3 in a series of 157 in Nigeria. Most reports of both
resuscitation is adequate. conditions have been from Mrica, where it is likely that large un-
If a Richter's hernia is neglected, the contained knuckle of bowel treated hernias and a high incidence of mobility of the cecum and
will necrose, with two possible outcomes. The intraperitoneal bowel right colon predispose to these complications.
may separate from the necrotic portion and the hernial orifice, re-
sulting in peritonitis. 45 Alternatively, the bowel may remain adher-
ent to the hernial ring while the contents progress to abscess Reduction en Masse
formation, which either spontaneously or by drainage leads to a fe-
cal fistula, as in the original case described by Hildanus. Fortunately Reduction of a strangulated hernia en masse consists of the forcible
these outcomes are now rare in developed countries, but they em- displacement of the hernial sac and its contents into the ex-
phasize the need for prompt diagnosis and operative treatment. traperitoneal space. The prerequisites are a tight peritoneal con-
striction ring and a lax musculoaponeurotic aperture, with the
addition of external force. The constriction ring of peritoneum re-
Littre's Hernia mains in place, so strangulation of the contents persists, although
the sac may be disrupted. There is a serious risk that mass reduc-
Littre's hernia, by the strict definition introduced by Treves,40 con- tion will be regarded as a "success" and that the continuing stran-
tains only a Meckel's diverticulum-there had previously been con- gulation will not be appreciated. This is one of the arguments
fusion with Richter's hernia. It is rare; there were four inguinal against attempts at reduction of symptomatic "irreducible" hernias.
and one femoral Littre's hernias in Frankau's series of 1487 stran- Pearse 51 collected a series of 193 cases of reduction en masse
gulations,19 and fewer than 50 cases have been reported in the from the literature in 1931, constituting the best source of infor-
twentieth century. According to Keynes, 50% are inguinal, 20 to mation. He estimated the risk of mass reduction, at that time, as
25% are femoral, and most of the remainder are umbilical. 46 Lit- 0.3% of strangulated hernias. The hernia had been reduced by
tre's hernia may be found at elective operation, but most reports the patient in 35% of cases and by the medical attendant in 60%,
are of strangulation, the effects of which are local, as there is no whereas in 5% the condition was the result of an inadequate op-
intestinal obstruction. If not treated surgically, the potential out- eration. The majority (87%) were indirect inguinal hernias, and
comes are fistulation (notably from the umbilicus) or peritonitis. only 13% were femoral. Renton 52 added 22 further cases, includ-
ing one direct inguinal hernia. The most important physical sign
was the absence of the previously reported hernia. In addition,
51 % had a mass either above the internal ring or in the iliac fossa.
Maydls Hernia and Proximal In 1970, Barker and Smiddy53 pointed out that in their two cases
Loop Strangulation the testicle was drawn up into the neck of the scrotum and that
traction produced pain in the iliac fossa.
These two rare complications of inguinal hernia involve strangu- The mechanism of reduction en masse has been controversial.
lation of a loop of intestine within the peritoneal cavity. In MaydI's Moynihan54 proposed that the reduction was into the preexisting
hernia, two or more loops of gut lie in the hernial sac, but it is preperitoneal sac of a bilocular hernia, but this is not a condition
the intervening loop, within the abdomen, that is most severely otherwise described at either open or laparoscopic operation. Oth-
affected-hence "hernia-en-W." Usually the cecum and a loop of ers preferred the simpler explanation of forcible reduction creat-
ileum lie in the sac of a right inguinal hernia, but rarely the he- ing a preperitoneal space. 55,56 Barker and Smiddy's sign supports
patic flexure,47 or transverse or sigmoid colon 48 is involved, with this mechanism. 53
strangulation of the intervening loop of colon. In proximal loop Reduction en masse was reported more frequently in the early
564 D. Watkin
years of the twentieth century, when operative treatment was less testinal obstruction, if established. A strangulated hernia is irre-
accessible and more hazardous. However, the diagnosis still needs ducible, but also tense and tender. It is often missed and must be
to be considered when evidence of intestinal obstruction persists sought specifically in any patient presenting as an emergency with
after a difficult reduction of a hernia. Surgical exploration should abdominal pain. If the hernia contains necrotic bowel, the over-
then be by laparotomy or a preperitoneal approach. 57 lying skin may show signs of inflammation and the patient may be-
come pyrexic. Intestinal obstruction, if present, is usually ileal, so
the abdominal distension is central and bowel sounds are typically
Pathophysiology obstructive. If obstruction is prolonged, the signs of fluid deple-
tion will progress.
Strangulated omentum is painful and tender and may result in ad-
hesions within the sac but is no threat to life. When bowel is stran-
gulated, however, there are potentially two serious consequences, Investigations
intestinal obstruction and necrosis.
If the sac contains a complete loop of intestine, or a substantial Hematocrit and blood urea and electrolyte estimations will assist
knuckle in a Richter's hernia, complete intestinal obstruction will in assessing the fluid deficit. Patients with severe dehydration
result, typically at the level of the distal small bowel. The accu- should also have blood gas and acid/base analysis. A plain ab-
mulation of secretions in the dilated bowel, and loss by vomiting, dominal radiograph may confirm intestinal obstruction and, if
lead to depletion of water and electrolytes and to contraction of strangulation is in doubt, this will establish the diagnosis. Theo-
the extracellular compartment.28.30.35.58.59 The urine output falls retically, duplex ultrasound or laser Doppler flow measurement
in compensation and uremia follows. If the patient presents late, might identity ischemia, whereas in unusual circumstances, such
and so does not receive fluid replacement, the blood urea may be- as reduction en masse, computed tomography may clarity the situ-
come grossly elevated over a few days, sometimes reaching 40 ation. In practice, no method, clinical, radiological, or laboratory,
mmol/L or more, with a failure of acid/base homeostasis. Ulti- can reliably identity ischemic bowel. 3o
mately, as the fluid deficit reaches 8 to 10 L, the patient will be-
come significantly hypovolemic. Where a Richter's hernia contains
a smaller knuckle of bowel, say one-third of the circumference, Differential Diagnosis: Symptomatic Hernia
the process is more insidious but may be neglected for longer, re-
sulting in even greater fluid depletion. Occasionally, other conditions may accompany45.62 or mimic a
The time interval before the bowel in a strangulated hernia be- strangulated hernia, notably pus draining from the peritoneal cav-
comes necrotic is variable. The minimum is about 12 hours, but ity. Cronin and Ellis 63 collected 30 symptomatic hernias, of which
the bowel may be found still to be viable after 3 or 4 days. Once 16 were due to perforated appendicitis and others to perforated
necrosis occurs, the intestine becomes permeable to bacterial en- peptic ulcer, pyosalpinx, a bile leak, or primary pneumococcal
dotoxin and then to bacteria from the lumen. Fortunately the her- peritonitis, but in 10 no cause was identified at laparotomy. Acute
nial sac is relatively avascular so that absorption and systemic appendicitis64 or other inflammatory conditions65 ,66 or primary
effects are much less marked than for necrotic bowel within the neoplasms (for example, in the sigmoid colon 67 ) or metastatic de-
general peritoneal cavity. Therefore, it is important, at operation, posits 68 in the sac may rarely be mistaken for a strangulated her-
to minimize dispersal of the fluid from the sac. As a consequence nia, but generally they will have a longer history.
of the escape of bacteria, a neglected strangulated hernia may pre-
sent, after several days, as an abscess, usually from a Richter's or
a Littre's hernia, where acute intestinal obstruction has not set the Management
pace. If the abscess is drained, or discharges spontaneously, a fe-
cal fistula will result. Alternatively, the bowel may separate from Unless the acutely presenting hernia can be reduced safely, an
the neck of a gangrenous Richter's hernia, giving rise to general- emergency operation will be necessary.
ized peritonitis or a localized abscess. Ischemic damage first af-
fects the mucosa so that, if marginally viable intestine is returned
to the abdomen, a fibrous stricture may develop.5O The patient ex- Manual Reduction or "Taxis"
periences recurrent colic and re-presents some weeks later with
intestinal obstruction. If the bowel is more seriously damaged, it Taxis is an archaic term used to describe an attempt at reduction
may perforate, resulting in generalized peritonitis or an abscess of a hernia that is acutely irreducible. It was popular when oper-
or small bowel obstruction due to adhesions. 61 ative mortality rates were high,69 but was then criticized on ac-
count of the risks of injury to the bowel, reduction of gangrenous
bowel, or reduction en masse. Kauffman and O'Brien 2 attempted
Clinical Features reduction of inguinal hernias in 81 of 102 adults, excluding those
with a history of over 24 hours and/or clinical evidence sugges-
The patient presents with a painful lump in the groin and/or fea- tive of gangrene. Sixteen were reduced after elevation of the feet
tures of acute intestinal obstruction. If the history is short (a few and a further 36 after analgesia or a muscle relaxant; none of these
hours), local symptoms predominate, although there may be vom- developed evidence of nonviable bowel. Hjaltason 1 added the re-
iting with the initial pain. Contrariwise, patients with a few days' sults from two other series 70,71 to give an incidence of reduction
history of abdominal colic, vomiting, and absolute constipation, en masse of 2 of 689, with one additional, fatal, case of intraperi-
indicating intestinal obstruction, may not have noticed a lump. toneal reduction of gangrenous bowel found at operation 24 hours
The physical signs likewise relate to the hernia itself and to in- later. The usual physical examination to determine irreducibility
does, of course, involve an attempt at reduction. A reasonable pol- Lotheissen's incision (through the inguinal canal), or a preperi-
icy for inguinal hernias is to give analgesia, while awaiting opera- toneal approach (McEvedy75) . Thomas 76 proposed a logical strat-
tion, and then to make a further attempt at reduction; if this is egy of an initial infrainguinal incision, with reassessment after
successful, the patient can be rescheduled for an early elective reopening the sac; if the viability of the bowel is in doubt, or resec-
pair. The chance of reduction of a strangulated femoral hernia is tion is needed, he then makes a McEvedy incision, thus avoiding
too low! to justify the greater risk incurred by postponing surgery. the trauma of reducing an anastomosis through the femoral
canal. 76 However, majority opinion favors the McEvedy incision in
all strangulated femoral hernias for its better access. Some authors
Preoperative Preparation also prefer a preperitoneal approach for strangulated inguinal her-
nias.77,780nly if there is thought to be reduction en masse or prox-
If the hernia cannot be reduced, an emergency operation is re- imal loop strangulation or some coincident intraabdominal
quired, but appropriate preoperative preparation is essen- pathology is a laparotomy indicated. There are, as yet, few reports
tial.!3.3o,58,72 The scenario ranges from a fit young man with a few of laparoscopic management of strangulated hernias.79,8o
hours' history of a painful and irreducible inguinal hernia to an
elderly female with some days of acute intestinal obstruction due
to a strangulated femoral hernia. The former needs only minimal Assessment of the Contents
resuscitation and an immediate operation, aiming to release the
bowel while it is still viable. The latter may have a fluid deficit of The sac is opened carefully to avoid damage to its contents. The
8 to 10 L, so the priority is to defer operation for up to 12 hours appearance of the fluid and any odor of ischemic gut should be
while this is replaced. The bowel may already have been irreversibly noted and the fluid removed to minimize contamination. Omen-
damaged so that resection was inevitable, or, surprisingly, it may tum, if viable, is returned to the abdomen, or, if not, is resected.
still be viable despite the wait. Achieving the right balance between Bowel must not be allowed to slip back into the abdomen, or a
time for adequate resuscitation and the urgency of surgery will laparotomy may be needed to retrieve it. Alternatively, laparoscopy,
maximize the patient's chance of survival. 73 This is still not always via the hernial sac, has been utilized.8! Mter dilation of the neck
appreciated: In 1987, the CEPOD Report identified failure to re- of the sac (Fig. 82.3), the intestine is eased out to allow inspection
suscitate or operation before resuscitation was adequate as im- of the site of constriction. Only rarely is it necessary to incise the
portant causes of mortality.74 margin of the hernial orifice, either laterally from the external
When substantial fluid replacement is required, ideally this ring or medially from the femoral canal (from above to visualize
should be given in an intensive care unit. A urethral catheter is an aberrant obturator artery).
inserted to monitor urine output and a central venous pressure Once the bowel has been released, it is assessed for viability. At
(CVP) line used to avoid overload, especially in the elderly. All pa- one extreme, it rapidly reverts to normal and can be replaced in
tients should have nasogastric suction intubation, to minimize the the abdomen. At the other extreme, it is obviously gangrenous-
risk of aspiration, and prophylaxis against venous thrombosis. As black, gray, or green; flaccid; malodorous and without a sheen-
there is the possibility of contamination at operation, broad-spec- and must be resected. If its viability is doubtful, warm packs are
trum antibiotic prophylaxis should be given, including coverage applied and 5 minutes allowed, while the anesthetist gives 100%
against anaerobes. oxygen, before reassessment. Particular attention must be paid to
Operation for Strangulated Hernia

Only aspects of operative management specific to strangulated her-
nias is considered here; for further operative details, please see
the relevant chapter.
Anesthesia
General anesthesia is usually employed, as it affords greater flexi-
bility if there are unexpected findings or for bowel resection. A
cuffed endotracheal tube must be used to prevent aspiration.
Sometimes the relaxation produced by the anesthetic results in re-
duction of the hernia, but gangrenous bowel is unlikely to have
escaped, so it is not then necessary to proceed to laparotomy un-
less there is another indication, such as malodorous fluid.
Approach
For an inguinal hernia, the standard groin incision provides ade- FIGURE 82.3. Dilation of the neck of the hernia to release the constriction
quate access for bowel resection via the internal ring, which may and allow the proximal bowel to be drawn down for inspection. (Reprinted
be enlarged laterally if necessary. Strangulated femoral hernias from Kirk RM. General surgical operations, 3rd ed. New York: Churchill Liv-
have been managed successfully by the infrainguinal route, ingstone; 1994, with permission.)
566 D. Watkin
the constriction rings and to the antimesenteric border, where three 3,84,85 in the 1990s produced better results. Three factors in-
ischemia is most severe. If there has been improvement-visible fluence this mortality: age, the duration of symptoms, and the need
mesenteric pulsation, improvement in color (although bruising for bowel resection. Under the age of 30 years, death from stran-
may persist) , and return of peristalsis through the affected bowel- gulated hernia occurred in only 4% of patients in Frankau's se-
then it is viable and may be returned to the abdomen. In the ab- ries l9 and is now extremely rare, but there is now a greater
sence of such improvement, resection is required; "if in doubt, proportion of patients in the older age groups, with higher mor-
resect." The lines of section must be through viable intestine, and talityrates. In 1931, only 14% ofFrankau's cases were over 70 years.
anastomosis is by the surgeon's usual technique. Occasionally, the By 1981, Andrews l5 had 51 % in that age group and Hjalasonl had
localized ischemia at a constriction ring, or from a small Richter's 44% over 75 years; more recently, Nicholson et al. 84 had 68% over
knuckle, may be invaginated with a seromuscular suture. 65 years and Brittenden et al. 3 71 % over 70 years. It seems that
the increasing proportion of frail elderly patients has obscured
any improvement in surgical care. As a result, a strangulated groin
Repair
hernia is now more dangerous than cardiac surgery!
The mortality rate was strongly related to the duration of stran-
The sac is dealt with in the usual way, but the method of repair
gulation in Frankau's series. 19 Six percent of those operated upon
for strangulated hernias is now contentious because of the possi-
for inguinal hernia before 24 hours died compared with 30%
bility of contamination, particularly if a resection is necessary.
thereafter; the figures for femoral hernias were 4% and 21 %, re-
There have been claims that the risk of infection using mesh is ac-
spectively. Cole,28 in West Africa, had no mortality for strangulated
ceptably low,82 but many prefer to use a nonprosthetic technique
hernias admitted within 24 hours, but 21 % of those admitted on
(such as the Shouldice). For femoral hernias, simple closure of
the fourth day died. Andrews,15 in 1981, had 1.4% mortality when
the canal avoids this dilemma.
the history was less than 24 hours, rising to 21 % at over 48 hours.
The incidence of gangrene increases with the duration of stran-
Postoperative Care gulation,34 the two factors being interrelated. The need for bowel
resection approximately doubles the mortality,86 as is demon-
Elderly patients with strangulated hernias have a high incidence strated in Table 82.4. However, although the percentage of mor-
of comorbidity and may require careful monitoring in a high- tality is greater for those requiring resection, analysis of five series
dependency unit or supportive therapy in an intensive care unit. since 1980, for which the necessary data are given, shows that 43%
of the deaths were in patients not needing resection,I,3,4,15,72 re-
flecting the severity of the physiological disturbance. Cole 28 con-
Results cluded that five out of eight early deaths in his series were related
to inadequate perioperative fluid replacement. In a recent series
Mortality of 54 assorted strangulated hernias, 15 required resection at a
mean delay of 96 hours compared with 40 hours for those with vi-
There has been little improvement in mortality rates for strangu- able bowel: two patients died, neither following resection. 87 In
lated groin hernias over the past 75 years (Table 82.4), although these elderly patients, supportive perioperative care is as impor-
for femoral hernias two small series36,37 in 1971 and 1975 and tant as prompt surgery.
TABLE 82.4. Mortality and resection rates for strangulated inguinal and femoral hernias
Year of No. of Percent overall No. of Mortality of

,
First author publication patients mortality resections resections (%)
Inguinal hernias
Frankau19 1931 604 13.4 32 50
Vick20 1932 1378 11.5
Requarth70 1948 145 13.1 18 72
Dennis83 1978 118 17 15 30
Hjaltason1 1981 86 7 8 37.5
Andrews l5 1981 66 13.6 6
Femoral hernias
Rogers (collected") 35 1959 1440 17
Waddington 36 1971 77 1.4 14
Wheeler37 1975 44 2.3
Dennis83 1978 69 30 35 46
Hjaltason1 1981 46 11 10 20
Andrews l5 1981 72 15 13
Tasker4 1982 38 15.8 12 42
Nicholson84 1990 63 8 22
Brittenden3 1991 44 5 4 25
KemlerB5 1997 33 9 9
'Some authors do not give the numbers of bowel resections or the mortality for this subgroup.
"Total from 11 papers, published 1900-1959, collected by Rogers. 35
Postoperative Complications 13. LaufIman H, Nora P. Physiological problems underlying intestinal

strangulation obstruction. Surg Clin North Am. 1962;42:219-229.
Operations for strangulated hernia are subject to the complica- 14. Giles G. The abdominal wall and hernias. In Cuschieri A, Giles G,
tions that occur after elective repair, but with a higher incidence.72 Moosa A (eds): Essential surgical practice, 2nd ed. London: Wright;
1988;1256-1268.
Bowel ischemia and the need for resection inevitably contaminate
15. Andrews N. Presentation and outcome of strangulated external her-
the wound and increase the risk of wound infection. 88 The older
nia in a district general hospital. Br] Surg. 1981;68:329-332.
average age of the patients, and the associated comorbidity, com- 16. Stolar C, Randolph J. Evaluation of ischemic bowel viability with a flu-
bined with the physiological disturbance resulting from strangu- orescent technique.] Paediatr Surg. 1978;13:221-225.
lation and fluid depletion predispose to cardiovascular, respiratory, 17. Quill D, Devlin H, Plant j, et al. Surgical operations rates: a twelve year
and renal complications, while the return of gastrointestinal func- experience in Stockton on Tees. Ann R Coll Surg Engl. 1983;65:248-
tion may be delayed by paralytic ileus. Additionally, there are two 253.
local complications resulting from the return to the abdomen of 18. Watkin D. Indications and urgency. In Kurzer M, Kark AE, Wantz GE
ischemic bowel. If there is full-thickness necrosis, perhaps at a con- (eds): Surgical management of abdominal wall hernias. London: Martin
striction ring from a Richter's hernia, or at an anastomosis, leak- Dunitz; 1999;1-10.
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age will result in either generalized peritonitis or a localized
1931;19:176-191.
abscess and subsequently a fecal fistula. Ultrasound imaging and 20. Vick R. Statistics of acute intestinal obstruction. BMJ 1932;2:546-548.
computed tomography are valuable in the early detection of these 21. McEntee G, Carroll A, Mooney B, et al. Timing of strangulation in
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survives, a fibrous stricture may develop over the succeeding weeks, 22. Berger P. La hernie inguino-interstitielle et son traitement par la cure
the patient re-presenting with intestinal obstruction. 60 •61 radicale. Rev Chir. 1902;21:1.
23. Neuhauser D. Elective inguinal herniorrhaphy versus a truss in the el-
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Conclusion efits of surgery. New York: Oxford University Press; 1977.
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The continuing mortality from strangulated hernias, particularly 25. Ellis H, Calne R, Watson C. Lecture notes on general surgery, 9th ed.
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operative resuscitation and excellent postoperative care. As Mc- elderly. Surg Gynaecol Obstet. 1966;122:100.
Dermot73 stated in 1966: "The attention paid to the correction of 27. Ralphs D, Brain A, Grundy D, et al. How accurately can direct and in-
metabolic abnormalities associated with intestinal obstruction and direct inguinal hernias be distinguished? BMJ 1980;280:1039-1040.
surgical judgement related to the timing of operation will deter- 28. Cole G. Strangulated hernia in Ibadan; a survey of 165 patients. Trans
R Soc Trap Med Hyg. 1964;58:441-447.
mine the mortality of the disease."
29. McPherson K, Coulter A, Stratton 1. Increasing use of private practice
by patients in Oxford requiring common elective operations. BMJ
1985;291:797-799.
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83
Abdominal Wound Dehiscence
Dirk van Geldere
Wound dehiscence and eventration after an abdominal operation dominal pressure. 12 In most series males outnumber females by
is one of the most serious postoperative complications, associated 3 to 1. 1.3•8.13-16 Increased age is another independent factor out-
with up to 30% mortality.1-3 In this phenomenon, about 1 week side the surgeon's control. Wound dehiscence is more likely to oc-
after laparotomy the wound suddenly opens up: The common cur in the elderly, although the problem is striking in newborn
name burst abdomen captures its calamitous nature. patients as well. Systemic factors such as obesity, malnutrition, hy-
The reported incidence has not diminished appreciably in the poproteinemia, diabetes, jaundice, uremia, anemia, and hypoxia
past five decades and varies between 0.5 and 5%, excluding some all may contribute to wound healing problems. The use of steroids,
individual series in which disruption has never occurred. 1.4-7 In a anticoagulants, or cytotoxic agents seems to playa role only in ex-
large randomized multicenter trial, Wissing et al. 6 reported 2.3% perimental models.8.12.17
wound dehiscences in 1491 patients. Only since the mass closure Emergency operations carry a much higher risk. In a recent sur-
technique became popular has the incidence fallen to 1% or less vey of 3768 patients, those who were operated on electively de-
of all major laparotomy incisions. 1.8 veloped wound dehiscence in 0.5% of cases. Acute operations
The disruption may be complete or incomplete, early or late, progressed to wound breakdown in 3.3%, an odds ratio of 6.4. 7
septic or aseptic. The disruption is incomplete when the skin or The duration of the operation also plays a role. Schmidtler et al. 17
the peritoneum remains intact, preventing evisceration, but com- describe an incidence of 0.9% in operations of less than 3 hours
plete when all layers separate and viscera protrude into the wound versus 3.25% in those lasting longer than 5 hours. Blood loss causes
or even onto the skin or the bed sheets (Fig. 83.1). An early de- anemia and coagulation disorders and, consequently, wound heal-
hiscence, within 4 days, usually signifies faulty technique, whereas ing problems. When no blood transfusions were necessary, the in-
in a late dehiscence other factors may also playa role. The dif- cidence of wound dehiscence was 0.77% versus 14.2%, when more
ference between wound rupture and incisional hernia is not clearly than 3 L were transfused,l7 Relaparotomy also increases the risk
defined; we suggest a division in terminology at 1 month. Small of wound dehiscence remarkably, from 0.9% after a primary lap-
incomplete ruptures may be asymptomatic and later present as an arotomy to 3.2% after a second laparotomy and 7.4% after a third
incisional hernia. Also small complete ruptures may be mi~udged laparotomy.17,18 The underlying condition necessitating relaparo-
and appear to heal after conservative treatment (Figs. 83.2 to 83.4). tomy (such as bleeding or peritonitis) may explain these differ-
There is evidence that all or most incisional hernias have their be- ences, because resuturing of the abdominal wound itself after
ginnings in the first weeks after operation. 9.10•11 wound rupture alone seldom leads to recurrent dehiscence.
Etiology
Local Factors
There is no single cause for abdominal wound dehiscence. Many
factors may lead to the ultimate breakdown of the wound, usually Active mechanical stress is a significant factor in abdominal wound
a combination of internal and external, local and systemic factors. dehiscence. This is caused mainly by traction of the abdominal
Mechanical and technical factors seem to play a crucial role in muscles, the tension due to intraabdominal pressure being much
most cases of wound disruption.l· 2.4 •7.11 In any case, knots slip, su- lower.19 Cough is mentioned in 75% of cases as the most impor-
tures break, or tissues tear, and the wound disrupts, following a tant cause of abdominal wound dehiscence, especially the uncon-
sudden and temporary or a gradual and more permanent rise in trollable cough during extubation after endotracheal anesthesia.
intraabdominal pressure (Figs. 83.5 and 83.6). Intraabdominal pressure, which does not normally exceed 8 cm
H 20, may rise to 150 cm. Involuntary actions such as sneezing, hic-
cups, vomiting, and straining at stool elevate the pressure to levels
Systemic Factors as high as 80 cm H 20, which is a much greater elevation than that
caused by standing up and walking.20 Passive elevation of the ab-
Wound dehiscence is more likely to occur in men, due, it is dominal pressure is of less importance, being less abrupt although
thought, to the greater ability of the male to raise his intraab- more long-standing. Postoperative gastric dilation and ileus are
569
570 D. van Geldere
FIGURE 83.3 Partial dehiscence of the skin wound after laparotomy, re-
FIGURE 83.1 Complete abdominal wound dehiscence with evisceration of vealing a part of the small bowel wall (arrow) as the tip of the iceberg that
small intestine and omentum. emerges at reoperation (see Fig. 83.4).
frequently mentioned, more than ascites, edema, and pregnancy. Technical Factors
Dysbarism, the expansion of air in hollow viscera during air travel
in low pressure cabins, is one of the reasons that patients are not Most dehiscences are the result of a faulty surgical technique. Ac-
accepted by airlines less than 3 weeks after an abdominal cording to Norris,29 writing in 1939, the elimination of postoper-
operation. 21 ,22 ative wound dehiscence is entirely within the jurisdiction of the
Wound infection is one of the leading causes of abdominal operating surgeon. The important factors are the type of closure
wound dehiscence and also of later incisional hernia (Fig. and, to a lesser extent, the type of suture material.
83.7).8,23,24 This septic variety should be excluded from the actual
phenomenon of postoperative wound dehiscence because infec-
tion is the primary complication and the wound dehiscence only The Incision
one of the consequences of tissue destruction by enzymatic bac-
terial activity.25,26 Hematomas are seldom mentioned as a cause of The type of incision is not as important as earlier studies suggested.
abdominal wound dehiscence, as they mainly disturb healing of No difference is found between incisions with a scalpel or with a
the skin. 27 ,28 Radiotherapy induces obliterating endarteritis, but diathermic knife.30,31 Larger incisions are as prone to wound de-
usually causes wound healing disorders only of the skin. hiscence as shorter ones. 32 Midline or vertical incisions have long
Looking at the problem from another angle, however, it would been blamed for a higher incidence of wound rupture and inci-
not be so odd, after all, if a coughing jaundiced patient with ileus sional hernias than transverse incisions.33-35 The studies were ret-
bursts open despite adequate closure. What is extraordinary is that rospective, and a most likely explanation is the use of midline
so many patients heal despite faulty closure. incisions for emergency and more extensive procedures.36 The
FIGURE 83.2 Prolapse of a slip of omentum in the comer of a supraum- FIGURE 83.4 Complete dehiscence of the fascial wound with prolapse of
bilical laparotomy wound. small bowel loops (arrow) in the subcutaneous tissues.
83. Abdominal Wound Dehiscence 571
FIGURE 83.5 Detail of the fascial wound edges in Fig. 83.4. The knots of
the sutures (arrow) are intact, but the sutures have torn a bridge of tissue
from the opposing fascial edge.
more sophisticated transverse incisions are reserved for planned,

elective operations. In prospective controlled and randomized
studies there is no difference between vertical and horizontal in-
cisions. 8 ,32,37-40 No difference is found between median and para-
median incisions. 8,41 It is true, however, that excellent results can FIGURE 83.7 Complete abdominal wound dehiscence following wound in-
be obtained with a lateral paramedian incision, with no burst ab- fection and necrosis of the fascia.
domen and extremely low incidence of incisional hernia. 42-44 No-
toriously unfavorable are the pararectal incisions, The risk of
evisceration is also enhanced by the practice ofleading colostomies
the only material that could meet these criteria at that time. Post-
or drains through the original incision. The best method, of
operative wound dehiscence fell, however, from 11.2% to 1.2%
course, for reducing the incidence of wound disruption is lap-
aroscopic surgery, which is also associated with an almost negligi- when Jones et al. 46 of Cleveland, abolished the layered closure with
ble incidence of incisional hernias. catgut in favor of mass closure with stainless steel. Chromic catgut
is completely unsuitable for abdominal wound closure; even as late
as the 1970s, incidences of burst abdomen of up to 10% were re-
The Sutures ported. 47- 51 With the advent of synthetic nonabsorbable and later
absorbable sutures in the second half of the twentieth century, all
In 1920, Moynihan 45 described the "ideal" suture. The material biological suture materials like catgut, collagen, silk, cotton, and
should achieve its purpose, disappear as soon as its work is ac- linen became obsolete. 51 - 54 Currently, the abdomen is closed with
complished, and be free of infection and nonirritant. Catgut was steel or synthetic absorbable or nonabsorbable sutures.
Absorbable sutures are braided multifilament polyglycolic acid
(Dexon®) or polyglactin 910 (Vicryl®) and more slowly absorbable
monofilament polydioxanone suture (PDS®) or polyglyconate
(Maxon®). Nonabsorbable sutures are braided polyester (Ethi-
bond® or Mersilene®) or polyamide (Nurolon®) and monofila-
ment polyamide (Ethilon®) or polypropylene (Prolene®). Because
the sutured fascia regains only 40% of its initial strength in 4 weeks,
and only 80% in 1 year, it is of paramount importance that sutures
retain their strength during this critical period. Dexon and Vicryl
lose their strength after 1 month and are sufficiently strong
to prevent wound disruption. 55 ,56 In many trials nonabsorbable
sutures were no different in performance, and the incidences of
burst abdomens and incisional hernias were the same in both
groups.37,50,57-62 On the other hand, Bucknall and Ellis 41 ,63 com-
pared Dexon and monofilament nylon in 216 patients and found
that the incidences of burst abdomen were 0,96% and 0,94%, re-
spectively, but the incidences of incisional hernias were signifi-
cantly different (11,5% vs. 3.8%, respectively). Other studies
FIGURE 83.6 Sutures have cut through the tissues of the abdominal wall confirm the higher incidence of incisional hernia when absorbable
(arrows) after are-laparotomy. sutures are used. 64 ,65 Monofilament PDS is more slowly absorbable,
572 D. van Geldere
is stronger initially than nylon or polypropylene, and retains 40% wound disruption in operations on the biliary tract from 11 %, in
of its strength after 4 weeks. closures with catgut, to 1.2%, in wounds closed with alloy steel
Krukowski et al. 66 randomized 757 patients undergoing a mid- figure-of-eight sutures alone. The stitch was devised by Dr. Louis
line abdominal incision to tension-free continuous mass closure Smead from Baltimore, and the technique since then has been re-
with PDS or polypropylene. Wound infection was significantly less ferred to as the Smead:Jones technique. Single layer closure never
with PDS (3.5% vs. 7%), and there was one dehiscence in each became very popular, however, because it prevents accurate coap-
group. Incisional hernia rate was similar after 1 year (7.7 vs. 9.7%). tation of the layers of tissues. The abdominal wall should be re-
Polypropylene suture removal for persisting wound pain or sinus garded as one entity, not healing layer by layer, but as one massive
formation was necessary in five patients. block of scar tissue: one wound, one scar, just as in resuturing a
Four techniques to close the fascia after midline laparotomy disrupted abdominal wound, where mass closure usually is suffi-
were compared in a prospective randomized multicenter trial by cient to prevent a new rupture. Ponka78 asked: "Why is it that a
Wissing et al. 6: interrupted closure with polyglactin, continuous technique, useful in the treatment of wound disruption, is not ap-
closure with polyglactin, continuous closure with PDS, and con- plied initially in its prevention? The question deserves careful
tinuous closure with nylon. In 1491 patients, the incidence of thought, and the answer becomes obvious."
wound infection was 8.3% and of postoperative wound dehiscence, Dudley79 gave a theoretical explanation. Cutting out of sutures
2.3%, with no statistically significant differences between the two is, in theory, the result of two things: pressure per unit area on
techniques. Wound pain and suture sinuses developed significantly the tissue and ischemic necrosis from continued pressure. This
more frequently in the nylon group. The average percentage of force per unit area at the tissue suture interface will decrease when
incisional hernias detected 1 year postoperatively was 15.2% (in- the diameter of the suture loop and its embedded length increase.
terrupted polyglactin, 16.9%; continuous polyglactin, 20.6%; con- Taking large bites of tissue, including as many layers as possible,
tinuous PDS, 13.2%; and continuous nylon, 10.3%). The reduces the rate of the burst abdomen. In midline incisions, the
difference between nylon and continuous polyglactin was statisti- needle should pass well away from the linea alba, through both
cally significant. Although nylon had the lowest incidence of in- layers of the rectus sheath, eventually including the rectus mus-
cisional hernia, it was also associated with more wound pain and cle. 8o Sutures should be tied snugly but not too tightly, to prevent
suture sinuses. 6 These results and other suggest that PDS may be tissue necrosis. 81 -83 "So where once we closed with well-intentioned
the best for abdominal closure. 1,66-69 Relatively heavy suture ma- forcefulness, like a sailor making fast at the quay, we now employ
terial should be used. A large diameter suture exerts less cutting a lighter touch (urging similar qualities to the assistant's follow-
action than a small diameter suture. 70 ing hand) and big loose bites," writes the editor in The Lancet in
1980.84 Suture material, however, may stretch, and others advise
tight suturing to compensate for the elastic elongation of monofil-
The Knots ament nylon. 85
Jenkins,86 although not an advocate of mass closure, wrote a
Slippage of knots is an important factor in wound dehiscence. In seminal paper in 1976 to stress the importance of wide tissue bites
33 cases of wound dehiscence, we found 5 cases (15%) due to a on either side of the incision. Abdominal wounds may lengthen
loosened knot. 1 Modem suture material has different physical by 30% if distension occurs. An adequate reserve of suture length
properties and requires different knotting techniques from those in the wound will allow this stretching to occur and ensure mini-
used in the past. The coating of braided synthetic absorbable su- mal rise in tension between the sutures and the tissues. Three vari-
tures and the smooth surface of monofilament sutures enhances ables present in every continuous wound closure-the suture
the chance of a knot slipping when sliding or granny knots are length inserted, the wound fascial length, and the number of
used. A minimum of five throws is necessary in any material. 71 ,72 sutures-determine the suture interval and the size of the tissue
Special and very secure knots exist for running monofilament bite, which are the two vital factors in wound strength that are un-
sutures. 73-75 der the surgeon's control. The rise of tension between sutures and
Although knots reduce the breaking strength of sutures to 40%, tissues by a wound stretch of 30% is minimal when the ratio of the
a broken suture is seldom the cause of wound dehiscence. Monofil- length of the spiraling suture to the length of the wound is 4: 1 or
ament sutures are very vulnerable when handled with surgical in- more. Tissue bites of 1 cm on either side of the wound require a
struments. In the past, broken catgut was a frequent cause.l 2 suture length of at least 4 cm. The stitch intervals should not ex-
ceed 1 cm. In a series of 1505 patients in whom these rules were
observed, only one wound dehiscence occurred.87 Others have had
The Suture Technique similar experience.88--92
Many trials testified to the efficacy of mass closure in reducing
The single most important factor in the prevention of a burst ab- the incidence of abdominal wound dehiscence.8,93-96 In children
domen is the suture technique. In the nineteenth century, the ab- and infants no difference was found. 97 In the quest for the ideal
domen was usually closed in toto as one layer from peritoneum to suture technique to prevent wound rupture, other factors, like the
skin with one large suture, which often led to wound infections elasticity of the abdominal wall, should not be forgotten. 98 ·In a re-
and subsequent herniation. In the first half of the twentieth cen- cent trial, the decreased compliance of the abdominal wall after
tury, when surgical techniques became more refined, the abdom- continuous double loop mass closure enhanced the risk of post-
inal wall was closed in layers. All separate anatomical layers were operative pulmonary complications and death. 99
neatly closed with interrupted sutures, usually of catgut. 76 In the Unfortunately, incisional hernia formation is not prevented by
1940s, the mass closure technique was advocated once more. The mass closure techniques. 1oo When continuous versus interrupted
abdominal wall, except for the skin, was closed as a single layer suture techniques were compared, no difference was found in
with heavy steel wire. 46,77 Jones et al. 46 reduced the incidence of many trials. 5,24,36,101-104 On theoretical grounds a running suture
is better, distributing the forces more evenly over the length of the wounds. The abdominal wound may even be stronger after sec-
wound, leaving only two knots in the subcutaneous wound and re- ondary closure of the skin wound.!24
ducing the tissue trauma. It is more economic as well by saving su- Discussion of open management of the abdomen in severe peri-
ture material and by saving time. tonitis or in the prevention of the abdominal compartment syn-
Retention sutures are of no benefit in closing midline incisions drome is beyond the scope of this chapter.
(Fig. 83.8). In a controlled trial, they did not prevent wound de-
hiscence, but they may prevent evisceration. 24.!05 They add much
to the discomfort of the patient but nothing to the strength of the Clinical Features
wound. In an experimental animal study, the disadvantages of
absorbable retention sutures at fascial level outweighed any ad- More than half of cases of abdominal wound dehiscence occur
vantage.! Alternatively, one study has shown a very significant re- without any prior sign or symptom, usually around the seventh
duction in the incidence of wound dehiscence, from 7.22% to postoperative day and after removal of the skin sutures. The great
1.19%, after emergency laparotomies when retention sutures were majority (90%) occur between the fourth and the eleventh days,
used in addition to layered closure.1°6 Most likely the layered clo- but a burst abdomen directly following operation or after only 4
sure was the weak point and the retention sutures would have been weeks is not rare. Often the first and only sign is the appearance
superfluous had mass closure been used instead. Many, sometimes of a large amount of pink serosanguinous fluid in the wound. This
elaborate, varieties of retention sutures have been described, usu- fluid is exudate from the visceral peritoneum or from extraperi-
ally including the skin. 107- 1l2 Internal retention sutures, through toneal bowel. Careful inspection or palpation of the wound may
all layers of the abdominal wall except the skin and the peri- reveal a bulge or just a gap. When in doubt, plain abdominal ra-
toneum, are in fact a variant of the mass closure technique.1!3.114 diography, ultrasonography, or computed tomography may reveal
The use of intraperitoneal absorbable polyglactin mesh reduces the diagnosis. Often, however, the abdominal wound bursts open
the rate of abdominal wound dehiscence, but does not prevent in- without warning, both in the severely ill patient with other ab-
cisional hernias. 1I5.116 dominal symptoms and in the apparently well-healed patient about
The peritoneum need not be closed, either as a separate layer to be discharged or already at home. Always there is a moment of
or as part of the mass closure method.1l 7- 119 Without adding a sudden rise of the abdominal pressure, such as coughing or vom-
strength to the wound, sutures in the peritoneum cause local iting, and the patient usually reports feeling something give way.
ischemic peritonitis and pain and may give rise to adhe- The frightened patient has remarkably little pain, and shock sel-
sions.l!7.!20-!22 It is recommended that this step be omitted. For dom occurs.
similar reasons, suture of the subcutaneous fat tissue is also un- In the open wound, omentum, transverse or sigmoid colon, or
necessary.!23 small bowel is visible with more or less evisceration (Fig. 83.1).
Skin sutures may prevent complete abdominal wound dehis- Sometimes the whole of the small bowel is on the bed sheets. Some-
cence. In the prevention of wound infection (and wound hernia- times only the skin margins of the wound are a little dehiscent,
tion) , skin and subcutaneous tissues are not closed in contaminated revealing something that looks like granulation tissue, but is in
fact a slip of eviscerated omentum or part of the bowel wall, the
tip of the iceberg (Figs. 83.2 to 83.4). When wound infection plays
a role, the occurrence is usually more gradual and the dehiscence
occurs upon drainage of the abscess (Fig. 83.7). Inflammatory ad-
hesions usually prevent the evisceration in these cases.
Treatment
Treatment of abdominal wall dehiscence consists of resuturing the
abdominal wound. Mter supportive or resuscitative measures have
been taken, with sterile and moist dressing of the wound, the
wound should be resutured as soon as possible. When the patient's
clinical condition prevents early reoperation, the viscera may be
dressed with gauze soaked in povidone-iodine and covered with
adhesive plastic sheeting.!25
At operation the skin is disinfected, and the protruding viscera
are flushed with warm saline. The wound is completely reopened,
even if part is still intact. Adhesions are gently separated to free
the wound margins. Inspection reveals whether knots have slipped
or sutures broken or if the thread has cut through the tissues, tear-
ing a bridge of the tissues, or if a combination of these events oc-
curred (Figs. 83.5 and 83.6). Mter removal of all suture material,
the total length of the suture material can be measured to deter-
mine whether it was more than four times that of the wound. M-
ter replacement of the viscera, the abdominal wall is closed in one
FIGURE 83.8 Retention sutures through all layers of the abdominal wall, in- layer, excluding the skin, with very large bites at short intervals of
cluding the skin, give rise to necrosis and pain; they should be avoided. heavy monofilament sutures. Good relaxation of the patient and
574 D. van Geldere
adequate assistance are mandatory to prevent undue tension dur- zur Ermittlung gefahrdeter Patientengruppen. Munch Med Wochen-
ing closure. Retention sutures are superfluous because the mass schr. 1977;1191:685-689.
closure with very wide bites fulfils their purpose (Fig. 83.8). 18. Fry DE, Osler T. Abdominal wall considerations and complications
In severe peritonitis or in anticipation of abdominal compart- in reoperative surgery. Surg Clin North Am. 1991;71:1-11.
ment syndrome, the abdomen is left open. 19. Seidel W, Tauber R, Hoffschulte H. Messungen zur Festigkeit der
Bauchdeckennaht. Chirurgie. 1974;45:266-272.
In otherwise uncomplicated cases, recovery and wound healing
20. Drye JC. Intraperitoneal pressure in the human. Surg Gynecol Obstet.
are usually uneventful. 126,127 With adequate closure, and in the ab-
1948;887:472-475.
sence of wound infection, recurrent wound dehiscence is not fre- 21. Hagelsten JO. The patient as air passenger. Saudi Med J 1981;2:
quent (5%) .1,13 However, at least half of the survivors subsequently 149-156.
develop incisional hernias. 128 22. AMA Commission on Emergency Medical Services, Chicago. Medical
The reported mortality after abdominal wound dehiscence is aspects of transportation aboard commercial aircraft. ]AMA. 1982;
high, ranging from 0 to 57% (average 28%), but this is partly due 247:1007-1011.
to the underlying pathology.129,130 The lethal factor leading to the 23. Bucknall TE. The effect of local infection upon wound healing: an
high mortality rate is often not the rupture itself but the emer- experimental study. Br] Surg. 1980;67:851-855.
gency procedure to correct it. Forceful reduction of the eviscera- 24. Gislason H, Gnmbech E, S0reide O. Burst abdomen and incisional
hernia after major gastrointestinal operations-Comparison of three
tion produces the often fatal abdominal compartment syndrome. 98
closure techniques. Eur] Surg. 1995;161:349-354.
25. Bierens de Haan B, Ellis H, Wilks M. The role of infection on wound
healing. Surg Gynecol Obstet. 1974;138:693-700.
Summary 26. Reynaert MS, Otte JB, Kester PJ, et al. Aspects therapeutiques de la
dehiscence d'une plaie de laparotomie apres fistule digestive ou apres
Mechanical factors are the main cause of abdominal wound de- intervention pour pancreatite aigue. Acta Chir Belg. 1981;1:27-35.
hiscence. Mass closure of the abdominal wound with a running 27. Myers MB, Cherry G, Heimburger S, et al. The effect of edema and
monofilament suture is the best prevention of the burst abdomen. external pressure on wound healing. Arch Surg. 1967;94:218-222.
28. Myers MB, Rightor M. Augmentation of wound tensile strength in
Incisional hernias remain a problem.
rats by induction of inflammation with autogenous blood. Surgery.
1978;83:78-82.
29. Norris JD. A review of wound healing and the mechanics of dehis-
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hernia. Int Surg. 1973;58:408-411. Br] Surg. 1964;51:448-456.
114. MakeHi jT, Kiviniemi H, Juvonen T, et al. Factors influencing 127. Dunphy JE. Wound healing. Surg Clin North Am. 1978;58:907-917.
wound dehiscence after midline laparotomy. Am] Surg 1195; 170:387- 128. Grace RH, Cox S. Incidence of incisional hernia after dehiscence of
390. the abdominal wound. Am] Surg. 1976;131:210-212.
115. Paye F, Rongere C, Gendreau D, et al. Le treillis resorbable in- 129. Eisenstat MS, Hoerr OS. Causes and management of surgical wound
traperitoneal dans la prevention des eviscerations postoperatoires. dehiscence. Cleve Clin Q 1972;39:33-36.
Vne etude comparative. Ann Chir. 1992;46:518-522. 130. Madsen G, Fischer L, Wara P. Burst abdomen-clinical features and
116. Pans A, Elen P, Dewe W, et al. Long-term results of polyglactin mesh factors influencing mortality. Dan Med BulL 1992;39:183-185.
84
Treatment of Strangulated Inguinal Hernias
with Nonabsorbable Prostheses
Alain Pans, c. Desaive, and N. Jacquet
For about 15 years, inguinal hernias in adults have been treated made a horizontal incision for esthetic reasons. The contents of
preferentially in our institution by a short midline suprapubic ap- the hernial sacs are reported in Table 84.1.
proach (usually 8 cm) and the application of prosthetic material. The midline laparotomy permitted careful exploration of the
The technique we use derives from that described originally by abdominal cavity and the detection of one volvulus of the small
Stoppa et al. 1 The preperitoneal dissection is carried out in the bowel around the strangulated hernia, one obutrator hernia, fIve
same manner. The difference is that the management of the asymptomatic contralateral inguinal hernias, two asymptomatic
hernia is achieved by a prosthesis considerably overlapping the contralateral femoral hernias, and one asymptomatic inguinal her-
hernial openings, one on each side in the case of a bilateral pro- nia ipsilateral to the strangulated femoral hernia.
cedure. The prosthesis is fIxed by a single suture in Cooper's lig- Once the hernia was reduced, the sac contents were treated ap-
ament and held in place principally by intraabdominal pressure. propriately. The peritoneum was then closed and the preperi-
This technique has been spread through the Liege region largely toneal space dissected. In all cases, a prosthesis was put in place:
by Lombard et al. 2 19 ofProlene®, 22 of Marlex®, and 4 of Mersilene®. In the 13 cases
Prostheses have acquired an important place in the elective of intestinal resection, Prolene was used 7 times, Marlex 5 times,
surgery of inguinal hernias in the adult. In strangulation, however, and Mersilene once.
the use of prostheses remains very controversial: The urgency and Hernia surgery was bilateral in 29 cases. In 23 cases, a prosthe-
the potentially septic environment represent a risk of infection sis was inserted on each side, while in 6 cases a single large pros-
that most surgeons consider a contraindication to their use. thesis was used (Stoppa's technique). A unilateral repair was
carried out in 16 patients, generally when intestinal resection was
necessary.
The Clinical Experience All patients received prophylactic antibiotics in the form of ce-
fazoline, cefuroxime, or amoxicillin-clavulanate for 24 to 48
Since 1986, 45 adults (19 men and 26 women) presenting with hours. When an intestinal resection or an appendectomy was re-
strangulated inguinal hernia have been operated on using this quired, the patients received either cefazoline (or cefuroxime)
technique at University Hospital in Liege and at the A. Renard and metronidazole (occasionally with netilmicine), or ticarcillin-
Clinic. The mean age of the men was 64 years (range 34 to 96 clavulanate alone, for 5 days. The last appendectomy case, how-
years) and that of the women was 74 years (range 45 to 93 years). ever, received only amoxicillin-clavulanate for 48 hours, without
Among the men, 18 inguinal hernias (one man presented with bi- complications.
lateral strangulated hernias) and two femoral hernias were ob-
served, while the women had 13 inguinal hernias and 13 femoral
hernias, confIrming the usual predominance of strangulated Observations
femoral hernias among women.
For 27 patients, the clinical picture was one of intestinal ob- There was one case of postoperative mortality. This was a man of
struction. This symptomatology was present in all the patients 96 years, operated on for bilateral strangulated inguinoscrotal her-
presenting with intestinal necrosis, except for three cases of stran- nias that did not necessitate intestinal resection. On the ninth
gulated hernias of the appendix. Forty-three times, the diagnosis postoperative day, he developed a hemorrhagic duodenal ulcer re-
of strangulated hernia was stated at the outset. In one case, it was quiring an emergency subtotal gastrectomy. Ten days later, he suc-
made following an exploratory laparotomy and in another after cumbed to renewed hematemesis.
laparoscopy prompted by the appearance of intestinal obstruction. General postoperative complications observed were two cases of
General anesthesia was used in 38 patients. Spinal anesthesia pneumonia, two of atrial fIbrillation, one atrial flutter, one urinary
was used in 6 patients and epidural anesthesia in 1 patient. infection, one respiratory distress, one myocardial infarct, one
In all the patients, the approach was through a midline supra- deep venous thrombosis, and one fracture of the neck of the fe-
pubic transperitoneal incision, except in one patient in whom we mur (following a fallon the eighth postoperative day). These com-
577
578 A. Pans et aI.
TABLE 84.1. Contents of the hernial sac son, strangulated hernia has always been considered an absolute
contraindication to the use of prostheses.
Viable Necrotic
In 1991, we were the first, to our knowledge, to report a series
Small intestine 22 9- of 17 strangulated hernias treated with nonabsorbable prostheses. 3
Cecum 1 o Encouraged by our good results,4 we report now a series of 46
Appendix o 4 strangulated inguinal and femoral hernias.
Omentum 1 2 Our experience demonstrates that the risk of sepsis appears to
Appendix epiploica of the sigmoid o have been overestimated. We have observed only two abdominal
Sigmoid colon o wall abscesses, both in situations when intestinal resection was not
Sigmoid colon and small intestine 1 o carried out. The hematomas and the superficial abscess were mi-
Sigmoid colon and omentum 1 o
Preperitoneal lipoma 2 o nor complications that could attend any operation. The deep ab-
Bladder o scess was more specific to the preperitoneal technique and was
Total 31 15 successfully treated without removal of the prosthesis.
As for the cutaneoaponeurotic dehiscence, this arose in the par-
'Without peritonitis. ticular circumstances of a very agitated trisomy 21 patient with bi-
lateral inguinal hernias, one of which was strangulated. Despite
plications reflect the debility of the aging population treated for reoperation, no septic phenomenon was observed.
this type of pathology. Since our initial publication, others5-8 have corroborated the
Local complications included seven inguinal hematomas, re- low incidence of septic complications. It has thus been possible to
quiring needle aspiration in three cases, one incisional hematoma, assemble a larger number of cases, allowing a more accurate esti-
one seroma that resolved spontaneously after 7 days, one superfi- mation of the septic risk. Review of the literature yields the ob-
cial abscess of the abdominal wall treated by drainage and systemic servations summarized in Table 84.2.
antibiotics, and one deep abscess treated successfully by computed In a combined series (personal series, with those ofPalot et al.,6
tomography-guided insertion of a drain, daily irrigation, and an- Gavioli et al.,7 and Ishihara et al. 8 ) of 106 patients with strangu-
tibiotics. In the last two cases, the Prolene prosthesis did not have lated inguinal and femoral hernias, treated surgically with non-
to be removed. These two abscesses developed in the absence of absorbable prostheses, there were 18 septic events: 12 small bowel
intestinal resection. One cutaneoaponeurotic dehiscence was ob- resections, 4 appendectomies, and 2 unspecified "intestinal resec-
served in an obese trisomy 21 patient. In this case, the hernia was tions." The overall rate of infection in this population was 1.88%
discovered during laparoscopic exploration for small bowel ob- (0.94% superficial and 0.94% deep), while the rate of septic events
struction. However, the reduction of the incarcerated small bowel was 17%.
could not be carried out laparoscopically, and, in addition, there Palot et al. 6 report an infection rate of 4% in a group of 174 pa-
was a significant bulge in the contralateral posterior inguinal wall, tients treated surgically for strangulated hernia without prosthe-
which led us to perform a bilateral operation using the midline ses. An infection rate of 1.2% is reported in the series by Vayre et
preperitoneal approach. On the fifth postoperative day, the pa- al. 9 involving 82 patients treated without prostheses. Note that the
tient became intensely agitated, causing dehiscence of the wound. rates of intestinal resections were 21 % and 22% in each of the
He was reoperated on to close the abdominal incisions; the post- above series.
operative course was uneventful, and 2.5 years later there was no We can therefore state that the overall rate of sepsis associated
evidence of recurrent herniation. with the use of nonabsorbable prosthesis is comparable with that
observed in the series of strangulated hernias treated without
prostheses.
Discussion and Review of the Literature Many surgeons prefer the inguinal approach for strangulated
inguinal hernias because of the associated risk of intestinal necro-
Strangulated hernia poses an obvious risk of infection: sterility is sis and infection. The midline approach, however, offers several
sometimes compromised in emergency cases, and the possibility specific advantages: ease of intestinal resection and easy access for
of contaminated serous effusion from within the sac may expose exploration of the abdominal cavity, allowing one to uncover un-
the prosthesis to an unacceptable risk of infection. For this rea- foreseen situations such as volvulus of the small bowel around the
TABLE 84.2. Review of the literature

No. of nonabsorbable inguinal prostheses
placed in emergency conditions
No. of
Giant bilateral superficial No. of deep
Unilateral prostheses Plugs abscesses abscesses
Henry et aI. (1994)5 21 11 15 0 1

Palot et aI. (1996)6 30 0 0 0 0
Gavioli et aI. (1996) 7 25 0 0 0 0
Ishihara et aI. (1996)8 6 0 0 0 0
Pans et aI. (1999) 62- 6 0 1 1
Total 144 17 15 1 2
·Twenty-three bilateral repairs with a prosthesis placed on each side.

84. Nonabsorbable Mesh in Strangulated Inguinal Hernia 579
strangulated hernia. It also allows the discovery of asymptomatic cations have been reported in association with small bowel resec-
hernias and their treatment, if necessary, at the same operation. tions, we believe that the use of a prosthesis in such cases should
This approach is particularly appropriate in bilateral hernias and be avoided unless absolutely necessary. As noted by Vayre et al.,9
recurrent strangulated hernias. the first duty of the emergency surgeon is to treat the strangula-
Localized abscess, intestinal perforation, and colon resection re- tion and eventual necrosis that threaten the patient's life; the pos-
main, for us, absolute contraindications to the use of a prosthesis. sibility of hernia recurrence is a secondary concern.
Recourse to a prosthesis in the treatment of strangulated her-
nia must be carried out with the greatest care to minimize the risk
of sepsis. Complete isolation of the operative field must be References
achieved with packs soaked with antiseptic. As soon as the peri-
toneum is closed, the operative field is copiously irrigated with 1. Stoppa RE, Rives JL, Warlaumont CR, et aI. The use of Dacron in the
antiseptics. Following a change of gloves and instruments, preperi- repair hernias of the groin. Surg Clin North Am. 1984;64:269-285.
toneal dissection and placement of the prosthesis may proceed. 2. Lombard R,Jacquet N, WeertsJ, et aI. La prothese synthetique dans la
Prophylactic antibiotics for 24 to 48 hours and observation for 5 cure des hernies de i'aine. A propos de 1120 observations. Lyon Chir.
1985;81:149-152.
days are recommended if bowel has been resected. Ideally, ex-
3. Pans A, Plumacker A, Legrand M, et aI. Traitement chirurgical des
ploration of the contralateral inguinal region should not be done
hernies inguinocrurales etranglees par interposition de prothese en sit-
in the case of intestinal resection. uation preperitoneale. Acta Chir Belg. 1991;91:223-226.
4. Pans A, Desaive C,Jacquet N. Use of a preperitoneal prosthesis for stran-
gulated groin hernia. Br J Surg. 1997;84:310-312.
Conclusion 5. Henry X, Randriamanantsoa V, Verhaeghe P, et aI. Le materiel prothe-
tique a-t-il une place raisonnable dans Ie traitement des urgences her-
Far from advocating routine use of prostheses in the treatment of niaires? Chirurgie. 1994;120:123-128.
strangulated hernias, we believe that their use must be considered 6. PalotJP, FlamentJB, Avisse C, et aI. Discussion en cours. Utilisation des
in light of the clinical situation, the characteristics of the patient, protheses dans les conditions de la chirurgie d'urgence. Chirurgie. 1996;
the perioperative observations, and the familiarity of the surgeon 121:48-50.
7. Gavioli M, Rosi A, Piccagli I, et aI. Prothese et chirurgie herniaire en
with the technique. Nevertheless, review of the literature demon-
urgence. J Chir. 1996;133:317-319.
strates that the risk of infection associated with strangulated her- 8. Ishihara T, Kubota K, Eda N, et aI. Laparoscopic approach to incar-
nias has been overestimated and that it should not be considered cerated inguinal hernia. Surg Endosc. 1996;10:1111-1113.
an absolute contraindication to the use of prostheses. Use of a 9. Vayre P, Majewsky M, DuronlJ. Le materiel prothetique a-t-il une place
prosthesis must be excluded in the case of localized abscess, raisonnable dans Ie traitement des urgences herniaires? Chirurgie. 1996;
intestinal perforation, and colon resection. Although no compli- 121:161-162.
85
Use of Prosthetic Materials in Incisional
Hernias with a Septic Risk
Vincenzo Mandala
The treatment of incisional hernias has been shifting toward a TABLE 85.1. Usual contraindications to the use of nonabsorbable mesh
in incisional hernias
greater use of prosthetic materials, as a result of the appreciation
of a biochemical pathology in the etiology of hernia formation. Associated visceral surgery (especially colon)
This pathology has been most evident in giant incisional hernias Eventration complicated by visceral necrosis
and in hernias with multiple defects l with or without the loss of Early postoperative dehiscence
abdominal wall substance. 2 From the early 1970s, French l and Moderate ascites
American 3 investigators have demonstrated the usefulness and ef- Irradiated abdominal wall
fectiveness of prosthetic materials, developing new techniques and
promoting these materials in their publications. Use of prostheses
varies with the personal experience of the surgeon, the tenden- TABLE 85.2. Large incisional hernias repaired with nonabsorbable mesh
cies of certain centers, and the dictates of the surgical problem at (1984-1998)
hand.
Through understanding the application of prostheses, guide- Hernia No.
lines are constantly being established and challenged. Absorbable Supraumbilical 84
meshes, for example, may serve as a temporary measure, for they Midline
lose their tensile strength within 10 weeks and invariably allow re- Infraumbilical 58
current hernia in 100% of cases.3.4 Suprainfraumbilical 38
A study carried out by J.P. Chevrel and J.B. Flament reviewed Subcostal 12
the experience of the French Surgical Association in 1990; they Lateral
formally condemned the use of nonabsorbable prostheses in the Inguinoiliac 16
presence of sepsis or during a surgical intervention on an ab- Lumbar 9
Total 217
dominal viscus. 5 These contraindications are listed in Table 85.l.
This attitude is shared by many authors l .5-7 but begs to be chal-
lenged to some extent. In 14 years' experience, covering 217
incisional hernias, 39 cases (18%) were associated with a simulta- TABLE 85.3. Visceral surgery associated with incisional hernia repair
neous procedure (Tables 85.2 and 85.3). This experience falls into using nonabsorbable mesh (1984-1998)
two stages: During the first period, abdominal reconstruction was Surgery No.
carried out with Mersilene® as an onlay; later, Mersilene or
polypropylene (Prolene®) was used in a preperitoneal or retro- Colostomy 3
muscular site. In some of the latter cases, a Vicryl® mesh was used Colon resection 4
for the peritoneal closure and Prolene mesh in the pre peritoneal Enterectomy 6
or retromuscular space, as described by Trivellini and Danelli. 2 No Hiatus hernia 1
prostheses were used when the clinical situation included a Liver resection
Viscerolysis 6
chronic suppurative discharge.
Appendectomy 4
The experience is limited, but we can already appreciate that a Cholecystectomy 3
simultaneous procedure that may involve a potential risk of con-
580
85. Prostheses in Incisional Hernias with Septic Risk 581
TABLE 85.4. Complications following incisional herniorrhaphies
With septic risk Without septic risk
Cases (n = 178) No. % Cases (n = 39) No. %

Seroma 7 3.9 Seroma 4 10.3
Hematoma 4 2.2 Hematoma 2 5.1
Skin necrosis 6 3.4 Skin necrosis 3 7.7
Superficial abscess 4 2.2 Superficial abscess 3 7.7
Deep abscess 1 0.5 Deep abscess 2 5.1
Mesh removal 0 0 Mesh removal 0 0
Recurrence 4 2.2 Recurrence 2 5.1
tamination does not rigidly contraindicate the use of prosthetic 3. Amid PK, Shulman AG, Lichtenstein IL. Selecting synthetic mesh for
materials. None of the complications reported in Table 85.4 was the repair of groin hernia. Postgrad Gen Surg. 1992;April:150-155.
significant. In particular, one obselVes that the infectious compli- 4. Tyrellj, Silberman H, et al. Absorbable versus permanent mesh in ab-
cation rate in the "septic" group is doubled when compared with dominal operations. Surg Gynecol Obstet. 1989;168:227-233.
the "nonseptic" group, but in neither case was it necessary to re- 5. ChevreljP, FlamentjB. Les eventrations de La paroi abdominale. Paris: Mas-
son;1990.
move the prosthesis. As expected, the recurrence rate is doubled
6. Brown GL, et al. Comparison of prosthetic materials for abdominal
in the "septic" group but still within acceptable range, consider- wall reconstruction in the presence of contamination and infection.
ing the extensive nature of these incisional hernias. Ann Surg. 1985;201.
7. Stoppa R. The treatment of complicated groin and incisional hernias.
World] Surg. 1989;13:545-554.
8. Mandala V. Considerazioni sull'uso di meteriale protesico eterologo
References nei laparoceli a rischio settico. XV Congresso GREPA, Milano;1993.
9. Vix S, Meyer CH, Rohr S, et al. The treatment of incisional and ab-
1. Rivesj, PirejC, FlamentjB, et al. Major incisional hernias in surgery dominal hernia with a prosthesis in potentially infected tissue. A se-
of the abdominal wall. In ChevreljP (ed): Surgery of the abdominal wall. ries of 47 cases. Hernia. 1997;1:157-161.
New York: Springer-Verlag; 1987;116-144. 10. Corcione F, Cristinzio G, Cimmino V, et al. Eventrations et pathologie
2. Trivellini G, Danelli PG. Perdita dis sostanza reale della parete ad- associee: a propos de 23 cas. GREPA. 1993;15:54-56.
dominale. Uso di due protesi nella riparazione chirurgica. Atti del 11. Corsi C, Confalonieri GM, Frigerio A, et al. Emploi de la technique
convegno "Attualita e prospettive nella chirurgia dei laparoceli." de Rives modifiee dans Ie traitement des eventrations associees a une
Padova;1991. pathologie viscerale. GREPA. 1993;15:61-63.
86
Incisional Hernias as Emergencies
David V. Feliciano
Pathophysiology Bowel Obstruction

Risk Factors Incarceration of small or large bowel in an incisional hernia may
lead to either a partial or complete bowel obstruction. When part
Despite improvements in suture materials and techniques of clo- of the circumference of the bowel (Richter's hernia) or a Meckel's
sure of abdominal incisions, hernias continue to occur. 1.2 Accepted diverticulum (Littre's hernia) is incarcerated, partial obstruction
risk factors include the disease process that led to the laparotomy, is likely to be present. Should an entire loop of intestine be be-
obesity, the type of incision, the technique of closure, and a deep yond the hernia ring, complete obstruction of the intestine with
wound infection in the postoperative period. 3 the potential for conversion to a closed loop obstruction is an ob-
The incidence of incisional hernias ranges from 2 to 11 % after vious risk.
abdominal operations, but varies widely depending on the pres- Strangulation obstruction results when venous obstruction in
ence or absence of the factors listed. 4 For example, there have the stretched mesentery of the entrapped bowel compromises ar-
been several retrospective studies documenting a significantly terial flow. Ischemic changes are first present on the antimesen-
greater incidence of incisional hernias in patients undergoing op- teric border of the incarcerated loop of intestine. With delay in
eration for abdominal aortic aneurysms than those with aortoiliac recognition, reduction, or operative treatment, a strangulation
occlusive disease.5.6 In the report by Hall et al.,5 the incidence of obstruction of the incisional hernia will lead to gangrene of the
incisional hernias after repair of an abdominal aortic aneurysm affected loop. The sepsis syndrome or septic shock may result
was 10% versus 3% after operation for aortoiliac occlusive disease. from aerobic and anaerobic bacteria entering the circulation.
Morbid obesity continues to be a significant risk factor, with Sug- Should the necrotic loop of intestine perforate before operation,
erman et al. 7 noting a 20% incidence of incisional hernias after a secondary necrotizing cellulitis or fasciitis of the abdominal wall
gastric bypass procedures. The use of a transverse incision lowers may ensue. This complication will dictate wide debridement of
significantly the long-term risk for an incisional hernia when com- the abdominal wall around the original hernia defect and pre-
pared with the standard midline incision. 8 Finally, the use of a conclude attempts at repair. Perforation of the necrotic loop beyond
tinuous closure technique with a suture of appropriate strength the hernia ring during operative manipulation will necessitate
placed at the "right" depth and width through the linea alba will open packing of the subcutaneous space over a primary repair.
minimize the incidence of postoperative incisional hernias. 1•2•7.9-12 Should gangrene of the bowel at the site of perforation extend
deep to the level of the hernia ring, peritonitis results. In such a
patient an extensive celiotomy may be necessary to irrigate and
Incarceration flush out purulent material and bowel spillage from the peritoneal
cavity.
While incarceration can occur in any incisional hernia, the great-
est risk is in patients with small defects in previous incisions. Once
the greater omentum or a loop of small or large intestine pro-
trudes beyond the defect in the abdominal wall, stretching of the Mortality
mesentery occurs. Lymphatic and small vein obstruction occurs,
and edema of the enclosed organ follows. With edema, incarcer- Death in the postoperative period, after urgent operations for in-
ation may result and become irreducible as adhesions form carcerated incisional hernias, is rare. When a secondary strangu-
between the hernia defect and the entrapped viscuS. 13 An incar- lation obstruction supervenes, or gangrene with or without
cerated incisional hernia may be a cause of bowel obstruction or perforation of the entrapped bowel occurs, mortality rates are 10
strangulation obstruction, and immediate admission to the hospi- to 20% and comparable to situations with adhesive bowel ob-
tal for early operation is indicated. struction. 14-16
582
86. Incisional Hernias as Emergencies 583
Presentation
Approximately 50% of incisional hernias are present at 1 year fol-
lowing the original surgery, with a continuing and increasing fail-
ure rate over the next 5 to 10 years. 14,15 When present, incisional
hernias continue to enlarge because of the migration of intraab-
dominal viscera into the sac, the stretching of abdominal wall mus-
culature adjacent to the sac, and the inevitable weakening of the
abdominal wall with aging. Because a primary repair is significantly
easier than repairs requiring synthetic meshes, patients should
have their surgery when the hernia is small and moderately symp-
tomatic.
A painful bulge through an abdominal incision is the most com-
mon presenting complaint of a patient with an incisional hernia.
In the emergency room, the decision to carry out an emergent or
urgent celiotomy is based on classic criteria. These include incar-
ceration of viscera in the protruding hernial sac, partial or com-
plete obstruction of the small or large intestine, clinical and
FIGURE 86.2. Same patient as in Fig. 86.1. Abdominal x-ray confirmed the
laboratory evidence of strangulation obstruction, or diffuse peri-
presence of an incarcerated cecum, which was found to be perforated at
tonitis on physical examination. Although operation for an incar- operation.
cerated inguinal hernia is usually deferred following manual or
spontaneous reduction to allow for local edema to resolve, early
operation is recommended after the reduction of an incarcerated sary surgery of a nonincarcerated incisional hernia when other
incisional hernia. This is primarily because the local effects of a causes could be the source of abdominal pain.
recent incarceration have minimal impact on operative repair of
a rigid defect of the anterior abdominal wall. Also, the well-known
difficulty in differentiating obstruction of the gut from strangula- Preparation for Operation
tion obstruction imposes early operation in such patients. 16-20
On physical examination in obese patients, there may be some Patients with incarcerated incisional hernias and obstruction of
difficulty in palpating the edges of the hernia defect and incar- the gastrointestinal tract with or without strangulation or patients
cerated preperitoneal fat, or omentum through a small deff.ct. On with peritonitis are usually prepared for operation in the emer-
occasion, a routine x-ray of the abdomen may reveal an incarcer- gency room or in a preoperative holding area, where a nasogas-
ated loop of small or large intestine anterior to the abdominal wall tric tube is inserted. Blood samples are drawn for hemoglobin,
(Figs. 86.1 and 86.2). It is not uncommon today for a referring white blood cell count, platelet count, prothrombin time, partial
physician to obtain an abdominal computed tomographic scan to thromboplastin time, and routine chemistry. Large bore (14
confirm the diagnosis before consulting with a general surgeon gauge) peripheral intravenous catheters are inserted in the upper
(Fig. 86.3). This study is particularly useful in avoiding unneces- extremities, and infusion of a crystalloid solution appropriate for
the correction of fluid and electrolyte losses from the stomach and
upper small intestine is begun. Supplemental intravenous potas-
FIGURE 86.3. Computed tomography documentation of an incarcerated in-

FIGURE 86.1. Incarcerated midline incisional hernia. cisional hernia.
584 D.Y. Feliciano
sium is restricted until a serum potassium level and normal renal

function are confirmed with laboratory testing. A bladder catheter
is also inserted to monitor urinary output.
When respiratory failure threatens, characterized by tachypnea,
hypoxia, or hypercarbia in association with complete bowel ob-
struction or strangulation obstruction with peritonitis and sepsis,
emergency tracheal intubation is performed. Hemodynamic in-
stability in the elderly or any patient with significant intercurrent
systemic diseases requires the insertion of a pulmonary artery
catheter to monitor the cardiovascular status.
Abnormalities of the coagulation cascade may be present in pa-
tients with cirrhosis or ascites or in those with peritonitis to com-
pensate for international normalized ratio (INR). Infusion of fresh
frozen plasma and platelets is based on abnormalities on labora-
tory testing. The administration of intramuscular or intravenous
vitamin K is appropriate in the cirrhotic patient when the pro-
thrombin time or INR is abnormal and should be continued in
the postoperative period. FIGURE 86.4. In this patient with omental cover of the midgut, a Marlex
All intravenous antibiotic should be administered in the pre- mesh prosthesis was used to repair an incisional hernia.
operative period so that an appropriate serum level is present
when incarcerated bowel is reduced or necrotic bowel is resected grenous bowel in the hernia sac, necrotizing fasciitis of the ab-
at operation. A third generation cephalosporin or a combination dominal wall, or diffuse peritonitis secondary to gangrenous bowel
of a semisynthetic penicillin/beta-Iactamase inhibitor adminis- with perforation. Bacterial contamination of the incisional hernia
tered 30 to 60 minutes before celiotomy is most appropriate. in all of these circumstances precludes the use of a synthetic mesh
In general, the decompression of the stomach, the correction when a large defect is present (Fig. 86.6).
of hypovolemia, electrolyte imbalance, coagulation defects, and With cellulitis or breakdown of skin overlying the peritoneal sac,
the administration of intravenous antibiotics can be completed the skin edges should be debrided back to areas that bleed freely.
within 1 to 2 hours in the preoperative holding area. Even for pa- Ischemia of adjacent subcutaneous fat is usually present, as well,
tients with the most severe metabolic disturbances appropriate pre- and this layer should be debrided, also.
operative preparation will make a subsequent operation safer. The presence of ischemic or gangrenous bowel should prompt
a celiotomy to allow for safe bowel resection and irrigation of the
peritoneal cavity. Resection of the ischemic or gangrenous small
Operation bowel is followed by a sutured end-to-end or stapled side-to-side
anastomosis unless advanced peritonitis or intraoperative seque-
Uncomplicated Incarcerated Incisional Hernia lae from sepsis are present. With ischemia or gangrene of the right
colon, an anastomosis may be performed as described for small
In general, an incision should follow the course of a previous one bowel. Ischemia or gangrene of the distal transverse or left colon
over the protruding incisional hernia. Following separation of the requires the creation of an end colostomy at a site distant from
thinned-out skin of the abdominal wall over the hernial sac, the sac the incisional hernia.
is dissected to its neck. Should there be a concern that continuing In the absence of advanced peritonitis or serious intraoperative
dissection will reduce viscera incarcerated in the hernial sac, a Bab-
cock clamp is placed across one corner of the lower hernial sac to
maintain the enclosed viscera. The apex of the peritoneal sac is
then opened, the color of the released fluid is noted, and a speci-
men of that fluid is sent for Gram staining if the enclosed viscus is
questionably ischemic. The peritoneal sac is then excised at the
level of the hernia ring, along with attenuated abdominal wall tis-
sues medial to the laterally displaced rectus abdominis.
In the absence of hemorrhagic, black, or turbid peritoneal fluid
or any evidence of ischemic bowel, the operative repair is based
on the ultimate size of the defect after debridement. Numerous
operative techniques for primary repair or insertion of a synthetic
mesh are described elsewhere in this text and in other publica-
tions 3•IS--25 (Figs. 86.4 and 86.5).
Complicated Incarcerated Incisional Hernia

A complicated, incarcerated incisional hernia is one in which any
of the following may be present: cellulitis, skin ulceration, dis- FIGliRE 86.5. In this patient without adequate omental cover of the midgut,
ruption of the skin overlying the sac, presence of ischemic or gan- an ePTFE prosthesis was used to repair the incisional hernia.
FIGURE 86.7. Plastic irrigation bag sewn to the skin edges of the abdomi-
FIGURE 86.6. Contraction of Marlex mesh used to close an incisional her- nal incision makes an excellent temporary silo. (Reprinted from Feliciano
nia in a septic situation caused erosion of the underlying stomach. et al.,29 McGraw-Hili, with permission.)
metabolic sequelae following resection and anastomosis of is- resuscitation as edema of the intestine decreases significantly over
chemic bowel, it is appropriate to attempt a primary repair of an 2 to 4 days. It is then appropriate to return the patient to the op-
incisional hernia using nonabsorbable, interrupted sutures placed erating room to complete the third phase of "damage control." At
in a figure-of-eight or near-far-far-near technique. When tension the first reoperation, the silo is removed, the small bowel is anas-
is present, a variety of operative techniques have been utilized. tomosed, and a decision is made on the safety of performing an
Among these are (1) longitudinal relaxing incisions of the rectus ileocolostomy or an end transverse or left colostomy. The peri-
sheaths; (2) longitudinal relaxing incisions on the external oblique toneal cavity is irrigated with antibiotic solution. A primary repair
aponeuroses approached through separate skin incisions approx- of the incisional hernia is attempted using nonabsorbable inter-
imately 1 to 2 inches medial to the anterior axillary lines; (3) stag- rupted sutures placed in a figure-of-eight or near-far-far-near tech-
gered relaxing incisions on the anterior rectus sheaths as described nique as noted above. When excessive tension is present, relaxing
by Clotteau and Premont26 ; (4) cane-bottoming with PDS bands 22 ; incisions should be used.
and (5) components separation. 27 ,28 If primary closure of the hernia cannot be performed at reop-
When advanced peritonitis or intraoperative cardiovascular, res- eration because of the size of the fascial defect (rather than dis-
piratory, renal, and/or coagulation failure from sepsis is present, tension of the underlying midgut), the surgeon has two options.
a "damage control" operation should be performed. 29 This oper- The first is to extend the size of the hernia defect to prevent fu-
ative philosophy, borrowed from surgical services in trauma ture incarceration and closure of skin only over the now much
centers, mandates that hemorrhage and leakage from the gas- larger incisional hernia. The patient is advised that repair of the
trointestinal tract, only, be dealt with at a first celiotomy. In the hernia can be performed with a permanent mesh or patch in 3 to
patient with an incarcerated incisional hernia and any of the lo- 6 months. The second option is to cover the exposed midgut with
calor systemic sequelae listed above, an abbreviated operation
would involve resection of the ischemic or gangrenous bowel. Re-
anastomosis of the small bowel or colon, creation of a colostomy,
or repair of the incisional hernia would not be performed. Ends
of the bowel are stapled shut after resection and left in the ab-
domen. Any exposed intestine is covered with a transparent silo
such as a large genitourinary irrigation bag sewn to the skin edges
of the incision (Fig. 86.7). Intraoperative cardiovascular, respira-
tory, renal, coagulation, and septic complications can then be cor-
rected in the surgical intensive care unit by the surgeon-intensivist.
Vigorous resuscitation with crystalloid solutions is directed by se-
rial hemodynamic measurements using a pulmonary artery
catheter during this second phase of "damage control" in the in-
tensive care unit. Appropriate resuscitation is characterized by re-
versal of the base deficit in arterial blood gases and restoration of
urine output. Once the cardiovascular, respiratory, renal, and co-
agulation systems have been returned to normal and appropriate
antibiotic therapy has been continued, a decision on the timing
for reoperation will depend on the extent of distension of the FIGURE 86.8. Double thickness absorbable mesh coverage of peritoneal cav-
midgut under the transparent silo. It is often worthwhile to allow ity in a patient with an abdominal septic process involving the abdominal
the patient to enter the diuretic phase of recovery after crystalloid wall. (Reprinted from Feliciano et al.,29 McGraw-Hili, with permission.)
586 D.V. Feliciano
References
1. Jenkins TP. The burst abdominal wound: a mechanical approach. Br
] Surg. 1976;63:873-876.
2. Israelsson LA,Jonsson T. Closure of midline laparotomy incisions with
polydioxanone and nylon: the importance of suture technique. Br]
Surg. 1994;81:1606-1608.
3. Wantz GE, Chevrel JP, Flament JB, et al. Incisional hernia: the prob-
lem and the cure.] Am Call Surg. 1999;188:429-447.
4. Santora TA, Roslyn]. Incisional hernia. Surg Clin North Am. 1993;
73:557-570.
5. Hall KA, Peters B, Smyth SH, et al. Abdominal wall hernias in patients
with abdominal aortic aneurysmal versus aortoiliac occlusive disease.
Am] Surg. 1995; 170:572-575.
6. Adye B, Luna G. Incidence of abdominal wall hernia in aortic surgery.
Am] Surg. 1998;175:400-402.
7. Sugerman JU, KellumJMJr, Reines HD, et al. Greater risk of in cisionaI
hernia with morbidly obese than steroid-dependent patients and low
recurrence with prefascial polypropylene mesh. Am] Surg. 1996;171:
FIGURE 86.9. Granulation tissue covering an open abdomen after 3 weeks. 80-84.
8. Luijendijk RW,JeekeIJ, Storm RK, et al. The low transverse Pfannen-
stiel incision and the prevalence of incisional hernia and nerve en-
a double layer of absorbable mesh and apply a bulky pressure dress- trapment. Ann Surg. 1997;225:365-369.
ing to keep the midgut below the body wall (Fig. 86.8). With ap- 9. Kendall SWH, Brennan TG, Guillou PJ. Suture length to wound length
propriate nutritional support and dressing changes, a bed of ratio and the integrity of midline and lateral paramedian incisions. Br
granulation tissue will appear over the next 2 to 4 weeks (Fig. 86.9). ] Surg. 1991;78:705-707.
When appropriate, a split-thickness skin graft from the anterior 10. Israelsson LA, Jonsson T. Suture length to wound length ratio and
thigh is applied (Fig. 86.lO). Repair of the hernia in 3 to 6 months healing of midline laparotomy incisions. Br] Surg. 1993;80: 1284-1286.
will usually involve the preliminary insertion of tissue expanders 11. Trimbos JB, Smit IB, Holm JP. A randomized clinical trial comparing
in the abdominal wall by the plastic surgeon. This technique will two methods of fascia closure following midline laparotomy. Arch Surg.
1992;127:1232-1234.
allow for coverage of the permanent mesh inserted after removal
12. Brolin RE. Prospective, randomized evaluation of midline fascial clo-
of the skin graft.
sure in gastric bariatric operations. Am] Surg. 1996;172:328-331.
13. Bergstein JM. Strangulating external hernia. In Nyhus LM, Condon
RE, (eds): Hernia, 4th ed. Philadeiphia:J.B. Lippincott; 1995:285-294.
Conclusions 14. Ellis H, Gajraj H, George CD. Incisional hernias: when do they occur?
Br] Surg. 1983;70:290-291.
Uncomplicated incarcerated incisional hernias can undergo pri- 15. Mudge M, Hughes LE. Incisional hernias: a ten year prospective study
mary repair or insertion of a synthetic mesh. Complicated incar- of incidence and attitudes. Br] Surg. 1985;72:70-71.
cerated incisional hernias may require "damage control" operative 16. McEntee GP, O'Carroll A, Mooney B, et al. Timing of strangulation in
techniques. If primary repair cannot be performed at an early re- adult hernias. Br] Surg. 1989;76:725-726.
17. Stoppa RE. The treatment of complicated groin and incisional her-
operation, the risk of infection precludes the use of a synthetic
nias. World] Surg. 1989;13:545-554.
mesh or patch. In such a patient, repair of the incisional hernia 18. Shatila AH, Chamberlain BE, Webb WR. Current status of diagnosis
should be deferred for 3 to 6 months. and management of strangulation obstruction of the small bowel. Am
] Surg. 1976;132:299-303.
19. Bizer LS, Liebling RW, Delany HM, et al. Small bowel obstruction. The
role of nonoperative treatment in simple intestinal obstruction and
predictive criteria for strangulation obstruction. Surgery. 1981;89:407-
413.
20. McEntee G, Pender D, Mulvin D, et al. Current spectrum of intestinal
obstruction. Br] Surg. 1987;74:976-980.
21. Condon RE: Incisional hernia. In Nyhus LM, Condon RE (eds): Her-
nia, 4th ed. Philadelphia: J.B. Lippincott;1995:319-328.
22. Skandalakis LJ, Gadacz TR, Mansberger ARJr, et al. Incisional hernia.
In Skandalakis LJ, Gadacz TR, Mansberger ARJr, et al. (eds): Modern
hernia repair. The embryological and anatomical basis of surgery. Pearl River,
NY: Parthenon Publishing Group, Inc.; 1996:14-44.
23. McLanahan D, King LT, Weems C, et al. Retrorectus prosthetic mesh
repair of midline abdominal hernia. Am] Surg. 1997;173:445-449.
24. Gillion JF, Begin GF, Marecos C, et al. Expanded polytetrafluoroeth-
ylene patches used in the intraperitoneal or extraperitoneal position
for repair of incisional hernias of the anterolateral abdominal wall.
Am] Surg. 1997;174:16-19.
25. U trera Gonzalez A, de la Portilla de Juan F, Carranza Albarran G. Large
FIGURE 86.10. Same patient as in Fig. 86.9 with healed split-thickness skin incisional hernia repair using intraperitoneal placement of expanded
graft over an open abdomen. polytetrafluoroethylene. Am] Surg. 1999;177:291-293.
26. Clotteau JE, Premont M. Cure des grandes eventrations cicatricielles 28. Fabian TC, Croce MA, Pritchard FE, et al. Planned ventral hernia.
medianes par un procede de plastie aponevrotique. Chirurgieo 1979; Staged management for acute abdominal wall defects. Ann Surg. 1994;
105:344-346. 219:643--653.
27. Ramirez OM, Ruas E, Dellon AL. "Components separation" method 29. Feliciano DV, Moore EE, Mattox KL. Trauma damage control. In
for closure of abdominal-wall defects: an anatomic and clinical study. Mattox KL, Feliciano DV, Moore EE (eds): Trauma, 4th ed. New York:
Plast Reconstr Surg. 1990;86:519-526. McGraw-Hill; 2000:907-930.
Part XIV
Pediatrics
87
Pediatric Hernias
Bradley M. Rodgers, Eugene D. McGahren, III, and Robert C. Burns
Inguinal and Femoral Hernias guinal canal. Inguinal hernias were reported in 1971 to be more
common on the right (60%) than on the left (30%) or bilateral
History (10%).5 This report holds true today, with the accepted incidence
approximating these rates. Boys are affected more frequently than
Inguinal hernias in children are almost always of the indirect va- girls are by a ratio of 3:1 to 10:1, and premature infants have a
riety and are the result of persistent patency of the processus vagi- higher risk than term babies (Fig. 87.1).6
nalis, which usually obliterates as a normal part of embryonic A direct inguinal hernia is an acquired defect. It occurs as a pro-
development. Reference to inguinal hernias can be found as early trusion of abdominal contents into the inguinal canal medial to
as 1552 Be in the Egyptian literature, although they were not the inferior epigastric vessels. Recurrent inguinal hernias in child-
treated surgically until 400 AD.I These reports are essentially lim- hood are most commonly of the direct variety and may occur due
ited to the adult manifestations of inguinal hernia. to iatrogenic injury to the floor of the inguinal canal. This may be
Celsus is generally credited with the first description of the avoided by carefully lifting the contents of the inguinal canal into
processus vaginalis in the second century, and the canal of Nuck the wound during repair of indirect hernias rather than blindly
was described in females in 1672.2 The modem approach to the encircling the contents while still inside the inguinal canal, as
management of pediatric hernias (high ligation of the hernia sac) is commonly done in adults. Direct inguinal hernias are rare in
was noted by Ferguson 3 in 1899. MacLennan 4 advocated elective children.
operation in 1914 and ushered in the current recommendation A femoral hernia is the result of herniation of abdominal con-
of elective high ligation of the processus vaginalis. tents into the femoral canal beneath the inguinal ligament. It has
been described not as a congenital deformity but as a weakness of
the junction between the transversalis fascia and Cooper's liga-
ment. It appears to develop as a protrusion of peritoneum as a
Embryology consequence of increased abdominal pressure. 7,s Femoral hernias
are extremely uncommon in children, but appear to occur twice
The testicular descent from the high retroperitoneal location into as frequently in females as in males. 9
the scrotum in the seventh to ninth months of fetal development
is fully outlined by Skandalakis et al. 2 A funicular process of peri-
toneum extends into the inguinal canal and scrotum (the proces-
sus vaginalis), perhaps playing a role in the descent of the testicle. Presentation and Diagnosis
The processus vaginalis then spontaneously obliterates through an
unknown mechanism, although factors have been proposed and A congenital inguinal hernia is usually discovered shortly after
are under investigation. The obliterated scrotal remnant remains birth or during the first few months of life, although it may pre-
as the tunica vaginalis around the anterior surface of the testis. sent even years later. The lesion presents as an inguinal mass, usu-
The inguinal portion of this process usually persists as a fibrous ally with straining or crying. The pediatrician or, at times, the
band. If the inguinal portion of the processus vaginalis fails to at- parents will have noticed a smooth, firm mass in the groin, lat-
rophy and close, the result is a patent processus vaginalis. The eral to the external inguinal ring that may reduce spontaneously
patent processus vaginalis represents a communication with the or with gentle pressure. The lesion may be demonstrated by hav-
general peritoneal cavity into which viscera can herniate or fluid ing the child cry during the examination. This is easily accom-
can collect. The extent of the defect may result in a diverticular plished in most infants by restraining the child with the legs
deformity of the processus vaginalis that may be open to the scro- straight and arms over the head. In older children, performance
tum (congenital indirect hernia) or may be a short funicular of a Valsalva maneuver can demonstrate the hernia. Alternative
process that does not present as a hernia until later in life. Alter- physical findings may include the size of the spermatic cord as it
natively, the inguinal processus may be closed or nearly closed, exits the external inguinal ring or the so-called silk sign on pal-
leaving a fluid filled cyst or hydrocele within the scrotum or in- pation of the cord structures, noting the slippery feeling of two
591
592 B.M. Rodgers et aI.
Peritoneal FIGURE 87.1. Different forms of inguinal her-

cavity nia and hydrocele occurring as a result of the
failure of complete obliteration of the proces-
Obliterated sus vaginaIis.
processus
vaginalis
Vas ---
Tunica - --\"1rm~1'
vaginalis
Normal Inguinal hernia Complete Hydrocele of cord Communicating
inguinal hernia hydrocele
silk surfaces rubbing together. This sensation is created by the didymitis. Usual organisms to be treated include Escherichia col~
two peritoneal surfaces of the hernia sac sliding against one an- Staphylococcus, and Haemophilus. A standard antibiotic regimen
other. Irreducible hernias are incarcerated and demand emer- would begin with trimethoprim/sulfamethoxazole.
gent intervention. If the diagnosis of incarcerated hernia remains in question when
these diagnoses are considered, then inguinal exploration is al-
ways justified.
Differential Diagnosis
The differential diagnosis of incarcerated inguinal hernia includes Treatment
testicular torsion, torsion of the appendix testis, acute hydrocele,
varicocele, and epididymitis. The evaluation of the acute groin or All inguinal hernias should be repaired because there is no prece-
scrotum must address each of these possible diagnoses. lO dence for spontaneous closure of the clinically evident hernia. The
Testicular torsion is a surgical emergency if the offended gonad significance of a patent processus vaginalis in the absence of a clin-
is to be saved. Clinical suspicion of testicular torsion is based on ical hernia is unclear,13,14 although, many pediatric surgeons con-
the typical history of sudden onset of scrotal pain in the pubertal sider a patent processus vaginalis to represent a potential hernia.
boy. Younger boys are occasionally affected as well. The scrotum Timing of the operation is related primarily to the reducibility of
subsequently develops erythema and swelling. The scrotum may be the hernia and certainty of the diagnosis. The risk of incarcera-
so tender as to preclude adequate physical examination. Doppler tion is highest in the first few months of postnatallife.I 5
flow studies have provided a fast, noninvasive method to confirm Consideration of the age is important when deciding anesthetic
the diagnosis in equivocal cases. Ancillary studies should not delay and postoperative management. Most children's hernias are re-
operative therapy in the case of suspected testicular torsion. paired on an outpatient basis, although in children under 50 weeks
Torsion of the appendix testis usually presents in the pubertal postconceptual age, overnight observation is recommended be-
or postpubertal boy. It begins suddenly with the onset of pain and cause of the risk of postanesthetic apnea. Steward 16 demonstrated
is followed by swelling and the development of the classic "blue a 39% risk of apnea in premature infants compared with less than
dot" sign of a bluish discolored area within the scrotum, signify- 1% in children born at full term. A survey of pediatric surgeons
ing the infarcted appendix testis. If this diagnosis is confirmed, revealed that 65% of surgeons operate on neonatal intensive care
then operative therapy may sometimes be avoided. unit patients with reducible inguinal hernias when convenient; the
The diagnosis of hydrocele may usually be discerned by the his- remaining one-third delay repair until postconceptual age greater
torical finding that the swelling has been chronic or present since than 40 to 60 weeks. 17 Anesthetic considerations are related to age
birth and by the physical finding of a cystic structure in the scro- and overall status of the patient, including the presence of asso-
tum that narrows to a small neck below the external inguinal ring. ciated problems. General endotracheal anesthetic is preferred by
The diagnosis may sometimes be difficult in those lesions enter- a majority of responders to the survey mentioned above (70%) be-
ing the inguinal canal and those that arise suddenly. If the lesion cause the control of ventilation is greater and the premature
is not distinguishable from an incarcerated hernia, then operation neonate may require postoperative ventilation. For the preterm
for a presumed incarcerated hernia should be conducted. child who is not intubated, some would prefer to avoid intubation.
Varicocele is a venous malformation of the spermatic cord. Vari- In these cases spinal anesthesia with sedation has been used ef-
cosities may arise either primarily within cremasteric fibers or sec- fectively. Regional analgesia is used routinely in most children,
ondarily from intraabdominal compression of the gonadal given by caudal block, ilioinguinal and iliohypogastric nerve block,
vessels.I 1,12 The classic "bag of worms" is noted on palpation ofthe or simple local infiltration of anesthetic. This appears to lessen
engorged hemiscrotum, especially when the boy is standing. The the requirement for intraoperative narcotic and postoperative
mass should resolve when the patient is supine. The diagnosis is analgesia.
usually not difficult to discern, and urgent treatment is rarely Reducible inguinal hernias should generally be repaired when
indicated. diagnosed. The operative strategy is directed at the ligation of the
Epididymitis is uncommon in boys before puberty and is usu- processus vaginalis at the level of the internal ring. The operative
ally a complication of a urinary tract infection. Urinalysis should procedure is undertaken through a transverse incision in the low-
aid in the differential diagnosis, as do systemic signs of infection. est groin skin crease approximately 1 cm lateral to the pubic sym-
Appropriate antibiotic therapy is the treatment of choice for epiphysis. The incision should be long enough to adequately expose
87. Pediatric Hernias 593
the cord structures, and a safe operation should never be com-

promised by a small incision.
Scarpa's fascia is first encountered. This may be a rather thick,
organized layer in children, and care must be taken not to mis-
take this layer for the external oblique aponeurosis fibers. Scarpa's
fascia can be lifted into the wound, whereas the aponeurosis usu-
ally cannot be elevated to that level. The aponeurosis of the ex-
ternal oblique muscle is exposed down to the inguinal ligament.
The external ring is then defined with blunt dissection. The in-
guinal canal is opened down to the level of the external ring by
dividing the fibers of the aponeurosis of the external oblique in
the direction of their course. Care is taken to avoid injury to the
ilioinguinal nerve.
The cremaster fibers are separated and the cord drawn into the
wound, and the hernial sac is separated from the underlying loose
tissues (Fig. 86.2) .18 This maneuver is facilitated by elevation of
the sac, with the vas deferens and vessels, taking care to avoid
FIGURE 87.3. The hernial sac is divided and ligated at the level of the in-
grasping the vas or vessels directly. The vas and vessels are then ternal ring.
bluntly dissected away from the hernial sac and retracted well out
of harm's way. The sac is cleared of loose areolar tissue up to the
internal ring and ligated with absorbable suture material (Fig. for a sliding component must be conducted in females because
86.3). In some cases it may be desirable to open the sac and con- the fallopian tube is not infrequently involved and may easily be
firm the complete reduction of the abdominal contents and the overlooked in a cursory examination. Many surgeons prefer to
absence of a sliding component. close the internal ring in female patients because there are no
In rare circumstances in children it may be necessary to repair cord structures to enter the canal.
the floor of the inguinal canal. In these situations, the cord struc- The operative strategy is the same in the case of the incarcer-
tures should be retracted out of the inguinal canal and the inter- ated hernia. If the hernia can be reduced in the preoperative pe-
nal oblique and transversus abdominis muscles approximated to riod, then the child is admitted and the operation is delayed for
Poupart's ligament, as in the Bassini repair in adults. The distal 24 to 48 hours to allow the edema to resolve. In the truly incar-
end of the sac is opened to avoid the accumulation of fluid, and cerated situation, the procedure should be considered an emer-
the testicle is returned to the base of the scrotum by gentle re- gency because the interval to strangulation is very short in
traction on the gubernaculum. The external oblique aponeurosis congenital indirect inguinal hernias. The operation is begun in
is then closed over the inguinal canal and its contents. the same manner as for reducible hernias, and the inguinal canal
The operation for females is essentially the same, although there is opened. The hernial sac is isolated from the cord structures and
is obviously no need to be concerned with cord structures. opened. Viable bowel is reduced, and necrotic bowel must be re-
Nonetheless, the ilioinguinal nerve must be protected. The search sected. Resection is most safely approached by converting the op-
eration to a laparotomy through a separate incision. In some cases,
however, the bowel may be resected and anastomosed through the
inguinal incision. If the bowel is difficult to reduce, the internal
ring may be either bluntly dilated or enlarged by dividing the fibers
of the internal oblique muscle lateral to the internal ring. This, of
course, must be repaired. The remainder of the operation is con-
ducted as for reducible hernias.
The operative approach to femoral hernias in children is simi-
lar to that in adults. The groin is opened through a typical in-
guinal incision, and the femoral triangle is approached by the
infrainguinal route. Alternatively, some surgeons prefer to gain ac-
cess to the femoral triangle by opening the floor of the inguinal
canal. The hernial sac is dissected free and transfixed with ab-
sorbable suture material. The femoral canal is narrowed by ap-
proximating Poupart's ligament to Cooper's ligament. An inguinal
exploration is recommended to evaluate the possibility of con-
current inguinal hernia. 9 ,IO
The role of routine contralateral groin exploration is a source
of debate among pediatric surgeons. However, the diligent exam-
iner can help select children for contralateral exploration if there
is any indication that a hernia may be present by careful physical
examination. The trend toward less intervention has been pro-
gressively lowering the age at which most surgeons recommend
FIGURE 87.2. Careful blunt dissection of the hernial sac by drawing the routine exploration in the asymptomatic child. A recent survey re-
contents of the inguinal canal into the wound. vealed that 35% of surgeons routinely explore the contralateral
594 B.M. Rodgers et al.
groin in boys under 2 years of age. This number is consistent rection, thus forming an oval line of reflection between the ecto-
among male patients regardless of side of presentation or prema- derm and amnion. This is the primative umbilical ring. The prim-
turity. In girls, 84% routinely explore the opposite side up to age itive umbilical cord forms as the vitelline arteries and vitelline
4 years. 17 Past reports of a patent processus vaginalis being found veins, and one of two umbilical veins become atretic while the ring
in all children at contralateral groin exploration may not be a true constricts around the remaining structures emanating from it.
indication of the eventual development of an inguinal hernia. 20 Thus, the primitive umbilical cord includes two umbilical arteries,
The true risk of metachronous hernia development ranges from one umbilical vein, the vitelline duct, and the allantois. The ab-
1 to 13% in recent series.6,21,22 The decision to perform con- dominal cavity is too small to accommodate all of the abdominal
tralateral groin exploration rests with each individual surgeon and organs at this point. Thus, the developing intestinal loops pro-
should take into account the overall status and the anesthetic risk trude into the proximal portion of the umbilical cord, resulting
of the patient. In children for whom the anesthetic is a significant in the so-called physiological umbilical hernia. The loops then
risk, it may be wise to perform the exploration to avoid a second withdraw into the abdominal cavity by the tenth week of gesta-
anesthetic. tion. 31 The umbilical ring continues to contract as the linea alba
narrows and the rectus abdominis muscles mature and approach
each other. It measures about 1 cm in diameter in the normal new-
Role Of Laparoscopy born. 32 Until final closure, the integrity of the ring is maintained
in large part by the umbilical fascia of Richet and by the crossing
Since the advent of laparoscopy, the application of this technol- of the obliterated umbilical vein, or falciform ligament, across the
ogy to the evaluation of inguinal hernias in children has gained ring. 26,32
much attention. Original attempts at laparoscopic hernia repair Failure of appropriate closure of the linea alba and rectus mus-
in children, performed primarily without prosthetic material, have cles and/or lack of support from the fascia of Richet and falciform
not gained wide acceptance. 23 Contralateral groin exploration by ligament results in an umbilical hernia. Because of this sequence
the use of a laparoscope, introduced through the ipsilateral her- of events, an umbilical hernia may not be fully defined until an in-
nial sac, has, however, gained wider acceptance. The capacity to fant is 1 month of age. 33 An umbilical hernia is covered by normal
evaluate the contralateral internal inguinal ring through the ipsi- skin, subcutaneous tissue, and peritoneum. This is to be distin-
lateral hernial sac using an angled telescope has been clearly guished from a hernia into the umbilical cord, which is essentially
demonstrated. 24,25 However, the presence of a patent processus a small omphalocele. This defect, like an omphalocele, represents
vaginalis does not necessarily predict the later development of a a primary failure of the abdominal wall to close at 10 weeks' ges-
clinically relevant inguinal hernia as discussed previously. tation. Abdominal contents are covered only by Wharton's jelly.
The technical aspects of laparoscopic evaluation of the con- Umbilical hernias occur in 4 to 30% of Caucasian infants,34-36
tralateral groin require the use of a telescope no larger than 3 with the incidence generally recognized as being higher in chil-
mm, and control of a hernial sac that is adequate for introduction dren with Mrican and Mrican-American ancestry.37-40 Infants of
of the scope. The premature child with a thin, friable sac may not low birth weight may have an incidence as high as 75%.41 Other
be a suitable patient because loss of control of the sac or sac in- conditions predisposing to umbilical hernia include Down syn-
jury complicates the hernia repair. Once the hernial sac is con- drome, trisomy 13, trisomy 18, mucopolysaccharidoses, congeni-
trolled, the patient is placed in a reverse Trendelenburg position. tal hypothyroidism, and Beckwith-Wiedemann syndrome. 42
A 5 mm StepTM cannula (Innerdyne) is introduced through the Virtually all umbilical hernias present in infancy and are usually
sac, and a ligature is secured around the sac and cannula. The lig- asymptomatic. They are most evident when the infant cries or
ature is secured with a slip knot to control the hernial sac, but al- strains and usually reduce spontaneously when the infant relaxes.
lows the sac to be enlarged as the cannula is expanded. A low In any case, they are easily reduced with gentle manual pressure.
pressure pneumoperitoneum (5 to 8 mm Hg) is produced by in- Umbilical hernias will occasionally present at a later age under
sufflation of carbon dioxide. The telescope is introduced into the conditions where increased abdominal pressure is induced, such
peritoneal cavity through the cannula, and one can then observe as with chronic constipation, peritoneal dialysis, ascites, or fluid
the contralateral deep inguinal ring for patency. Once this is com- from a ventriculoperitoneal shunt. Small umbilical hernias may
pleted and the telescope removed, the pneumoperitoneum is re- also present spontaneously at a later age with vague abdominal
leased through the open sac and the hernia is repaired as pain, especially if some preperitoneal fat is incarcerated in the her-
previously described. nia. It is unusual for intestinal contents to become incarcerated
or strangulated in an umbilical hernia at any age, although the in-
cidence is higher in older individuals.
Umbilical Hernia Diagnosis of an umbilical hernia is easily confirmed by physical
examination. The fascial defect should be measured because the
Umbilical hernias have been recognized since ancient times, but diameter of the defect is the primary prognostic factor for spon-
the first surgical treatment is attributed to Celsus in the first cen- taneous closure. The size of the hernia proboscis holds no prog-
tury AD. He treated these hernias by ligation with an elastic su- nostic value. The area around the umbilicus should also be
ture. 26-29 William Mayo introduced the modern surgical treatment carefully examined to rule out any hernia above or below the um-
of umbilical hernias in 1901 by emphasizing a fascial closure of bilical ring. Umbilical hernias with a fascial defect less than 1.5 cm
the umbilical defect. He described an overlapping fascial repair at infancy will usually close spontaneously, whereas paraumbilical
more commonly referred to as the "vest-over-pants" closure. 3o Cur- defects will not. No prospective, longitudinal studies have been
rent surgical treatment continues to rely on a secure fascial clo- performed to follow the natural progression of umbilical hernias.
sure of the umbilical defect. However, evidence suggests that most defects 1.5 cm or less can
The umbilicus is derived from structures that form early in ges- be expected to close by about 5 years of age. 38,44,45 Some may even
tation. At the fifth week, the embryo folds in a craniocaudal di- close in later years. 46 Because umbilical hernias are rarely symp-
tomatic and often close spontaneously, operative intervention is tissue completely.49 In some instances complete removal may leave
usually deferred until about 4 to 5 years of age. 26 ,28,42,43,47 Indica- the umbilical skin too thin and thus risk ischemia or necrosis. The
tions for operative repair at an earlier age include a fascial defect peritoneum is then trimmed from the fascial edges to provide good
greater than 2 cm or symptomatology such as pain, excoriation of fascial tissue for closure. The fascia is closed in a transverse fash-
skin on a large proboscis, incarceration, or strangulation. There ion with interrupted absorbable or nonabsorbable sutures. Some
is no reason for taping or strapping umbilical hernias. These ma- surgeons may prefer to use the overlapping "vest-over-pants"
neuvers will only injure the underlying skin. 20 ,4O method described by Mayo,30 although this is not necessary.26,35,50
Surgical repair of an umbilical hernia is usually performed un- Meticulous hemostasis is then achieved, and an absorbable suture
der general anesthesia on an outpatient basis. The principles of re- is used to attach the underside of the umbilical skin to the under-
pair have changed little from those espoused by May030 and lying fascia. If the umbilical hernia is associated with a large pro-
Gross. 48 The primary goals are a secure fascial closure and preser- boscis, it is better to leave all of the umbilical skin intact, as this
vation of the appearance of the umbilicus. The hernia is ap- redundant skin will contract with time. 28 The subcutaneous tissue
proached through a curvilinear incision made in the infraumbilical and skin are then closed with fine absorbable sutures. A pressure
skin crease (Fig. 87.4). Dissection is carried out around the sac, dressing is placed for 48 hours. Recurrences are rare, although
and the sac is then divided after determining that all contents are hematoma or infection may predispose to recurrence. 42
reduced. Some of the excess peritoneum on the underside of the
umbilicus may be resected, but it is not necessary to remove this
Epigastric Hernia
An epigastric hernia, also known as a paraumhilical hernia, is a de-
fect that occurs through the midline of the abdominal wall out-
side of the umbilical ring. Most such hernias are superior to the
umbilicus and may occur anywhere along the linea alba from the
umbilical region to just caudad to the xiphoid process. 26,51 Occa-
sionally herniation may occur in the paraumbilical region just be-
low the umbilicus. When herniation occurs in close proximity to
the umbilicus, care must be taken on physical examination to de-
termine that the defect is indeed outside of the umbilical fascial
ring. Epigastric hernias may occasionally be multiple and do not
resolve spontaneously.
Epigastric hernias are often recognized as a protrusion in the
midline of the abdomen on routine physical examination. How-
ever, unlike true umbilical hernias, epigastric hernias are fre-
quently symptomatic. A patient may complain of intermittent or
constant pain from irritation of the peritoneum due to traction or
entrapment of preperitoneal or omental fat. Intestinal loops are
only very rarely entrapped in these hernias.
Epigastric hernias should be surgically repaired, usually on an
elective basis, when recognized. At the time of repair, the area of
the hernia should be marked on the skin with the patient awake
and erect, as these hernias may be difficult to detect once the pa-
tient is supine and muscle relaxation is achieved under anesthesia.
In the immediate paraumbilical region, surgical approach may
be through an infraumbilical or supraumbilical skin crease as ap-
propriate. Any associated umbilical hernia should be repaired. Epi-
gastric hernias that are further from the umbilical region may be
approached through either a small transverse or a vertical inci-
sion. Any incarcerated fat is reduced or removed, and the fascial
defect is then closed in a vertical or transverse fashion as appro-
priate. These defects are rarely more than 5 mm in diameter and
may be closed with simple interrupted sutures of absorbable or
FiGURE 87.4. Technique for umbilical hernia repair. (A) An incision is nonabsorbable material. If defects are multiple, a vertical skin in-
made in the infraumbilical skin crease. (B) The hernial sac is opened, leav- cision is probably best so as to gain access to all defects most eas-
ing a portion of the sac attached to the umbilical skin. (C) The umbilical ily. Recurrences of epigastric hernias are rare.
sac is completely divided and excised. (D) The fascial defect is closed in
a transverse fashion with interrupted simple sutures. (E) The remaining
umbilical sac, which is attached to the umbilical skin, is secured to the fas-
cia with an interrupted absorbable suture. (F) The skin is closed with a
Unusual Hernias
subcuticular suture. Pressure dressing is placed to prevent formation of a
hematoma or seroma. (Reprinted from Neblet WW III, Holcomb GW III. Spigelian Hernia
Umbilical and other abdominal wall hernias. In Ashcraft KW, Holder TM
[edsl: Pediatric surgery, 2nd ed. Philadelphia: W.B. Saunders; 1993:559, with Spiegelian hernias occur only rarely in infants and children. A
permission.) spigelian hernia was first described in an infant by Scopinaro,52 in
596 B.M. Rodgers et aI.
1935, although at the time of the last collective review of spigelian aroscopy for the diagnosis and treatment of spigelian hernias. 61 ,62
hernias by Sprangen,53 in 1995, there were only 30 children Usually a 30° telescope is placed at the umbilicus, and instrument
younger than 16 years of age in whom spigelian hernias had been ports are placed in the contralateral abdomen. Some authors have
diagnosed. In contrast to the adult series in which females tend advocated placement of retroperitoneal nonabsorbable mesh
to predominate, 19 of these children (63%) were male. It is said while others have primarily closed the defect with intracorporeal
that children represent less than 3% of all patients described with sutures. Laparoscopy has not been employed for the diagnosis or
spigelian hernias. Classically, these hernias tend to occur in older treatment of spigelian hernias in children, although this probably
patients, with a mean age of 51.5 years. Silberstein et al. 54 in 1996, reflects the rarity of the disorder rather than representing an in-
added two infants to the previously 12 reported infants with con- dictment of the technique.
genital spigelian hernias. 54 Both of the patients of Silberstein et A spigelian hernia should be suspected in any child with a visi-
al. were male, and both had ipsilateral cryptorchid testes. In each ble bulge or intermittent pain in an area lateral to the rectus
case the testicle was encountered in the sac of the spigelian sheath, particularly below the level of the umbilicus. In the ab-
hernia, and there was no discernible ipsilateral inguinal canal pres- sence of visible bulging in this region, it appears that the most ef-
ent. This association of congenital body wall hernias and crypt- ficacious diagnostic test is a high-resolution ultrasound study of
orchidism has been reported with several types of hernias. 55 the abdominal wall.
Walton and Bass56 reported two female infants with spigelian
hernias. 56 The ovary was present in the sac of one. In the second
infant the hernia presented 1 month following a subcostal inci- Lumbar Hernia
sion for repair of an ipsilateral diaphragmatic hernia. The
spigelian hernia was asymptomatic and was followed up, and by 1 Lumbar hernias are as uncommon as spigelian hernias. There have
year of age the physical signs of the spigelian hernia had disap- been approximately 300 cases of lumbar hernias reported in the
peared. Some spigelian hernias occurring in children over the age English literature. Lumbar hernias may occur anywhere in the
of 1 year appear to have been as a result of direct trauma to the lumbar region, between the twelfth rib and the crest of the ilium.
anterior abdominal wall or laparotomy.57,58 Petit63 in 1774 described the inferior lumbar triangle. This trian-
Spigelian hernias in children, like those in adults, occur through gle is formed by the iliac crest at the base, the posterior free edge
the spigelian aponeurosis, the aponeurosis of the transversus ab- of the external oblique muscle as the lateral limit, and the lateral
dominus muscle, lateral to the rectus sheath. 53 With the exception border of the latissimus dorsi muscle as the medial border. This
of those hernias caused by trauma, it appears that virtually all of area may be quite variable in size in different individuals. In 1866,
the congenital spigelian hernias described have occurred within Grynfeltt64 described the superior triangle. This area is an inverted
the "spigelian hernia belt," between the level of the anterior su- triangle with the twelfth rib as the base, the lateral border of the
perior iliac spine and the umbilicus. Ninety percent of the adult quadratus lumborum muscle as its lateral edge, and the posterior
hernias occur in this area, where the spigelian aponeurosis is border of the internal oblique muscle as the medial edge. This tri-
widest. The m.gority of the congenital hernias occur at the level angle is more constant in nature. A third anatomical type of lum-
of the arcuate line (the fold of Douglas). bar hernia is described as a diffuse lumbar hernia, and it involves
The diagnosis of spigelian hernia in children has usually been areas of both of these triangles. Most lumbar hernias, particularly
a clinical one with findings of an abdominal bulge lateral to the the congenital types, occur in the superior triangle. Approximately
rectus sheath and localized tenderness. Ultrasonography has not 20% oflumbar hernias reported are congenital in nature, and the
been reported for confirming the diagnosis in children, although remainder are acquired, resulting from either chronic elevations
it appears to be the most efficacious radiological modality for mak- of intraabdominal pressure as from chronic respiratory disorders
ing this diagnosis in adults. 59 Likewise, the use of computed to- or obesity, trauma, or infection of the lumbar spine. 65 Lumbar her-
mography has not been described in children, although it has been nia defects tend to be relatively large, and the incidence of stran-
used to diagnose spigelian hernias in many adults. 60 gulation appears to be less than with other forms of hernia.
Most of the spigelian hernias described in childhood have been In 1972, Touloukian66 described the association of congenital
repaired with open surgical techniques. Occasionally, as in the in- lumbar hernias with various skeletal defects such as scoliosis,
fant described by Walton and Bass,56 the hernias have been ob- hemivertebrae, and rib agenesis. He termed this association the
served, and some of these appear to have regressed spontaneously. lumbocostovertebral syndrome. Touloukian proposed that this syn-
The area of abdominal wall bulging is marked on the skin before drome was caused by hypoxic stress that interferes with somite de-
induction of general anesthesia. A transverse skin incision overly- velopment in the third or fourth week of gestation. These somites
ing this area has usually been employed, in all of the congenital differentiate into the vertebral column, ribs, and skeletal muscle.
hernias described and most of the acquired hernias, the external Congenital lumbar hernias in children tend to be asymptomatic
oblique muscle and aponeurosis are intact overlying the hernia. and present with visible bulging in the lumbar region. Because
The spigelian hernia sac always penetrates the spigelian aponeu- these hernias gradually enlarge during childhood, early repair is
rosis and usually penetrates the internal oblique musculature. The generally advised. Many authors have suggested performing repair
sac and the defect in the spigelian aponeurosis are visible after the at 6 months of age, at a time when the surrounding anatomical
external oblique has been opened in the direction of its fibers. All structures have achieved some stability. The surgical repair is per-
of these hernias have relatively small fascial defects, which can be formed with the patient in the lateral decubitus position. An
closed primarily, without use of prosthetic material. The recur- oblique skin incision is made over the midpoint of the visible
rence rate after spigelian hernia repair in collected series of adults bulge. Most smaller congenital hernias may be repaired by pri-
is approximately 0.6%.60 There have been no recurrences reported marily closing the surrounding musculature to eliminate the de-
after repair in childhood. fect. Occasionally, the larger defects may require the use of local
Several authors have described in the past decade the use of lap- fascial flaps or prosthetic material for a tension-free closure. Most
authors recommend opening the peritoneal sac during the repair Between the sixth and tenth weeks, the midgut grows too rapidly
of lumbar hernias to allow careful definition of the surrounding to be contained within the small, primitive abdomen and herni-
anatomy and to identify those patients with sliding hernias. 65 Some ates into the extraembryonic coelom within the yolk stalk. During
authors have described laparoscopic repair in adults. 67 Recurrence the tenth week, this midgut hernia spontaneously reduces, and the
of the defect after surgical repair appears to be quite uncommon intestines become fixed to the dorsal aspect of the abdominal cav-
in children with lumbar hernias. ity. The midgut detaches from the yolk stalk, and the lateral folds
of somatopleure close around the umbilical cord. Omphaloceles
occur between the fourth and tenth weeks of development, as the
The Use of Prosthetic Materials abdominal wall forms. Closure of the lateral folds is arrested, leav-
in the Pediatric Patient ing a midline defect, the size of which varies, depending upon the
timing of the insult. 69 Omphaloceles are frequently associated with
The use of prosthetic materials has played an important role in other anomalies because all of the other major organ systems are
the management of many congenital and acquired defects en- beginning their development at this same time in gestation, and
countered in children. 68 any single teratogenic influence can have numerous effects. The
most frequently seen coexistent defects are cardiac, facial, intesti-
nal, and genitourinary.
Omphalocele The sac covering the omphalocele is thin and allows significant
fluid, electrolyte, and thermal loss. In addition, there is consider-
An omphalocele is a congenital midline abdominal defect allow- able risk of rupture of the sac and subsequent sepsis if the om-
ing herniation of the liver and gut into the base of the umbilicus. phalocele is not repaired in the immediate postnatal period.
There is always a covering over the defect, or at least remnants of Primary closure of many small omphaloceles is not difficult and
a cover, and the liver is evident within the larger defects (Fig. 87.5). results in full recovery. However, primary closure of omphalocele
Omphalocele occurs in approximately 1 in 5000 live births and is defects 4 cm or greater in diameter carries a significant mortality
equally common in male and female infants. Approximately 45% due to overcrowding of the abdominal viscera in the relatively hy-
of these infants have significant associated congenital defects, and poplastic abdominal cavity. This causes elevation of the diaphragm
virtually all of them have associated nonrotation of the intestine and respiratory compromise, pressure on the inferior vena cava
and a diminutive abdominal cavity. and diminished venous return to the heart, and mechanical in-
Differentiation of omphalocele from other abdominal wall de- testinal obstruction.
fects is done by determining the location of the fascial defect, and In 1948, Gross 70 reported the first two-stage closure of a large
the nature of any covering over the bowel. These features are dis- omphalocele. The purpose of the initial operation was to provide
tinct for omphalocele because of the events during embryogen- temporary coverage for the bowel without increase in the in-
esis that bring about this entity. The formation of the abdominal traabdominal pressure. Gross undermined the skin, beginning at
wall begins during the fourth week of gestation. The right and left the margin of the omphalocele, progressing to the pubic symph-
sides of the flat embryo fold anteriorly around the yolk sac. These ysis, the flanks, and up to the nipples. This skin was then closed
lateral folds grow toward the midline around the midgut, creating over the omphalocele, with its amnionic membrane left intact. The
the abdominal cavity and giving the embryo a more cylindrical omphalocele was subsequently reduced with closure of the fascia,
shape. The yolk stalk forms the small remaining attachment be- muscle, and skin layers months later, after the child's abdominal
tween the midgut and the yolk sac. This structure, which will be- cavity had enlarged sufficiently to accept the intestines without
come the umbilical cord, is covered with a layer of amnion. stress. The problem with the Gross repair was that giant ventral
hernias often developed, which were frequently difficult to repair
at the second stage of the procedure.
In 1967, Schuster7l published the first report using prosthetic
material to primarily close an omphalocele. He recommended
making a midline incision above and below the omphalocele, ex-
tending the defect from xiphoid to pubic symphysis. One sheet of
Teflon® material was then sutured to the medial aspect of each
rectus muscle. The Teflon sheets were sewn together in the mid-
line to cover the abdominal viscera and apply gentle pressure to
the intestines to reduce them into the abdominal cavity. The skin
was left open. The Teflon sac thus created was revised multiple
times as needed to retain some degree of tension on the abdom-
inal wall, forcing the abdominal cavity to expand more rapidly. A
polyethylene sheet was used to line the inner surface of the Teflon
because it was nonreactive and prevented the formation of adhe-
sions between the bowel and the Teflon. Teflon was chosen be-
cause of its strength and inelasticity, allowing it to maintain
pressure on the bowel. As the prosthetic material was gradually
FIGURE 87.5. Typical large omphalocele. The abdominal viscera are cov- tightened, the fascial and muscle layers could ultimately be closed
ered by amnion, and the umbilical cord inserts at the apex of the defect. directly as the prosthetic material was removed. There were sev-
The liver occupies the cephalad portion of the defect. (Reprinted from eral benefits of this procedure. The first was that it worked for om-
Rodgers et al. ,68 with permission.) phalocele closure whether or not the amniotic sac had ruptured,
whereas skin coverage of a ruptured omphalocele might cause ad- in approximately 10% of these children, and correction can usu-
hesion formation. Schuster71 also made the argument that skin ally be performed at a later age by primary fascial closure.
was distensible, and it stretched instead of forcing any expansion The results of treatment of omphalocele have improved dra-
of the abdominal cavity. The use of prosthetic materials allowed matically since the initial reports of Gross 70 and Schuster. 71 Before
more rapid progression toward definitive abdominal closure. More the development of the Gross technique, allowing prompt surgi-
recent modifications of Schuster's technique include the use of cal coverage of the omphalocele, this disease entity was nearly
Dacron® mesh sandwiched between Silastic® sheets. 72 This mate- uniformly fatal. The mortality of omphalocele decreased to ap-
rial is easier to manage than the dual layers of Teflon and poly- proximately 70% in most series utilizing the Gross technique. With
ethylene. Most authors now sew the prosthetic material to the the development of the Schuster-Allen techniques,7I·72 utilizing
fascia of the omphalocele defect rather than to the rectus muscles temporary or permanent prosthetic materials, the mortality of om-
themselves. phalocele has been reduced to 15 to 30%. In most contemporary
Modern management of omphalocele can be separated into series of infants with omphalocele, one-third to one-half of the
three distinct techniques. Small omphaloceles, with defects of 2 deaths are directly related to the associated anomalies. The most
to 3 cm or less, can be repaired primarily with closure of the fas- severe of these anomalies are cardiac, and many of these patients
cia and skin with nonabsorbable sutures. Moderate sized om- are not candidates for corrective surgery. Other valuable adjuncts
phaloceles, with fascial defects between 4 and 8 cm in diameter, to the treatment of these infants have been developed in the past
may be closed by bridging the fascial defect with a permanent pros- two decades and have surely helped to improve the overall out-
thetic material such as Teflon mesh (0.7 mm) or lyophilized hu- come of these infants. The development of specialized newborn
man dura. 73 The skin may then be undermined as in the Gross intensive care units, improvement in anesthetic techniques for pre-
procedure and closed primarily over this prosthesis (Fig. 87.6). mature infants, the use of total parenteral nutrition, and the de-
Larger omphaloceles, with fascial defects measuring greater than velopment of newer antibiotics have all become part of the
8 cm in diameter, usually cannot be closed primarily or covered standard of care of these infants.
with skin, and these patients are managed with techniques utiliz-
ing temporary Silastic prosthetic materials such as proposed by
Schuster7I and Allen and Wrenn 72 (Fig. 87.7). It is important that Gastroschisis
these materials be removed completely and the abdominal wall
closed within 7 to 10 days of birth or else the incidence of sepsis Gastroschisis is a full-thickness abdominal wall defect located on
from infection at the union between the prosthesis and the ab- the right of the umbilicus and presenting with evisceration of the
dominal fascia becomes prohibitive. small and large bowel. There is usually a skin bridge separating
Three of the most common complications encountered follow- the defect from the umbilicus. The fascial defect, which is usually
ing the use of prosthetic material to close omphalocele defects are 2 em in diameter, permits the majority of the bowel to eviscerate.
sepsis, peritonitis, and incisional hernias. The development of The bowel has no tissue covering and usually presents as an edem-
sepsis or infection of the prosthetic material requires complete re- atous, discolored mass with significant interloop adhesions (Fig.
moval of the prosthesis. Occasionally, these infants can be man- 87.8). Gastroschisis defects occur in approximately 1 in every 6000
aged using biological dressings over the granulation tissue base live births. Females appear to be affected slightly more frequently
stimulated by the prosthetic material, or the skin may be closed than male infants. Infants with gastroschisis tend to be small (less
primarily over this area, as in the original Gross closure. 74 Ventral than 2000 g) and children of younger mothers. The incidence of
or incisional hernias following correction of omphaloceles occur associated anomalies is significantly less than that seen with om-
A B
FIGURE 87.6. (A) A large omphalocele that could not be closed primarily. (B) Mter partial reduction of the abdominal viscera, the fascia was bridged
with Teflon mesh. Subsequently skin flaps were mobilized widely and the skin was closed over the prosthesis. (Reprinted from Rodgers et al.,68 with
permission.)
why the gastroschisis defect is consistently found in the same lo-

cation. Amnionic fluid causes a serositis that is responsible for the
edema and adhesions of the gut seen at birth. The timing of the
rupture determines the length of exposure of the bowel to the
amnionic fluid and therefore the degree of edema and adhesion
formation seen. The amount of bowel that is eviscerated is in-
versely proportional to the degree of fixation of the mesentery to
the posterior abdominal wall before the rupture. Usually the en-
tire stomach, small bowel, and colon has herniated through the
defect. The liver never herniates through the defect, in distinction
to omphalocele. The defect may close around the eviscerated por-
tion of midgut and may actually strangulate some segments. In ad-
dition, due to the abnormal mesenteric fixation, the midgut is at
significant risk for volvulus.
The anatomical dilemma in treating gastroschisis is similar to
that for omphalocele. The intestine is exposed, losing heat, fluid,
and electrolytes, and this predisposes the newborn to shock and
FIGURE 87.7. Large omphalocele covered temporarily with Dacron-rein- sepsis. Primary closure may cause respiratory compromise, com-
forced Silastic sheets. The viscera were gradually reduced, and the fascial pression of the inferior vena cava, and bowel obstruction due to
defect was closed secondarily at 10 days of life. (Reprinted from Rodgers visceroabdominal disproportion. However, with gastroschisis, the
et al.,68 with permission.) abdominal cavity is usually more normal in size, and it is the edema
and adhesions of the herniated bowel that prohibit primary clo-
sure. A further distinction from omphalocele is the prolonged
phalocele. Approximately 15% of these infants have associated gas-
ileus, often lasting several weeks, that gastroschisis babies experi-
trointestinal anomalies, such as intestinal atresia. More distant
ence following abdominal wall closure.
anomalies are uncommon.
In 1968, Gilbert et al. 76 published the first case report of clo-
Theories of the etiology of gastrochisis are controversial. One
sure of a gastroschisis defect using a Silastic prosthesis. This was
theory, however, explains most of the anatomical findings and is
followed by other reports by Allen and Wrenn 72 and Cordero et
supported by serial sonograms of fetal development. Shaw75 pro-
a1. ,77 demonstrating the temporary use of prosthetic materials to
posed that gastroschisis results from midgut herniation, not from
initially cover the intestines in neonates with gastroschisis anom-
a teratogenic exposure or event. This herniation occurs while the
alies. Coverage of the viscera was accomplished by sewing Dacron-
midgut occupies the extraembryonic coelom, between the fourth
reinforced Silastic sheets (0.02 inch) to each side of the fascia,
and tenth weeks of development. Shaw75 postulated that a weak
using nonabsorbable sutures. The two sheets were joined in the
area at the base of the umbilical cord develops due to regression
midline to provide some tension on the abdominal contents.
of the right umbilical vein at 6 w eeks. The bowel ruptures through
Staged revisions were performed approximately every 2 days to
this defect after completion of abdominal wall muscle develop-
maintain this tension as the prosthetic "silo" became lax. When
ment and before total closure of the umbilical ring. This explains
the bowel was fully reduced into the abdomen the prosthetic ma-
terial was completely removed and the abdominal fascia closed
(Fig. 87.9) . Cordero et a1. 77 advocated a midline incision, from pu-
bic symphysis to xiphoid, to examine the midgut derivatives for
volvulus, stenosis, or atresia. Allen and Wrenn 72 suggested that ex-
tension of the defect and examination of the entire small bowel
for this purpose was unnecessary.
The results of the therapy for gastroschisis have improved dra-
matically with the use of prosthetic materials. Before the utiliza-
tion of Silastic silos, the mortality of infants with these defects
approached 100%. With modern therapy, selectively using tem-
porary coverage with Dacron-reinforced Silastic sheeting, the mor-
tality of infants with gastroschisis is less than 5%. Most of these
deaths are associated with sepsis from wound infection. The mor-
bidity of repair of gastroschisis anomalies is similar to that en-
countered with omphalocele. It is important that the Silastic
material be removed as soon as possible and final abdominal wall
closure achieved to avoid the development of sepsis from infec-
tion at the margins of the prosthetic material.
FIGURE 87.8. Gastroschisis defect. The small bowel herniates through a

small defect at the base of the umbilical cord on the right side. The um- Congenital Diaphragmatic Hernia
bilical cord inserts normally. There is no covering of amnion, and the bowel
wall is thickened with serositis. The liver never herniates through a gas- Congenital diaphragmatic hernia of the Bochdalek type is a de-
troschisis defect. (Reprinted from Rodgers et al.,68 with permission.) velopmental defect in the posterolateral portion of the diaphragm
A B
FIGURE 87.9. Staged reduction of a gastroschisis. The abdominal defect is

enlarged vertically, and Dacron-reinforced Silastic sheets are sutured to the
abdominal fascia circumferentially to protect the bowel. (A) The Silastic
"silo" is gradually reduced by applying pressure from the apex and forc-
ing the intestine into the abdominal cavity. (B,C) When the viscera are
completely reduced, the Silastic is removed and the fascia and skin are
closed.
c
associated with herniation of abdominal viscera into the ipsilateral hernia are twofold. First, there is a lack of an appropriately de-
chest, displacement of the mediastinum to the contralateral side, veloped and functioning diaphragm. More importantly, there is
and hypoplasia of the ipsilateral lung. The contralateral lung may poorly developed lung parenchyma and vasculature that may re-
also be hypoplastic, possibly because of compression by the dis- sult in pulmonary hypertension and inadequate oxygenation and
placed mediastinum (Fig. 87.10). The Bochdalek hernia is the ventilation. Unfortunately, surgical efforts can only truly address
most common type of congenital diaphragmatic hernia and oc- the diaphragm defect itself. Nonetheless, closure of the diaphragm
curs in 1 in 2000 to 4000 live births. 78 ,79 It is found on the left side remains a necessary part of the treatment of diaphragmatic her-
in 85% of infants, and a true hernial sac of the peritoneum may nia. Today, the diagnosis of diaphragmatic hernia is usually made
be found in 10% of these infants. 78 •80 either by prenatal ultrasound or immediately at birth. Many in-
The diaphragm develops in the fetus between the third and fants have enough anterior and posterior diaphragm muscle to al-
eighth weeks of gestation. It is derived from four structures: (1) low primary closure. However, an increasing number of more
the septum transversum, which forms the anteriorly placed cen- critically ill infants have large defects requiring the use of pros-
tral tendon; (2) two dorsal pleuroperitoneal membranes, forming thetic material for closure.
the posterior diaphragm; (3) muscular components from the lat- The goals of closure of the diaphragm are (1) to return the her-
eral and dorsal body walls, forming the lateral muscular di- niated viscera and organs to the abdominal cavity, (2) to provide
aphragm; and (4) the mesentery of the esophagus, which develops the lungs with appropriate space to grow into, and (3) to restore
the crura. 78 •79 The chest and abdominal cavities are separated by the diaphragm to as physiologically and anatomically correct a po-
the pleuroperitoneal membranes, and myoblasts then migrate sition as possible for adequate function. The optimal timing of
from the body wall to form the muscular portion of the di- such a repair is controversial. This issue is beyond the scope of
aphragm. 79 The lungs begin to develop at approximately 16 weeks this text, but most pediatric surgeons now agree that infants should
of gestation. Alveolar proliferation continues well beyond postna- be as medically stable as possible before repair, even if that re-
tal life until about 10 years of age. 78 quires placing the infant on extracorporeal membrane oxygena-
The anatomical and physiological dilemmas of diaphragmatic tion (ECMO) support before repair.
Parasternal
(Morgagni) hernia
Postero ateral
A (Bochdalek) hernia B
FIGURE 87.10. (A) Locations of congenital diaphragmatic defects.

Note that Bochdalek hernias may also occur on the right side.
(Reprinted from Spitz 1. Congenital diaphragmatic hernia and
eventration. In Dudley H, Carter D, Russell RCG reds]: Rnb and
Smith 's oplffative surgery: pediatric surgery, 4th ed. London: Butter-
worths; 1988, with permission.) (B) Schematic drawing of a left-
sided Bochdalek hernia showing hypoplastic left lung and
compression of mediastinum and right lung. (Reprinted from Spitz
1. Congenital diaphragmatic hernia and eventration. In Dudley H,
Carter D, Russell RCG reds] : Rnb and Smith's ojJlffative surgery: pedi-
atric surgery, 4th ed. London: Butterworths; 1988;146, with permis-
sion.) (C) Chest radiograph of an infant with a left-sided Bochdalek
hernia. Bowel gas can be seen in the left chest field with shifting of
the mediastinum toward the right. C
At the time of diaphragmatic repair, meticulous hemostasis is so as to reconstruct a rudimentary crura around the esophagus.
required to avoid bleeding difficulties if the infant is on ECMO However, in other cases, total agenesis of the diaphragm is
support or in case ECMO support is needed later. There is usu- present.
ally a readily evident anterior leaf of the diaphragm of varying size The earliest techniques employed to repair diaphragmatic de-
(Fig. 87.11). The posterior leaf is usually less well formed and is fects too large to be closed primarily involved the use of natural
often contracted within a peritoneal-pleural covering. Once the tissue. Most commonly, muscle flaps on vascularized pedicles were
posterior leaf is mobilized, a primary repair may be accomplished mobilized from the chest wall, abdomen, or back to close the de-
in some cases by approximating the anterior and posterior leaves fect. 8l Although these methods achieved some success, none were
with interrupted simple or mattress nonabsorbable sutures. If without their deficiencies. The greatest disadvantage of such pro-
a tension-free primary repair cannot be accomplished, the di- cedures is the extensive dissection that is required to mobilize
aphragm can usually at least be approximated at the medial aspect these flaps. This increases the duration of the operation and the
A B
FIGURE 87.11. (A) Operative view of a left-sided Bochdalek hernia showing a well-<leveloped anterior diaphragm leaf. (This infant's posterior leaf was
poorly developed, and a patch was required to close the diaphragm.) (B) The leaf is retracted, revealing the hypoplastic left lung.
postsurgical morbidity in these already severely ill infants. Perhaps fewer adhesions during tissue ingrowth. 98 ,99 Although Gore-Tex
most significantly, the risk of bleeding during anticoagulation for material strength and suture retention exceed those of Marlex and
ECMO is significantly increased by these dissections. Dacron, none of these materials have failed clinically due to pros-
Currently, the most common approach to closing a diaphrag- thetic material failure. All of these materials have been associated
matic defect that cannot be closed primarily is to use a prosthetic with some recurrence of diaphragmatic hernia, but failure of a
patch. Indeed, some have proposed that a patch should always be prosthetic is essentially always due to suture breakage or to failure
employed so as to restore the anatomical "dome" of the di- of the suture line at the tissue interface. lOo Thus, technique of su-
aphragm,81 but this opinion has not been universally accepted, ture placement is critical to a sound repair. None of these mate-
and there are no studies that address any potential physiological rials have emerged as superior in resisting infection. Impregnation
benefits of such reconstruction. The ideal prosthetic material is of prosthetic material with antibiotics may hold some promise for
strong, allows tissue ingrowth, resists infection, and is relatively the future in that regard. 101 ,102
easy to handle during surgery. The patch should be fashioned so There is a theoretical concern that the use of a nonabsorbable
that it generously bridges the defect, and it should be secured in prosthetic patch for the repair of a diaphragmatic hernia may re-
place with nonabsorbable, interrupted mattress sutures. These su- sult in later thoracic cage deformity due to growth of the chest
tures are best preplaced around the edges of the defect and then from a surgically fixed point. 95 ,103 However, no proven correlation
passed through the patch so that the patch lies on the abdominal has ever been reported, and this has not been a difficulty in this
side of the diaphragm. Teflon pledgets may be used on the mus- author's experience. Nonetheless, researchers are investigating
cular side for greater security. If the posterior and lateral edges of alternative prosthetics that are absorbable, such as polyglactin
the diaphragm are extremely hypoplastic or absent entirely, the (Vicryl), combinations of absorbable and non absorbable mate-
sutures should incorporate adequate tissue in the chest wall, in- rial,104 or natural such as acellular dermis or small intestine mu-
cluding ribs if necessary, to maintain integrity of the patch closure. cosa. 95 However, use of Vicryl alone for diaphragmatic hernia
Materials used for repair of large diaphragm defects have in- repair has failed in clinical use,105 and the value of the latter ma-
cluded polyester (Dacron) ,82 polytetrafluoroethylene (PTFE, terials has yet to be determined.
Teflon),83 silicone (Silastic),84,85 expanded PTFE (Gore-Tex),86-ll8 In addition to the diaphragm, closure of the abdominal wall
polypropylene (Marl ex, Prolene), 89,90 and lyophilized dura. 91 may also require use of a prosthetic patch in children with con-
Although there have been no prospective studies to determine genital diaphragmatic hernia. The herniated viscera and organs
which prosthetic materials function best for diaphragm closure, sev- often lose the right of domain within the abdomen, thus creating
eral materials have significant disadvantages. Dacron induces a se- a situation where the abdominal wall cannot be closed without
vere fibrotic reaction and can cause extensive adhesions to the lung, causing respiratory and renal compromise from high abdominal
liver, and small bowe1. 83-92 Silastic, which does not allow native tis- pressure. If a prosthetic is used to close the abdomen, it may be
sue ingrowth, has been associated with multiple failures of di- left uncovered, or skin flaps may be mobilized to cover the patch.
aphragm repair.85 Lyophilized dura has also been associated with The abdominal prosthesis is sutured to the muscles and fascia at
an unacceptable rate of repair failure, presumably from weaken- the margins of the abdominal incision with a running suture of
ing of the dura as it stiffens and calcifies. 82-90 Moreover, lyophilized nonabsorbable material (Fig. 87.12).
dura poses a risk for the transmission of Creutzfeldt:Jakob virus. 93 ,94 Unlike those used to close the diaphragm, prosthetics used to
Currently, Gore-Tex is the most commonly used material for close the abdomen are usually temporary and removal is planned
diaphragmatic hernia repair.8~95 The Gore-Tex Soft Tissue Patch as soon as the size of the abdomen and the infant's medical con-
(lor 2 mm in thickness) is easy to trim and handle. It allows ex- dition allow removal, usually no longer than 2 weeks after place-
cellent tissue ingrowth. In addition, Gore-Tex is stronger than Mar- ment. If the prosthesis is to be left uncovered and early removal
lex or Dacron mesh96,97 and causes less inflammatory reaction and is anticipated, Dacron-reinforced Silas tic sheeting is preferable be-
although the use of Marlex has been reported in repairs done lap-
aroscopically in adults. IOS ,109
Hepatomegaly
Hepatomegaly secondary to tumor invasion of the liver is not un-
common in children. Although most of these conditions have a
poor prognosis, there are two childhood tumors that may produce
massive hepatomegaly and yet have a peculiarly favorable prog-
nosis. In these patients, aggressive attempts to temporarily surgi-
cally decompress the abdomen may be warranted. Massive
hepatomegaly is particularly poorly tolerated in infants because of
their reliance on the diaphragm for respiratory exchange.110 In-
terference with diaphragmatic excursion in the newborn, such as
produced by massive hepatomegaly, may cause severe and even
life-threatening respiratory compromise. In addition, massive he-
FIGURE 87.12. An infant who is status post repair of a Bochdalek hernia. patomegaly in infants may diminish cardiac output by compres-
The Silastic abdominal patch is sutured in place to the surrounding ab- sion of the inferior vena cava or may produce renal failure by
dominal muscles. obstructing venous or arterial blood flow. It may also create life-
threatening anorexia by direct compression of the upper gas-
trointestinal tract.
Neuroblastoma is a malignant tumor of the autonomic nervous
cause it does not adhere to the underlying bowel and does not al-
tissue. These tumors arise from embryological neural crest cells
low tissue ingrowth. If the prosthetic is to be covered with skin
and are among the most common of solid tumors in child-
flaps and early removal is not anticipated, Gore-Tex is preferable
hood. Ill ,112 They may occur in the neck, chest, abdomen, or pelvis,
as it allows some tissue ingrowth, but with minimal adhesions to
but most arise from sympathetic tissue within the abdomen, either
the underlying bowel.
from the adrenal medulla or the paravertebral sympathetic chain.
Metastases to the regional lymph nodes, liver, bone marrow, and
cortical bone are commonly seen. In general, the prognosis for
Congenital Hernia of the Foramen these patients is guarded and is most directly related to the stage
of Morgagni of the tumor and the age of the patient at initial diagnosis. In
1971 , a peculiar pattern of widespread neuroblastoma involve-
Diaphragmatic hernias of the foramen of Morgagni arise from a ment, carrying a particularly favorable prognosis, was defined and
defect between the sternal and costal origins of the diaphragm classified as stage IV_S,I13 This type of neuroblastoma is charac-
(Fig. 87.l0A). They account for less than 2% of congenital di- terized by a small primary tumor, usually within the adrenal
aphragmatic defects. They are most commonly unilateral, but oc- medulla, and metastases that, by definition, only involve liver, skin,
casionally may be bilateral, and usually have an associated sac. and/ or bone marrow.114 Approximately 9% of all children pre-
These hernias are not associated with the pulmonary hypoplasia senting with neuroblastoma present with stage IV-S disease, and
or pulmonary hypertension seen with diaphragmatic hernias of most are less than 1 year of age. The majority of these patients
the Bochdalek type. Consequently, many of these hernias are dis- have metastatic involvement of the liver, and approximately 80%
covered well beyond the infant stage, and often in adulthood. develop massive, rapidly progressive hepatomegaly (Fig. 87.13). In
Morgagni hernias are often asymptomatic and may be found in- many cases, the death of these patients is caused by the mechan-
cidentally as a mass or air-fluid level on chest radiograph or dur- ical problems related to liver size rather than by the tumor it-
ing a contrast study of the upper gastrointestinal tract. However, self,u4-119 Traditionally, treatment of these patients has involved
symptoms may include coughing, choking, vomiting, and epigas- surgical resection of the primary tumor and postoperative
tric distress. Associated conditions may include trisomy 21 and con- chemotherapy and/ or low dose hepatic irradiation with the hope
genital heart defects.I06.107 of shrinking the enlarged liver. 120,12l
Repair consists of resection of the hernial sac and approxima- Hemangioendotheliomas of the liver are rare neoplasms char-
tion of the diaphragm muscle to the posterior rectus sheath. Uni- acterized by the presence of associated cutaneous hemangiomas,
lateral hernias may be repaired by a thoracic, thoracoabdominal, extensive hepatic involvement with nodular hemangioendothe-
or abdominal approach. Bilateral hernias are best approached liomas, and progressive congestive heart failure resulting from left
through a transverse upper abdominal incision. Morgagni hernias to right shunting.122 Hemangioendotheliomas of the liver are not
may also be repaired via a laproscopic approach in appropriately considered to be malignant neoplasms, and the natural history of
selected patients.IOS.109 these lesions is one of gradual regression in size resulting in com-
The need for a prosthetic is determined by the size of the de- plete involution with reduction of the vascular shunting. However,
fect and the tension under which a repair will be. In addition, lap- these tumors can reach gigantic proportions within the liver, thus
aroscopic repairs may be technically easier to accomplish by causing the difficulties associated with hepatomegaly in infants
stapling or suturing a prosthetic patch over the defect than by try- (Fig. 87.14) . Several therapies have been used to reduce the size
ing to mobilize diaphragm tissue and suturing primarily. As in de- of large liver hemangiomas with varying success. These include
fects of the Bochdalek type, Gore-Tex is a favorable prosthetic, high dose steroids, hepatic artery ligation, hepatic irradiation, enu-
the use of a large Silas tic patch. A long midline abdominal inci-
sion was made, and the patch was sutured to the linea alba on
each side to create a large ventral defect into which the liver her-
niated. The suture line was covered with antibiotic ointment, and
intravenous hyperalimentation was used to maintain nutrition
while irradiation therapy or chemotherapy was employed. In one
infant the patch was removed after 4 weeks of therapy, and the ab-
dominal wall was closed. This patient had no evidence of residual
tumor 20 months later. The second patient died of sepsis sec-
ondary to chemotherapy-induced leukopenia before the patch
could be removed.
Subsequent authors have reported the use of this technique in
similar situations. 133 Silastic, reinforced with Dacron, is the prefer-
able material because it does not react with underlying tissues. Sur-
vival has been achieved in some of these infants, but sepsis is a
threat with this technique as the prosthesis may need to be in place
for several weeks until the liver shrinks enough from medical ther-
FIGURE 87.13. CT image shows massive hepatomegaly with left adrenal apy to allow abdominal closure.
mass (arrows) in an infant with stage IV-S neuroblastoma. In 1982, Ricketts et al.I 34 described a ventral fasciotomy of the
linea alba, performed through a short supraumbilical incision, in
a patient with hepatic hemangioendothelioma. This technique cre-
cleation of the hemangioma, liver resection, administration of
ated a large ventral hernia without the use of prosthetic material.
chemotherapeutic agents such as cyclophosphamide and vin-
This patient was treated with steroids and hepatic irradiation, and
cristine, and administration of interferon-alpha 2a. 123-131
the ventral hernia was successfully closed 6 months later after the
Because medical therapy is successful in reducing the size of the
liver had regressed in size. This technique appears to obviate the
liver in a large number of patients with hemangioendothelioma
problem of sepsis seen with the use of prosthetic material, but
and stage IV-S neuroblastoma, in selected patients, temporary ab-
may limit to some extent the size of the ventral hernia that may
dominal wall expansion may provide relief of mechanical symp-
be created.
toms while medical therapy is instituted and begins to have an
In 1998, we described an infant with hepatomegaly from stage
effect. In 1975, Schnaufer and Koop 132 reported two infants with
IV-S neuroblastoma who underwent placement of an abdominal
massive hepatomegaly from stage IV-S neuroblastoma. In each pa-
Silastic patch over the enlarged liver (Fig. 87.15). Mter 2 weeks of
tient, temporary abdominal wall expansion was accomplished with
medical therapy, the liver had not yet reduced in size, and infec-
tion appeared to be setting in. The patch was removed and re-
placed with a Vicryl mesh. As this mesh was absorbed, it created
a physiological seal. When the liver size began to reduce, skin flaps
were fashioned to close the abdomen over the mesh. Further re-
duction of the liver allowed the fascial edges to coapt. 13S The child
is 4 years old at the time of this writing and is without residual
tumor or a ventral hernia. This may be a very useful technique
for treating hepatomegaly from hemangioendothelioma or stage
IV-S neuroblastoma when the liver does not respond rapidly to
medical therapy.
The creation of a temporary ventral hernia with a nonab-
sorbable and/ or absorbable prosthetic may have an important role
in the management of carefully selected patients with massive he-
patomegaly in whom recovery is expected. Early application of this
technique may minimize the complications and management dif-
ficulties presented by massive hepatomegaly.
Prune-Belly Syndrome
Prune-belly syndrome (Eagle-Barrett syndrome) is a triad of ab-
dominal muscle deficiency, undescended testicles, and obstructive
uropathy first recognized by Parker l36 in 1895. In addition to these
more commonly recognized manifestations, the prune-belly syn-
drome may be accompanied by gastrointestinal, cardiac, muscu-
loskeletal, and pulmonary abnormalities. 137 This syndrome affects
FIGURE 87.14. Massive hepatomegaly in a I-month-old infant with heman- about 1 in 40,000 children and afflicts males almost exclusively.137
gioendothelioma of the liver. This lesion caused severe respiratory com- The abdominal wall in prune-belly syndrome is characterized by
promise. its lax, wrinkly appearance, with its very apparent redundancy of
FIGURE 87.15. (A). Prosthetic silo is

placed after decompressive laparotomy to
allow better excursion of the diaphragm.
(B) Sagittal view. (C) Prosthetic silo has
been replaced by absorbable mesh, al-
lowing the development of granulation
tissue and a physiological closure of the
abdomen. (D) . Sagittal view. (E) . After
adequate reduction in liver size, surgical
closure of the abdomen has been accom-
plished by mobilization of skin flaps. (F).
Sagittal view. (Reprinted from McGahren
et al.,115 with permission.)
---- ./
skin and subcutaneous tissue (Fig. 87.16). There is variability in to appear. 138,139 One theory to explain the abnormal wall forma-
the involvement of the muscular wall, with the upper abdominal tion postulates that there is a defect in the evolution of the somites.
musculature usually being better developed than the lower mus- This hinders appropriate muscle development, thereby resulting
culature. The most commonly involved muscles, in decreasing in a large fibrous tissue component of the abdominal wall. Opin-
order of frequency, are the transversus abdominis, the rectus ab- ions vary as to whether the affected somites are derived from the
dominis below the umbilicus, the internal oblique, the external thoracic or lumbar regions. If from the latter, associated lower limb
oblique, and the rectus abdominis above the umbilicus. anomalies might be explained. This theory of abnormal somite
There are a number of theories that attempt to explain why the formation suggests that the associated urinary defects may arise
abdominal wall forms as it does in prune-belly syndrome. The ab- from an overdistended bladder, which in turn results from a lack
dominal wall arises from the somatic layer of mesoderm. From the of inhibition of such distension from the flaccid abdominal
third to fifth weeks of gestation, somites give rise to myotomes that wall. 137-140
in turn develop into the musculature of the abdominal wall. By A second theory suggests that there is a period of intrauterine
the end of the twelfth week, recognizable striated muscle begins bladder outlet obstruction. This obstruction leads to a distended
bladder and ureters and, in some cases, to renal dysplasia and pul-
monary hypoplasia. The distended bladder causes pressure on the
abdominal wall and thereby inhibits its proper development. The
testicles are theoretically blocked from descending by the dis-
tended bladder. 137
Early approaches to the treatment of prune-belly syndrome fo-
cused primarily on the urologic anomalies. The abnormal anatomy
of the bladder and ureters prompted reconstruction efforts to pre-
vent ureteral reflux and preserve renal function. However, recon-
structive surgery carried a significant morbidity. Most authors now
believe that surgery is not initially indicated and that observation
and antibiotic treatment of urinary infections will preserve renal
function, allow resolution of reflux and some of the accompany-
ing ureteral dilation, and allow normallongevity.137 Orchiopexy is
universally advocated, however.
As late as 1974, Welch and Kearneyl41 considered reconstruc-
tion of the abdominal wall "unnecessary" in patients with prune-
belly syndrome. However, it has become clear that the laxity of the
abdominal musculature interferes with normal micturition and
respiratory function . In addition, many of these children experi-
ence severe psychological stress from the cosmetic deformity of
this anomaly. Thus, modern treatment of prune-belly syndrome
usually includes an aggressive approach toward treatment of the
abdominal wall laxity.
Randolph142 reported an extensive experience with abdominal
wall reconstruction in these patients in 1977. With the aid of elec-
FIGURE 87.16. Infant with features of severe prune-belly syndrome. The ab-
dominal wall is extremely thin with sagging flanks. Intestinal loops are vis- tromyography, he identified the strongest muscles in the abdom-
ible through the abdominal wall. (Reprinted from Hendren WH, Carr MC, inal wall, usually in the upper abdomen. He then employed a
Adams MC, Megaureter and prune-belly syndrome. In O'Neill JA, Rowe curvilinear incision extending from one flank to the other in the
MI, GrosfeldJL, reds]: Pediatric surgery, 5th ed. St. Louis: Mosby; 1998, with suprapubic region, thus allowing removal of redundant skin and
permission.) subcutaneous and fascial tissue. The abdominal fascia was tight-
ened by suturing the remaining muscle and fascia to the iliac 5. Rowe MI, Clatworthy HW. The other side of pediatric inguinal her-
spines and pubic tubercles. Good functional and psychological re- nia. Surg Clin North Am. 1971;51:1371-1376.
sults were reported for the children, although 6 out of 16 patients 6. Rajput A, Gauderer MWL, Hack M. Inguinal hernias in very low birth
required a revision of the repair.I43 weight infants: incidence and timing of repair. J Pediatr Surg. 1992;27:
In 1986, Ehrlich et al.I 44 described a repair using a long mid- 1322-1324.
7. Burke J, Femoral hernia in childhood. J Pediatr Surg. 1967;166:287-
line incision. Any necessary urological procedures were per-
289.
formed. The subcutaneous layer was then undermined and a 8. Tam PKH, Lister J. Femoral hernia in children. Arch Surg. 1984;
double-breasted, overlapping approximation of the opposing fas- 119:1161-1164.
ciallayers was performed. These patients reportedly had vastly im- 9. Ollero Fresno JC, Alvarez M, Sanchez M, et al. Femoral hernia in
proved cosmetic and functional results, and revisions have not childhood: review of 38 cases. Pediatr Surg Int. 1997;12:520-521.
been required. In 1991, Monfort et al.I 45 reported a technique of 10. Gilchrist BF, Lobe TE. The acute groin in pediatrics. Clin Pediatr.
abdominal wall reconstruction consisting of excision of the cen- 1992;31 (8):488-496.
tral redundant skin while preserving the umbilicus. Fibrous tissue 11. Lyon RP, Marshall S, Scott MP. Varicocele in childhood and adoles-
was excised on either side of the midline, with the lateral flaps cence: implication in adult infertility? Urology. 1982;19:641-644.
then sutured to the remaining strip of midline tissue. Cosmetic 12. Heinz HA, Voggenthaler J, Weissbach L. Histological findings in testes
with varicocele during childhood and their therapeutic consequences.
and functional results have been satisfactory, with no revisions re-
Eur J Pediatr. 1980;133:139-146.
quired to date. 13. Snell RS. Clinical anatomy fqr medical students, 2nd ed. Boston: Little,
In 1998, Furness et al.I 46 described an extraperitoneal plication Brown;1981:136-138.
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Part XV
The Female Hernia Patient
88
Epidemology of Hernias in the Female
Alejandro Weber, Salvador Valencia, Denzil Garteiz, and Alfredo Burguess
Introduction sac itself, while the round ligament is attached to the midportion
of the fallopian tube near the ovary.2 In the female, the analogue
Women are affected by hernias very differently from men. It is well of the processus vaginalis, fundamental in the origin of indirect
known that, in general, men are remarkably more prone to her- inguinal hernias, is the evagination of the peritoneum related to
nias than women, but the reasons are not well understood. As Ben- the round ligament in the canal of Niick. This structure is oblit-
david points out (Chapter 93), for every woman with a hernia, at erated near the eighth month of fetal life. If it persists, an indi-
least 19 men require treatment of some type of hernia. The great rect inguinal hernia can result. Arnheim and LinderS stated that
epidemiological difference between the sexes is relevant to the the broad ligament plays an important role in the development of
surgeon's clinical practice, and it cannot be attributed to chance. sliding hernias in females. Because this structure is near the in-
It is surprising that females do not develop more hernias than ternal ring, traction on it or on the genital organs can result in
males, given the great increases in intraabdominal pressure seen sliding hernias of the ovary, fallopian tubes, and even the uterus.
in pregnancy.
Musculoskeletal Differences
Embryological and
Anatomical Considerations The bones of the female are more slender, the iliac fossae shal-
lower, and the true pelvis wider. The angle between Cooper's lig-
Important structural differences between men and women can ex- ament and the inguinal ligament is not as great in the female as
plain the variations in type and incidence of inguinal hernias. it is in the male. The round ligament and the internal ring are
These include (1) descent of the testes and ovaries (2), differences smaller structures in females than the corresponding spermatic
in the bony pelvis, and (3) differences in the relationship of mus- cord and internal ring in males. The transversalis fascia and trans-
culofasciallayers of the lower abdomen. versus abdominis layers are well developed in the female. These
layers are of such strength that direct hernias through the floor
of Hesselbach's triangle are rare indeed. The broad attachment
Descent of Testes and Ovaries of the transversus abdominis arch to Cooper's ligament further
adds to the strength in this area and gives protection against di-
The descent of the testis in the male definitely causes a weakness rect and femoral hernias, as pointed out by McVay and Savage. 4
in the groin that accounts for a high incidence of hernias. Failure In dissections of human specimens and observations during op-
of obliteration of the processus vaginalis is directly implicated in erative procedures, it has been found that in the male, on the con-
the formation of these hernias in both sexes. During the female trary, the high insertion of the rectus abdominis and the
developmental process, the pelvic organs move through the comparatively narrow attachment of the transversus abdominis
retroperitoneum caudally and laterally so that the ovaries and fal- arch to Cooper's ligament predispose him to direct and femoral
lopian tubes eventually reach the pelvis. The ovary remains in the herniation. 5
embryonic intraabdominal position after birth; the cranial part of
the gubernaculum ovarii becomes the suspensory ligament of the
ovary, while the caudal part turns out to be what textbooks of Age Distribution
anatomy call the round ligament of the uterus. Observations in girls
with indirect inguinal hernia suggest that this structure is the real Aging is a factor in hernia formation, but its precise influence is
suspensory ligament of the ovary.l It can be assumed that the ovary difficult to state. With aging, some tissue atrophy occurs, leading
occasionally seen in a hernia sac has mimicked the descent of the to gradual weakening of the inguinal floor, the internal ring, and
testis because in these patients the distal portion of this ligament other points of the abdominal wall. The geriatric patient may also
does not reach the labium majorum but terminates in the hernial suffer from certain conditions (such as pulmonary emphysema)
613
614 A. Weber et al.
TABLE 88.1. Age distribution in females according to hernia type et al,u inJordan, reported a difference ratio of 8 to 1.2. The great-
est disproportion was reported by McClure and Fallis,12 who found
0-2 years 3-59 years >60 years
that only 1.1 % of inguinal hernia operations in their series were
Inguinal 24.3% 65.7% 9.8% performed in females (Table 88.2).
Femoral 0.9% 71.4% 27.6%
0-5 years 6--59 years >60 years
Indirect Inguinal Hernias
Umbilical 33.8% 57.8% 8.3%
Ventral 3.3% 72.5% 24.1%
Indirect inguinal hernia in women is much more frequent than
Other 8.9% 66% 24.3%
the direct type, as it is in men, but in these hernias also the male
predominance is evident. COley13 found that from a total of 2168
operations, 72% were performed for indirect inguinal hernias in
that often result in increases in intraabdominal pressure. Direct males, while only 7.9% were conducted in females. Approximately
and indirect sliding hernias are seen in increasing numbers with one-third of the total number of cases occurring in females are
increasing age. Femoral and ventral hernias in females are very primary indirect inguinal hernias. 14 Hagan and Rhoads 15 also
rare before the age of 5 years, but predominate thereafter until found that indirect inguinal hernia was the most common hernia
the age of 60 years. On the other hand, inguinal and umbilical encountered in females, occurring in 51 % of their cases studied.
hernias in girls under 5 years of age account for approximately
24% and 33%, respectively. Obturator hernias, on the other hand,
are almost exclusively seen in elderly women. The general distri-
bution of hernias in females, according to age, is summarized in
Direct Inguinal Hernias
Table 88.1. Direct inguinal hernia in women is so rare that a primary inguinal
hernia is considered to be indirect until proved otherwise.I 6 In the
years from 1965 to 1967, a study at the Henry Ford Hospital col-
Inguinal Hernia lected 453 primary direct and recurrent direct inguinal hernias in
males, while only five such hernias were seen in females. 17 The
The different distribution of inguinal hernia among men and male to female ratio of direct inguinal hernias was found to be ex-
women is evident and was first recognized by Malgaigne 6 in the ceptionally high (approximately 90:1).
nineteenth century. He found that while 7.7% of men had inguinal Anatomical factors such as the narrowness of the gap between
hernia, only 1.9% of the women were affected, a frequency almost the transversus arch and the inguinal ligament plays an important
four times greater for men. Although this disparity may vary in dif- factor in protecting women against direct inguinal hernias. The
ferent series, the greater male to female ratio has remained con- transversalis fascia in the floor of Hesselbach's triangle in females
stant throughout time in all geographical regions. The male is usually so strong that it rarely permits a large diffuse disruption
predisposition to inguinal hernia is seen from birth onward, as such as those seen in males. The strength of the posterior waIl of
they are affected nine times more than female infants. 7,8 the inguinal canal in women suggests that surgeons should leave
In 1893, Macready,9 in a collected series of 21,795 adult patients it intact whenever possible when dealing with indirect hernias. If
with hernia, found that 18,223 (84%) occurred in men, while only any evidence of weakness is present, however, it is crucial to rein-
3572 (16%) were present in women. Watson,lO in 1938, pulled to- force the posterior wall to prevent recurrences or the occurrence
gether figures from Malgaigne, Berger, Macready, and Coley for a of associated untreated hernias; Glassow16 found that 67% of di-
total of 104,641 hernias yielding similar findings. From the total, rect hernias in his series were associated with contralateral or ip-
77% occurred in males and 23% in females. Recently, el-Qaderi silateral inguinal or femoral defects.
TABLE 88.2. Male:female distribution of the different types of hernia repair in large series
Coley76 Rutkow62 Heydorn59 Rutkow75
Source New York's Hospital National Center for U.S. Army Patient National Center for Health
for Ruptured and Health Statistics/National Administrations Systems Statistics/National Hospital
Crippled Hospital Discharge and Biostatistics Activity Discharge Survey +
National Survey of
Ambulatory Surgery
Population 70,090 2,087,000 36,250 1,060,000
Period 1910 1979, 1981, 1983 1981-1985 1996
Hernia type
Inguinal 85%, 15%, 5.6:1 91%, 9%,10:1 92%, 8%,11.5:1 90%,10%, 9:1
Femoral 29%,71%, 1:2.4 26%,74%, 1:2.8 39%,61%, 1:1.5 30%,70%, 1:2.3
Umbilical 36%,64%, 1:1.7 35%,65%, 1:1.8 55%,45%, 1.2:1 57%,33%, 1.7:1
Ventral 26%,74%, 1:2.8 34%,66%, 1:1.9 55%,45%, 1.2:1 35%,65%, 1:1.8
Other 33%,67%, 1:2 66%,34%, 1.9:1 43%,57%, 1:1.3
·Percent males, percent females, and male/female ratio.

88. Epidemology of Hernias in the Female 615
Side Predominance single defect is the most common finding patients with hernia,
these conditions should raise suspicion that the case could be more
There is a right-sided predominance of inguinal hernia corrobo- difficult. In these cases the possibility of a recurrence is greater.
rated by some authors, such as Nordback,18 who reported this pre- Indirect, direct, and combinations of such hernias are seen far
ponderance of right inguinal hernias in different subgroups of more frequently in men than in women. Ofili23 found combined
patients (children, women, men; direct, indirect, older people) as inguinal defects (pantaloon hernias) in 94% of men, while only
being statistically significant. In direct hernias, right-side presen- 6% were seen in women. In both groups, these hernias appeared
tation occurred in 56.7% of the cases. 16 No hypothesis for this phe- only from the fourth decade of life on. 23 Combinations of direct,
nomenon has been confirmed, but even in congenital inguinal indirect, and femoral hernias occurred 12 times more often in
hernias this difference is maintained with a ratio of 1.5 to 1, ac- males than in females in Ponka's experience. 17 These findings sug-
cording to Czeizel,19 gest that females are probably better protected against collagen
defects. In any case of complex hernia, the surgeon should rein-
force all possible hernia sites to avoid recurrences and prevent
Contents of Inguinal Hernia Sacs new herniations.
An interesting fact particular to females is that indirect inguinal

hernias and sliding hernias are not at all rare and may contain ad- Risk Factors of Inguinal Hernia
nexa even in infants, as has been described since the second cen-
tury A.D. This possibility is important to bear in mind since these Predisposition to the development of an inguinal hernia may have
organs may become incarcerated and even strangulated. Watson 10 a hereditary component, but unfortunately the inheritance pat-
was able to collect 469 such cases in which some combination of tern has not been clearly identified yet. 29 An epidemiological study
ovary, fallopian tube, and uterus was found in hernial sacs in fe- of more than 2000 cases of congenital·hernia found that a girl
males of all ages. Several authors have referred to the existence with an affected sister was at a higher risk of developing a hernia
of such defects: Arnheim and Linder2° reported in 1956 on 29 than a girl or a boy with an affected brother. According to these
cases of inguinal herniation of pelvic viscera in 28 female infants. results, the authors concluded that the pattern of transmission for
Ovary and fallopian tubes were present in 14; ovary, fallopian tube, inguinal hernia must be multifactorial and probably not sex
and uterus in 9; fallopian tube in 3; fallopian tube and uterus in linked. 3o On the other hand, a study of 280 families with more
2; and the uterus alone was present in only 1 of the 28 infants. than one member affected by inguinal hernia found a frequent
vertical transmission pattern. 31 It is clear that factors of familial
predisposition exist, but to date there is no conclusive evidence of
Bilateral Inguinal Hernia a specific transmission pattern for inguinal hernia.
An epidemiological study in a female population by Liem et al. 32
Bilateral indirect hernias in infants are more common than sur- reported that the only statistically significant factors associated with
geons think and may contain ovaries, fallopian tubes, and even hernia were a positive family history of this entity and constipa-
the uterus as sliding components. The percentage of bilaterality tion. Interestingly, in females, obesity was found to be a probable
in hernias of male infants is 15%, with a higher proportion in fe- protective factor against inguinal hernia, a fact borne out also in
male infants, and perhaps as high as 40% of hernias in premature another study by Abrahamson et al. 29 in men. Verhaeghe et al. 33
babies. 21 .22 undertook a computerized retrospective study of 10 years of her-
In adults, according to a study of a 10-year period by Ofili,23 of nia surgery, analyzing the specific characteristics of hernias in
all the bilateral hernias seen, 87% were found in men versus 13% women; this revealed the role of multiple gestation (more than
in women. This was also corroborated by Serpell et al., 24 who found three pregnancies) in the etiology of inguinal hernias. On the
93% in men and only 7% in women. Glassow16 found 7.3% bilat- other hand, females who performed exercise on a regular basis
eral defects in 124 cases of direct inguinal hernia. Percentages of also had a lower prevalence of hernia. Exercise must be differen-
bilaterality are increasing, probably because there is a better un- tiated from actions that involve lifting heavy objects. While one
derstanding of this entity, and surgeons and clinicians look for bi- probably reinforces the abdominal wall and inguinal region, the
lateral defects. It is postulated that defective collagen synthesis in other contributes to increased abdominal pressure and hernia for-
the tissues of the inguinal region occur more in males than in fe- mation. F1ich et al. 34 demonstrated that both the weight of the
males and that this is responsible for the higher proportion of bi- lifted objects and the number of years of lifting are factors that
lateral hernias in males. 25-27 Herniography has been very useful contribute to inguinal herniation.
in detecting bilateral or multiple hernias, and laparoscopy may The smoking habit has increased especially in the female pop-
also be helpful in detecting them, especially in cases with chronic ulation around the world. It is well known that patients who smoke
inguinal pain without palpable mass, which is a frequent situation have a higher probability not only of developing inguinal hernia
among women. but also of recurrence, probably because of metabolic distur-
bances. 35.36
Complex Inguinal Hernia

Occult Inguinal Hernias
The term complex hernia is used by us when one or more of the fol-
lowing conditions are present: family history of bilateral hernia, Symptomatic but nonpalpable hernias often remain undiagnosed.
recurrent familial hernia, when the patient has bilateral or recur- It is mandatory for a surgeon to consider it, even if no palpable
rent hernia, or when multiple defects are found. 27.28 Although the mass is found, every time a female patient presents with symptoms
616 A. Weber et al.
of local tenderness over the deep inguinal ring elicited by palpa- more prone to develop femoral hernias. However, as was reported
tion during a Valsalva maneuver or with dull inguinal pain or neu- by Glassow42 from a 17-year review at the Shouldice Hospital, even
ralgic pain that occurs intermittently and often radiates toward the in the female population inguinal hernias occurred three times
thigh, the flank, or the lower abdomen on the same side. In such more often than femoral ones. However, the number of elective
patients the diagnosis is primarily based on history, the location repairs of femoral hernias was roughly equal between men and
of the pain, and an otherwise normal clinical evaluation. 37 women. In a study of 1101 primary operations for femoral hernia,
Although most information in the literature is about small Glassow42 found that 687 operations (62.4%) were performed on
groups of patients, Herrington38 reported an 8% incidence of re- females. Macready9 found, when analyzing sex distribution of in-
pair of occult defects in his total experience with inguinal hernias. guinal and femoral hernias, that femoral hernias comprised 5.9%
He even defines this entity as the syndrome of occult inguinal her- in females but only 2.1 % in males. Differences between sexes re-
nia in the female because of the obvious sex predominance. 38 garding femoral hernias are frequently not well understood. Men
These hernias may go undiagnosed in women until very late for a predominated in Glassow's review of femoral hernias, 3:1, but, at
number of reasons: the difficulty of exploring the internal inguinal the same time, Zimmerman and Anson41 concluded that femoral
ring during physical examination compared with male patients, hernias account for only about 2% of all hernias in men, but they
the fact that these defects are usually small, and because many constitute 24% of all hernias in females. Thus, although more men
times such symptoms are suggestive of gynecological, urological, are affected with femoral hernias than women, it is accurate to say
or colonic problems. The surgery is often simple, requiring only that the proportion of women affected by femoral hernias is
high ligation of the sac and repair of the musculoaponeurotic de- greater than the proportion of men. Ljungdahl43 also confirmed
fect at the internal ring. They may also, however, have bowel or these figures, reporting that femoral hernias accounted for 1.6%
other viscera incarcerated and necessitate emergency surgery. of the hernias in men and 30.8% of the hernias in women. He did
With a high index of clinical suspicion, herniography, and the find, however, that there were almost as many men as women with
advent of laparoscopy, this entity should be diagnosed earlier, femoral hernias. 43
avoiding some unnecessary complications and laparotomies.
Recurrent Groin Hernia

Inguinal Hernias and Pregnancy
As pointed out by Bendavid, the first attempt at surgical treatment
It is estimated that 1 of every 1000 to 3000 pregnancies is associ- of a hernia affords the best chance of success and should be per-
ated with groin hernia. Hernias not evident before pregnancy may formed correctly to avoid recurrence. The overall recurrence rate
first become symptomatic during pregnancy because of the in- of inguinal hernia repair is approximately 10% and ranges from
crease in intraabdominal pressure. 39 If a woman presents with a 0.2% to 15%.44,45 For reasons not well understood, recurrent in-
groin hernia during pregnancy, she should be observed for indirect inguinal hernias are seen rarely in females. In a multicen-
carceration or strangulation and should be operated on promptly ter study, Cahlin and Weiss46 reported no recurrent cases among
if these occur. Little information is available on repair at the time women from a total of 10.4% occurrence rate.
of cesarean sections, delivery, or other gynecological procedures, A significant number of patients recur repeatedly, as shown by
but it should be considered in selected circumstances. Known in- Ijzermans et al.,47 who found a cumulative percentage of repeated
guinal or femoral hernias should be repaired promptly in women recurrent hernia of 23% after 5 years, mainly of the direct type.
before pregnancy intervenes or as soon as possible after delivery.40 However, re-recurrent inguinal hernias are rarely seen in women.
Only 3% of these cases were women, possibly due to collagen al-
terations. Other factors such as the number of previous recur-
Femoral Hernia rences, their location, increase of intraabdominal pressure, body
weight, and the method of anesthesia employed seemed to have
According to Bendavid, "femoral hernias have not received the re- no effect on this recurrence rate.
spect they deserve as a surgical entity." When they are not diag- Femoral hernias behave differently.48,49 There is a higher inci-
nosed, they may lead to emergency surgery with complications and dence of recurrence of femoral hernia than inguinal defects. Half
mortality. They strangulate 10 times more frequently than inguinal of the patients with femoral hernia admitted to the Shouldice
hernias mainly because the diagnosis and treatment are often de- clinic had recurrent femoral hernia. Here again, men had a higher
layed. They are much less common than inguinal hernias.l 2 Zim- proportion of recurrences than women, 82% versus 18%.50
merman and Anson41 showed that the incidence of femoral hernia Bendavid50 reviewed 508 femoral herniorrhaphies performed
is from 5 to 7% of all hernias. Probably the scarcity of femoral her- on 453 patients (251 primary femoral repairs and 257 recurrent
nias contributes to the low level of suspicion among physicians. It femoral repairs) and found a strikingly high proportion of re-
is a common idea that femoral hernia in women is more frequent recurrences. The recurrence rate for primaries was 6.1 % and for
than inguinal, but McClure and Fallis 12 in 1939 found only 36 fere-recurrence was 22.2% on average, with a range of 1l.8% with
males with femoral hernias out of 241,037 hospital admissions, a the first recurrence to 75% in patients after five recurrences. Glas-
ratio of 1 femoral hernia per 6700 admissions. Coley13 found the sow42 reviewed a series of 2105 femoral hernia repairs performed
incidence of femoral hernia in both males and females to be only in a 17-year period. Of these, 1138 were primary and 967 were re-
3.3% in 3000 operated cases, 1.5% in men and 1.8% in women current. The re-recurrence rate was approximately 10% in men
(Table 88.2). and 7% in women, much less of a sex difference when compared
The configuration of the feminine pelvis and the musculo- with inguinal recurrence rates. These studies stress the importance
aponeurotic attachments are such that women are proportionally of the nature and quality of the tissues available for femoral re-
pair and the given anatomical configuration of a particular pa- operated on in the United States in 1979, 1981, and 1983, women
tj.ent. They found in some patients the iliopubic tract nonexistent were affected twice as frequently as men (Table 88.2).62
or Cooper's ligament too distant, while in others the femoral de- Gynecological procedures have accounted for the statistical pre-
fect was too large, increasing the possibility of femoral vein com- ponderance of such hernias in females. In most studies, the high
pression with repair. The surgeon must also consider again the incidences have been attributed to hysterectomy, probably with
possibility of structural, metabolic, and biological abnormalities in wound infection as a key factor, more than other sex-related fac-
some patients' tissues, which could explain failures of the hernio- tors such as multiple gestations. With improved techniques of
plasty as a local manifestation of defective collagen metabo- wound management, the use of appropriate sutures, and the ad-
lism. 28 ,51-56 Whenever faced with a recurrent femoral hernia, the vent of laparoscopic surgery, the incidence of incisional hernias
surgeon should consider the use of a prosthesis. will probably decrease. No matter what causes incisional hernias,
it is important that they be treated as soon as possible; delay leads
to constant enlargement over time, increasing the risk of morbidity
and mortality due to incarcerated or strangulated viscera and mak-
Risk of Emergency and Complications ing correction with adequate cosmesis more difficult.
Herniorrhaphies performed electively are usually easy procedures.
Emergency events, on the other hand, involving strangulation or
intestinal obstruction, especially in the elderly, in whom these
Umbilical Hernias
events are more frequent, are associated with higher morbidity
The preponderance of umbilical hernias in the adult female pop-
and mortality. Workers at Oxford University reviewed more than
ulation is also striking, although operations for umbilical hernia
30,000 cases of inguinal hernia repair and found significant risk
performed during the first 2 years of life (probably due to an ab-
factors related to age and sex. 57 Approximately 9% of these were
normal development of the abdominal wall) are more frequent in
operated on as emergency procedures, and patients over 50 years
male infants. When considering umbilical hernias in general, re-
were most likely to fall into this category. The cumulative proba-
gardless of age, there is again a male preponderance. This was
bility of strangulation for inguinal and femoral defects has been
shown by the National Hospital Discharge Survey and the National
shown to be high in a study by Gallegos et al. 58 with a proportion
Center for Health Statistics of the United States, which reported
approximately 10 times greater for femoral hernias. As we know,
57% of umbilical hernias in males versus 33% in females (Table
femoral herniations are occasionally difficult to diagnose in elderly
88.2).63 Other studies confirmed this finding. 59 The overall inci-
females and can progress to incarceration and strangulation of the
dence of umbilical defects declines during late childhood, and the
bowel. While for inguinal hernia this probability was 2.8% at 3
lowest incidence is found in teenagers, increasing gradually dur-
months and 4.5% at 2 years, for femoral hernia it was 10 times
ing early adulthood. In the adult population, conversely, the inci-
greater (22% and 45%, respectively).
dence is higher in females. Umbilical hernia in adult females is
Bendavid50 draws attention to the problem of complicated
frequently associated with an increase in intraabdominal pressure
femoral hernias commonly associated with a delay in diagnosis and
due to pregnancy, obesity, or other circumstances. Many patients
treatment, too often resulting in emergency resections, a stormy
attribute the onset of umbilical herniation to pregnancy; further-
postoperative course, and prolonged convalescence. It is clear that
more, multiple pregnancies often precede the development of an
the highest risk of hernia complications and the need for emer-
umbilical hernia. They may cause separation and atrophy of the
gency surgery is among older males with any type of hernia and
rectus abdominis muscles, and the recurrent high pressure within
among femoral hernias especially in females with hernia on the
the abdomen during pregnancy culminates in a protrusion at the
right side. In the study of 36,000 abdominal hernia repairs by Hey-
umbilicus.
dorn and Velanovich,59 mortality due to femoral hernia was seen
Obesity is another common finding in females with this type of
only in women. 59
hernia. Fatly infiltration decreases the qualily of abdominal mus-
culature; muscles become lax, and, as they separate at the um-
bilicus, herniation results. Obviously, other factors that increase
Incisional Hernias intraabdominal pressure such as ascites, chronic constipation, ob-
structive pulmonary diseases, abdominal tumors, cystitis, and cys-
It is very distressing when any elective abdominal surgery patient tocele are associated also with umbilical hernias.
develops a postoperative hernia. A number of factors, such as the Umbilical hernias account for 12 to 16% of the hernias in
surgeon's reluctance to report these hernias and the patient's de- women. In a study carried out by Ponka17 in the years 1965 and
lay in seeking assistance, account for the variety of frequencies re- 1967 at Henry Ford Hospital, umbilical hernias occurred with an
ported. Incisional hernias have increased in incidence in the past overall incidence of 4.65%. From all umbilical hernias encoun-
60 years as abdominal operations have grown in frequency and tered in this review, adult men constituted 41.3%, and women
magnitude. The incidence of incisional hernias has ranged from 58.7% of the incidenceP Most of the umbilical hernias (approx-
2 to 17% in various reported series, but may vary considerably imately 60%) are symptomatic in women, while relatively few men
among hospitals. 5O Postoperative incisional hernias are seen more present with symptoms (36%).64
frequently in women. In 1934, Branch61 found that females had Umbilical hernias in adults can cause prolonged morbidity and
71.6% of all incisional hernias. Ponka17 looked for the incidence even death in a few patients. Repair is sometimes deferred, usually
of postoperative hernias at Henry Ford Hospital for the years 1965 because of serious comorbidities. Delay may, however, result in se-
and 1967. Of 325 females, 11.08% were found to have incisional rious complications such as spontaneous perforation of the skin,
hernias while only 3.4% of men developed them. Of the patients rarely, if ever, seen in other types of hernias. This rupture is reported
618 A. Weber et al.
to be associated with multiple gestations, ascites, cirrhosis, nephro- phy, and laparoscopy can be helpful in diagnosis. Early diagnosis
sis, or obesity, conditions that frequently discourage surgery.65 is very important to permit a better chance of the patient's sur-
vival. Contralateral exploration is recommended, as bilateral her-
nias are quite common.
Epigastric Hernias Women are very different from men in many ways. With regard
to hernia, they are affected in different proportions and to dif-
Epigastric hernias are not commonly encountered in either sex, ferent degrees, presenting different challenges that surgeons must
but they are far more common than is generally realized, for many bear in mind in order to understand, recognize, detect, and treat
of them are never diagnosed. They account for approximately 2% appropriately.
of all hernias in both men and women. The relative incidence of
epigastric hernias in women was 2.46%,I7 The total incidence was,
however, less than 1 % of all hernias in women and nearly 2.5 per-
cent of those in men. In other series, epigastric hernias are re- References
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inguinal hernia after three years. Acta Chir Scand. 1980;146:421- 72. Solli P, Bobbio A, Di Gioia MV, et al. The obturator hernia: a diag-
426. nostic challenge? Acta Biomed Ateneo Parmense. 1994;65:235-240.
47. IjzermansJ, Wilt H, Hop W, et al. Recurrent inguinal hernia treated 73. Cueto-GarciaJ, Rodriguez-Diaz M, Elizalde-Di Martino A, et al. An in-
by classical hernioplasty. Arch Surg. 1991;126:1097-1100. carcerated obturator hernia successfully treated by laparoscopy. Surg
48. Ponka JL. Hernias of the abdominal wall. Philadelphia: W.B. Saunders Laparosc Endosc. 1998;8:71-73.
Co., 1980;264-273. 74. Yip AW, Ah Chong AK, Lam KH. Obturator hernia: a continuing di-
49. Nyhus LM, Condon RE (eds). Hernia, 2nd ed. Philadelphia:J.B. Lip- agnostic challenge. Surgery. 1993;113:266-269.
pincott; 1978:250-263. 75. Rutkow I. Epidemiologic, economic, and sociologic aspects of hernia
50. Bendavid R Femoral hernias: primary versus recurrence. Int Surg. surgery in the United States in the 1900s. Surg Clin North Am. 1998;
1989;74:99-100. 78:941-951.
51. Wagh PV, Read RC. Collagen deficiency in rectus sheath of patients 76. Coley WB: Hernia. In Keen WW, Da CostaJC (eds): Surgery, its princi-
with inguinal herniation. Proc Soc Exp Bioi Med. 1971;137:382. ples and practice, vol 4. Philadelphia: W.B. Saunders; 1910:23.
52. Wagh PV, Read RC. Defective collagen synthesis in inguinal hernia- 77. Eccles WM (ed). Hernia, its etiology, symptoms and treatment. London:
tion. Am] Surg. 1972;124:819-822. Tindall and Cox; 1908:3.
89
Anesthesia for Hernia Repair in
Pregnancy and Lactation
Stephen Halpern and Margaret Srebrnjak
Introduction hip bolster or tilting the operating table 15 to 20 degrees. Lateral

tilt should be considered when the uterus is higher than the um-
In most cases, hernia repair in a pregnant woman should wait un- bilicus or greater than 20 weeks gestation.
til after delivery. There are occasions, however, when hernia
repair must be performed before delivery or immediately post-
partum. When this occurs, there are many factors that must be Respiratory System
evaluated when considering the best anesthetic management for
these patients. Important maternal physiological changes begin Numerous physiological changes occur in the respiratory system
early in the first trimester. Uterine blood flow must be preserved during pregnancy. These include changes to the upper respiratory
to ensure fetal well-being. Both pharmacokinetics and pharmaco- system, lung volumes and capacities, and oxygen consumption sec-
dynamics of the commonly used sedative, analgesic, and anesthetic ondary to an increased metabolic rate.
agents can be significantly altered during pregnancy. All drugs
given to the mother pass the placenta and may affect the fetus.
Factors associated with anesthesia and surgery may precipitate Upper Respiratory Tract
pre term labor. Finally, drugs given to lactating mothers may affect
lactation or the newborn. The upper respiratory tract becomes increasingly edematous
throughout pregnancy. Nasal stuffiness and epistaxis are common,
leading some patients to erroneously assume that they have an up-
per respiratory tract infection. This may lead the patient to use a
Physiological Changes in Pregnancy number of over-the-counter medications that may interact with
analgesics. Although mild laryngeal edema and voice change is
Cardiovascular System common, symptoms of laryngeal obstruction secondary to infec-
tion or toxemia may occur more rarely. 2
Cardiovascular changes start very early in pregnancy and peak at
about week 32 of gestation (Fig. 89.1). Although blood pressure
does not change significantly throughout gestation, both heart Lower Respiratory Tract
rate and stroke volume increase by 25%, and cardiac output in-
creases by 50% compared with nonpregnant women. l This is As the uterus progressively enlarges, the diaphragm is progressively
achieved with a proportional drop in peripheral vascular resistance pushed upward. This also causes the lungs to be displaced upward
(Fig. 89.1). Much of the increase in cardiac output is directed to and the cardiac apex to shift laterally. Later in pregnancy, the ribs
the enlarging uterus. become flared and the abdominal muscles lose tone. The di-
As the uterus increases in size and occupies space in the ab- aphragm then becomes the main respiratory muscle.
domen, compression of both the abdominal aorta and inferior Table 89.1 shows how the lung volumes and capacities change
vena cava occurs. Compression of the inferior vena cava results in toward the end of pregnancy. The reduction in the functional
a decrease in venous return and may lead to severe hypotension residual capacity leads to airway closure during normal tidal
if the patient is supine. This may lead to a reduction in uterine breathing and mild hypoxemia at rest. It is worsened by the supine
blood flow and consequently to fetal distress. Compression of the position and by the increase in weight as pregnancy progresses.
aorta does not usually result in altered maternal hemodynamics, This coupled with an increased oxygen consumption of up to 50%
but may cause fetal distress if the compression occurs proximal to causes an increased susceptibility to hypoxemia if hypoventilation
the origin of the uterine arteries. Positioning the patient with the or upper airway obstruction from sedatives or opioids occurs.
uterus displaced from the midline will prevent aortocaval com- Under the effects of progesterone, the parturient chronically
pression in most cases. This is most effectively done with a right hyperventilates, reducing the arterial partial pressure of carbon
620
89. Anesthesia for Hernia Repair in Pregnancy and Lactation 621
FIGURE 89.1. Changes in cardiovascular parameters with 160

increasing gestation. HR, heart rate; CO, cardiac output;
PVR peripheral vascular resistance. (Data are from Rob-
son et al. l )
i£ 140
120
I
IS 100
Z
c..... 80
0
Q)
~ 60
-=~
Q) 40
~ 20
0
o 5 8 12 16 20 24 28 32 36 38
Gestation (weeks)
I--HR ---CO ......--PVR I
dioxide to about 30 mm Hg. This results in a mild respiratory al- Hematological System
kalosis. Opioids and anxiolytics cause hypoventilation and respi-
ratory acidosis. The effects of acidosis on the fetus are minimal if Red cell volume is increased by about 45% by the end of gesta-
mild, but severe acidosis can cause myocardial depression. Mater- tion. Because the plasma volume increases by a greater amount
nal hyperventilation causes a decrease in fetal oxygenation by two (about 55%), there is a relative decrease in the normal hematocrit
mechanisms. A low maternal arterial carbon dioxide tension of about 10%. These changes begin early in the second trimester
causes umbilical artery vasoconstriction, reducing placental per- and are caused by a relative sodium retention secondary to hor-
fusion on the fetal side, resulting in reduced oxygen uptake by the monal changes. The dilution also affects plasma proteins, includ-
fetus. In addition, the oxygen dissociation curve of maternal he- ing serum albumin. 7 This causes an accumulation of edema fluid,
moglobin is shifted to the left, impairing its ability to transfer oxy- both peripherally and centrally (see Upper Respiratory Tract,
gen to the fetus. 3 above). Importantly, reduced albumin leads to a reduction in the
protein binding of some drugs, exaggerating their pharmacolog-
ical properties. Pseudocholinesterase concentrations are also
reduced, leading to a slight prolongation in the action of suc-
Gastrointestinal System cinylcholine. Coagulation factors are increased, making patients
"hypercoagulable" and susceptible to venous thrombosis if activity
Whether or not pregnancy causes a delay in gastric emptying is
is curtailed.
controversia1. 4,5 However, pregnant women have an increased in-
cidence of gastroesophageal reflux. At term, reflux can be demon-
strated in up to 75% of parturients compared with only 16% Other Physiological Changes
immediately postpartum. 6 This may be due to mechanical, hor-
monal, or neurological mechanisms. Reflux predisposes the par- Kidney perfusion is increased, leading to an increased glomeru-
turient to aspiration pneumonitis if her upper airway reflexes are lar filtration rate and increased creatinine clearance. Serum crea-
obtunded from sedation or general anesthesia. tinine normally falls by almost 50%. Renal tubules function
normally, but glycosuria is a common problem because of the in-
creased glucose presented to the tubule system. 8
TABLE 89.1. Respiratory changes in pregnancy Pregnancy is characterized by an increased resistance to insulin.
This results in wider swings in serum glucose after a carbohydrate
Lung parameter Change
load and an increased tendency to starvation ketosis. Gestational
Total lung capacity No change diabetes may also occur. This condition resolves quickly after the
Expiratory reseIVe volume Decreases 8-40% placenta is delivered. 7
Residual volume Decreases 7-22% Pregnant patients are much more sensitive to both regional and
Functional residual capacity Decreases 10-25% general anesthetic agents. The 30% reduction in drug require-
Inspiratory capacity Increases 15% ments is secondary to a number of factors, including the effects
Vital capacity No change of progesterone and an increase in endorphin levels. 3
Tidal volume Increases 33-45%
Respiratory rate No change
Minute ventilation Increases up to 45%
Lung compliance No change
Uterine Blood Flow
Total pulmonary resistance Decreases up to 50%
Uterine blood flow increases rapidly throughout gestation. It ap-
Data are from Elkus and Popovich 2 and Conklin.7 proaches 700 mll min at term compared with about 100 mll min
622 S, Halpern and M. Srebrnjak
in the nonpregnant uterus. 9 Under normal circumstances, the of protein binding. Fentanyl, alfentanil, and sufentanil are exam-
uterine arteries are maximally dilated, with flow being dependent ples of such drugs. Conversely, morphine, which is less lipid solu-
on the difference between uterine artery and venous pressure. A ble but is also less protein bound, rapidly crosses the placenta. 13
drop in mean uterine artery pressure is therefore accompanied by Local anesthetics exist in the ionized and un-ionized form. At
a proportional reduction in uterine blood flow. This may occur physiological pH, the concentration of the ionized form increases
secondary to a reduction in maternal systemic blood pressure or as the pH decreases. Maternal pH is normally about 7.45, and fe-
to local conditions such as aortocaval compression. tal pH is often less than 7.3. The un-ionized molecules easily pass
Uterine blood flow is inversely proportional to uterine artery the placental barrier but then become ionized because of the lower
vascular resistance. Although these vessels are normally fully di- pH, trapping them in the fetus. This "ion trapping" effect is most
lated, vasoconstriction can be induced by a number offactors. Any prominent in distressed fetuses when the fetal pH is low and may
maternal stress that causes an increase in maternal catecholamines lead to toxicity in the compromised fetus if excessive doses are
will increase vascular resistance and reduce uterine blood flow. used.I 4
Some examples include pain, maternal anxiety, and maternal hy- Molecular size is an important determinant of placental trans-
povolemia. Exogenous vasoconstrictors such as high doses of epi- fer. The rate of transfer is very slow if the molecule is greater than
nephrine have a similar effect. 10 500 Daltons. Most drugs are much smaller than this, provided they
When uterine blood flow is not preserved, the fetus may suffer are not bound to protein.
serious consequences. In the first trimester, fetal hypoxia may Breastfeeding women may pass systemically administered drugs
cause abortion or major teratogenesis. 3 Later in pregnancy, the fe- to their newborns. As a general rule, most drugs that are systemi-
tus may suffer central nervous system damage leading to a range cally absorbed will appear in the breast milk. Drugs with a high
of disorders from mild neurological abnormalities to severe cere- lipid solubility, low molecular weight, and low protein binding and
bral palsy. In some cases, the fetal heart rate can be monitored for that are un-ionized are secreted most easily. Most breast milk is
signs of fetal distress. If this occurs, the precipitating factors should synthesized and secreted during and immediately after feeding.
be removed if possible, or if the fetus is viable, immediate deliv- Taking medications after breastfeeding or when the infant has the
ery of the fetus should be considered. longest interval between feeds minimizes transfer. Long-acting
medications should be avoided. 15
Placen tal Transfer of Drugs
Any drug that is given to the mother will pass the placental bar-
Anesthetic Considerations
rier. Substances can cross the placenta to the fetus by four main During Pregnancy
mechanisms: passive diffusion, facilitated transport, active trans-
port, and pinocytosis. Of these, passive diffusion is most impor- The anesthetic must be suitable for the proposed surgery. In the
tant for the transport of drugs. case of hernia operations, a number of factors must be consid-
There are several factors that influence the rate of drug trans- ered. These include the urgency of the surgery, the anatomical
fer across the placental membrane. Drug transport is directly pro- site (above or below the umbilicus), the size of the incision, the
portional to the difference in concentration of free drug in the requirement for muscle relaxation, and the involvement of bowel
maternal and fetal circulation. Lipid-soluble drugs cross more or peritoneum. The conduct of anesthesia must then be modified
quickly than ionized drugs. For example, highly lipid-soluble to take into account the physiological changes that occur during
agents such as diazepam cross the placenta quickly, whereas 10- pregnancy and the effects of anesthesia and surgery on the uterus
razepam crosses much more slowly.11,12 Some agents are highly and the fetus. Table 89.2 shows how the importance of each of
lipophilic but do not cross the placental barrier rapidly because these factors changes as pregnancy progresses.
TABLE 89.2. Anesthetic considerations at increasing gestational age and for breastfeeding mothers
First Second Third Breastfeeding

Anesthetic consideration trimester trimester trimester mother
Maternal susceptibility to hypoxemia ++ +++ ++++ 0

Precautions for "full stomach" + ++ ++++ 0
Need for left uterine displacement to 0 + ++++ 0
avoid maternal hypotension and
reduced uterine blood flow
Dose modification for epidural/ + +++ +++ 0
spinal anesthesia
Dose modification for general +++ +++ +++ +
anesthetic agents
Potential for medications to ++++ + 0 0
cause teratogenesis
Monitoring uterine activity + +++ ++++ 0
Fetal heart rate monitoring 0 + ++ 0
Effect of drugs on the newborn 0 0 + +++
0, Not important; +, may be important; + +, should be considered; + + +, important; + + + +, very
important.
89. Anesthesia for Hernia Repair in Pregnancy and Lactation 623
Recommendations and induction agents, but fetal bradycardia is ominous. Most

anesthesiologists prefer to monitor the fetal heart rate if tech-
In most cases, surgery should be postponed until after delivery. In nically feasible. 16
the case of hernia surgery, the potential risk of waiting, such as 5. There must be facilities available to deliver a viable fetus if uter-
the possibility of damage to the bowel or other structures if the ine activity persists or if fetal distress has occurred. A pediatri-
hernia strangulates, must be weighed. In some cases, surgery dur- cian should be available to resuscitate the newborn if delivery
ing pregnancy may be justified, particularly if there is already bowel might occur.
obstruction or compromise to the circulation. The following are 6. The type of anesthetic should be considered carefully. Local
recommendations for the conduct of anesthesia for both elective anesthetic with a field block is often effective. However, care
and emergency cases. must be taken to ensure that the dose of local anesthetic is be-
1. All patients must have a complete history and physical exami- low the toxic range. Epinephrine may be added to the solution,
nation. This includes an assessment of the complications of but the dose must be less than 100 ILg to avoid uterine artery
pregnancy such as gestational diabetes and preeclampsia. Ide- vasoconstriction. A local anesthetic such as chloroprocaine,
ally, surgery is postponed until the second trimester, when the which has a very short half-life, may be preferred to lidocaine
risk of preterm labor is lowest. 3 if large quantities are required. The pregnant patient might
2. Fasting guidelines are the same for pregnant and nonpregnant benefit from epidural or spinal anesthesia. Compared with a
patients. However, because pregnant women are at risk for ke- field block, these have the advantage of better analgesia and
tosis after prolonged fasting, an intravenous infusion should be therefore a reduced reliance on opioids and anxiolytics to re-
started with a glucose-containing solution. inforce the block. This in tum will reduce the incidence of ma-
3. Women in the second and third trimester should receive med- ternal hypoxemia. Inadequate analgesia is associated with
ication to reduce the risk of aspiration pneumonitis. A non- increased circulating catecholamines, which may cause a re-
particulate antacid such as 0.3 M sodium citrate (15 to 30 ml) duction in uterine blood flow and fetal distress. General anes-
is effective in reducing gastric acidity for about 45 minutes and thesia should be reserved for emergency cases in which the
can be administered orally immediately before surgery. Alter- bowel is compromised or selected hernias above the umbilicus.
natively, 150 mg of ranitidine can be given orally the night The type of anesthetic should be determined by the anesthesi-
before surgery and 90 minutes preoperatively. Oral metoclo- ologist, taking into account the requirements of the surgery and
pramide, given 30 minutes before surgery, may be effective in the patient's preference. Even under local anesthesia, an anes-
reducing esophageal reflux by increasing gastric motility and thesiologist should be present to monitor the mother.
lower esophageal tone. 7. Patients in the second and third trimester require special po-
4. An obstetrical opinion should be sought concerning the need sitioning on the operating table with left uterine displacement.
for intraoperative and postoperative monitoring of the fetal The usual anesthetic monitors are necessary. Sicker patients
heart rate and uterine activity. Continuous fetal heart rate may require invasive monitoring, depending on the patient's
monitoring is feasible from 18 weeks' gestation with variability hemodynamic status.
occurring some time later, at 25 to 27 weeks' gestation. 3 Mon- 8. Medications used both during and after the procedure should
itoring may be continuous or intermittent and allows the anes- be known to be safe. This is the case whether the fetus is in
thesiologist to recognize the effects of potentially reversible utero or newly born. The most critical period for minimizing
causes of fetal distress such as hypotension, hypoxia, aortocaval maternal drug exposure to the fetus is during organogenesis at
compression, and acidemia. This is particularly important for 4 to 10 weeks' gestation.I 5 No anesthetic agent, general or lo-
emergency surgery. The presence of someone to interpret the cal, has been found to be teratogenic or harmful during breast-
tracing should also be considered. This may rest on the anes- feeding. Useful guidelines are presented by the Food and Dl!lg
thesiologist or a delivery room nurse. A decrease in fetal heart Administration, which has categorized medications on their
rate variability is common with the administration of opioids pregnancy risk classification (Table 89.3).
TABLE 89.3. Pregnancy risk classification of pain medications according to the Food and Drug Administration (FDA)
FDA classification Definition Examples
Category A Controlled human studies indicate no apparent risk to fetus Multivitamins

Category B Animal studies do not indicate a fetal risk or animal studies Acetaminophen, nalbuphine, caffeine, fentanyl,
do indicate a teratogenic risk, but well-controlled human hydrocodone, methadone, meperidine, morphine,
studies have failed to demonstrate a risk oxycodone, oxymorphone (unless used for long
periods or large doses, then Category D), ibuprofen,
naproxen, indomethacin
Category C Studies indicate teratogenic or embryocidal risk in animals, Aspirin, ketorolac, codeine, lidocaine
but no controlled studies have been done or there are no
controlled studies with animals or humans
Category D Positive evidence of human fetal risk, but in certain Diazepam, phenytoin
circumstances the benefits may outweigh the risks
Category X Positive evidence of significant fetal risk and risk clearly Ergotamine
outweighs any positive benefit
Modified from Rathmell et al. 15

624 S. Halpern and M. Srebrnjak
Induction agents, muscle relaxants, and local anesthetics, with stetrician should be consulted to determine the most appropriate
the exception of cocaine, appear to be safe.I 6 Opioids, in general, intraoperative and postoperative monitoring for uterine activity
have not been found to be teratogenic or carcinogenic in the fe- and fetal heart rate. A pediatrician should be informed of the pos-
tus. There may be a slight risk of respiratory malformations with sibility of a premature delivery.
codeine, but morphine, hydrocodone, meperidine, fentanyl, and The drugs and techniques used to provide intraoperative and
sufentanil all appear to be safe. 15 Early observations associating di- postoperative comfort for the patient should be specifically tai-
azepam exposure during the first trimester with cleft lip and palate lored to the gestational age of the fetus. Extra precautions are re-
is controversial. 16 Benzodiazepines used immediately before de- quired at all gestational ages to reduce the risk of maternal
livery can lead to fetal hypothermia, hyperbilirubinemia, and res- hypoxemia, which may lead to fetal damage or loss. Drugs used
piratory depression 15 and therefore should be avoided. If opioid and the dosage required must also be carefully considered in
analgesics or sedatives are required, supplemental oxygen should breastfeeding mothers in order to reduce exposure of the infant.
be given to the mother. Maternal oxygenation should be measured
with a pulse oximeter.
If general anesthesia is required, potent inhalational agents such References
as isoflurane or sevoflurane, and nitrous oxide in concentrations
of less than 50% are acceptable. Oxgen, even at high concentra- 1. Robson SC, Hunter S, Boys RJ, et al. Serial study of factors influenc-
ing changes in cardiac output during human pregnancy. Am J Physiol.
tions, does not increase the risk of retrolental fibroplasia or pre-
1989;256:Hl 060-1 065.
mature closure of the ductus arteriosus. 2. Elkus R, PopovichJr J. Respiratory physiology in pregnancy. Clin Chest
Pain must be treated, as the catecholamines that are released Med.1992;13:555-565.
can restrict uterine blood flow in the developing fetus. For pain 3. Cohen SE. Nonobstetric surgery during pregnancy. In Chestnut DH
relief, aspirin is safe in the first trimester. In the third trimester it (ed): Obstetric anesthesia: principles and practice. St. Louis: Mosby; 1994:
should be used with caution as it can impair platelet function. 273-293.
Ibuprofen, naproxen, and indomethacin have not been linked to 4. Simpson KH, Stakes AF, Miller M. Pregnancy delays paracetamol ab-
congenital defects, but in later pregnancy indomethacin and sorption and gastric emptying in patients undergoing surgery. Br J
ibuprofen have been found to diminish the ductus arteriosus di- Anaesth. 1988;60:24-27.
ameter; ibuprofen also decreases amniotic fluid volume. 15-17 5. O'Sullivan GM, Sutton AJ, Thompson SA, et al. Noninvasive mea-
surement of gastric emptying in obstetric patients. Anesth Analg. 1987;
Ibuprofen, naproxen, and ketorolac are compatible with breast-
66:505-511.
feeding, but indomethacin should be avoided. Acetaminophen 6. Vanner RG, Goodman NW. Gastroesophageal reflux in pregnancy at
can be used during pregnancy as well as during breastfeeding. 1 term and after delivery. Anaesthesia. 1989;44:808-811.
Postoperative monitoring of the mother and fetus in the recov- 7. Conklin KA. Maternal physiologic adaptations during gestation, labor,
ery room is necessary. The decision as to how long to continue and the puerperium. Semin Anesth. 1991;4:221-234.
monitoring for contractions and the fetal heart rate is a decision 8. Conklin KA. Physiologic changes in pregnancy. In Chestnut DH (ed):
best left to the obstetrician. Care should be taken to avoid atelec- Obstetric anesthesia: principles and practice. St. Louis: Mosby; 1994:17-42.
tasis and pulmonary and wound infection. Maternal fever greater 9. Thaler I, Manor D, Itskovitz J. Changes in uterine blood flow during
than 38.9°C during the first half of pregnancy has been associated human pregnancy. AmJObstet Gynecol. 1990;162:121-125.
with congenital anomalies especially of the central nervous system. 3 10. Shnider SM, Levinson G, Cosmi EY. Obstetric anesthesia and uterine
blood flow. In Shnider SM, Levinson G (eds): Anesthesia for obstetrics,
The effects of the use of uterine relaxation before, during, and
3rd ed. Baltimore: Williams & Wilkins; 1993:29-51.
after the operative procedure is unclear. Second trimester proce- 11. Mandelli M, Morselle PL, Nordio S. Placental transfer of diazepam and
dures that avoid uterine manipulation carry the lowest risk of its disposition in the newborn. Clin Pharmacol Ther. 1975;17:564-572.
preterm labor, and there is no evidence that any anesthetic agent 12. McBride RJ, DundeeJW, MooreJ. A study of plasma lorazepam in the
or technique influences the onset of prelabor. 3 mother and neonate. Br J Anaesth. 1979;51:971-978.
13. Herman NL. The placenta: anatomy, physiology and transfer of drugs.
In Chestnut DH (ed): Obstetric anesthesia: principles and practice. St.
Conclusion Louis: Mosby; 1994:57-75.
14. Biehl D, Shnider SM, Levinson G, et al. Placental transfer of lidocaine:
effects of fetal acidosis. Anesthesiology. 1978;48:409-412.
When nonobstetrical surgery is required in an obstetrical patient,
15. Rathmell JP, Viscomi CM, Ashburn MA. Management of nonobstetric
a multidisciplinary approach often has the best outcome. It is es-
pain during pregnancy and lactation. AnesthAnalg. 1997;85:1074-1087.
sential that the surgeon determine whether the risk of surgery is 16. Vincent RJr. Anesthesia for the pregnant patient. Clin Obstet Gynecol.
justified in the clinical setting. In consultation with an anesthesi- 1994;37:256-273.
ologist, an anesthetic plan should be formulated considering the 17. Moise Ig Jr, HuhtaJC, SharifDS, et al. Indomethacin in the treatment
general condition of the patient, the urgency of the surgery, the of premature labor. Effects on the fetal ductus arteriosus. N EnglJ Med.
gestational age of the fetus, and the patient's preference. An ob- 1988;319:327-331.
90
Nonpalpable Inguinal Hernia in Women
Leif Spangen and Sam G.G. Smedberg
A non palpable hernia is often overlooked as a possible cause of During the first postoperative months, three cases of hematoma
inguinal and lower abdominal pain in women. Upon review of the that required no treatment and two cases of superficial wound in-
literature, we find few reports on this type of hernia. 1-7 We believe, fection occurred. No other serious early complications were ob-
however, that symptomatic, nonpalpable (incipient, occult) in- served. In about 20% of the cases, mild postoperative pain of a
guinal hernia is relatively common in women, although seldom di- neuralgic type continued, but this usually disappeared after 1 to
agnosed. Nevertheless, this type of hernia presents a typical clinical 3 months. Pinprick hyperalgesia could often be demonstrated days
picture and can be accurately confirmed by simple diagnostic to weeks after the patients had been pain free.
methods. In all, 186 operations for inguinal hernias were followed up (Fig.
To obtain relevant information on history, diagnosis, operative 90.2); the mean observation time was 20 months (range 1 to 60
findings, and results of treatment, we carried out a follow-up study months). At the latest examination, 108 of the 186 were symptom
of 188 women judged preoperatively to have nonpalpable inguinal free and 58 were markedly improved, whereas 16 had no signifi-
hernia. They had all consulted us about inguinal and/or lower ab- cant changes and 4 reported aggravation of symptoms. The pro-
dominal pain, but had no history of a lump in the groin. None cedure obtained good results in 89% of the cases.
had undergone previous inguinal hernia repair on the involved The reasons for persisting symptoms or deterioration are pre-
side, and there was no palpable hernia or detectable impulse while sented in Table 90.4. Neuralgia dominated, and recurrence of in-
coughing. Most of the patients were 20 to 50 years of age (Fig. guinal hernia was observed in two of the cases with postoperative
90.1), and the mean age was 32 years (range 7 to 76 years). neuralgic-like pain. In eight cases the cause of the postoperative
inguinal pain was not found.
Symptoms and Surgical Findings Mechanism of Nonpalpable Groin

In most instances, a woman with a symptomatic nonpalable indi- Hernia in Women
rect inguinal hernia reports dull inguinal pain aggravated by
physical exertion. About three-fourths of the patients notice neu- In men, the external inguinal ring can usually be explored by in-
ralgic-type pain that varies in intensity and occurs intermittently. sertion of a finger into the inverted skin of the scrotum; even mi-
In almost two-thirds there is pinprick hyperalgesia of the skin cor- nor hernias can be diagnosed by this means. The skin of the labium
responding to the distribution of the ilioinguinal nerve. The pa- m~us cannot be inverted in the same way, and the external in-
tient always experiences a distinct point tenderness on palpation guinal ring in women is usually so narrow that a palpating finger
over the internal inguinal ring during a Valsalva maneuver, and cannot reach the inguinal canal. We must therefore detect a her-
the pressure reproduces pain or increases her current pain. The nia by the cough impulse through the skin, the subcutaneous tis-
most important diagnostic and surgical findings are presented in sue, and the firm external oblique aponeurosis. Inguinal hernias
Tables 90.1 to 90.3. in women thus tend to be diagnosed after a prolonged sympto-
The inguinal explorations were performed over an IS-year pe- matic period.
riod. A total of 192 inguinal hernias in 180 women were found, During a Valsalva maneuver the posterior wall of the inguinal
128 were on the right and 64 on the left side. The surgical find- canal is partly protected by a shutter mechanism, and the internal
ings are summarized in Table 90.3. In 192 cases we found an indi- inguinal ring is normally closed by a closure or sphincter mecha-
rect hernia. One hundred thirty-two had a hernial sac (l.5 to 5.0 nism. s In our patients with nonpalpable inguinal hernias, the in-
cm in length), whereas in 57 cases the hernia consisted of pre peri- ternal inguinal ring was always wider than normal and could admit
toneal fat only. In all the patients, the internal inguinal ring was one fingertip or more. The inner shutter-like closing mechanism
abnormally wide (2.5 cm or more). In one patient a femoral her- and the pressure-valve mechanism are incompetent in this situa-
nia was the only surgical finding, and in eight cases the exploration tion, and contraction of the muscles only reduces the width of the
provided no explanation for the patient's complaints. internal inguinal ring without being able to close it completely.
625
626 L. Spangen and S. Smedberg
No. of patients TABLE 90.2. Clinical findings in 192 cases of occult inguinal hernia
88
Finding No.
70
Tenderness corresponding to the deep inguinal ring
60
upon palpation during a Valsalva maneuver 192
Hyperalgesia of the skin corresponding to the
50
45 distribution of the ilioinguinal nerve 121
40
30
23 TABLE 90.3. Findings at operation in 200 inguinal explorations
22
20 17
(in 188 patients) for suspected occult inguinal hernia
Finding No.
10 8
5
I I Indirect inguinal hernia consisting of
o Hernial sac (one sliding hernia) 132
:s 19 20 -29 30 - 39 40 -49 50- 59 60-69 > 70 Age (years)
Preperitoneal fat only 57
FIGURE 90.1. Age distribution of 188 patients with a history and clinical Combined indirect and direct hernia 3
findings that prompted exploration for suspected occult inguinal hernia. Direct inguinal hernia only o
Femoral hernia only 1
Normal operation findings 7
In women, the insertion of the internal oblique and transversus

abdominis muscles into the rectus sheath is located more distally
than in men, and the insertion in Cooper's ligament is broader. nerve runs from the retroperitoneal space and penetrates the
Hesselbach's triangle is thus narrower, and, in addition, the trans- transversus abdominis and internal oblique muscles stepwise some-
versalis fascia and transversus abdominis muscle are usually better what cranially and laterally to the internal inguinal ring. The en-
developed and stronger in women than in men. All these factors trapment or trigger point is located in the area where the nerve
contribute to make women less susceptible to direct inguinal crosses these two muscles medial and somewhat caudally to the
hernia. 9 ,10 Because the round ligament is a structure of smaller di- anterior superior spine. The dull pain is probably caused by stim-
ameter than the spermatic cord, the internal ring is correspond- ulation of the pain fibers present in large numbers in both the
ingly narrower in women. This creates a more effective closure preperitoneal fat and the parietal peritoneum when these struc-
mechanism and reduces the risk of acquired indirect inguinal her- tures are forced out through the internal inguinal ring. The pain
nia. The oblique path taken by the round ligament through the is aggravated on palpation because the hernia is pressed against
abdominal wall laminae indirectly serves to protect against herni- the edge of the ring, which during a Valsalva maneuver is well de-
ation. As the transversus abdominis muscle contracts, the obliq- fined and firm. In the present series, there were no differences in
uity of exit of the round ligament through the deep ring increases, the clinical appearances between cases with a peritoneal hernial
and an additional protection of the opening against the onset of sac and cases where the hernia consisted of preperitoneal fat only.
a hernia is obtained. The cause of the neuralgic-like pain is uncertain, but a direct
mechanical influence of the hernia on the ilioinguinal nerve is
unlikely. We consider the following explanation more probable.
Mechanism of Groin Pain The inguinal hernia pain and even increased intraabdominal pres-
To understand the patient's symptoms, it is important to be fa-

miliar with the topographic anatomy of the ilioinguinal nerve. This Nr. of eases
50 46
TABLE 90.1. Preoperative symptoms in 192 cases of nonpalpable 42
inguinal hernias
40
Type of inguinal pain No.
30 29
Dull, gnawing pain 190 28
Neuralgic pain only 2
Combined dull and neuralgic pain 136
20
Pain, radiating from the groin to the
ipsilateral
Thigh lOl 10 9
Flank
Lower abdomen
62
33
I ..
Pain accentuated by o I I lime
0-6 7 -12 13-24 25-36 37-48 >48 (months)
Physical exertion 176
Menstruation 19
FIGURE 90.2. Follow-up time in 156 cases investigated after herniorrhaphy
Mental stress 3
for nonpalpable inguinal hernia.
90. Nonpalpable Inguinal Hernia in Women 627
TABLE 9004. Causes of persisting or accentuated symptoms have performed herniography in 16 of the patients with suspected
postoperatively in 24 of 186 operated cases of nonpalpable non palpable hernia. In three cases with normal findings on the
inguinal hernia herniography, a peritoneal hernial sac (1.5 to 3.0 cm) was found
Cause No. at the exploration. In the remaining 13 cases herniography and
operative findings agreed. Thus, if the history and clinical find-
Postoperative neuralgia 6 ings in a woman suggest the presence of a hernia, exploration
Adductor tendoperiostitis 5 should be considered despite a normal herniogram in patients
Gynecological disease 3 with no other explanation of their groin pain.
Recurrence of inguinal hernia 2 Laparoscopy has been reported and recommended as a possi-
Fibromyalgia
ble diagnostic modality in patients with groin pain. If laparoscopy
Postoperative hernia in a gridiron incision
No known cause 8
is performed on the indication of obscure groin and lower
abdominal pain, the lower abdominal wall should be carefully in-
spected to discover existing hernias. A lipoma cannot be demon-
strated by this method. There is need for a simpler method than
sure cause a local reflex increase of tone in the internal oblique laparoscopy for the diagnosis of inguinal hernia.
and transversus abdominis muscles. As the nerve passes between Ultrasonography is a valuable technique in diagnosing nonpal-
the fibers of these muscles, it may be subjected to mechanical pres- pable femoral hernias, but it does not appear to be reliable in the
sure, thereby giving rise to neuralgic pain (entrapment neuropa- diagnosis of nonpalpable inguinal hernias. 16
thy). The fact that the increase in tone is only intermittent would Our experience is limited, but in several cases a computed to-
explain why the neuralgic-like pain and the pinprick hyperalgesia mographic examination has demonstrated a hernia consisting of
occur intermittently. Hyperalgesia, on the other hand, can often preperitoneal fat only.
be demonstrated several days or weeks after the neuralgic pain has
disappeared, a possible indication that the pressure can cause a
temporary nerve injury. Differential Diagnosis
There are many possible causes of inguinal pain, and many dif-
Diagnostic Investigations ferent specialists are involved (Table 90.5). For those diagnoses
that are most relevant to us, we have prepared a checklist that in-
Herniography has been found to be a sensitive and reliable diag- cludes adductor tendoperiostitis (ATP) , different types of hernias,
nostic aid capable of demonstrating nonpalpable hernial sacs in and genuine neuralgia. Table 90.6 lists common symptoms of these
the groin. The use of herniography in adults with unexplained conditions. It is helpful to differentiate between neurogenic and
groin pain was advocated by Gullmo ll in 1980. One must re- non-neurogenic pain. In both indirect inguinal and obturator her-
member, however, that in about one-third of symptomatic non- nias, there is initially often intermittent neuralgic-like pain, com-
palpable inguinal hernias in women, at least in our experience, bined with pinprick hyperalgesia (Fig. 90.3). These are generally
the hernia consists entirely of preperitoneal fat (Table 90.3). not present in patients with ATP and femoral hernia.
Preperitoneallipomas are a variety of indirect inguinal herniation. Pinprick hyperalgesia is easy to demonstrate in a patient with
Characteristically, a lipoma is found within the internal spermatic nerve entrapment. We use a safety pin to test it. The hyperalgesia
fascia. Although herniography appears to be sensitive in demon- for touch and temperature is less pronounced. The pain in nerve
strating small hernial sacs, it is not a reliable procedure for de- entrapment is not as intense as in genuine or postoperative neu-
tecting lipoma of the round ligament/cord. 6,7,12-15 Since 1990, we ralgia. This type of pain is usually intermittent and varies in in-
TABLE 90.5. Examples of different conditions that can cause inguinofemoral pain
Condition Pain
Hernia (palpable, nonpalpable) Inguinal, femoralis, obturator, ischial, spigelian

Postoperative neuralgia Involving nerves ilioinguinal, iliohypogastric, genitofemoral
Entrapment neuralgia Involving nerves ilioinguinal, iliohypogastric, obturator, genitofemoral, lateral cutaneous
of the thigh, ramus med. Nn Th XI, XII
Closed compartment within iliopsoas muscle Femoral nerve entrapment
Changes in spinal cord or brain (CNS) Central neurogenic pain
Adductor tendoperiostitis (overuse injuries) Specific to adductor muscles
Hip joint disease/injury Arthritis, arthrosis, fracture, foreign body, osteochondritis dessecans, ganglion
Disease of sacroiliac joint
Disease/injury of the pelvis Fracture, metastasis, osteomyelitis, osteochondritis
Disease/injury to spinal column, medulla spinalis L IV syndrome, radiculopathy, herniated disk, fracture
Disease in the retroperitoneal space Kidney disease (tumor, calculi, pyelonephritis)
Disorders involving organs in pelvic cavity Gynecological disorders, prostatovesiculitis, pelvic varicosities
Enlarged lymph glands Benign, malignant
Infection/abscess Migrating abscess, bursitis
Arterial insufficiency Hip claudication, aneurysm
Varicosities In fossa ovalis, round ligament varices in pregnancy
628 1. Spangen and S. Smedberg
TABLE 90.6. Differential diagnosis of nonpalpable inguinal hernia in women
Hernia
Symptoms Genuine
(pain) ATP Femoral Inguinal Obturator neuralgia
Neuralgic +75% +50-75% ++

intermittent initially intermittent constant
Dull, drawing, ++ + + +
spontaneous even at night
Accentuated ++ + + + +
during physical (Howship-
exertion Romberg)
Radiating to leg + + +(50%) + (+)
Tenderness on ++ +(+) ++ (+) per
palpation (internal inguinal ring) vaginam/ rectum
Pinprick +60-70% + ++
hyperalgesia intermittent 50-75% constant
ATP, adductor tendoperiostitis; -, absent.
tensity. In genuine neuralgia, the pain is constant, very intense,

and accompanied by pronounced hyperalgesia for touch and
temperature.
Patients with non palpable inguinal hernia frequently have a sec-
ondary ATP. Conversely, if a patient who is treated for an ATP does
not respond to conservative treatment, an inguinal hernia should
be suspected. Herniography is then strongly indicated at an early
stage of the workup.
Radiating pain can also be helpful during differential diagnos-
tic workup. Table 90.7 shows how radiating pain to or from the
groin characterizes some diseases or disorders.
There may be tenderness to palpation several centimeters cra-
nial to the internal inguinal ring, corresponding to the spigelian
aponeurosis, in patients with indirect inguinal hernia. Many pa-
tients referred to us with suspicion of spigelian hernia below the
interspinal plane have proved to have a nonpalpable indirect in-
guinal hernia.
Caution should be exercised before performing inguinal ex-
ploration in patients with severe, continuous, neuralgic pain. One
must rule out central nervous system involvement. If this is sus-
pected, then surgery should be avoided or planned carefully.
Four patients with severe postoperative neuralgia in this study
proved, after review of their history, to have had severe continu-
ous neuralgic-like pain preoperatively and would therefore today
have been treated differently. Two patients who developed post-
operative neuralgic-like pain after a symptom-free period of 4 to
6 months had a nonpalpable recurrent hernia, shown by herniog-
raphy and verified at operation.
Conclusion
Nonpalpable indirect inguinal hernia in the female may be the
cause of groin and lower abdominal pain and presents a typical
clinical picture. Above all it is a diagnostic challenge, and it is im-
FIGURE 90.3. Diagram of the pinprick hyperalgesia zones in some entrap- portant to keep this condition in mind because patients respond
ment neuralgias: 1, eleventh and twelfth thoracic nerves (rami medialis); well to surgical treatment. We would emphasize, however, that in-
2, iliohypogastric nerve; 3, ilioinguinal nerve; 4, genitofemoral nerve; 5, guinal pain is a common symptom with multifactorial causes and
lateral cutaneous nerve of the thigh; 6, obturator nerve. that more than one cause may be present simultaneously (Table
90. Nonpalpable Inguinal Hernia in Women 629
TABLE 90.7. Radiating pain to or from the groin in some diseases or disorders
From To In
Back/Flank Groin Kidney disease (stone, pyelonephritis, tumor) back disorders

(L IV syndrome, low back syndrome, rhizopathy)
Disease of the sacroiliac joint
Herpes zoster
Gynecological disease (e.g., salpingitis)
Prostatovesiculitis
"Referred pain" in diseases of the abdominal organs
Groin Epigastrium Omentum in a hernia
Groin Thigh Deep: Femoral hernia
Adductor tendoperiostitis
Hip disease
Superficial: Inguinal hernia
Obturator hernia
Meralgia paresthetica
Groin In a band to Postoperative neuralgia
the flank/back Distal ureteral stone
90.5). The patient should be thoroughly examined for other pos- not exclude the presence of a hernia. Ann R Coll Surg Engl. 1997;
sible or concomitant causes of pain before the decision is made 79:372-375.
to perform an inguinal exploration. 8. Spangen L. Shutter mechanisms in the inguinal canal. In Arregui ME,
Nagan RF (eds): Inguinal hernia, advances or controversies? New York:
Radcliffe Medical Press; 1994:55-59.
9. Condon RE. The anatomy of the inguinal region and its relationship
References to groin hernia. In Nyhus LM, Condon RE (eds): Hernia. Philadelphia:
J.B. Lippincott; 1978: 14-78.
1. Fodor PB, Webb WA. Indirect inguinal hernia in the female with no 10. Ponka]L. The hernia problem in the female. In PonkaJL (ed): Her-
palpable sac. South MedJ 1971;64:15-16. nias of the abdominal wall. Philadelphia: W.B. Saunders; 1980:82-90.
2. Herrington JI\. Occult inguinal hernia in the female. Ann Surg. 11. Gullmo A. Herniography. Acta Chir Scand Suppl. 1980;361.
1975;181:481-483. 12. Ekberg 0, Blomqvist P, Olson S. Positive contrast herniography in adult
3. Spangen L, Andersson R, Ohlsson L. Nonpalpable inguinal hernia in patient with obscure groin pain. Surgery. 1981;89:532-535.
the female. Am Surgeon. 1988;54:574-577. 13. Smedberg SGG, Broome AEA, Elmer 0, et al. Herniography in the di-
4. Roos H, Smedberg S. Symptomatic nonpalpable inguinal hernias. Post- agnosis of obscure groin pain. Acta Chir Scand 1985;151:663-667.
grad Gen Surg. 1992;4:131-134. 14. Hall C, Hall PN, Wingate JP, et al. Evaluation of herniography in the
5. Spangen L. Groin pain and the occult inguinal hernia in women. In diagnosis of an occult abdominal wall hernia in symptomatic adults.
Arregui ME, Nagan RF (eds): Inguinal hernia, advances or controversies? BrJ Surg. 1990;77:902-906.
New York: Radcliffe Medical Press; 1994:65-71. 15. Eames NWA, Deans GT, LawsonjT, et al. Herniography for occult her-
6. MiikehijT, Kiviniemi H, Palm], et al. The value of herniography in nia and groin pain. Br J Surg. 1994;81:1529-1530.
the diagnosis of unexplained groin pain. Ann Chir Gynaecol. 1996;85: 16. Arregui ME. The value of ultrasound in the diagnosis of hernias. In
300--304. Arregui ME, Nagan RF (eds): Inguinal hernia, advances or controversies?
7. Loftus 1M, Ubhi SS, Rodgers PM, et al. A negative herniogram does New York: Radcliffe Medical Press; 1994:73-79.
91
Hernia and Chronic Pelvic Pain in Women
Ibrahim M. Daoud
The treatment of chronic pelvic pain (CPP) has been limited by cases in which an indirect inguinal hernia was identified at surgery,
our ability to specifically diagnose and treat the causes of the pain. although no palpable sac or impulse was noted clinically. In 1975,
It has been estimated that about 10% of all office visits to a gyne- Herrington14 stated that the incidence of occult hernias is 8%; he
cologist are for Cpp.l More than 40% of laparoscopic procedures reported on 14 cases.
are performed for the evaluation of patients with Cpp.2,3 In women A restrospective study reported on 100 consecutive patients
with CPP, the findings on physical examination are not reliable treated by this author between 1995 and 1998. All patients in the
predictors of laparoscopic findings. Over 70% of patients with ab- study had occult hernias. The patients were all female, aged 20 to
normal examinations will have abnormallaparoscopic findings,4 48 years, with CPP due to occult hernias, suspected on the basis
and more than 50% of women with normal examinations will have ofa long-standing history (6 months to 20 years) of inguinal pain
abnormal laparoscopic findings. 5 radiating to labia and/or thighs, reproduction of the pain by in-
Diagnosis of the underlying cause of CPP can be difficult. A com- ternal palpation of the inguinal and femoral rings (on bimanual
bination of history, physical examination, laboratory findings, and examination by the patient's gynecologist), and tenderness of the
imaging techniques lead to incorrect diagnosis in 20 to 70% of external/internal ring on external examination. Diagnostic lapa-
women.6--8 Even with laparoscopy, the causes of CPP can be identi- roscopy revealed obvious indirect hernias in 12% of the patients,
fied in only 60% ofwomen. 6 Reiter and Gambone9 made a signifi- and preperitoneal dissection revealed one or more findings: en-
cant contribution when they reported that occult somatic pathology larged internal ring with incarcerated preperitoneal fat, incarcer-
was present in 47% of women with negative laparoscopies. ated fat in a femoral ring, and/or defect in the transversalis fascia.
If a patient continues to have significant pain after inconclusive All hernias were repaired laparoscopically using a Gore-Tex®
diagnostic laparoscopy, other causes of pain should be considered. Mycro-Mesh® patch. The average follow-up was 3 to 16 months.
The most common diagnoses are abdominal wall trigger points, Sixty-two percent of patients reported complete relief of pain.
hernias, and pelvic congestion. 10 If the diagnosis of a hernia is es- Twenty-three percent obtained partial relief, and 15% reported no
tablished by physical examination, the hernia can be repaired by change in pain after surgery.
an open or laparoscopic approach. In a patient with a typical Occult hernias are a common cause of CPP. Effective pain re-
history for hernia, even if the examination fails to confirm the her- lief can be obtained by diagnostic laparoscopy and laparoscopic
nia, the assumption should not be ruled out; repeated examina- repair in carefully selected patients.
tions, magnetic resonance imaging, computed tomography,
ultrasonography, or herniogram may disclose it. Diagnostic lapa-
roscopy should be considered in order to evaluate persistent symp- References
toms, particularly when the examination and investigation are
negative. 1. Reiter RC. A profile of women with chronic pelvic pain. Clin Obstet Gy-
Laparoscopically, an indirect inguinal hernia is evident as an necoL 1990;33:130.
opening adjacent to the round ligament. However, a direct or 2. Cunanan RG, Courey NG, Lippes J. Laparoscopic findings in patients
femoral hernia may not be clearly seen until the peritoneum is with pelvic pain. Am] Obstet GynecoL 1983;146:587.
opened. The hernia is usually found after dissecting the preperi- 3. Bahary CM, Gorodeski IG. The diagnostic value of laparoscopy in
toneal fat.I 1 Spangen 12 reported on 168 patients who were sus- women with chronic pelvic pain. Ann Surg. 1987;11:672.
pected preoperatively of having nonpalpable inguinal hernias. At 4. Ripps BA, Martin DC. Focal pelvic tenderness, pelvic pain and dys-
menorrhea in endometriosis.] Refrrod Med. 1991;36:470.
exploration, all but seven had hernias or preperitoneal fat. Fifty
5. Kresh Aj, Seifer DB, Sachs LB, et al. Laparoscopy in the evaluation of
percent of the patients were free of symptoms postoperatively and 100 women with chronic pelvic pain. Obstet Gynecol. 1984;64:672.
35% were markedly improved, but 12% had no improvement and 6. Howard FM. The role of laparoscopy in chronic pelvic pain: promise
3% were worse. 12 and pitfalls. Surg Gynecol Obstet. 1993;48:357.
The first report in the literature about nonpalpable or occult 7. Steege]F, Stout AL, Somkuti SG. Chronic pelvic pain in women: to-
hernias came from Fodor and Webb,l3 In 1971, they reported 12 ward an integrative model. Surg Gynecol Obstet. 1993;48:95.
630
91. Hernia and CPP in Women 631
8. Farquhar CM, Rogers V, Granks S, et al. A randomized controlled trial 11. Daoud I. General surgical aspects. In SteegeJ, Metzger D, LevyB (eds):
of medroxy progesterone acetate and psychotherapy for the treatment Chronic pelvic pain: an integrated approach. Philadelphia: W.B. Saunders;
of pelvic congestion. BrJ Obstet GynaecoL 1989;96:1153. 1998:330.
9. Reiter RC, Gambone JC. Non-gynecological somatic pathology in 12. Spangen L. Non-palpable inguinal hernia in women. In Nyhus LM,
women with chronic pelvic pain and negative laparoscopy. ] &prod Condon RE (eds): Hernia. Philadelphia:J.B. Lippincott; 1995:87.
Med. 1991;36:253. 13. Fodor PB, Webb WA Indirect inguinal hernia in the female with no
10. Metzger D. Laparoscopy in diagnosis. In Steege J, Metzger D, Levy B palpable sac. South MedJ 1971;64:15-16.
(eds): Chronic pelvic pain: an integrated approach. Philadelphia: W.B. 14. Herrington JK. Occult inguinal hernia in the female. Ann Surg. 1975;
Saunders; 1998:107-114. 181:481.
92
Chronic Pelvic Pain in Women
Michael S. Kavic
Chronic pelvic pain is a common gynecological problem, ac- been described in thin, elderly women in whom atrophy of the
counting for 10 to 30% of all gynecological visits. Approximately piriformis muscle allows the potential space of the greater sciatic
78,000 hysterectomies are performed each year for chronic pelvic notch to become an actual defect. The hernia may occur superior
pain. 1 Chronic pelvic pain may, however, have its origins not only to the piriformis muscle (suprapiriformis), inferior to the piri-
in the structures of the reproductive system but also in the uro- formis (infrapiriformis), or through the lesser sciatic notch (sub-
logical, musculoskeletal neurological, myofascial, or gastrointesti- spinous) (Fig. 92.1). Ovary, tube, or intestine may become
nal systems. 2,3 In a series of 500 patients with chronic pelvic pain, entrapped, causing chronic pelvic pain or obstruction. Known var-
70% were found to have reproductive organ disease; 10% had gas- iously as sacrosciatic hernia, ischiatic hernia, ischiocele, hernia in-
trointestinal tract disorders, 8% had musculoskeletal neurological cisurae ischiadicae, or gluteal hernia, sciatic hernia was first
disease, 7% had myofascial abnormalities, and 5% had urological described by Verdier in 1753. 6,7
causes. 3 Chronic pelvic pain can have many etiologies, and a mul- Only 39 cases of sciatic hernia were reported in the world lit-
tidisciplinary approach is frequently necessary.4 erature up to 1958. 6,7 In 1998, however, Miklos and associates 3 re-
Chronic pelvic pain has three main dimensions: (1) duration- ported 20 patients with sciatic hernia in a series of HOO female
any type of pelvic pain lasting 6 months or longer; (2) anatomi- patients who required surgical intervention for chronic pelvic
cal-pelvic pain defined by physical findings at laparoscopy; and pain. All of these cases of sciatic hernias contained the ipsilateral
(3) affective/behavioral-pain accompanied by significant alter- ovary, alone or with the fallopian tube. If the incidence of 1.8%
ations in physical activity such as work, recreation, and sex, as well of females who required laparoscopic exploration for chronic
as changes in mood related to the chronic pain.l Significantly, pelvic pain is an indication,s this hernia cannot be as rare as pre-
most standard laboratory tests of patients with chronic pelvic pain, viously thought.
including the complete blood count, barium enema, abdominal
and pelvic ultrasonography, and computed tomographic studies,
are often within normal limits. Anatomy
In the past, general surgeons have been only too eager to refer
patients with chronic pelvic pain to the gynecologist. Frequently The sacrum, ischium, and ilium are bound together by strong lig-
referred to as "woman trouble," chronic pelvic pain has resisted aments. The sacrospinous ligament converts the greater sciatic
intensive efforts to determine its cause. Many general surgeons notch into the greater sciatic foramen, which transmits the piri-
have avoided treating patients with chronic pelvic pain, neglect- formis muscle, gluteal vessels and nerves, internal pudendal ves-
ing the disease and, ultimately, trivializing it. sels and nerve, and nerves to the obturator internus and quadratus
Chronic pelvic pain is, however, a real entity with a multifactor- femoris muscles. The greater sciatic foramen is filled with the pir-
ial etiology. It has been estimated that between 7 and 60% of pa- iformis muscle. Above this muscle, the suprapiriformis area allows
tients with chronic pelvic pain may have a gastrointestinal etiology.2,5 passage of the superior gluteal artery, vein, and nerve. Below the
In addition it is now being appreciated that obscure, rare con- piriformis muscle lies the infrapiriformis space, which transmits
ditions such as sciatic, obturator, supravesical, perineal, and sports the inferior gluteal vessels and nerve, the sciatic nerve, nerve to
hernias may cause chronic pelvic pain in women. A case in point the quadratus femoris, posterior femoral cutaneous nerve, nerve
is the very seldomly diagnosed sciatic hernia. to the obturator intern us, and the internal pudendal vessels and
nerve.
The lesser sciatic notch is converted into a foramen by the sacro-
Sciatic Hernia tuberous ligament inferiorly and the sacrospinous ligament supe-
riorly. The lesser sciatic foramen transmits the tendon of the
Sciatic hernia has been considered the rarest of abdominal and obturator internus, its nerve, and the internal pudendal vessels
pelvic hernias. It is the protrusion of a peritoneal sac and contents and nerve. The lesser sciatic foramen transmits the internal pu-
through the greater or the lesser sciatic foramen. It has usually dendal vessels and nerve back into the pelvis. Included are the
632
92. Chronic Pelvic Pain in Women 633
FIGURE 92.1. Sciatic hernia.
Suprapiriformis Hernia Site

Piriformis Muscle
Sacrospinous
Ligament
Infrapiriformis Hernia Site
Sacrotuberous
Subspinous Hernia Site
Ligament
nerves to the obturator internus and quadratus femoris muscle. 6 They may contain a "pilot tag" of preperitoneal tissue, large bowel,
The abdominal opening of a sciatic hernia in females is posterior small intestine, appendix, uterus, tube, or ovary,12 Herniation
to the broad ligament. In males, the opening lies in the lateral through the obturator canal is rare, occurring in 0.073% of all
pelvis between the bladder and the rectum. hernias in one large series,l3
Sciatic hernias are rarely noted on physical examination as the Two broad groups of patients with obturator hernia have been
large gluteal muscles overlap the sciatic foramen. Pain secondary described12 ,13,14:
to sciatic nerve compression may be present with sensory and mo-
tor findings suggestive of chronic sciatica. Nonspecific chronic 1. Elderly patients, usually women, with a history of chronic dis-
pelvic pain of more than 6 months' duration may be the only pre- ease, increased intraabdominal pressure, and attenuation of the
senting symptom. S,9 Intestinal involvement in the hernia can pro- obturator membrane
duce signs of intermittent or complete intestinal obstruction. 2. Women of childbearing age
Treatment Anatomy
Sciatic hernias have been repaired via a transgluteal or transab- The obturator foramen, roughly circular in shape and shielded
dominal approach. 9,10 The transabdominal approach is recom- with the obturator membrane, is the largest bony foramen in the
mended as it allows complete evaluation of the abdomen and body. The internal opening of the obturator canal is found in the
pelvis with adequate visualization of the hernia and its content. superior midsection of the obturator membrane. The obturator
Laparoscopic transabdominal access allows satisfactory visual- canal is a fibroosseous tunnel, its roof formed by the obturator sul-
ization of sciatic hernias. s Mter pneumoperitoneum has been es- cus of the pubic bone and its floor by the internal and external
tablished, a thorough intraabdominal examination is performed. obturator muscles and their fasciae. The obturator nerve, after
In cases of chronic abdominal pain, the liver, gallbladder, stom- passing through the obturator canal, divides into an anterior and
ach, intestine, appendix, uterus, tubes, ovaries, and peritoneal sur- posterior branch. The anterior branch passes over the superior
faces are examined,u The pelvis is inspected for hernias, border of the obturator externus to supply the adductor longus,
adhesions, and endometriosis. gracilis, and adductor brevis. The posterior branch pierces the
If a sciatic hernia is found, the sac and its contents are reduced. obturator externus to supply the adductor magnus and adductor
In females, a fallopian tube or ovary may be involved in the her- brevis.
nial sac. s A preperitoneal dissection is performed and the sac re- Obturator hernia sacs that follow the anterior division of the ob-
duced. A plug of rolled synthetic mesh may be placed in the hernia turator nerve pass between the pectineus and above the obturator
defect if the piriformis muscle is markedly atrophic. The sciatic externus muscle. Hernial sacs that follow the posterior division of
foramen is then completely covered and overlapped with synthetic the obturator nerve pass through the obturator externus muscle
nonabsorbable mesh. The mesh is secured with endohernia sta- (Fig. 92.2).
ples or tacks to the obturator internus fascia laterally and the coc-
cygeus medially. Reperitonealization is performed, and the
peritoneal incision is closed with an intracorporeal running stitch Signs and Symptoms
of absorbable suture, endoscopic staples, or tacks.
Traditionally obturator hernia has been associated with four signs
or symptoms 13:
Obturator Hernia
1. Intestinal obstruction
Obturator hernia, another rare hernia, traverses the obturator 2. Howship-Romberg sign
canal to create symptoms of chronic pelvic pain or obstruction. 3. History of previous attacks
These hernias are rarely visualized and are usually not palpable. 4. A palpable mass
634 M.S. Kavic
Obturator Canal
Obturator Hernia Sac
Obturator Externus
Muscle \.,
. '\ \ Pectineus
~
\\
, \
Muscle
\; ,
\..
\. \r
\ \
\ ,
Obturator Canal
Pectineus Muscle
Obturator Externus
Muscle
FIGURE 92.2. Obturator hernia.
Although intestinal obstruction and Howship-Romberg findings into the hernia. Symptoms of intestinal obstruction result from in-
are the most common signs, the nature of the presenting ob- carceration of small or large bowel in the obturator canal.
struction is usually unclear, and the Howship-Romberg sign is typ-
ically recalled only after an exploratory procedure has revealed
the obturator hernia. Treatment
A palpable mass is occasionally noted on pelvic or rectal exam-
ination, or in the upper medial aspect of the involved thigh, and Abdominal exploration remains the mainstay of diagnosis and
can suggest the possibility of obturator hernia. I5 However, because treatment of obturator hernia. Access to the abdomen can be via
an obturator hernia is rarely considered, the mass is usually not open laparotomy or minimally invasive laparoscopy. The entire
sought. If the possibility of obturator hernia were entertained pelvis must be examined, and, if bilateral defects are noted, both
more often, more of these hernias might be diagnosed. hernias are repaired.
Pressure on the obturator nerve is the genesis of the Howship- After the obturator hernia has been identified and the sac con-
Romberg sign. First noted by John Howship in 1840 and later, intent reduced, a preperitoneal dissection is performed to expose
dependently, by Moritz Romberg in 1848, this sign is characterized the obturator hernia and canal. Suture herniorrhaphy can be used
by pain extending down the inner surface of the involved thigh to bring adjacent soft tissue together and fashion a repair. It is
and is exacerbated by extension, adduction, or medial rotation of probably more efficacious, however, to use permanent synthetic
the thigh. I2 ,I6,I7 mesh to reinforce the breached obturator membrane. Polypropyl-
It has been postulated that an obturator hernia begins as a pre- ene or polyester mesh and expanded polytetrafluoroethylene can
hernia with a plug of preperitoneal connective tissue or "pilot tag" be used. The mesh must cover the entire defect with adequate
entering the obturator foramen. IS In one postmortem study, this overlap (at least 2 cm circumferentially), and be secured with ad-
plug of tissue or "pilot tag" was found in 64% of female cadavers equate fixation. In Figure 92.3, two pieces of polypropylene mesh,
examined. I9 The second stage in hernia development is dimpling, each 8 by 13 cm, have been positioned to cover the obturator
which begins at the peritoneum over the obturator canal and pro- foramen. One has been positioned horizontally, the other verti-
gresses to invagination of a peritoneal sac. The third stage consists cally, to ensure adequate coverage, and each is secured with
of the entrance of bowel, uterus, tube, or ovary into the peritoneal endotacks.
sac. Pressure from sac contents causes the Howship-Romberg sign. After mesh fixation has been obtained, the operative area is
Chronic pelvic pain can result from incarceration of tube or ovary reperitonealized. The peritoneal incision is closed with an intra-
A B
c o
E F
FIGURE 92.3. (A) Left obturator hernia. (B) Preperitoneal dissection. (C) Horizontal mesh applied. (D) Vertical mesh applied. (E) Mesh secured with
endotacks. (F) Repaired hernia.
corporeal running suture of 2-0 absorbable material; polydiox- resection, and, in men, perineal prostatectomy. Perineal hernias
anone and polyglactin 910 are suitable choices. may present anterior or posterior to the superficial perineal mus-
cle, through the levator ani, or between the levator ani and coc-
cygeus muscles (Fig. 92.4).
Perineal Hernia A pudendal hernia is an anterior perineal hernia that occurs
only in females . This hernia, also known as a labial hernia, may pro-
Perineal hernias are very rare hernias that insinuate themselves trude into the labium majus as an overt mass. It exits the pelvis
through muscles and fascia of the perineal floor. Perineal hernias through a triangle bounded by the bulbocavernosus, ischiocaver-
are commonly found in women and are true hernias with a dis- nosus, and transversus perinei muscles.!9
tinct peritoneal sac. A posterior perineal hernia may emerge between fibers of the
Factors contributing to perineal hernia are the broad female levator ani or between the levator ani and coccygeus muscles. 20 ,21
pelvis, childbirth, injuries incident to childbirth, obesity, exenter- Perineal hernias can cause chronic pelvic pain. Because the her-
ation procedures for advanced pelvic cancer, abdominal perineal nia rings are composed of pliant muscle and soft tissue, it is un-
636 M.S. Kavic
FIGURE 92.4. Perineal hernia.

Bulbocavernousus Perineal Hernia
Levator Ani Muscle
usual for intestinal strangulation to occur. Typically, a soft bulge in young, active sportsmen and -women. They can be frustratingly
is palpable in the perineum that is easily reducible or reduces it- difficult to diagnose because of the paucity of physical findings. 22- 25
self when the patient lies down. The presentation of sports hernia varies. The onset may be in-
Surgical repair is the only definitive treatment for perineal her- sidious and gradual or sudden, typically a sharp, tearing sensation.
nia. Access can be obtained by a perineal incision or transab- Pain usually begins on one side, but may radiate laterally to the
dominally, using open laparotomy or laparoscopic techniques. opposite groin, ipsilateral thigh, labia, or perineum. Conservative
Previously, most authors described an open herniorrhaphy repair measures, including prolonged bed rest, physiotherapy, and in-
for perineal hernia. In this technique, the hernia was defined, and jections oflocal anesthetic and steroids, rarely bring long-term re-
the patient's own tissues were used to close the defect. This pro- lief. Only 20% of patients with sports hernia treated conservatively
cedure, although grounded in classic surgery, has the disadvan- return to full activity.25
tage of using attenuated muscle and fascia to accomplish a repair. Physical examination reveals pain with adductor stretch. In ad-
More recently a laparoscopic approach has been advocated for dition, the symphysis pubis is tender to palpation on the involved
evaluation of abdominal and pelvic wall hernias. 11 This offers all side, with palpatory discomfort over the pubic tubercle. The great-
the benefits of minimal access and maximum visualization of the est discomfort, however, is elicited upon palpation of the midin-
abdominal and pelvic cavities. Laparoscopic transabdominal ac- guinal canal. There may be a slight cough impulse noted in this
cess is used to identify and evaluate the perineal hernia. Hernia area.
content is reduced, and a preperitoneal dissection is performed The syndrome of chronic groin in an active, vigorous person is
to define the boundaries of the hernia ring. Permanent prosthetic thought to indicate an early direct inguinal hernia. Pain in these
mesh is used to cover and overlap the defect. Laparoscopic staples patients is hypothesized to be triggered by distension of the pos-
or tacks are employed to fix the mesh to adjacent tissue. Reperi- terior inguinal wall with strain and exercise. The differential di-
tonealization is performed closing the peritoneal incision with in- agnosis includes osteitis pubis, snappy hip syndrome, psoas
tracorporeal suture, staples, or tacks. bursitis, simple adductor strain, and tendonitis.
Operative intervention has relieved the symptoms of sports her-
nia in the majority of patients. Bassini herniorrhaphy has been re-
ported to be effective, as well as a darning technique that secures
Sports Hernia the conjoined tendon to the inguinal ligament with nylon suture. 25
As this hernia represents an early direct inguinal hernia, it is rea-
Sports hernia is a rare hernia characterized by a syndrome of sonable to believe that a laparoscopic approach using synthetic
chronic groin pain coupled with weakness of the posterior inguinal mesh in a preperitoneal position that covers the myopectineal ori-
wall. There is no palpable hernia. Sports hernias are usually seen fice will be equally effective.
Median Umbilical Fold
Medial Umbilical Ligament
Hernia
FIGURE 92.5. SupravesicaJ hernia (external).

FIGURE 92.6. Supravesical hernia (internal).
Hernia within Retropubic

Hernia
Space of Retzius
Bladder
SVITlolhv<:j<: Pubis
Supravesical Hernia plete visualization of the abdomen and pelvis. As with other her-
nias of the abdominal and pelvic walls, a preperitoneal dissection
Supravesical hernias are protrusions of abdominal content with reduction of hernia content is performed. Hernioplasty with
through a supravesical fossa of the anterior abdominal wall and application of prosthetic, nonabsorbable mesh to the hernia de-
are classified as external or internal supravesical hernia. 26 Exter- fect and adequate overlap of the hernia margins is followed by
nal supravesical hernias pass downward through the supravesical reperitonealization of the operative site as described previously.
fossa to become direct inguinal or femoral hernias (Fig. 92.5). In-
ternal supravesical hernias pass downward to enter the retropubic
space of Retzius (Fig. 92.6). Conclusion
The diagnosis of supravesical hernias that exit through the pos-
terior inguinal wall or femoral canal may be obvious. An internal Classically, the diagnosis of hernia was only seriously entertained
supravesical hernia that passes into the retropubic space of Retz- if a mass or bulge was palpable at a hernia's point of presentation.
ius can be more difficult to diagnose preoperatively. Internal This mindset did not include the possibility of symptomatic non-
supravesical hernias can manifest themselves as chronic pelvic pain palpable hernias that were only evident at their site of originP-29
of uncertain origin. Although a small bowel series, abdominal ul- Nonpalpable, clinically significant occult hernias do, however,
trasonography, or computed tomography may aid in the workup, exist, and in one series they constituted 8% of hernia cases
diagnosis is usually made at the time of abdominal exploration. repaired.27
Management of a supravesical hernia is operative repair. Open Symptomatic non palpable inguinal and femoral hernias can be
access using traditional Bassini or Shouldice herniorrhaphy tech- visualized at their site of origin during a laparoscopic preperi-
niques or a Lichtenstein-type anterior hernioplastywith mesh have toneal dissection of the myopectineal orifice. The laparoscopic im-
been satisfactory for those hernias presenting as external supravesi- ages depicted in Figure 92.7 demonstrate femoral, direct, and
cal hernias, that is, direct inguinal hernias. Femoral hernias and indirect inguinal hernia defects. The femoral defect is not large
hernias in the retropubic space of Retzius, however, may be bet- and could easily be missed during an open anterior repair. In this
ter served by a laparoscopic approach that permits a more com- circumstance, the small femoral hernia could be symptomatic or
A 8
FIGURE 92.7. (A) Pre peritoneal dissection of left myopectineal orifice, demonstrating femoral, direct, and indirect hernias. (B) Close-up of left femoral
defect.
638 M.S. Kavic
increase in size and cause continued pain after open repair-a 12. Gray SW, SkandalakisJE. Strangulated obturator hernia. In Nyhus LM,
"missed" hernia. These groin defects, as well as other defects of Condon RE (ed): Hernia, 2nd ed. Philadelphia:J.B. Lippincott; 1978:
the abdominal and pelvic wall, after appropriate laparoscopic dis- 427-442.
section, can be effectively cured with permanent synthetic mesh 13. Bjork KJ, Mucha P, Cahill DR. Obturator hernia. Surg Gynecol Obstet.
that covers and overlaps the borders of the defect. 1988;167(3):217-222.
14. Rizk TA, Deshmukh N. Obturator hernia. South Med J 1990;83(6):
Although laparoscopic access is characterized as a minimal ac-
709-712.
cess technique, this does not mean minimal visualization or min- 15. Wantz GE. Abdominal wall hernias. In Schwartz SI, Shires GT, Spencer
imal scope for dissection. Laparoscopic abdominal and pelvic FC, et al. (eds): Principles of surgery, 7th ed. New York: McGraw-Hill;
exploration permits a thorough intracavitary examination and the 1999:1585-1611.
ability to repair common and rare abdominal and pelvic hernias 16. Howship J. Practical remarks on the discrimination and appearances of sur-
at their site of origin rather than at their point of presentation. gical disease. London: John Churchill; 1840.
17. Romberg MH. Die Operation des singeklemmten Bruches des eirun-
den Loches. Operatio herniae foraminis ovales incarceratae. In Dief-
References fenbachJF (ed): Die operative chirurgie, vol. 2. Leipzig: F.A. Brockhaus;
1848.
1. Kloch SC. Psychosomatic issues in obstetrics and gynecology. In Ryan 18. Gray SW, Skandalakis JE. Strangulated obturator hernia. In Nyhus LM,
KJ, Berkowitz R, Barberi RL (eds): Kistner's gynecology. Principles and Condon RE (eds): Hernia, 2nd ed. Philadelphia:J.B. Lippincott; 1978:
practice, 6th ed. St. Louis: Mosby Yearbook Inc.; 1995:391-411. 427-452.
2. Kamm MA. Chronic pelvic pain in women-gastroenterological, gy- 19. Singer R, Leary PM, Hofmeyer NG. Obturator hernia. S Afr Med J
naecological or psychological. Int] Colurect Dis. 1997;12:57-62. 1955;29:74.
3. Carter JE. Surgical treatment for chronic pelvic pain. JSLS. 1998;2 (2): 20. Koontz AR. Perineal hernia. In Nyhus LM, Condon RE (eds): Hernia,
129-139. 2nd ed. Philadelphia:J.B. Lippincott; 1978:453-462.
4. Rapkin AJ, Mayer EA. Gastroenterologic causes of chronic pelvic pain. 21. Gray SW, Skandalakis JE, McClusky DA Atlas of surgical anatomy. Bal-
Obstet Gynecol Clin Nmth Am. 1993;20(4):663-683. timore: Williams & Wilkins; 1985:326-327.
5. Steege]F, Metzger DA, Levy BS. Chronic pelvic pain: an integrated ap- 22. Spinelli A A new sports injury: pubic pain in fencers. Orthop Trauma-
proach. Philadelphia: W.B. Saunders; 1998. tol Asparato Motore. 1932;4:111-127.
6. Black S. Sciatic hernia. In Nyhus LM, Condon RE (eds): Hernia, 2nd 23. Bandini T. Notes on a syndrome of the recto-adductors in football play-
ed. Philadelphia: J.B. Lippincott; 1978:443-452. ers. Informatorio Med. 1948;2:295-297.
7. Watson LF. Hernia: anatomy, etiology, symptoms diagnosis, differential di- 24. Schneider PG. "Gracilis syndrome." Z Orthop. 1963;98:43-50.
agnosis, prognosis and treatment, 3rd ed. St. Louis: C.v. Mosby; 1948. 25. Hackney RG. The sports hernia: a cause of chronic groin pain. Br]
8. Miklos JR, O'Reilly MJ, Saye WB. Sciatic hernia: a cause of chronic Sports Med. 1993;27 (1) :58-62.
pelvic pain in women. Obstet Gynecol. 1998;91(6):998-1001. 26. Gray SW, Skandalakis JE, McClusky DA Atlas of surgical anatomy. Bal-
9. Gaffney LB, SchandJ. Sciatic hernia: a case of congenital occurrence. timore: Williams & Wilkins; 1985;316-319.
Am] Surg. 1958;95:974. 27. HerringtonJK Occult inguinal hernia in the female. Ann Surg. 1995;
10. Losanoff J, ~ossen K Sciatic hernia. Acta Chir Belg. 1995;95(6): 181:481-483.
269-270. 28. Fodor PB, Webb WA Indirect inguinal hernia in the female with no
11. Kavic MS. Laparoscopic hernia repair. Amsterdam: Harwood Academic palpable sac. South MedJ 1971;64:15-16.
Publishers; 1997:33-40. 29. BascomJU. Pelvic pain. Perspect Colon Rectal Surg. 1999;11(2):21-40.
93
Femoral Hernias in Females:
Facts, Figures, and Fallacies
Robert Bendavid
"Conventional wisdom" is a slightly ironic term that implies that Elective Surgery for Primary
what may once have been wise has become corrupted by repeti-
tion, like a message in a party game. One example is the confi-
Femoral Hernias
dently repeated statement that "females have more femoral
During the same period, there were 251 primary femoral repairs on
hernias than males."
242 patients. Females made up 52% of this group (n = 126) compared
Reported series of femoral hernias tend to be small. It is con-
with 48% (n = 116) for males. The difference is not significant
venient to make use of information from the Shouldice Hospital
data bank. At that institution, over 7000 cases are processed every
year, providing statistical numbers that reflect a wide segment of Elective Surgery for Recurrent
the patient population. What emerges from a review of these sta-
tistics is that, to begin with, women have far fewer groin hernias Femoral Hernias
than men. "Groin hernias" is an inclusive term applied to inguinal
direct, inguinal indirect, femoral, parafemoral, and inguino- In this interesting group there were 257 operations on 211 pa-
femoral hernias. tients. Females made up 18% (n = 38) of this group, while males
accounted for 82% (n = 173)!
In this group, and in absolute numbers, there are far more males
Incidence of Hernias in Females than females affected by the hernia diathesis, in a ratio of more
than 4.5 to I! This significant difference has not been explained.
Between March 31, 1994, and April 1, 1996, 12,588 patients un-
derwent hernia repairs at the Shouldice Hospital (figures obtained Emergency Femoral Hernia Surgery
directly from records). Incisional, umbilical, and epigastric hernias
are excluded from these figures. There were 781 females in this I have reviewed the statistics ofX. Henry (Chapter 81). There were
2-year series. The incidence of females coming to elective surgery 116 patients with strangulation of a femoral hernia. Females num-
was thus 6.2%. On a yearly basis, the figure has been constant. bered 89, or 76.7%, compared with 27, or 23.3%, for males. On
this basis, a patient seen in emergency with a strangulated femoral
hernia is 3.3 times more likely to be female than male. In absolute
Elective Surgery for Femoral Hernias as well as relative terms-that is, if the incidence of femoral her-
nia were equal in men and women-hernias tend to incarcerate
Probably the largest reported study of femoral hernias came from and strangulate more in females than in males.
this author, reviewing the Shouldice Hospital records in 1989, cov- It is interesting to note that, out of 148 strangulated inguinal
ering a 4-year period from 1981 to 1984. 1 During that time, 28,179 hernias, women made up 22.3% (33 cases), against 77.7% (115
groin hernia repairs were carried out. There were 508 femoral her- cases) for men. With a ratio of 3.5 males to 1 female, this situa-
nia repairs, giving an overall incidence of femoral hernias of 1.8%. tion is the mirror image of that for strangulated femoral hernias!
A breakdown according to sex reveals that there were 331 males
(1.1 %) and 177 females (0.62%). In absolute numbers, therefore,
there were twice as many males as females in the 4-year period. In Summary
the same series, there were 26,432 males and 1747 females, mak-
ing up the total of 28,179 groin hernias. The ratio offemoral her- Of all elective hernia repairs, 6.2% are performed on women.
nias for men was 331/26,432, or 1.25%, while for women it was Of all hernias in women, 10.13% are femoral compared with
177/1747, or 10.13%. In other words, femoral hernia was eight 1.25% of all hernias in men.
times more common than inguinal hernias in female patients In primary elective surgery for femoral hernias, men and women
when compared to male patients. are equally represented.
639
640 R. Bendavid
Recurrent femoral hernias occur less often in women than in hernias than men. However, women with hernias have propartionally
men. more femoral hernias than men with hernias.
Strangulated femoral hernias present in emergency more than
three times more often in women than in men.
Conclusion Reference
As is often the case, the conventional wisdom has lost a few key 1. Bendavid R. Femoral hernias: primary versus recurrence. Int Surg.
words. In absolute numbers, women do not have more femoral 1989;74:99-100.
Part XVI
Special Problems
94
Hernias in the Elderly
Pierre J. Verhaeghe, Tsiry B. Andriamihamisoa, and Fidy M. Ralaimiaramanana
Inguinal hernia is a common problem in the geriatric population, 1 exceptional. Strangulation is seen in two out of three femoral her-
yet publications on this theme are rare. The growing importance nias. As this location is particularly severely affected by age in
of the elderly patients in national health care systems 2 is well doc- women, suspicion of strangulated hernia should come to mind
umented, but the age group has not been precisely defined; in the every time an older woman presents with unexplained vomiting.
literature, the onset of old age may range from 65 to 80 years of According to Berliner7 and Ponka,8 6 out of 10 hernias in el-
age. This causes difficulties in comparing data. We discuss data derly men will be indirect inguinal hernias; our figure is closer to
from a series of 1421 hernias operated on between 1980 to 1990 1 in 3 (Fig. 94.1). One-third of elderly inguinal hernias are slid-
in a university clinic. Included was a group of 411 patients over 70 ing hernias. Associated secondary hernias occur in 12% of patients.
years of age, divided into three groups: under 70, 70 to 80, and Careful and systematic intraoperative exploration is essential.
over 80 years 01d. 3
Size of the Hernia

Influence of Age on the Patient's History
Large hernias, due to a prolonged neglected evolution, present
The more aged the patient, the more associated medical patholo- nursing problems in the form of associated conditions and chal-
gies are present (Table 94.1). Cardiovascular, urological, or pul- lenges to the quality of personal life. On the other hand, small di-
monary impairment is observed in two out of three patients. 4 The rect hernias raise the question of the etiology of inguinal pains.
detailed patient history may contain suggestive associated patholo- Inguinal dysesthesias can appear some weeks before the emer-
gies such as adenoma or prostatic cancer, diverticulosis of the gence of an inguinal hernia, while nerve root pain (Tl2 to Ll),
colon, or chronic bronchitis that may lead to the discovery of a linked to lumbar arthrosis, may refer pain to the inguinal region.
hernia, even if relatively asymptomatic. Herniography is helpful in the clinical investigation of groin pain
The inguinal region of the aged patient reflects the general state of unclear origin in elderly women. 9 Ultrasonography is more sub-
of health, but also, more particularly, the degenerative processes jective and depends more on the skill of the radiologist in pari-
that lead to hernia. Fruchaud's myopectineal orifice is an area of etal examination.
natural weakness; over time, the muscular fibers of its frame are
replaced by fibroadipose tissues, and the collagen fibers of aponeu-
roses and fascias become disorganized. 2 The decrease in oxytalan
fibers as a function of aging may be responsible for alteration in
Silent Hernias
the integrity of the transversalis fascia. 5 Obesity will aggravate the
When a small reducible direct inguinal hernia remains asympto-
condition. Local dermatoses such as intertrigo, eczema, or myco-
matic in an older patient, the choice of treatment weighs the op-
sis create a local infectious risk that may require prolonged pre-
erative risk against the natural evolution of the hernia. On the
operative treatment. Age is not, however, the key factor in the
other hand, all femoral hernias should be operated on as soon as
mortality rate of hernia surgery in elderly people; the patient's
possible, particularly if they are recent.
general condition, strangulation,6 and associated emergent
surgery tend to be more directly related.
Complicated Hernias
Statistics
Strangulation is a life-threatening condition associated with bowel
Sex necrosis and poor general health; this is exacerbated by delayed
diagnosis. The options are either an inguinal incision to reduce
In elderly women there are three times more femoral hernias than viable bowel or an emergency laparotomy when the occlusive syn-
indirect inguinal hernias, and the occurrence of a direct hernia is drome is dominant and findings are ambiguous.
643
644 PJ. Verhaeghe et al.
94.1. Incidence of associated pathologies 800

TABLE
Gianetta15 Ponka21
o >80y 739
Deysine16 Verhaeghe 3 700 ED 70-80y
(n = 221) (n = 226) (n = 200) (n = 411) 1m <70y
UI 600
111
Cardiovascular 39% 68% 87% .~ 500
Urological 18% 40% 55% ~
Gastrointestinal 14% 16% '5 400

Pulmonary 13% 13.20% 39% 54% Cii
Neuropsychological 5% 12% ~ 300
:::J
Others 7% 11% Z
200
None 29% 13.30% 30%
100
0
Local Spinal General
Which Surgery for Which Patient?
FIGURE 94.2. Breakdown of anesthetic techniques according to patient age.
Do All Hernias Need Surgery?
hence the respiratory, urinary, and venous risks. It allows quick re-
The socioeconomic cost linked to the high incidence of silent her- turn home and to normal activities l5 (Fig. 94.3), which is impor-
nias in the elderly must be considered. Although some surgeons tant to the psychological well-being of the elderly person. That is
prefer not to operate on small, reducible, asymptomatic inguinal why we favor local anesthesia in hernia surgery in the elderly.16
hernias, the gravity of the sequelae of strangulation contrasts
sharply with the simplicity of the postoperative course of elective
surgery under local anesthesia, even in the elderly patient. Elec- Which Surgical Technique?
tive surgery should be avoided only if associated diseases cannot
be controlled. lo There are no reliable indices for predicting which Shouldice or Bassini Pure Tissue Repairs
hernia will become complicated. l1 Therefore, as complications be-
come more common with increasing age (2% under 70 years, 5.6% The well-known technique described by the Toronto group is prac-
between 70 and 80 years, and 6% over 80 years old; p < 0.01),12 ticed worldwide. 17 Under local anesthesia, the deep layer is sutured
we think it preferable, sociologically and economically, as well as generally with stainless steel wire, but frequently with a nonal>-
medically, to operate electively on most elderly hernia patients. 13 sorbable monofilament synthetic suture material. This procedure
Appropriate management may often require the collaboration of gives a less than 1% recurrence rate to its promoters, but is a little
geriatric specialists. higher in other hands. The recurrence rate may be acceptable in
elderly patients,18 taking life expectancy into account, but the level
of postoperative pain has led many surgeons to give up pure tissue
Which Anesthesia? herniorrhaphy in favor of the tension-free techniques.
Currently, general anesthesia is better attuned to the needs of

older patients,14 but can still lead to postoperative respiratory, uri- 12r-------------------------------------
nary, and venous thrombotic complications. Spinal anesthesia re-
duces these risks but is more difficult to administer in a patient
m<70y 0.4
[J 70-80 Y
with osteoarthritis. Local anesthesia is well adapted to the surgery
of elderly patients (Fig. 94.2), diminishing decubitus time and
10
o >80y ---------------4
8.4
8~---------------
250
205 [jill Males

200 1--W:lIT:mll----- 61--------
III Females
.!!!
E
~
CD 150 4
'0
"-
CD
~ 100
:::J
Z 2
50
4 6 o
o Direct inguinal Indirect inguinal Femoral
Local Spinal General
FIGURE 94.3. Mean hospital duration (in days) according to age and anes-
FIGURE 94.1. Locations of hernias in men and women. thesia.
94. Hernias in the Elderly 645
Tension-Free Techniques (Patch and Plug) References

Inserted under local anesthesia, patch and plug prostheses have 1. Tingwald GR, Cooperman M. Inguinal and femoral hernia repair in
the added advantages of small incisions and the comfort of ten- geriatric patients. Surg Gynecol Obstet. 1982;154:704-706.
sion-free repair. All these prostheses have the same aim: to reduce 2. Nano M. Technique for inguinal hernia'repair in the elderly patient.
the sac into the abdominal cavity and to occlude the defect. Si- Am] Surg. 1983;146:373-375.
3. Verhaeghe PJ, Andriamihamisoa TB, Ralaimiaramanana FM, et al. Spe-
multaneously, the weak posterior inguinal wall can be reinforced
cificite des hernies du sujet age, apropos de 411 observations. Chirurgie.
with an onlay patch. This type of mesh hernia repair is safe, ef- 2000;125 (in press).
fective, and reliable in the elderly patient. 7•9,19 4. Solorzano CC, Minter RM, Childers TC, et al. Prospective evaluation
of the giant prosthetic reinforcement of the visceral sac for recurrent
and complex bilateral inguinal hernias. Am] Surg. 1999;177:19-22.
5. Rodrigues Junior AJ, Tolosa EM, De Carvalho CA. Electron microscopic
Preperitoneal Prosthesis study on the elastic and elastic related fibers in human fascia transver-
salis at different ages. Gegenbaurs Murpkal]ahrb. 1990;136:645-652.
Performed under general or spinal anesthesia, the insertion of a 6. Le Neel JC, Letessier E, Genier F, et al. Pronostic immediat de la
large mesh reinforces the transversalis fascia and at the same time chirurgie parietale apres 75 ans. Abstract in Congres Fran~ais de
prevents the peritoneum from stretching; thus recurrence is Chirurgie, Paris 1998.
virtually impossible. Median, in the original Stoppa or giant pros- 7. Berliner SD, Spier N. Elective herniorrhaphy in the aged. Hernia.
thetic reinforcement of the visceral sac technique,4,2o or hori- 1998;2:85-88.
zontal (Henry) or suprainguinal (Mehary) incisions can be used. 8. Ponka JL, Brush BE. Sliding inguinal hernia in patients over 70 years
Recently the laparoscopic approach has been tried. These proof age.] Am Geriatr Soc. 1978;26:68-73.
cedures (transabdominal preperitoneal or totally extraperi- 9. Ekberg 0, Kesel P, Bergenfelt M, et al. The value of herniography in
elderly women with groin pain of obscure origin. Acta Chir Scand.
toneal), performed by different surgical teams, have given similar
1989;155:99-101.
good results, but they are more serious operations than proce-
10. Nehme AE. Groin hernias in elderly patients: management and prog-
dures carried out under local anesthesia. For patients over nosis. Am] Surg. 1983;146:257-260.
70 years of age, indications may be restricted, depending on the 11. Williams JS, Hale HW. The advisability of inguinal herniorrhaphy in
history, the level of activity, and the impairment of the groin the elderly. Surg Gynecol Obstet. 1966;138:100-104.
structures. 12. Lewis DC, Moran CG, Vellacott KD. Inguinal hernia repair in the el-
derly.] R Coll Surg Edinb. 1989;34:101-103.
13. Nano M, Lubrano T. Inguinal hernia in the elderly patient. Boll ernie
laparoceli. 1995;3:511-512.
Femoral Hernias 14. Makuria T, Alexander-Williams J, Keighley MR. Comparison between
general and local anaesthesia for repair of groin hernias. Ann R Coll
In the elderly, we recommend repair of femoral hernias through EngL 1979;61:291-294.
a direct incision under local anesthesia and the use of a prosthetic 15. Gianetta E, De Cian F, Cuneo S, et al. Hernia repair in elderly patients.
plug in the femoral canal. Br] Surg. 1997;84:983-985.
16. Deysine M, Grimson R, Soroff HS. Herniorrhaphy in the elderly: ben-
efits of a clinic for the treatment of external abdominal wall hernias.
Am] Surg. 1987;153:387-391.
17. Shouldice EE. The treatment of hernia. Ontario Med Rev. 1953;20:670.
Conclusion 18. Faucompret S, Cuche J. La herniorraphie, SollS anesthesie locale selon
la technique du Shouldice Hospital chez l'homme de plus de 75 ans,
There is no single technique specific to the elderly patient. 2 Nei- a propos de 70 interventions. Lyon Chir. 1992;88:439-442.
ther chronological age nor severe systemic disease is a con- 19. Rfilrbaek-Madsen M. Herniorrhaphy in patients aged 80 years or more.
traindication to hernia repair. 7 Current elective surgery on A prospective analysis of morbidity and mortality. Eur] Surg. 1992;158:
adequately prepared patients has a much better prognosis than 591-594.
emergency procedures. 12,21 Elderly patients should be managed 20. Stoppa R. The preperitoneal approach and prosthetic repair of groin
preoperatively and monitored closely during and after the opera- hernias. In Nyhus LM, Condon RE (eds): Hernia, 4th ed. Philadelphia:
J.B. Lippincott; 1995:188.
tion 10 by a multidisciplinary team, including the surgeon, the anes-
21. Burns-Cox N, Campbell WB, Van Nimmen BAJ, et al. Surgical care and
thetist, the physiotherapist, and the geriatrician. The reported outcome for patients in their nineties. Br] Surg. 1997;84:496-498.
hernia recurrence rate is very low. 8 ,22 Elective surgical repair of 22. Ponka JL, Brush BE. Experiences with the repair of groin hernia in
groin hernias in aged patients can improve the quality of their 200 patients aged 70 or older.] Am Geriatr Soc. 1974;22:18-24.
lives and may well be a lifesaving measure. Early elective repair of 23. Allen PIM, Zager M, Goldman M. Elective repair of groin hernias in
hernias in the elderly should therefore be encouraged. 18,23 the elderly. Br] Surg. 1987;74:987.
95
Elective Herniorrhaphy in an Aging Population
Stanley D. Berliner and Nathaniel Spier
Introduction vealed that a patent processus vaginalis was present in 22% of

adults with no clinical history of hernia. 2
The integrity of the transversus abdominis aponeurosis and its
Aging: The process of growing old, especially by failure of replace-
investing sheath of transversalis fascia is of paramount importance.
ment of cells in sufficient numbers to maintain function (Stedman's
Medical Dictionary 1976) The active and passive closure mechanisms that prevent hernia-
tion through the deep ring produce a sphincter, a pulley, and a
shutter effect. Condensations of transversalis fascia fibers delin-
The Random House Dictionary (1966) defines elderly as somewhat
eate the medial and superior margins of the internal ring. This U-
old; between middle and old age. Old age is defined as the last pe-
shaped structure, described by Hesselbach, serves as a sphincter
riod of human life, generally considered to be the years after 65.
and as a pulley. A slit-like opening is created when intraabdomi-
With the explosion of the chronologically gifted population, how-
nal pressure increases. The spermatic cord, exiting from the ring,
ever, 65 is no longer considered very old. Websters Universal Dic-
is displaced superiorly and laterally under the muscular arch of
tionary (1993) differentiates between elderly as quite old and aged
the internal oblique. With increased pressure, the conjoined fibers
as very old. The clinical material in this chapter concerns elective
of the transversus abdominis aponeurosis and internal oblique
herniorrhaphy in the senior population, and in reviewing our per-
muscle abut against the inguinal ligament to provide a passive
sonal data we have chosen to include patients over the age of 80
shutter-like protection for the posterior wall and, to a lesser de-
years.
gree, the internal ring. 3- 5 As the transversalis fascia/transversus ab-
The very rapid growth of this segment of the population is dra-
dominis aponeurosis layer deteriorates, these protective devices
matized by figures from the Bureau of the Census. l In the United
become less effective.
States during the 26-year period from 1970 through 1996, persons
Because the underlying anatomical defect is the same whether
over the age of 75 years increased from 3.7 to 5.7% of the popu-
it leads to a direct or an indirect hernia, it is not surprising that
lation. Furthermore, it is projected that by the year 2050 this fig-
the pathological findings in the aged are similar. Histological stud-
ure will reach 11 %. In 1996, the over 80 group comprised 3.1 %
ies show the expected degeneration in the musculoaponeurotic
of the total population, and it is projected that this figure will reach
layer of the transversus abdominis. More interesting are findings
6% by the year 2050 (Tables 95.1 to 95.3).
of paucity and fragmentation of elastic tissue fibers at patulous
Primary care physicians will therefore be increasingly faced with
deep rings and at direct hernia sites. Similar findings have been
the dilemma of whether or not to recommend surgery for the el-
reported in Marfan's and the Ehlers-Danlos syndromes. It is not
derly high-risk patient with a symptomatic hernia. This is particu-
clear how collagen metabolism disorders contribute to the devel-
larly important because, in our experience, indirect hernias
opment of a direct ("old man's) hernia in the young adult male
including large bowel sliders are much more common in patients
with a strong family history of direct hernia. In the aged, me-
over 80 years than are less dangerous direct hernias.
chanical factors secondary to degenerative changes are likely.6
Pathophysiology and the Aging Process Techniques of Repair in the Aged

In the healthy adult, the transversus abdominis aponeurosis exists In dealing with the elderly high-risk population, we feel that sim-
as interlacing bundles of collagen fibers that give substance to the plicity of technique dictates the use of a biomaterial in virtually all
posterior wall and protect the internal ring. The aging process re- cases. At the same time, sound principles of hernia repair must be
sults in disruption of these fibers. If this occurs within Hesselbach's adhered to.
triangle, a direct hernia results; if it involves the closure mecha- In the historical introduction to his 1300-page treatise on her-
nisms at the internal ring and the processus vaginalis is patent, an nia, Alfred lason 7 wrote: "They hacked, hewed and slashed; they
indirect hernia develops. A compilation of five autopsy studies re- incised, cauterized and scarified; they castrated young and old
646
95. Elective Herniorrhaphy in an Aging Population 647
TABLE 95.1. Resident population in the United States 1970-1996 TABLE 95.3. Resident population" in the United States in patients 80
years and older, 1996
Age (years)
Age
Year 75-84 85+ total 75+ % over 75 (years) No. % Population
1970 6122 1408 7530 3.7 80-84 4557 1.72
1980 7729 2240 9969 4.4 85-89 2394 0.90
1990 10,012 3022 13,034 5.2 90-94 1024 0.39
1996 11,430 3762 15,192 5.7 95--99 286 0.11
100+ 57 0.02
Data from the U.S. Department of Commerce, Bureau of the Census, 1997
(in thousands). Total 80 and older 3.14%
Projection by year 2050 6.0%
. . . they stood their victims on their heads . . . they applied hot 'In thousands.
and cold poultices; they tortured with tobacco enemas and dras-
tic purges ... they tried manual manipulations; they placed iron folded, with imbrication of the transversalis fascia. This removed
filings on hernial tumors, hoping, by magnetic action, to replace a major stimulus for fibroplasia.
them .... They used screws, pins, needles, wires ... wooden spikes,
In 1922, Harrison ll described the Bassini and Halsted repairs
ivory, testicles, animal skins. . . . Prehistoric methods solely? Ro- as "satisfactory for the hernias of children, reasonably satisfactory
man, Greek or Byzantine? Dark or Middle Ages? Renaissance? No. for small indirect hernias and very unsatisfactory for direct her-
Methods in vogue down to the mid-nineteenth century! Among nias." Using local anesthesia, Harrison incised the posterior wall
the 'Scientific' errors of Mankind, it was one of The Seven Blun- and then overlapped the edges of the incision. This was reinforced
ders of the World!" with a fascia lata onlay graft. He had no known recurrences in 200
Speaking before medical and surgical faculties in Maryland, cases, but the follow-up was poor. Harrison worked in the Bahrein
William Halsted8 commented that "there is no operation that Peninsula (now Qatar), and his patients, mostly Bedouin tribes-
would be better appreciated than a perfectly safe and sure cure men, would fold their tents and disappear into the night. Despite
for rupture." For a century we have been bombarded with a myr- a problem with wound infection, the autogenous fascial graft was
iad of so-called new operative cures for hernia that have proved never rejected.
disappointing. It is encouraging to report that, thanks to modem
The type of repair must depend on the findings at surgery. Our
synthetics, we have converted what lason called a blunder into a current methods include a conical plug at the internal ring
scientific wonder. Mesh prostheses and the use of local anesthesia
(Gilbert); a posterior wall plug and overlay patch technique (Rob-
have provided a more realistic approach to achieving a safer and bins and Rutkow); and the Lichtenstein onlay graft.l 2- 14
surer cure for rupture in the aged.
Edoardo Bassini's presentations before Italian and German sur-
gical societies and the sketches by Catterina indicate that Bassini Clinical Material
incised "the triple layer of the abdominal wall," the internal
oblique muscle, the transversus abdominis aponeurosis, and the
During the 5-year period from January 1994 through December
vertical (transversalis) fascia of Cooper. 9 ,lO An incision into the
1998, 1734 elective abdominal wall herniorrhaphies were per-
posterior wall as advocated in the original Bassini technique is formed at the New York Institute for Hernia Surgery. Ninety-nine
helpful. Nothing promotes wound healing more effectively than
patients (lll operations) were over age 80 years. The types of
a broad sweep of the knife. It is most impressive to see a relatively
groin hernias in the over 80 group were essentially the same as in
acellular aponeurosis transformed into a bed of fibroblasts days the entire series and comprised 6% of the total. The ages ranged
after the incision. Fibroblasts are mobile in tissue culture and pre- from 80 to 97, with a median of 83 years (Tables 95.4 and 95.5).
fer a smooth surface onto which they can adhere and deposit their
collagen and proteoglycans. The reproducible success of the
Shouldice overlap hernioplasty tends to confirm this. Similarly, the TABLE 95.4. Repairs (n = 111) in patients over 80 years in 1742
interstices of a mesh prosthesis inserted preperitoneally behind a abdominal wall herniorrhaphies, January 1994 to December 1998
weak posterior wall will be infiltrated by fibroblasts. A functional
No. % of1742 Over 80 % of 111 % of1742
wall results. Unfortunately, the original Bassini operation was mod-
ified, and the direct hernial sac was not incised but merely in- Primary inguinal 1374 78.9 86 77.5 4.9
Recurr. inguinal 200 11.5 19 17.1 1.1
Femoral 33 1.9 1 0.9 0.06
TABLE 95.2. Population" projections 2000-2050 Inguino-femoral 5 0.3 0 0 0
Age (years) Total groin 1612 92.6 106 95.5 6.06
Total % Umbilical 63 3.6 2 1.8 0.11
Year population 75-84 85+ Total 75+ Population Incisional 35 2.0 1 0.9 0.06
Epigastric 30 1.7 2 1.8
2000 274,634 12,315 4259 16,574 6.0 Spigelian 2 0.1 0
2030 346,899 23,517 8455 31,972 9.2 Total ventral 130 7.4 5 4.5 0.28
2050 393,931 25,905 18,223 44,128 11.2 Total groin and
ventral 1742 100% 111 100% 6.34%
'In thousands.
648 S.D. Berliner and N. Spier
TABLE 95.5. Age range in 99 patients over 80 years' TABLE 95.7. Systemic disease'
Age No. Disease No.
80-84 76 Cardiac
85-89 14 Hypertension, angina, congestive heart failure
90-95 9 Arrhythmias, previous infarct 75
Malignancy
"Median age, 83 years; 88 males and 11 females. Gastrointestinal, kidney, tongue, lung, larynx, prostate,
bladder, lymphoma, chronic lymphatic leukemia 16
Endocrine
One hundred seven cases were treated on an outpatient basis. Diabetes 12
Four hospital admissions were discharged on the first postopera- Central nervous system
tive day. One hundred ten operations were performed using local Cerebrovascular accident, transient ischemia 10
anesthesia with intravenous sedation. One incisional hernia was Pulmonary
repaired under general anesthesia. Eleven patients had bilateral Chronic obstructive pulmonary disease, asthma 9
inguinal hernias, and in nine of these the repairs were staged. Gastrointestinal
There were two simultaneous bilateral repairs and one simulta- Diverticulitis, peptic ulcer 4
Renal
neous repair of a left inguinal and epigastric hernia. One groin
Dialysis 3
exploration in a 90-year-old female with a preoperative diagnosis
Peripheral vascular
of an irreducible femoral hernia revealed adenopathy at the fossa Abdominal aortic aneurysm 2
ovalis. I5 Carotid artery stenosis
Hematological
Thrombocytosis 1
Preoperative Physical Status
'35 of 99 patients (35%) had multiple systemic diseases.
Preope~ative classification conformed to that established by the
American Society of Anesthesiologists (ASA) .16 Sixty-seven patients direct hernias, including large sliders, were repaired by high dis-
were ASA class III having severe systemic disease with definite func- section and inversion of the indirect component. This is main-
tional limitations, and four patients were ASA class Iv. Their sys- tained by the insertion of a conical plug, which is fixed to the
temic disease was considered a constant threat to life. Surgery was margins of the internal ring with one or more absorbable sutures.
performed in the class IV group because of episodes of incarcer- An onlay mesh reinforces the repair with or without sutures. The
ation. Cardiac disease (hypertension, angina, congestive heart fail- biomaterial employed in all cases is monofilament polypropylene
ure, arrhythmias, and prior myocardial infarction) was the most mesh (Marlex®, Prolene®, or Trelex®); fixation is with absorbable
common diagnosis (76%). Multiple systemic diseases were sutures of 2-0 polyglactin 910 (Vicryl®).
recorded in 35% of the patients (Tables 95.6 and 95.7). In focal direct defects, the posterior wall is circumferentially in-
cised, and a cone-shaped plug is sutured to the rim of the defect
with interrupted sutures. In diffuse direct hernias, one of the au-
Operative Repair thors (S.D.B.) incises the entire posterior wall and develops a flap
superiorly to the transversus arch. This has been the author's pro-
Primary hernias numbered 86, of which 49% were indirect, in- cedure of choice since 1973 for selected Nyhus type III and type
cluding 9 sliders; 20% were combined indirect and direct, in- IV hernias. I7 Polypropylene or an expanded polytetrafluoroethyl-
cluding 2 pantaloon hernias; and 31 % were direct. Recurrent ene soft tissue patch proved satisfactory, but the latter requires
hernias numbered 19, 15 of which (79%) had an indirect com- fixation with continuous nonabsorbable sutures. The rapid incor-
ponent. These may have been due to missed sacs or failure to carry poration of monofilament polypropylene mesh allows the use of
out a high dissection of the indirect component (Table 95.8). absorbable sutures. If the size is suitable, a preformed plug (Bard)
The techniques employed in the III operations are detailed in may be used. In large direct hernias, it is often necessary to fash-
Table 95.9. Mesh was used in 104 of the 105 inguinal repairs. In- ion a conical plug using the entire 15 X 15 cm prosthesis.I8 The
mesh is sutured above to the transversus arch, below to both the
cut edge of the transversalis fascia and the inguinal ligament, and
Class .
TABLE 95.6. Preoperative physical status
Description No.
TABLE 95.8. Operative findings in 105 inguinal repairs
I Healthy patient 6
Nonrecurrent No. % Recurrent No. %
II Mild systemic disease,
no functional limitation 22 Indirect sac 33 38.4 Indirect sac 13 68.4
III Severe systemic disease, Sliders (sigmoid slider, 1)
definite functional limitation 67 Sigmoid 6 7.0
IV Severe systemic disease that Cecum 3 3.5
is a constant threat to life 4 Indirect/ direct 15 17.4 Indirect/ direct 2 10.5
V Moribund patient 0 Pantaloon 2 2.3
Total patients 99 Direct 27 31.4 Direct 4 21.1
Total nonrecurrent 86 100% Total recurrent 19 100%
'American Society of Anesthesiologists.
95. Elective Herniorrhaphy in an Aging Population 649
TABLE 95.9. Operations (n = 111) in patients over age 80 years

Operation Nos. Operation Nos.
Cone to internal ring Cone to internal ring 7

+ onlay 48 Suture internal ring
Preperitoneal cone to Cone to pubic
posterior wall + onlay 13 tubercle defect
Internal ring and preperitoneal Cone to femoral canal
cones + onlay 12 Inlay, incisional
Lichtenstein onlay 13 Cone + onlay, epigastric
Cone to internal ring Onlay, epigastric
+ Lichtenstein onlay 10 Cone + onlay, umbilical
Cone, umbilical
medially to the pubis (Fig. 95.1). Two absorbable sutures are used
above, two below, and one at the pubis to secure the mesh. In a
large pantaloon hernia, a plug of equal size may be necessary to
secure the internal ring. In both instances an overlay mesh is FIGURE 95.2. The Lichtenstein tension-free repair: The direct hernial sac
added. (F) is inverted, and the onlay mesh (K) is sutured above to the muscular
One of the authors (N.S.) prefers a Lichtenstein-type repair for fibers of internal oblique (B) and below to the inguinal ligament (I). The
a diffuse direct hernia (Fig. 95.2). The inverted direct sac is se- transversalis-iliopubic tract layer (G) is not included in this repair.
cured with a continuous suture of 2-0 Vicryl without tension. An (Reprinted from Lichtenstein et al.,14 with permission.)
onlay polypropylene mesh, tailored to fit and split laterally to ac-
commodate the spermatic cord, is then inserted. The mesh is su-
tured from the fascia overlying the pubic tubercle to the rectus There was no operative mortality. A class IV patient developed
sheath and the conjoined fibers of transversus abdominis and in- transient angina on the afternoon of his hospital discharge that
ternal oblique with continuous 2-0 Vicryl. The inferior border of did not require re-hospitalization. In one female with a left indi-
the mesh is sutured to the inguinal ligament again with continu- rect hernia, a right inguinal hernia was detected and repaired at
ous 2-0 Vicryl. The lateral "legs" of the split overlay mesh are over- the 3-year follow-up visit. A second female developed a contralat-
lapped and held together, lateral to the cord, with a single 2-0 eral hernia after 2 years. This will be repaired. There was one re-
Vicryl suture. 19 currence and three deaths. The three deaths occurred 30, 18, and
15 months after operation and were due to myocardial disease
(Table 95.10).
Complications and Follow-Up A recurrence was detected adjacent to the pubic tubercle at the
2-year follow-up in a male who had had an indirect hernia and a
Patients were examined 1 week and 6 weeks after surgery and an- small direct hernia. The patient was asymptomatic and unaware
nually thereafter. Ninety-nine patients were followed up from 6 to of the recurrence, not an unusual event. In a series of over 8000
66 months, with a mean follow-up time of 33 months. No patients cases, one-third of our pubic tubercle failures fell into this cate-
were lost to follow-up. gory and were detected at the annual office examination. This
emphasizes the importance of personal follow-up by the operat-
ing surgeon. The defect was repaired with a conical plug. At the
2-year office visit, the re-repair remains intact. This failure was most
likely due to inadequate coverage of the pubic tubercle area with
the mesh.
Long-term follow-up is difficult and requires office staffwith the
instincts of a Sherlock Holmes, the charm of a head waiter, and
the tenacity of an insurance salesman. To compare and evaluate
results accurately, we need to know the numbers of patients per-
sonally examined, the mean rather than the median follow-up
time, and the type of recurrence. The criterion by which the reli-
ability and success of a procedure may be judged is the ability of
others to reproduce the reported results.
TABLE 95.10. Deaths during postoperative follow-up

Months Postop. Age at death Status of repair
FIGURE 95.1. A conical plug repair for a large direct inguinal hernia. The 30 87 Intact
polypropylene mesh is sutured above to the white line of the transversus 18 83 Intact
arch (A) and below to both inguinal ligament and the transversalis layer 15 87 Intact
adjacent to iliopubic tract (B). (Reprinted from Berliner, 18with permission.)
650 S.D. Berliner and N. Spier
Discussion tive day, and the other was a patient who died on the third post-
operative day following a myocardial infarction.
According to the Professional Activity Study figures, herniorrha- When dealing with high-risk aged individuals, local anesthesia
phy is one of the most common surgical operations performed. assumes great importance. The thermoregulatory response dur-
Before ambulatory hernia surgery became the norm, in-hospital ing general, spinal, and epidural anesthesia is disrupted, and hy-
repair numbered 5% of all primary operations performed. A re- pothermia results. Even a mild hypothermia of OS to 1°C below
view of 15,000 consecutive general surgical operations performed normal core temperature triggers sympathetically mediated hy-
during the 5-year period between 1972 and 1978 revealed that in- pertension resulting in a twofold to sevenfold increase in circu-
guinal herniorrhaphy constituted 30% of the total. 2 lating levels of norepinephrine. Tonic vasoconstriction persists.
At one ambulatory surgical center, 4223 general surgical oper- Shivering may occur, and total body oxygen consumption in-
ations were performed during the 3-year period from 1996 creases, which places great demands on the cardiovascular system.
through 1998. Of these, 1268 were for hernias, an incidence of A cooperative study from Hopkins and Vanderbilt demonstrated
30%.20 In both the Professional Activity Study and ambulatory cen- the association between mild intraoperative hypothermia and post-
ter statistics, simultaneous bilateral herniorrhaphies are listed as operative cardiac morbidity. They found that in patients with car-
one operation. diac risk factors undergoing non cardiac surgery, the perioperative
The danger of incarceration and strangulation of a groin her- maintenance of normothermia is associated with a reduced inci-
nia in the aged poses a serious threat to life. In several earlier se- dence of serious cardiac complications including ventricular tachy-
ries, 26 to 32% of emergency operations in the elderly were for cardia. 32 We are currently conducting a clinical trial to demonstrate
hernia, with an operative mortality as high as 22%. In a series re- whether or not local anesthesia with intravenous sedation for
ported from Milan with no mortality, all elective cases were done herniorrhaphy is associated with changes in body temperature sim-
using local anesthesia, and 4 of the 10 emergency procedures were ilar to that which occurs during general and regional anesthesia.
also done under local anesthesia. 21 A report from the United King- Local mixtures of bupivacaine and chloroprocaine or bupiva-
dom on the outcomes of surgery in patients in their 90s revealed caine and lidocaine have proved satisfactory, but they must be used
that hernia was second only to gastrointestinal disorders as the ad- judiciously. Chloroprocaine, with its hydrophilic ester linkage,
mission diagnosis and constituted 16% of the series. Fifty-six pa- and the amide lidocaine are short acting, less potent, and have an
tients required emergency surgery, and, of the seven deaths, four immediate onset of action. Bupivacaine is a lipophilic, highly
were due to a strangulated hernia. Perioperative mortality for protein-bound amide with a large molecule. It has a delayed on-
emergency hernia repair was 14%, and the overall mortality in the set of action but is long acting. The risk is the enhanced ability of
collected series was 12%.22 bupivacaine to depress myocardial conductivity if used in exces-
In weighing the merits of conservative management versus elec- sive amounts.
tive herniorrhaphy in symptomatic class III and IV patients, the Cardiac muscle appears to have a greater affinity for local anes-
high mortality in the event of emergency surgery needs to be care- thetic agents than either skeletal or smooth muscle. The car-
fully considered. In our experience, modern prosthetic techniques diotoxic effect of bupivacaine is directly related to its in vivo
and local anesthesia should encourage a decision in favor of elec- potency and dependent on the conformational state of the sodium
tive repair. channel. Experimental data suggest a more rapid block by bupi-
vacaine of inactivated cardiac sodium channels and a slower re-
covery compared with lidocaine. 33,34 The threshold for the
Local Anesthesia generation of an action potential is therefore raised, and the rate
of diastolic depolarization in the conduction tissues is decreased.
It is our opinion that in all groin hernia repairs, a well-conducted This reflects a diminished sinoatrial nodal automaticity. The re-
local anesthesia is preferable to a well-conducted general or result is an increased PR interval, a prolonged QRS complex, and a
gional anesthesia. This has ample support in the literature. 23-25 sinus bradycardia. The vagolytic action of atropine counters this
Bloodgood's remark26 in 1923 is still appropriate today: "If the sur- by accelerating the rate of discharge at the sinoatrial node.
geon reserves local anesthesia for only those operations in which Early in our series, the heart rate dropped to the mid-20s in two
the general anesthetic is distinctly contraindicated, he will very patients. Atropine was used in increments of 0.4 mg intravenously,
slowly if ever acquire the art of completing the operation for in- and in one case it was necessary to use a total of 1.2 mg. Currently,
guinal hernia under a local anesthetic with entire satisfaction to with equal parts of 1% lidocaine and 0.5% bupivacaine combined
himself and to his patient." with judicious use of the mixture, bupivacaine bradycardia has not
In 1948, Pratt27 reported 378 inguinal repairs under local anes- been a problem. A 1:400,000 dilution of epinephrine is used by
thesis, with no deaths. The Shouldice Hospital, where local anes- one of the authors.
thesia is used exclusively, reported 1 death in 2874 hernia
operations in 1949; in 1973, they reported no mortality in 4132
primary repairs compared with a 0.2% mortality in all other hos- Summary
pitals in Ontario, in elective primary repairs using all anesthesia
modalities. In patients over 65 years, Ontario hospitals had a 1.2% The population explosion in the aged is creating a dilemma for
mortality in elective primary hernia repairs compared with no mor- the primary care physician as to whether to recommend surgery
tality at the Shouldice Hospital in over 4000 cases. 28-31 We have for elderly, high-risk patients with a symptomatic hernia. In our
had 2 deaths in more than 8000 groin repairs under local anes- experience, groin hernia repair in the aged is a safe operation that
thesia. One was an irreducible femoral hernia in a patient with can usually be performed on an outpatient basis. Local anesthe-
ovarian carcinomatosis who died on the twenty-ninth postopera- sia is strongly recommended whenever possible. The risks of op-
Commentary 651
erating on ASA class III and selected class IV patients appear to 29. Vayda E, Lons D, Anderson GD. Surgery and anesthesia in Ontario.
be less than the dangers of incarceration and strangulation. Can Med AssocJ 1977;116:1263-1266.
30. Iles JDH. Surgery and anesthesia in Ontario [letterJ. Can Med Assoc J
1978;118:114.
References 31. Iles J. The management of elective hernia repair. Ann Plastic Surg.
1979;538-541.
1. u.s. Department of Commerce, Bureau of the Census. National data 32. Frank SM, Fleisher LA, Breslow Mj, et al. Perioperative maintenance
book: statistical abstract of the United States. Lawrence, KS: Bureau of the of normothermia reduces the incidence of morbid cardiac events. A
Census; 1998. randomized clinical trial. ]AMA. 1997;277:1127-1134.
2. Berliner SD. Adult inguinal hernia: pathophysiology and repair. Surg 33. Kendig]. Clinical implications of the modulated receptor hypothesis:
Annu. 1983;15:307-329. local anesthetics and the heart. Anesthesiology. 1985;62:382.
3. Hesselbach HC. De ortu herniarum. Wurzberg, Stahel. 1816. Cited by 34. Clarkson CW, Hondeghem LM. Mechanism ofbupivacaine depression
Lytle~. The deep inguinal ring, development, function and repair. of cardiac conduction: fast block of sodium channels during the ac-
Br] Surg. 1970;57:531. tion potential with slow recovery from block during diastole. Anesthtr
4. Lytle~. The internal inguinal ring. Br] Surg. 1945;32:29. siology. 1985;62:382-384.
5. Keith A. On the origin and nature of hernia. Br] Surg. 1924;11:455.
6. Berliner SD. An approach to groin hernia. Surg Clin North Am. 1984;
64:197-213.
7. Iason AH. Hernia. Philadelphia: Blakiston Co.; 1941.
8. Halsted WS. Surgical papers, vol. 1 Baltimore: johns Hopkins University
Press; 1924:265. Commentary
9. Wantz GE. The operation of Bassini as described by Attilio Catterina.
Surg Gynecol Obstet. 1989;168:67-80. R. Bendavid
10. RaccuiajS, Azoulay D. The "Bassini" of Edoardo Bassini. In Maddern
Gj, HiattJR, Phillips EH (eds): Hernia repair. New York: Churchill Liv- "Clinical Guidelines on the Management of Groin Hernias in
ingstone; 1997;83-93. Adults" is the title of a publication issued in July 1993 and repre-
11. Harrison pw. Inguinal hernia: a study of the principles involved in the sented a "Report of a Working Party Convened by the Royal Col-
surgical treatment. Arch Surg. 1922;4:680-689. lege of Surgeons of England." The first three lines of the report,
12. Gilbert AI. Inguinal hernia repair. Biomaterials and sutureless repair. which began under the heading of Guidelines, read: "Indirect and
Pcrspect Gen Surg. 1991;2:113-129.
symptomatic direct inguinal hernias may be repaired electively and
13. Robbins AW, Rutkow 1M. The mesh plug hernioplasty. Surg Clin North
prioritized on the waiting list by employment considerations. Re-
Am. 1993;73:501-512.
14. Lichtenstein IL, Shulman AG, Amid PK The tension-free repair of pair of small, easily reducible direct inguinal hernias is not manda-
groin hernias. In Nyhus LM, Condon RE (eds): Hernia, 4th ed. tory especially in the elderly...."1
Philadelphia: J.B. Lippincott; 1995:237-247. Devlin 2 and Green3 suggested that "small, reducible direct in-
15. Berliner SD, Spier N. Elective herniorrhaphy in the aged. Hernia, 1998; guinal hernias in the elderly may be ignored." Kettlewell4 and EI-
2:85-88. lis5 "go further, stating that the majority of direct inguinal hernias
16. Miller RD. Anesthesia, 2nd ed. New York: Churchill Livingstone; are wide-necked and do not need an operation."
1986:365-366. What surgeon has never erred in his diagnosis? Certainly I have
17. Berliner SD. An anterior iliopubic tract-transversus abdominis repair mistaken direct, indirect, femoral hernias for the others, in every
using an inlay graft for selected type III and N inguinal hernias.
permutation possible. I have seen and operated on incarcerated
In Nyhus LM, Condon RE (eds): Hernia, 4th ed. Philadelphia: J.B.
Lippincott; 1995:150-152. direct inguinal hernias, knowingly and unknowingly.
18. Berliner SD. Biomaterials in hernia surgery. In Maddern GJ, HiattJR, In that respect, I feel that Dr. Berliner's contribution is timely
Phillips EH (eds): Hernia repair. New York: Churchill Livingstone; and relevant. My own interest in hernias and the elderly led me
1997;199-214. to publish the observations in Tables 1 and 2,6 revealing that 52.1 %
19. Spier N, Berliner SD. The open tension-free mesh repair of inguinal of all hernias were seen in patients over the age of 50 years while
hernia. Analysis of 1235 cases. Hernia. 1998;2:81-83. 11.6% were 70 years old and older. In the group of primary her-
20. Day Op Center of Long Island, Mineola, NY, 1999. nias and recurrent hernias, direct inguinal hernias accounted for
21. Gianetta E, De Cian F, Cuneo S, et al. Hernia repair in elderly patients. 30.4% and 41.5%, respectively.6 May I also add, from experience,
Br] Surg. 1997;84:983-985.
that in recurrences, direct and indirect, inguinal hernias are even
22. Bums-Cox N, Campbell WB, van Nimmen BAj, et al. Surgical care and
more difficult to distinguish. Mortality in elective hernia surgery
outcome for patients in their nineties. Br] Surg. 1997;84:496-498.
23. Nehme AE. Groin hernias in elderly patients. Am] Surg. 1983;146: is of the order of 0.0086%6 but can be much higher with stran-
257-260.
24. Deysine M, Grimson R, Soroff HS. Herniorrhaphy in the elderly. Ben-
efits of a clinic for the treatment of external abdominal wall hernias. TABLE C95.1. Patient population above age 50 years in 7159 operations
Am] Surg. 1987;153:387-391. (1990)
25. Young DY. Comparison of local, spinal and general anesthesia for in-
guinal herniorrhaphy. Am] Surg. 1987;153:560-563.
Age group (years) No. of patients No. of operations %
26. BloodgoodjC. Operations for inguinal hernia under local anesthesia. 50-59 1116 1369 19.1
Am] Surg. 1923;37:185-188. 60-69 1330 1533 21.4
27. Pratt GH. Steel wire sutures, local anesthesia and immediate ambula- 70-79 603 689 9.6
tion in the treatment of hernia. Surg Gynecol Obstet. 1948;86:530-534. 80-89 124 144 2.0
28. Campbell EB. Anaesthesia in the repair of hernia. Can Med Assoc J Total 3173 3735 52.1
1950;62:364--366.
96
Management of Genitourinary Tract Pathology
Encountered During Inguinal Herniorrhaphy
W. Scott McDougal
Complications of the genitourinary tract during and following in- Injury to the Cord
guinal herniorrhaphy are rare. On occasion, however, unexpected
pathology is found during inguinal exploration, or an inadvertent Injuries to the cord may involve the veins, arteries, and/or vas def-
i~ury to structures of the genitourinary tract may occur. The abil- erens. Injuries to veins of the cord are generally of little conse-
ity to recognize unexpected pathological processes or injuries and quence. They can be ligated with impunity; however, if too many
deal with them appropriately during the operative event minimizes of the veins are ligated and lymphatic drainage is interfered with,
postoperative morbidity. In this chapter, complications involving a postoperative hydrocele may result. Indeed, extensive stripping
the bladder, the cord and its structures, the testicle, and the epi- of the cord with aggressive venous ligation frequently results in a
didymis are explored. hydrocele. Care must be taken not to make the internal ring too
tight, as this may result in venous occlusion of the cord vessels,
the possible sequelae being a varicocele or hydrocele.
Injury to the Bladder The testicle receives its arterial supply from three sources-the
testicular artery, the external spermatic artery, and the deferential
Occasionally a portion of the bladder wall proper or a diverticu- artery. Generally the testicle will survive if one of these vessels is
lum of the bladder may herniate through the internal ring. l More patent. On the other hand, when all three testicular arteries are
commonly, however, when involved in an inguinal hernia, the blad- transected, particularly in the adult, one-third to one-half of the
der is found on the medial side of a direct hernia. Cases have been testicles will have significant atrophy.4,5 The incidence of atrophy
reported in which substantial portions of the bladder have been is increased if the testicle has been mobilized from the scrotum.
involved in the hernia, resulting in ureteral or bladder outlet If the testicular artery is transected, a microvascular testicular
obstruction. 2 Portions of the bladder wall thought to be part of artery reanastomosis should be considered, particularly if there is
the hernial sac have been removed, significantly reducing bladder a significant abnormality of the contralateral testicle. Inadvertent
volume. J transections of the testicular and internal spermatic arteries are
Injuries of the bladder involve removal of a small portion, an often not recognized at the time of surgery and are only suspected
inadvertent opening into the bladder, or a nonabsorbable suture postoperatively. Ischemic orchitis often becomes apparent 2 to 3
or mesh secured to its wall. The latter may result in either erosion days postoperatively and is manifested by fever, leukocytosis, and
into the bladder wall or pseudo-tumor formation within the blad- a tender testicle on the side of the herniorrhaphy. This rarely re-
der mucosa. 3 When recognized, repair of such bladder injuries sults in gangrene of the testicle; more commonly, symptoms re-
should be undertaken immediately. The bladder should be closed solve over a period of several weeks. The long-term sequelae are
with interrupted 2-0 chromic, the first layer to include the mucosa atrophy in one-third and foreshortening of the cord with malpo-
and muscularis, with a second interrupted 2-0 chromic bringing sition of the testicle in another one-third. 4 There is atrophy of the
the serosal margins together. Nonabsorbable sutures should never tubules with preservation of the Leydig cells on pathological sec-
be used to close the bladder. A Foley catheter should be placed tion. 5 The incidence of ischemic orchitis is about 0.5% in primary
transurethrally in the bladder, which is then distended to confirm herniorrhaphies and 3 to 5% in recurrentrepairs. 6 When the sper-
that the closure is watertight and returned to its normal anatom- matic cord is intentionally transected, ischemic orchitis develops
ical location. The herniorrhaphy can then be completed and the in two-thirds of patients, one-half of whom will end up with tes-
patient maintained on Foley catheter drainage for 5 to 7 days. Pro- ticular atrophy.4,5 Thus, spermatic cord transection will result in
vided the Foley catheter is in place and the bladder is decom- ischemic orchitis alone in one-third, orchitis and atrophy in one-
pressed, the retrovesical space need not be drained. If a drain is third, and no symptoms in one-third. When the cord is inten-
required, it should be placed in the space of Retzius through a tionally cut to facilitate hernia repair, it should be transected
separate suprapubic stab wound in the midline. Erosion into the at the internal ring. The testicle should be left in situ and not
bladder by foreign bodies or pseudo-tumor formation occurs long mobilized from the scrotum if postoperative morbidity is to be
after the herniorrhaphy and is dealt with at a later date. minimized.
653
654 W.S. McDougal
On rare occasions, the vas deferens may be absent. It is possi- Tumors of the Cord
ble to have a perfectly normal testicle despite the absence of the
vas deferens as the structures are derived from different embry- Tumors of the cord may not be suspected before surgery and are
ological origins. Generally, when the vas deferens is absent, the usually benign. Benign lesions include embryonal remnants,
kidney on the ipsilateral side is also absent. The vas may be in- adrenal rests, hydroceles of the cord, mesothelial hypertrophy,
jured; this occurs in less than 2% of herniorrhaphies. When it oc- leiomyoma, incarcerated fat, and lipomas, among others. An
curs it is usually obvious. This is borne out by a recent report of adrenal rest is recognized by its orange-ish hue. If it is very promi-
hernial sacs sent to pathology for identification of missed vas def- nent, one should think of an indolent adrenogenital syndrome or
erens injuries; in all cases when the vas deferens was found in the increased adrenal cortical stimulation due to an excess of adreno-
hernial sac, the surgeon was already aware of the injury. 7 If the vas corticotropic honnone. These benign tumors of the cord are eas-
has been transected and fertility is a concern, it should be repaired ily removed. A hydrocele of the cord may be opened, care being
even though the contralateral side may appear nonnal. Obviously, taken to ligate or resect the processus vaginalis.
if the patient has had a vasectomy or is not concerned about fer- Malignant tumors of the cord are extremely rare and include
tility, one need only ligate both transected ends. rhabdomyosarcoma, leiomyosarcoma, and liposarcoma. If such le-
The proper repair involves the use of an operative microscope. sions are found, a radical orchiectomy should be perfonned, much
If the operating surgeon is not skilled in this technique and a as one would do for a malignant genn cell tumor of the testis.
skilled individual is not available, both ends of the transected vas
should be ligated with a 2-0 silk. Care should be taken not to mo-
bilize the vas either proximally or distally and to return the cord Lesions of the Scrotal Contents
to its nonnal anatomical position when the herniorrhaphy is com-
pleted. The suture ligation minimizes the development of a sperm Lesions of the tunica vaginalis include hydrocele and mesothe-
granuloma and facilitates identification of the two ends should mi- lioma. Hydroceles may be congenital, due to a patent processus
croscopic repair be undertaken subsequently. Preferably, however, vaginalis. In this case, the hydrocele need not be excised, but its
the microscopic repair should be undertaken at the time of injury. distal end should be left open. Extensive dissection of the cord may
The technique involves freshening the ends and placing a hold- result in a hematoma. If the hydrocele is isolated and a repair is
ing suture of 4-0 chromic in the adventitia so that the two ends indicated, the sac should be excised, the edges sutured with a run-
are opposed. Under microscopic guidance, four quadrant sutures ning 3-0 chromic for hemostasis, and a Penrose drain brought out
of 9-0 nylon (or 8-0 collagen) are placed through the full thick- through the dependent portion of the scrotum. The drain may be
ness of the wall of the vas. These are then tied tight, and four sero- removed in 24 hours. Some choose not to drain the repair, but this
muscular sutures of 9-0 nylon are then placed between the four results in an increased incidence of postoperative hematoma and
securing sutures (Fig. 96.1). With this technique, a patency rate swelling. The placement of the drain will reduce the incidence of
greater than 95% should be achieved. The use of loops or stents scrotal hematoma and the prolonged morbidity associated with it.
is to be avoided, as the success rate is not comparable with that of Hydroceles occasionally occur following inguinal herniorrha-
the technique described above. phy. They may be the result of extensive dissection of the cord,
Transection of the vas results in testicular/epididymal tender- ischemic orchitis, or ligation of the distal sac. Some will respond
ness in about two-thirds of patients. It usually resolves sponta- to aspiration; if this fails, surgical repair is required when the pa-
neously within 2 to 4 weeks. tient is symptomatic.
A 8
FIGURE 96.1. A two-layer anastomosis of the transected vas. (A) The posterior inner layer sutures have been placed. (B) The anastomosis is completed
with a second layer of seromuscular sutures.
96. Management of Genitourinary Tract Pathology 655
Fifteen percent of the population have varicoceles, usually

found on the left. Such lesions may cause discomfort or infertil-
ity. If the varicocele was not discovered during the physical
examination before the elective surgery and the patient is asymp-
tomatic, it is recommended to leave it alone at the time of inguinal
herniorrhaphy. On the other hand, if the patient has symptoms,
there is no reason that ligation of multiple veins in the cord may
not be performed during the inguinal herniorrhaphy. Ligating an
asymptomatic varicocele is to be condemned, as one cannot im-
prove on the asymptomatic condition of the patient. On the other
hand, care should be taken not to secure the internal ring too
tightly, as this can exacerbate a varicocele. The complications of
a varicocelectomy are loss of the testis, hydrocele formation, and
orchialgia. Thus, there should be good justification for conduct-
ing a repair. Surgery consists of isolating the cord and removing
a 1 cm segment of all dilated veins. If the patient has a varicocele
that is not repaired during the inguinal herniorrhaphy and be-
comes symptomatic postoperatively, simple ligation of the gonadal FIGURE 96.2. A3-cm seminoma of the lower pole of the bivalved testicle.
vein may be performed in the retroperitoneal space above the in-
guinal herniorrhaphy incision. Alternatively, it may be treated an-
giographically by placing a coil in the gonadal vein percutaneously. cord or by placing an intestinal clamp across the cord. The testi-
cle is then brought into the wound and walled off with laparotomy
pads and biopsied; if the mass is malignant, a radical orchiectomy
Masses of the Epididymis is performed. If it is benign, the tumor may be removed and the
tunica albuginea closed with interrupted 3-0 chromic catgut su-
Masses of the epididymis are rarely malignant. They are usually
tures. It is important not to violate the scrotum during this pro-
cysts or spermatoceles or, if solid, may be a cystadenoma or ade-
cedure and to use electrocautery for hemostasis.
nomatoid tumor. Cystadenomas may be associated with Lindau
If a radical orchiectomy is indicated, the vas is isolated at the in-
von Hippel disease. Removal of any of these lesions will inevitably
ternal ring, transected, and tied with 2-D silk. The vessels are then
result in transection of an epididymal tubule, thereby in essence
transfixed with 0 silk and divided. At the internal ring, the peritoneal
performing a vasectomy on that side. When such lesions are to be
sac should be dissected off the cord structures, ligated, and placed
removed in a patient who wishes to have children, one should be
in the retroperitoneum so that the cord remnants may lie freely in
assured of a normal contralateral testicle and vas. Removal of an
the retroperitoneal space, allowing easy identification of the distal
asymptomatic mass would not be justified at that stage in the pa-
end of the cord for a retroperitoneal lymph node dissection.
tient's life. If, on the other hand, a solid tumor is found, it must
If an undescended testis is identified during inguinal hernior-
be removed. This may be done by resecting the epididymis adja-
rhaphy and the patient is prepubertal, it should be mobilized, if
cent to the tunica albuginea of the testicle. The tumor should be
possible, enough to be brought down into its normal anatomical
sent for frozen section; if it is an adenomatoid tumor or a cys-
position in the scrotum where it can be palpated throughout the
tadenoma, nothing further need be done. If it is malignant, a rad-
person's life, to minimize the risk of unrecognized tumor. Al-
ical orchiectomy should be performed as described below.
though there is an increased incidence of testicular malignancy in
undescended testes, the overall incidence is relatively small. If the
Testicle testicle is undescended in an adult, chances that it will contribute
to fertility are relatively small. It will, however, produce testos-
Tumors of the tunica albuginea are generally benign. Not infre- terone. If it cannot be brought down into the scrotum in a post-
quentlya pseudo-tumor-a small fibroma-is found. It may be ex- pubertal patient, and if there is a normal contralateral testicle, the
cised and the tunica albuginea repaired with interrupted 3-0 undescended testicle should be removed. It should not be left in
chromic. Solid masses of the parenchyma of the testis are almost the canal, where it is difficult to palpate. If during the preopera-
always malignant. Generally, solid tumors of the testis are germ tive physical examination no testis is palpable and none is found
cell in origin and are of one of five histological types: seminoma, in the canal, the peritoneum should be opened. The testicle is of-
embryonal carcinoma, teratoma, teratocarcinoma, or choriocarci- ten found just deep to the internal ring.
noma (Fig. 96.2). Tumors involving the substance of the testis, if A hematoma of the scrotum may occur as a consequence of an
they are solid by palpation and if they replace most or all of the inguinal herniorrhaphy. More commonly, it can result from ex-
testis, should not be biopsied but should be removed by radical tensive dissection of the distal sac or inadequate hemostasis of the
orchiectomy, as salvage of a small segment of testicle, even if the veins along the cord. Such hematomas can be extensive and can
tumor were benign, is of little benefit. If unsure, the operating take up to 3 months to resolve. If such a hematoma is discovered
surgeon may biopsy the lesion. in the postoperative period, it is unwise to reexplore it unless it is
If a biopsy is to be performed, the cord should be isolated at expanding. Ecchymosis of the scrotum commonly appears. This
the internal ring and a venous occlusion clamp should be placed. is generally of no concern, and patient reassurance is all that is
This may be accomplished either by encircling the cord with a necessary.
Penrose drain and securing it tightly with a K elly clamp near the Occasionally, following a herniorrhaphy, the testis may be dis-
656 W.S. McDougal
placed. This can be extremely painful if it is at the level of the ex- the catheter is removed unless there is a high likelihood that the
ternal ring or near the pubic tubercle. One should always verify patient will be unable to void subsequently, as in patients who had
that the testis is in its normal anatomical position at the end of significant voiding difficulties preoperatively or elderly male pa-
the procedure. Draping to expose the scrotum allows it to be tients who are too unsteady to stand to void. It is preferable to
checked at the termination of the procedure. IT the testis is not treat patients who cannot void subsequently by intermittent self-
replaced in its proper site, it will scar in the abnormal position catheterization. Usually, the addition of an alpha blocker is help-
and become extremely painful to the patient, necessitating a sec- ful if the patient has not had a transurethral prostatic resection.
ond exploration and relocation. The use of bethanechol chloride in this population is to be con-
Congenital appendages of the testicle and epididymis are occa- demned.
sionally found if one looks carefully. They would not normally be In summary, there are a number of genitourinary tract prob-
discovered in a routine inguinal herniorrhaphy, as the testicle must lems that may be discovered during inguinal hernia repairs. Of
be delivered into the wound and the tunica vaginalis opened. Ap- greatest concern is the incidental discovery of solid tumors of the
pendages arise at the junction of the globus major of the epididymis testis, which are invariably malignant. These tumors should not be
and the testis. IT they arise from the epididymis they are appendices biopsied, leaving the testis in situ to be dealt with later. Instead,
epididymis, and if they arise from the testis they are appendices the testis should be removed at the time of the herniorrhaphy.
testis. They should be removed if larger than 0.5 cm. They may be Similarly, malignancies of the cord require immediate removal.
simply removed by using electrocautery and transecting them or li- Alert recognition of inadvertent injuries is the key to minimizing
gating them with a 4-0 chromic and surgically excising them. postoperative complications.
Difficulties Due to Previous

Genitourinary Procedures References
1. Pasquale MD, Shabahang M, Evans SR. Obstructive uropathy secondary
Following radical retropubic prostatectomy there is an increased to massive inguinoscrotal bladder herniation. J Urol 1993;150:1906-
incidence of inguinal hernias, as high as 12% in one series,6 al- 1908.
though this incidence appears much too high. For the most part, 2. Bolton DM, Joyce G. Vesical diverticulum extending into an inguinal
the hernias are indirect. They are usually recognized within the hernia. BrJ Urol 1994;73:323-324.
first year following radical prostatectomy. Approaching them 3. Jackman SU, Schulam PG, Schoenberg M. Pseudo tumor of the blad-
preperitoneally would likely be difficult, as the previous surgery der: a late complication of inguinal herniorrhaphy. Urology. 1997;50:
results in significant adherence of the bladder to the pelvis and 609-611.
surrounding structures. A standard inguinal herniorrhaphy inci- 4. Heifetz CJ. Resection of the spermatic cord in selected inguinal hernia:
sion works well. The hernias are often extremely adherent to the twenty years' experience. Anh Surg. 1971;102:36-39.
5. Bodhe YG. Condition of testicle after division of cord in treatment of
cord, and the sac is thickened. They can be dissected from the
hernia. BMJ 1959;1:1507-1510.
cord with care and patience. In our experience, postoperative com- 6. Wantz GE. Complications of inguinal hernia repair. Surg Clin Nurth Am.
plications have been minimal with this approach. 1984;64:287-298.
7. Patrick DA, Bensard DD, Karrer FM, et al. Is routine pathological eval-
uation of pediatric hernia sacs justified? J Pediatr Surg. 1998;33: 1090-
Postoperative Urinary Retention 1094.
8. Regan TC, Mordkin RM, Constantinople NC, et al. Incidence of in-
Initial treatment of urinary retention in the immediate postoper- guinal hernias following radical retropubic prostatectomy. Urology. 1996;
ative period is by straight catheterization. Upon decompression, 47:536-537.
97
Sports Injuries and Groin Pain
OJ.A. Gilmore
Introduction may also be of value. 4 Treatment involves a prolonged period of

rest. Local steroid injection may be of benefit, provided that in-
Groin pain is a common yet often complex presenting symptom fection can be excluded. Some patients may require symphysis pu-
in patients with sports injuries. Five percent of all patients referred bis fusion. In the past, a number of patients underwent unnecessary
to sports medicine clinics have groin injuries. l Such injuries ac- pelvic fusion due to misdiagnosis. They were in fact suffering from
count, however, for a greater percentage of time lost from sport. groin disruption, a condition only recently recognized. 5
Injuries to the groin are unilateral or bilateral; they may be acute
but are more often subacute or chronic. In many patients, groin
pain presents a challenging management problem.2 Muscle Injuries
Because of the various anatomical structures involved, patients
with sports injuries of the groin may be referred to orthopedic, Adductor
urological, or general surgeons, as well as to sports medicine spe-
cialists. The assessment of such patients includes taking a careful Adductor injuries occur in sportsmen as a result of eversion, ab-
history, meticulous examination of the abdomen, spine, hips, duction, and external rotation. Onset may be acute but is more
groin, scrotum, and lower limbs, and appropriate investigations. often insidious due to repeated minor traumas. Examination re-
The most common causes of groin pain in sport are reviewed in veals local tenderness at the adductor origins, extending along the
Table 97.1. muscles themselves. Pain is exacerbated by passive abduction and
resisted adduction. Ultrasonography and MRI scanning may be
useful in delineating the lesion.
Direct Trauma
Iliopsoas
Direct trauma may result from falls, punches, stick injuries, or kicks
to the groin, resulting in injuries to the external genitalia, mus- Iliopsoas strains occur when the hip is flexed actively against re-
cles, vessels, nerves, bones, and joints of the pelvis. Diagnosis is sistance, as sometimes occurs with repeated and rapid sit-ups. Ten-
based on history and examination, and in some patients x-rays, ul- derness is often difficult to localize as the iliopsoas origin is deep.
trasonography, magnetic resonance imaging (MRI), or even arte- Hip flexion against resistance is often painful.
riography is indicated.
Rectus Femoris
Osteitis Pubis The rectus femoris may be damaged at its origin, the anterior in-
ferior iliac spine. Injury tends to occur when kicks are blocked or
Osteitis pubis used to be the most common diagnosis in soccer play- as a result of sprint starts. The patient complains of pain on re-
ers with groin pain. 3 Today osteitis pubis is better referred to as sisted hip flexion and tenderness over the muscle insertion.
symphysis pubis instability. It is a distinct entity, but its occurrence is
not as frequent as was once thought. It is a low grade inflamma-
tion with associated increased movement at the symphysis pubis. Fractures
The patient usually complains of pain in the midline over the sym-
physis pubis and has a typical radiological appearance. Similar ra- Stress Fractures
diological findings are, however, present in many soccer players
who have been active for many years. In osteitis pubis, scintigraphy Stress fractures affecting the femoral neck or the inferior pubic
using technetium-99m shows an increased uptake at the symphysis ramus may typically present with pain at the site of the fracture.
pubis rather than in the region of the pubic tubercle. MRI studies The latter injury is seen in long-distance female runners.
657
658 OJ.A. Gilmore
TABLE 97.1. Causes of groin pain in sport injuries tient will have a femoral hernia, more rarely an obturator hernia.
Patients with an inguinal hernia have a palpable lump with a cough
Direct trauma impulse on standing, whereas femoral hernias are usually irre-
Muscular
ducible, presenting as a lump below and lateral to the pubic tu-
Adductor
Iliopsoas
bercle. Symptomatic hernias require surgical repair.
Rectus femoris
Rectus abdominis
Osteitis pubis Referred Pain
Fractures
Stress Referred pain may come from the spine, sacroiliac joints, testes,
Avulsion or urinary tract. Careful examination of the spine, looking par-
Bursitis
ticularly for a prolapsed intervertebral disk or spondylolisthesis, is
Iliopsoas
Trochanteric
mandatory in all patients with groin pain. Pain in the testicles may
Hip be related to trauma, inflammation, torsion, or, rarely, a tumor.
Osteoarthritis Retractile testicles often give discomfort in the groin, and patients
Perthes' disease should be directly questioned regarding this phenomenon. Occa-
Slipped epiphysis sionally, testicular fixation is indicated in patients with a trouble-
Hernia some retractile testicle. Obturator neuropathy has also been
Inguinal described as a cause of chronic groin pain.
Femoral
Referred pain
Spinal
Testicular Acute Groin Strains
Gynecological
Urological Acute groin strains are common in soccer, often seen in casual
Groin disruption players who fail to warm up adequately. The patient feels acute
pain, usually in the adductor insertion region, sometimes in the
inguinal region, following an abduction or external rotation in-
jury. Pain is felt on resisted adduction, and the patient is often ten-
Avulsion Fractures der along the line of the adductors. Treatment involves the
application of ice and a period of rest, followed by physiotherapy
Avulsion fractures are more common than stress fractures and may in the form of strengthening and stretching exercises. Local
occur at the insertion of adductor longus or the origin of rectus steroid injections should be avoided. In some patients, especially
femoris. Avulsion fractures are more common among younger those who sustain repeated trauma, acute groin strain may become
soccer players. Diagnosis is based on physical and radiological find- a chronic problem.
ings, and treatment is usually conservative, although large frac-
tures may require internal fixation.
Groin Disruption ("Gilmore's Groin")
Bursitis Groin disruption is a severe musculotendinous injury of the groin
that can be successfully treated by the surgical restoration of nor-
Bursitis is an inflammation most frequently affecting the iliopsoas mal anatomy.5-S The syndrome was first recognized in 1980 fol-
and trochanteric bursae. Diagnosis of the former condition can lowing the successful treatment of three English Premier Division
be difficult, as it is often associated with muscular damage. Treat- soccer players who had been unable to play for many months.
ment is conservative. Since 1980, 3550 patients, 3448 sportsmen and 102 sportswomen,
have been referred to the author, of whom 2131 males and 22 fe-
males have undergone surgery (Table 97.2).
Hip Problems
Patients may present with pain in the groin due to conditions such
as osteoarthritis or avascular necrosis of the hip. In the younger
patients, Perthes' disease or a slipped capital femoral epiphysis can TABLE 97.2. Incidence of operation related to sport, 1980--1998
cause symptoms. Sport Total referred Operation Percentage
Association football 2280 1593 70

Hernia Rugby 400 241 60
Athletes 106 41 39
Sportsmen complaining of pain in the groin could have a hernia. Racquet games 136 40 29
Cricket 84 56 66
An indirect inguinal hernia that becomes irreducible can produce
Hockey 53 27 51
groin pain. Patients with a direct inguinal hernia notice discom-
Other sports/general fitness 491 155 31
fort, particularly with prolonged standing or slow walking rather Total 3550 2153 60
than during more energetic sporting activities. Occasionally a pa-
97. Sports Injuries and Groin Pain 659
Etiology TABLE 97.3. Causes of increased pain in groin disruption

During sport Mter sport
In studies on soccer players we have shown that the underlying
problem in groin disruption is muscle imbalance and overuse. The Sudden movement Coughing
strong hip flexors that are used to kick the ball tilt the pelvis for- Sprinting Sneezing
ward; the forward tilted pelvis stretches the abdominal muscles, Striding Sit-ups
which become weak and fail to stabilize the pelvis; excessive phys- Accelerating
ical activity results in tears of the groin muscles, tendons, and lig- Twisting and turning Turning in bed
aments and thus groin disruption. Because of the underlying Side stepping Getting out of bed/car,
Dead ball kicking especially day after game
muscle imbalance, these patients also often have hamstring and
Long ball kicking Sexual intercourse
back problems, often lordosis.
Pathology Players' symptoms vary with their position. Goalkeepers com-

plain of pain with dead ball kicking; fullbacks and central de-
The severity of pathology found at operation varies. However, the fenders complain of pain with long ball kicking and turning; while
main features include midfield players, who are often smaller and faster, find their game
Tom external oblique aponeurosis inhibited and their high work rate slowed. Strikers and wingers
Tom conjoined tendon lose acceleration and speed. Patients with adductor tears complain
Conjoined tendon tom from the pubic tubercle of pain with instep kicking.
Dehiscence between conjoined tendon and inguinal ligament Pain in the groin increases throughout a game, particularly dur-
Lower rectus abdominis tear ing the last 20 minutes, and is exacerbated by specific movements
No inguinal hernia present (Table 97.3). The day after a game, turning or getting out of bed
or a car often causes pain, as does coughing, sneezing, and vig-
Edema and occasionally evidence of hemorrhage are present in orous sexual intercourse.
acute cases. The severity of the tears usually correlates with the pa-
tient's symptoms. Groin disruption is not a hernia because there
is no protrusion of viscus beyond its normal confines. Rugby
The incidence of groin disruption has increased in Rugby Union
Symptoms since the game turned professional in 1966 due to the greater
number of games played each season and the speed and more vig-
All patients present with pain in the groin, usually unilateral in orous nature of the professional game. Additional symptoms to
the inguinal region. More than 98% of patients presenting with those encountered in soccer include pain with jumping in the line
groin disruption are male, and in 70% the onset of symptoms is out and getting up after a tackle.
insidious, suggesting an overuse injury. In only 30% is there a his-
tory of a specific injury, usually overstretching, abduction, and
eversion injuries. The condition is most frequent in soccer play- Athletes
ers. Seventy percent of all patients referred to a groin clinic were
soccer players. Many symptoms are common to all sports; some The vast majority presenting are middle-distance, long-distance,
specific symptoms occur more frequently in different sports ac- and fun runners, hurdlers, and decathletes. No sprinters have pre-
cording to the activities involved. sented, perhaps because, compared with fun runners, sprinters
warm up and stretch for 90 minutes in order to run 10 seconds!
Soccer
Symptoms from the largest single group, professional soccer play-
Racquet Games
ers, have been analyzed; 1114 cases have been referred, and 915 Racquet game players may also complain of pain in the groin while
required operation. Players came from 85 of the 92 English foot- serving at tennis or when stretching high at the net.
ball league clubs and from Scotland, Ireland, Wales, Europe, and
the Middle East, representing a total of24 different countries. Play-
ers presented with pain in the groin, mostly unilateral in the in- Field Hockey
guinal region. The site of the pain was not related to the patient's
dominant side (right 47%, left 38%). In 12% symptoms were bi- The majority of players are from midfield. A history of a specific
lateral. Forty-eight percent also had adductor pain, and 6% had injury is unusual, while a history of frequent games on Astroturf
pain in the perineum. is common.
The duration of symptoms varied from 2 days to 5 years; while
the time since the last game, a most important consideration in a
professional sportsman, varied from 1 to 57 weeks. During the first Cricket
3 years of the study, the average delay before referral was 15 weeks;
during the next 4 years the average delay was 6 weeks, and more A history of specific injury is rare. Most patients are fast bowlers,
recently most players were referred within 2 to 3 weeks. usually complaining of pain of2 or more months' duration in the
660 OJ.A. Gilmore
groin of their landing leg. Symptoms are increased during the sec- Investigations
ond and subsequent bowling spells of each game.
Stork (flamingo) views of the pelvis are taken to exclude pelvic in-
stability and to check the hips and pelvis. Movement at the sym-
American Football physis pubis should be less than 3 mm. A herniogram has not
proved a reliable method for investigation since it often fails to
Symptoms encountered are similar to those in soccer players, es- demonstrate musculotendinous tears.
pecially pain with pushing off, striding out, sprinting, and twisting An isotope bone scan is useful to exclude osteitis pubis or hip,
and turning. pelvic, and spinal pathology.
In experienced hands, the MRI scan is proving valuable in groin
pathology. Symphyseal degeneration, osteitis pubis, muscle tears
Gaelic Football and Australian Rules (adductor, obturator, rectus femoris, and rectus abdominis), il-
iopsoas bursitis, true inguinal hernia (direct or indirect), and pre-
Such sportsmen, like certain positions in rugby, also get pain in hernia complex may be recognized, as well as hip and spinal
the groin with jumping and getting up after a tackle. pathology.4
Fitness Enthusiasts Treatment

Casual sportsmen and those who VISit gymnasia often develop
Surgery is indicated for patients who fail to respond to physio-
groin pain following inappropriate sit-ups and "crunches."
therapy and a standard rehabilitation program. Professionals usu-
ally require surgery if their game or training is restricted, resulting
in deterioration of their performance. For amateurs, surgery is
Physical Signs only indicated if normal activities are inhibited or lack of sport af-
fects quality of life.
There are no visible physical signs except in acute cases where
Successful treatment depends on accurate diagnosis, meticulous
there may be bruising at the inguinal region (Fig. 97.1). There is
surgery repairing each element of the disruption, and vigorous re-
no hernia or swelling. Diagnosis is made by inverting the scrotum
habilitation. Patients are admitted on the day of the operation and
and placing the examining little finger in the external inguinal
return home following postoperative physiotherapy within 24
ring on each side. On the affected side the ring is usually dilated,
hours.
there is a cough impulse, 'and most importantly there is tender-
Operation consists of a diagnostic exploration of the groin and
ness. Sometimes the tenderness is exquisite, but in patients who
surgical repair of each element using a six-layered suture tech-
have been resting it may be minimal. In some patients the tear in
nique. Exploration is carried out through a 6 cm incision, and
the external oblique is palpable via the scrotum as a V-shaped, ten-
each element of the disruption is identified. The external oblique,
der defect extending laterally from the superficial ring.
conjoined tendon, rectus abdominis, transversalis fascia, inguinal
In female athletes diagnosis is based on history and the pres-
ligament, pubic tubercle, lacunar ligament, and adductor inser-
ence of pain and tenderness in the inguinal region with sit-ups
tion are all examined and checked for contusions, tears, and
and resisted hip flexion.
dehiscence.
All patients must be tested for adductor weakness: Pain on re-
Normal anatomy is restored by repairing each element. The con-
sisted adduction and tenderness over the adductor insertion are
joined tendon and transversalis fascia are repaired using 2-0 Vicryl®
diagnostic of an adductor tear.
and the rectus abdominis with 1-0 nylon. The repaired conjoined
tendon is reattached to the pubic tubercle using 1-0 nylon and ap-
proximated to the inguinal ligament at a constant tension using
a 1-0 nylon darn, carefully avoiding further tears to the inguinal
ligament. The torn external oblique aponeurosis is repaired with
2-0 Vicryl before Scarpa's fascia is closed. The skin is sutured with
an absorbable subcuticular stitch. Occasionally, an adductor ten-
otomy is carried out through a separate, short adductor incision.
In patients requiring repair following previous exploration and
either laparoscopic or mesh repairs, plication of transversalis fas-
cia is omitted.
Rehabilitation
All patients are given physiotherapy in hospital immediately be-
fore discharge and follow a standard rehabilitation program (Table
97.4). Patients are instructed to start sprinting before resuming
FIGURE 97.1. Acute groin disruption. Bruising indicates site of disruption. twisting, turning, and kicking.
97. Sports Injuries and Groin Pain 661
TABLE 97.4. Groin disruption rehabilitation program pain on a simple diagram. Clinical examination of the groin must
be methodical, with assessment of the lower abdomen and inguinal
Week Actions
and adductor regions; the spine, hips, pelvis, thighs, and external
1 First day after operation: essential to stand upright and walk genitalia are also examined.
20 minutes The recognition and treatment of groin disruption has cured
Thereafter walk gently four times a day. Gentle stretching groin pain in many sportsmen. Although soccer players are the
exercises given by physiotherapists to be followed. most common patients with groin disruption, other sportsmen and
2 Jogging and gentle running in straight lines a few sportswomen (22 operations in 19 years) are affected.
Gentle sit-ups with knees bent Surgery is indicated most frequently for professional sportsmen.
Adductor exercises
In soccer, 82% of professionals required surgery compared with
Step ups
63% of semiprofessionals and 56% of amateurs. In cricket, 66%
3 Increase speed to sprinting
Increase sit-ups and adductor exercises of the 84 players seen required surgery, and in rugby 241 of 400
Cycling (60%) needed surgery.
Swimming (crawl) The incidence of groin disruption is increasing in sport, as more
4 Sprint games are played and breaks between seasons become shorter. The
Twist and tum incidence of diagnosis increases as more sports medicine special-
Kick ists and physiotherapists become aware of the syndrome. Previ-
Play ously some patients were diagnosed as osteitis pubis and were
subjected to long periods of rest; a few underwent unnecessary pu-
bic symphysis fusion, and some professional sportsmen were
Results forced to retire.
Careful rehabilitation is effective for some, especially younger
Surgery in professional players was considered successful in 887 patients with less severe disruption. However, many do not recover
of 915 cases, as measured by a return to league football. During even with prolonged rest. In chronic cases, healing will not occur
the first 8 years of the study, the average time of return was at 6 because the tom conjoined tendon is separated from the pubic
weeks (range 4 to 10 weeks). During the subsequent 11 years the tubercle and the inguinal ligament, and no amount of rest will re-
average return was at 5 weeks (range 20 days to 7 weeks). sult in the approximation of these structures. The recognition and
In patients with associated chronic adductor tears recovery may surgical treatment of groin disruption has resulted in the rapid
be delayed. Experience has shown the most effective treatment of restoration of many sportsmens' careers.
patients with combined groin disruption and adductor tears is re-
pair of the groin disruption with vigorous adductor stretching and
strengthening exercises both before and after surgery. References
During the course of the study, 10% of patients returned within
1 to 5 years with contralateral disruption, having recognized the 1. Renstrom P. Swedish research in sports traumatology. Chir Orthop. 1994;
symptoms themselves. 191:144-158.
2. Fricker PA. Management of groin pain in athletes. Br ] Sports Med.
Complications have been minimal, most patients being slim
1997;31:97-101.
and fit.
3. Harris NH, MurrayRO. Lesions of the symphysis in athletes. BM] 1974;
Reexploration for recurrent disruption has been required in 23 4:211-214.
professional soccer players. In over 19 years, 266 international 4. Gibbon WW. Abstracts-Annual Congress, BASM, 1998. BrJ Sports Med.
sportsmen have been successfully treated, including 180 soccer 1999;33:56--68.
players from 24 countries. 5. Gilmore OJA. Gilmore's groin: Ten years experience of groin disrup-
tion-a previously unsolved problem in sportsmen. Sports Med Soft Tis-
sue Trauma. 1991;3:12-14.
Discussion 6. Gilmore OJA. Gilmore's groin: A previously unsolved problem in sports-
men. In MacLeod DAD, Maughan RJ, Williams C, et al. (eds): Inter-
mittent high intensity exercise-preparation, stresses and damage
Groin pain in athletes presents a difficult clinical problem because
limitation. London E & FN Spon. 1993;477-486.
of the various conditions that may be responsible. The manage-
7. Gilmore OJA. Groin pain in the soccer athlete: fact, fiction and treat-
ment of sports injuries resulting in groin pain starts with a tenta- ment. Clin Sports Med USA. 1998;17(4):787-793.
tive diagnosis based on the patient's history. The site, onset, and 8. Gilmore OJA. Groin disruption in sportsmen. In Kurzer M, Kark A,
duration of pain must be recorded, as must exacerbating and re- Wantz G (eds): Surgical management of abdominal wall hernias. London:
lieving factors. The patient should identify the site (or sites) of Martin Dunitz Ltd, 1999:151-157.
98
Hernias and Patients with Ascites
J. Belghiti and M. Hakim
The presence of ascites increases the incidence of hernias in gen- suIts in a portocaval collateral circulation. This venous collateral
eral and umbilical hernias in particular. It greatly complicates the circulation through paraumbilical veins may sometimes be very
decision-making process necessary to provide optimal care. 1,2 As- important and is referred to as the Cruveilhier-Baumgarten syn-
cites may be seen in conditions such as chronic renal disease, con- drome. 6 In some cases, inflammatory phenomena within the peri-
gestive heart failure, or massive fluid overload, but it is more often toneal sac are pronounced enough to favor adhesions between the
related to intraabdominal factors that lead to the formation of omentum and the deep surface of the peritoneal sac, thus creat-
peritoneal fluid at a more rapid rate than that at which it can be ing further collateral circulation from the omental veins to the
absorbed. These conditions are malignancies, tuberculosis, pan- paraumbilical and epigastric veins.
creatitis, acute liver diseases, and chronic liver diseases, which are
by far the most common causes of ascites. The problem of ab-
dominal hernias and, in particular, umbilical hernias in patients
with ascites concerns almost exclusively patients with cirrhosis. In
Natural History of Umbilical Hernia in
these patients, chronic increased intraabdominal pressure as well Cirrhotic Patients
as muscular wasting, a consequence of malnutrition, are thought
to be the main predisposing factors to umbilical hernia develop- When ascites is absent, the prevalence of umbilical hernias is sim-
ment. 3 Incisional hernias and groin hernias are seen less fre- ilar to that usually observed in noncirrhotic patients. Umbilical
quently in cirrhotic patients than umbilical hernias. Whereas hernias are observed in up to 20% of cirrhotic patients who de-
umbilical herniorrhaphy of an uncomplicated hernia in patients velop ascites. 7,s Umbilical hernias occur usually during the third
without ascites can be performed with low mortality and morbid- ascitic episode. s The size and evolution of an umbilical hernia de-
ity, cirrhotic patients with ascites bear a higher risk of complica- pend on the evolution of the ascites. The size of the hernia in-
tions before and after operation. 4 ,5 There, the treatment of ascites creases with persistence of the ascites and diminishes when ascites
appears to be a major determinant of prognosis. disappears. The hernia may take on the appearance of a cutaneous
appendage imparting an undesirable cosmetic aspect. In some
cases, when the umbilical ring remains very narrow, ascites may
disappear from the peritoneal cavity, leaving ascitic fluid in the
Umbilical Hernia peritoneal sac, which becomes partitioned, persistent, giving the
impression of irreducibility and, hence, an erroneous diagnosis of
Anatomical Considerations strangulation.
Cutaneous trophic disorders could, as well, complicate long-
The umbilicus is a cutaneous scar that adheres to a fibrous ring standing umbilical hernias. The skin becomes very thin, and
through a very thin subcutaneous layer. This layer consists of a fat telangiectasias appear before ulceration and rupture. These cuta-
panniculus and a fascia superficialis. On the deep side, the um- neous changes are particularly prominent when hepatocellular
bilicus is covered by peritoneum and subperitoneal tissue. The fi- functions are impaired. It has been shown that cutaneous trophic
brous ring of the umbilicus often adheres directly to peritoneum. changes and! or umbilical rupture have always been associated
Ascites results in intraabdominal pressure that displaces the peri- with decreased coagulation factors and resistance of ascites to med-
toneum through the umbilical ring, thus flattening out the um- ical treatment. 9 Umbilical hernias may strangulate. This event is
bilicus. Should ascites persist or recur, the peritoneal sac enlarges actually quite rare and can be explained by the fact that the um-
as it spreads out through the umbilical ring into the subcutaneous bilical ring often remains very narrow, preventing regress and
space. This subcutaneous peritoneal sac, which contains ascitic hence leading to incarceration of a viscus through the ring. When
fluid, is directly in contact with the skin. The skin becomes thin- an umbilical ring is wide enough to permit the passage of a por-
ner and may ulcerate, leading to an umbilical rupture. The per- tion of a hollow viscus, in general a loop of small intestine, the as-
sistence or recurrence of ascites may also lead to a widening of cites favors slipping of this portion back from the umbilical ring.
the umbilical ring. The portal hypertension due to cirrhosis re- In such situations, the ascites acts as a lubricating agent. Umbili-
662
98. Hernias and Patients with Ascites 663
cal hernia strangulation may occur if rapid and/ or sudden diminu- is most important to verify the absence of ascites infection by punc-
tion of ascites is attempted by an evacuating paracentesis, effec- ture and bacteriological cultures before contemplating a perita-
tive medical treatment, peritoneojugular shunt, or simply by neovenous shunt for refractory ascites.
natural umbilical rupture. Pre- or postoperative treatment of ascites by transjugular, in-
Umbilical rupture is the most serious complication because of trahepatic portocaval shunt could become an attractive alterna-
the high risk of infection of the ascitic fluid and difficulty in ob- tive in patients with intractable ascites associated with an umbilical
taining wound healing. When ascites has free contact with the skin, hernia. 12
infection rapidly sets in. Infection and a continuous leak prevent Recurrence rates for umbilical herniorrhaphy in cirrhotic pa-
proper wound healing and cause maceration of the skin.l° Um- tients with ascites have been reported to be as high as 50 to 60%.1
bilical rupture is almost always preceded by cutaneous trophic The increased risk of recurrence is due to the recurrence of as-
changes. The skin gets thinner, and small ulcerations can appear. cites. 9 To prevent a recurrence, nonresorbable prosthetic mesh
These signs should be recognized early in order to initiate proper should be used. Whether the use of this material can prevent a
treatment before rupture takes place. postoperative recurrence has not been resolved. It is certain, how-
ever, that the risk of infection is increased. In a collective review
of 180 abdominal hernias in cirrhotic patients, nonresorbable
Surgical Indications prostheses were used in 16 patients with 2 (12.5%) postoperative
deaths from sepsis, while there were only 4 (2.4%) postoperative
As mentioned above, ascites is indeed the main therapeutic prob- deaths among the 164 patients in whom mesh prostheses were not
lem facing surgery of umbilical hernias in cirrhotic patients. The employed. 13
treatment of ascites should be the first objective. An abdominal
ultrasound should always be done in order to be sure of the ab-
sence of ascites from the peritoneal cavity, around the liver, and Postoperative Care in Cirrhotic Patients
in the pouch of Douglas. Surgical treatment becomes easy, with
low morbidity and mortality, when the patients are operated on As shown in Table 98.1, postoperative mortality rate is higher in
after the ascites has been properly treated. complicated hernias (i.e., strangulated and ruptured) than in un-
When ascites persists, even after sound medical treatment, it is complicated hernias. In a cirrhotic patient, the factors that could
reasonable to perform an isolated surgical treatment of an um- make a postoperative course worse are portal hypertension, he-
bilical hernia. However, surgery under such conditions may be as- mostatic disorders, high risk of infection, and ascites. The veins of
sociated with a discharge of ascitic fluid in the postoperative a collateral circulation have very fragile walls with high pressure
period. The treatment of postoperative ascites is possible either by blood flow. Surgical dissection may be difficult and results in in-
repeated paracenteses or by suction drainage tubes. In special creased blood loss during operation. It has been suggested that
cases, a simultaneous peritoneojugular shunt at the same opera- an umbilical herniorrhaphy could precipitate an acute variceal
tion could be proposed. bleed through the interruption of portal systemic venous collat-
Results from the simultaneous surgical treatment of hernia and erals. 6 As shown in Table 98.2, our experience and that of others
ascites, using a peritoneojugular shunt, show that the morbidity does not substantiate this hypothesis. Disturbances in hemostasis
associated with infectious complications are more important than are considered to be a reflection of hepatic cellular dysfunction
after the surgical treatment of the hernia alone. 9 Herniorrhaphy and failure. When moderate, they usually do not have any clinical
and concomitant peritoneovenous shunt should be reserved for significance. When the prothrombin time is markedly prolonged,
patients operated on in an emergency for umbilical rupture (there its correction necessitates the administration of fresh frozen
is cutaneous ulceration that precedes rupture) and for patients in plasma. The increased risk of infection in cirrhotic patients ac-
whom ascites is really refractory to medical treatment. 9,1l When counts for the high rate of both spontaneous peritonitis and post-
patients are operated on in an emergency for a strangulated her- operative ascitic infection. Prophylaxis of infectious complications
nia, a peritoneovenous shunt cannot be carried out at the same in cirrhotic patients requires broad spectrum cephalosporins.l4
time if there are ischemic changes of the gastrointestinal tract. It Postoperative ascites, which is the principal complication in cir-
TABLE 98.1. Mortality rates for umbilical herniorrhaphy in cirrhotic patients according to the
presence or absence of a complicated hernia
Complication present
Complication absent Rupture Strangulation
No. Death No. Death No. Death
O'Hara5 26 2 6 1 3 3
Baron 6 12 4 3 2 1 0
Be1ghiti9 29 0 4 0 7 0
Yonemoto 17 7 0 1 0 o
Gillet18 6 0
Lemmer19 9
Total 74 6 19 4 12 3
(8.8%) (14%) (25%)
664 J. Belghiti and M. Hakim
TABLE 98.2. Postoperative variceal bleed following umbilical cites leakage around them and the almost certain infection of the
herniorrhaphy in cirrhotic patients ascitic fluid.
Postoperative
No. Mortality bleed
Umbilical Rupture
O'Hara5 35 5 2
Baron6 16 4 5 The indications for operative treatment of an umbilical rupture
BeIghiti9 40 0 o remain controversial. Some authors do not recommend emer-
Yonemoto l7 9 0 o gency surgery, but suggest daily sterile dressings associated with in-
Lemmer l9 9 1 o
Fisher2° travenous antibiotics, fluid and electrolyte balance, and medical
2 0 1
Eisenstadt21 3 0 1 treatment of the ascites. Dressings should be tight and occlusive.
Pescovitz22 22 1 2 The medical treatment of the ascites should be complemented by
Total 136 13 (9.5%) 11 (8%) repeated paracentesis.
Because of the high risk of ascites infection and the possibility
of concomitant surgical treatment of both ascites and umbilical
hernia, some authors recommend a more expedient operation.
Compressive sterile dressings are applied along with electrolyte
rhotic patients, is almost constant after surgery for umbilical her-
balance, antibiotics, and paracenteses. Samples are collected for
nia. This ascites is caused by several mechanisms, including in-
cell count and bacteriological culture. If the ascites is not infected,
creased water and sodium retention, the suppression of collateral
it becomes possible to realize a simultaneous umbilical hernior-
circulation, and lymphatic dissection. The main consequences of
rhaphy and peritoneovenous shunt.
ascites include increased intraabdominal pressure with the risk of
leakage through the abdominal wall and pleural effusions.
Herniorrhaphy and Concomitant

Technical Considerations of Umbilical Peritoneovenous Shunt
Herniorrhaphy in Cirrhotic Patients To prevent the reaccumulation of ascitic fluid postoperatively,
herniorrhaphy and concomitant peritoneovenous shunting in cir-
Uncomplicated Umbilical Hernia rhotic patients with umbilical hernia can be proposed. 9 The op-
eration is usually performed under general anesthesia. Insertion
Operation can be performed under local or general anesthesia.
of the peritoneovenous shunt is divided into the following steps:
The surgical repair begins with a transverse elliptical incision,
(1) extraperitoneal insertion of the valve through a right subcostal
which is done at least 2 cm beyond the umbilicus and cuts through
incision and introduction of the perforated tube into the ab-
healthy, thick skin. The sac is reflected from the skin, and the neck
dominal cavity; (2) dissection of the right jugular vein and place-
of the sac is isolated from the margins of the umbilical ring,
ment of the valve outlet tubing subcutaneously-the tip of the tube
opened at the level of the umbilical ring, and the contents
is left in the incision surrounded by gauze pads; (3) replacement
inspected.
of ascitic fluid with 5-6 L of normal saline to prevent coagulopa-
When omentum is adherent to the deep margins of the sac, it thyl6; (4) surgical repair of the hernia (the periumbilical fascia is
should be freed carefully. Hemostasis is done by vessel ligation be-
closed with a continuous suture of nonabsorbable material only
cause of collateral circulation. Ascitic fluid samples should be taken
when fluid is observed in the catheter in order to avoid entry of
for bacteriological cultures. The peritoneal sac is then excised and
air and into the abdomen and ultimately through the shunt); and
closed with a continuous resorbable suture. The margins of the
(5) the venous tube is inserted in the jugular vein down to the su-
umbilical defect are closed transversely with interrupted or con-
perior vena cava.
tinuous nonresorbable sutures by overlapping these margins.
Cutaneous closure should be impervious and hemostatic, but
not create ischemia. Ascitic leakage could delay wound healing
and promote the bleeding diatheses usually seen in cirrhotic pa- Groin Hernias
tients and could be responsible for persistent, diffuse bleeding. 15
The incidence of groin hernias and the natural history of this com-
plication are not well established in cirrhotic patients. Strangula-
Strangulated Hernia tion of a groin hernia is rarely observed in cirrhotic patients with
ascites. In a series of 18 patients with a groin hernia published by
In the case of strangulated hernia, the neck of the hernial sac is Hurst et al.,2 three patients were operated on urgently, two be-
generally wider. Often the omentum needs to be resected, hemo- cause of recent difficult reduction and one because of incarcera-
stasis being done by ligatures. If intestinal loops are incarcerated, tion without strangulation. In a collective review of 26 groin
their viability must be ascertained before proceeding to the repair. hernias operated on since 1985, incarceration was observed in 3
The peritoneum can frequently be very thick in patients with (12%).13 No patients required a bowel resection. In all patients
long-standing ascites. Necrosis of an intestinal loop should lead to who presented as emergencies and were operated on, ascites was
resection. The operative field should be thoroughly protected absent, suggesting that, similar to patients with umbilical hernias,
from contamination because of the high risk of ascites infection. the persistence of ascites protects against strangulation. Incarcer-
Stomas should be strongly avoided because of the high risk of as- ation and strangulation are apt to occur when the rapid or sud-
98. Hernias and Patients with Ascites 665
den diminution of ascitic fluid is attempted. Elective groin hernia concomitant peritoneovenous shunting in cirrhotic patients with um-
repairs in cirrhotic patients without ascites or in the presence of bilical hernia. World] Surg. 1990; 14:242-246.
moderate ascites can be performed safely. 2 However, when a groin lO. Rosemurgy AS, Statman RC, Murphy CG, et al. Postoperative ascitic
hernia is associated with significant ascites, the treatment of the leaks: the ongoing challenge. Surgery. 1992;1II:623-625.
11. O'Connor M, Allen JI, Schwartz ML. Peritoneous shunt therapy for
ascites becomes a priority because postoperative ascitic infection,
leaking ascites in the cirrhotic patients. Ann Surg. 1984;200:66-69.
poor wound healing, and recurrence can be observed in these pa-
12. Zemel G, Katzen BT, Becker GJ, et al. Percutaneous transjugular por-
tients with limited life expectancy.2
tosystemic shunt.]AMA. 1991;266:390-393.
13. BelghitiJ, Gillet M. La chirurgie digestive chez Ie cirrhotique. In Mono-
graphie de l'Association de Chirurgie Digestive. Paris: Springer Verlag; 1993.
14. FelisartJ, Rimola A, Arroyo V, et al. Cefotaxime is more effective than
References is ampicillin-tobramycin in cirrhotics with severe infections. Hepatol-
ogy. 1985;5:457-462.
1. Runyon BA, Juler GL. Natural history of repaired umbilical hernias in 15. Belghiti J. Traitement chirurgical de la hernie ombilicale du cirrho-
patients with and without ascites. Am] GastroenteroL 1985;80:38-39. tique. Editions Techniques. Encycl Med Chir (Paris, France). Tech-
2. Hurst RD, Butler BN, Soybel DI, Wright HK Management of groin niques chirurgicales, Appareil Digestif 40146,1991; 6p.
hernias in patients with ascites. Ann Surg. 1992;216:696-700. 16. BiaginiJR, BelghitiJ, Fekete F. Prevention of coagulopathy after place-
3. Franco D, Charm M, Jeambrun P, et al. Nutrition and immunity after ment of peritoneovenous shunt with replacement of ascitic fluid by
peritoneovenous drainage of intractable ascites in cirrhotic patients. normal saline solution. Surg Gynecol Obstet. 1986;163:315-318.
Am] Surg. 1983;146:652. 17. Yonemoto RH, Davidson CS. Herniorrhaphy in cirrhosis of the liver
4. Leonetti JP, Aranha GV, Wilkinson WA, et al. Umbilical herniorrhaphy with ascites. N Engl] Med. 1956;255:733-739.
in cirrhotic patients. Arch Surg. 1984;119:442-445. 18. Gillet M, AdIoff M, Imler M. Les ruptures de hernie ombilicale chez
5. O'Hara ET, Olia A, Patek AJ, Nabseth DC. Management of umbilical les cirrhotiques avec ascite.] Chir. 1967;93:83-92.
hernias associated with hepatic cirrhosis and ascites. Ann Surg. 1975; 19. Lemmer JH, Strodel WH, Knol JA, Eckhauser FE. Management of
181:85-87. spontaneous umbilical hernia disruption in the cirrhotic patient. Ann
6. Baron HC. Umbilical hernia secondary to cirrhosis of the liver. Com- Surg. 1983;198:30-34.
plications of surgical corrections. N Engl] Med. 1960;27:824-828. 20. Fisher J, Calkins GW. Spontaneous umbilical hernia rupture; a report
7. Chapman CB, Snell AM, Rowntree LG. Decompensated portal cir- of 3 cases. Am] GastroenteroL 1978;69:689-693.
rhosis. ]AMA. 1931;97:237-244. 21. Eisenstadt S. Symptomatic umbilical hernias after peritoneovenous
8. BelghitiJ, RueffB, Fekete F. Umbilical hernia in cirrhotic patients with shunts. Arch Surg. 1979;114:1443.
ascites: Prevalence, course and management. Gastroenterology. 1983;84: 22. Pescovitz MD. Umbilical hernia repair in patients with cirrhosis. No
1363A evidence for increased incidence of variceal bleeding. Ann Surg.
9. BelghitiJ, Desgrandchamps F, Farges 0, Fekete F. Herniorrhaphy and 1984; 199:325-327.
99
Paraostomy Hernias: Prevention and
Prosthetic Mesh Repair
Paul H. Sugarbaker
Definition of Paraostomy Hernia Paraostomy hernia is the most frequent late complication of an
ostomy. It occurs in 10 to 25% of the patients. l -4 A hernia as a re-
A hernia is the abnormal protrusion of an organ or tissue through sult of ostomy construction is more common after an ileal conduit
an opening. An ostomy is an artificial opening through the ab- than after ileostomy or colostomy. Hernias almost universally oc-
dominal wall of intestine or ureter for the discharge of intestinal cur at the lateral side of the ostomy site. A separation between the
contents or urine. Unfortunately for patients with ostomies, a her- segment of the intestine and the lateral aspect of the tunnel per-
nia alongside the viscus that penetrates the abdominal wall is not mits omentum or the small intestine to move into a subcutaneous
unusual. Hernias that are associated with colostomies, ileostomies, space. With time, this space enlarges, and a hernia progressively
jejunostomies, or urostomies would all be classified as paraostomy increasing in size is formed.
hernias. With a sliding enterostomy hernia (Fig. 99.1) there is migration
of the same segment of intestine that terminates in the ostomy
into a subcutaneous pocket. There are two causes for this sliding
Mechanism of Paraostomy Hernias hernia. First, the segment of intestine used to construct the os-
tomy was not sutured to the lateral wall of the abdomen. Second,
A paraostomy hernia occurs most frequently in patients who have and more important, a separation occurs between a segment of
inadequate wound healing between the ostomy tunnel and the vis- intestine and the tunnel. The intestine leading to the ostomy slides
cus that extends through the abdominal wall. Any decrease in scar into this space and creates a subcutaneous pocket. In this type of
formation in the early postoperative period will increase the inci- hernia the ring of peritoneum, muscle, and fascia that occurs at
dence of paraostomy hernia. Poor nutrition, progressive cancer, the abdominal entrance of the hernia is quite narrow. Conse-
and poor surgical technique that fails to approximate bowel and quently these hernias are at risk for incarceration.
abdominal wall are all prominent causative factors. Other post- The second type of hernia is a paraenterostomy hernia. In this
operative problems that would tend to separate these tissues will type of hernia the opening in the layer composed of peritoneum,
also lead to an increased incidence of paraostomy hernias. Cough- muscle, and fascia has greatly expanded. Omentum, loops of small
ing, sneezing, and ascites are associated etiological factors. The bowel, and other abdominal contents will fill the hernial sac. This
improper location of an ostomy through a tendinous portion of type of hernia is easy to reduce and rarely results in an incarcer-
the abdomen rather than through a muscular area will also ination (Fig. 99.2).
crease the incidence of paraostomy hernia formation. Hernias have tended to form laterally in a m3Jority of patients
because it has been impossible, using previously described tech-
niques, to place sutures accurately and bring together the sero-
muscular layer of the intestine and the lateral aspect of the tunnel.
Prevention of Paraostomy Hernia The surgical technique described below introduced a new method
of suturing the remote surface of the intestine to the lateral as-
Patients who must use an ostomy usually tolerate this change in pect of the tunnel so that separation lateral to the enterostomy
lifestyle well if their quality of life is not impaired. If leakage of does not occur and hernias are prevented.
the appliance and its accompanying embarrassment repeatedly oc-
cur, there is a marked decrease in the quality of life for the pa-
tient. Hernias that occur around an ostomy cause an unstable base
for the appliance. Coughing, sneezing, exercise, and other activi- Surgical Technique
ties that cause an increase in intraabdominal pressure will often
dislodge the ostomy bag. To preserve an optimum quality of life Adair clamps are placed on the peritoneum and the fascia along
and provide the best possible rehabilitation after surgical proce- the midline incision of the abdomen. This allows the abdominal
dures, it is imperative that the incidence of hernia from ostomy wall to be elevated and the enterostomy site to be exposed. An ap-
be kept at a minimum. propriate site is selected for the enterostomy. A plug of subcuta-
666
99. Paraostomy Hernias 667
','
FIGURE 99.1. Sliding enterostomy hernia.
neous tissue, fascia, muscle, and peritoneum is removed from the

wall of the abdomen. Its diameter will vary with the size of the in-
testinal segment that is to be brought through the abdominal wall.
Care is taken while removing the tissue of the abdominal wall to
avoid injury to the inferior epigastric artery.
The intestine is divided using a stapling device. The proximal
segment of intestine is brought up through the abdominal wall
and made to protrude approximately 3 cm above the skin. Care
must be taken not to damage the delicate mesenteric vasculature
while moving the segment of intestine through the abdominal wall. FIGURE 99.3. Preparing the enterostomy tunnel. A plug of skin, subcuta-
The position of the intestine as it comes from the tunnel entrance neous tissue, fascia, muscle, and peritoneum, approximately 3 cm in di-
is marked by stay sutures. These stay sutures should go through ameter, is removed from the abdominal wall of the lateral border of the
the seromuscular layer of intestine and then through all of the lay- rectus muscle. Care is taken to avoid the inferior epigastric artery. The in-
ers offascia, muscle, and peritoneum (Fig. 99.3). testine has been divided with a stapling device. Its distal end is brought up
Now the segment of intestine is removed from the tunnel and through the abdominal wall and made to protrude 3 cm above the skin.
placed on traction within the abdominal cavity. Interrupted su- Adair clamps are placed on the skin and fascia of the abdominal wall so
tures are individually placed through the seromuscular layer of that the exit site for the intestine through the wall of the abdomen can be
clearly visualized. The position of the intestine within the tunnel entrance
the intestine on the remote side of the intestinal segment (Fig.
is marked with lateral stay sutures. These sutures should go through the
99.4). These sutures also incorporate the full thickness of peri- seromuscular layer of the intestine and full thickness of the muscle and
toneum, muscle, and fascia. The sutures are placed approximately fascia of the abdominal wall.
0.5 cm apart and distributed so that there is minimal gathering of
the tissues. This layer of sutures prevents the separation of ab-
dominal wall and bowel at the lateral aspect of the enterostomy tunnel and will prevent a hernia from forming medial to the en-
and the development of a space that would eventually result in a terostomy site.
hernia. To prevent prolapse and a sliding hernia, the mesentery of the
The segment of intestine is again passed through the enteros- segment of the intestine is sutured to the lateral side of the ab-
tomy tunnel. Sutures through the seromuscular layer of the front dominal wall defect. This series of sutures also prevents hernia-
part of the intestine and full-thickness fascia, muscle, and peri- tion of the loops of the small intestine between the intestinal
toneum are individually positioned and tied (Fig. 99.5). This layer segment and the abdominal wall. At this point, the midline inci-
of sutures prevents separation of the wall of the intestine and the sion in the abdominal wall is closed.
If the bowel has been well prepared and no stool leakage can
occur, the staple line closing off the end of the bowel should be
removed. Figure 99.6 shows the three-cornered stitch that is used
to mature the ostomy primarily.
If proper healing occurs, a functional ostomy is constructed that
affords the patient a reasonable quality of life and minimal dys-
function. The structure of the ostomy and its component parts are
illustrated in Fig. 99.7.
Discussion
We have described an essential new step in the construciton of an
ostomy, consisting of a layer of sutures to prevent separation of
FIGURE 99.2. Paraenterostomy hernia. the lateral wall of the intestine from the peritoneum, fascia, and
668 P.H. Sugarbaker
FIGURE 99.6. The ostomy bud is matured primarily with a three-cornered

FIGURE 99.4.Suturing the back wall of the intestine to the lateral aspect stitch.
of the enterostomy tunnel. The intestine is now removed from the en-
terostomy tunnel and placed on traction within the peritoneal cavity. In-
terrupted sutures are individually placed along the back wall of the
intestine to bring the seromuscular layer of intestine into apposition with A m.yor problem seen with enterostomies may result from mi-
the fascia and muscle of the abdominal wall. gration of the terminal segment of intestine into a subcutaneous
space. This is a sliding enterostomy hernia. Alternatively, this in-
muscle of the enterostomy tunnel. Thus, the eventual formation testinal segment may intussuscept through the stoma and result
of a hernia is prevented. in prolapse. Both of these problems can be prevented if the mesen-
Even if the separation of the enterostomy tunnel and the seg- tery of the intestine is sutured in multiple areas to the lateral as-
ment of intestine is minimal, a hernia may eventually develop. If pect of the abdominal wall. Securing the mesentary to the
this space becomes lined with peritoneum, omentum or loops of abdominal wall also prevents the formation of an internal hernia.
intestine can enter this space. Over time, the subcutaneous pocket
enlarges due to continuous pressure. As the space enlarges, the
hernia grows in size more rapidly. This is why hernias tend to con- Peritoneal Approach to Prosthetic Mesh
tinue to enlarge and never regress spontaneously. Repair of Paraostomy Hernias
The incidence of paraostomy hernia approaches 30% following
abdominoperineal resection. 1•2 Following more extensive dissec-
tions, such as pelvic exenteration, the incidence is yet higher. Some
authors have suggested that paracolostomy herniation may be re-
duced if the colon is brought to the abdominal wall through a
retroperitoneal approach. 3 Others have found that this reduces
the incidence of hernia little or not at all. 2.4
The incidence of paraostomy hernia recurrence following a stan-
dard repair is difficult to determine from the surgical literature.
However, success with the technique is limited, and recurrence
rates of 50% are not unusual.
Three different approaches to paraostomy hernia repair have
been reported. Thorlakson5 advocated a direct surgical attack on
the hernia; the hernia, usually occurring lateral to the stoma site,
is opened, the sac is dissected away, colon is secured to the ab-
dominal side wall, and fresh fascial edges are tightened up around
the intestine. Goligher4 suggested an operation to relocate the
colonic stoma with direct repair of the abdominal wall defect.
In large hernias present for many years, direct reapproximation
of fascia to close the defect may not be possible. Use of a pros-
FIGURE 99.5. Suturing the front wall of the intestine to the enterostomy
tunnel. The intestine is again brought out through the enterostomy tun- thetic mesh is indicated in this situation. However, its use may
nel. Interrupted sutures through the seromuscular layer of the intestine cause serious infectious complications because of bacterial contam-
and the fascia of the abdominal wall are individually positioned and tied. ination of the mesh by the stoma itself, which must be within the
The mesentery is secured to the lateral abdominal wall to prevent prolapse. operative field. Rosin and Bonardi,6 Abdu,7 and more recently
99.7. The completed enterostomy with

FIGURE Stoma Exit Site
nomenclature. Mucosal Bud
Skin --==~==::::~=~~
Subcutaneous ----,,-<s;:......-+......."\-....>--i~.:>'iJJ..
Tissue ~~~~~~=--Tunnel
Muscle/Fascia
Peritoneum
Garnjobst and Sullivans advocated the use of Marlex® mesh within pairs done for hernias at the site of the colonic stoma in that the
a contaminated operative field surrounding a stoma. They re- old midline or paramedian abdominal incision is reopened. Adair
ported only minor problems with sepsis in the patients studied. clamps or a self-retaining retractor are used to elevate the fascial
Nevertheless, the use of foreign material in a contaminated oper- edge of the left side of the abdominal incision. As adhesions are
ative field should be avoided if possible. dissected away, the contents of the hernial sac are delivered into
We advocate prosthetic mesh for repair of the fascial defect with- the abdominal cavity (Fig. 99.10). The portion of the colon exit-
out the problems that bacterial contamination of the operative ing through the colonic stomas is easily located because it was ear-
field presents. The stomal bud is not disturbed, and thus return lier intubated with a large catheter or colonoscope.
to normal intestinal function is rapid. In addition, the colon is led It is important to identifY clearly the fascial ring at the perime-
out through a mesh flap valve so that further herniation around ter of the hernia. It is not necessary to dissect the parietal peri-
the colon is unlikely.9,IO toneum out of the hernial sac, but this is usually accomplished
without difficulty if the exposure is adequate. A ring of prosthetic
mesh is cut so that it will snugly fill the fascial defect. Individual
Surgical Procedures sutures are placed at approximately 1 cm intervals around the fas-
cial ring except directly laterally, where the colon will enter the
The intestine is prepared as for a colonic operation using me- abdominal cavity from the subcutaneous tissue. Sutures are se-
chanical and antibiotic preparation. A short course of periopera- cured to the mesh so that all sutures are under equal stress, and
tive systemic antibiotics is begun before surgery. To facilitate it is therefore, unlikely that individual sutures will pull through.
location of the colon intraoperatively, a large rubber catheter or The colon is led out over the mesh to the left lateral abdominal
colonoscope is passed approximately 20 cm into the colon. The wall and secured there with sutures (Fig. 99.11). The abdominal
colonic stoma is walled off from the operative field with an adhe- incision is closed in a routine manner (Fig. 99.12).
sive plastic drape. One primary and six recurrent paraostomy hernias have been
Figure 99.8 shows a large paracolostomy hernia appropriate for repaired using prosthetic mesh positioned through a peritoneal
this type of repair. Figure 99.9 shows the anatomical situation one approach. No recurrences have been observed during a minimum
may encounter, with small intestine lying alongside the exiting
colon and, often omentum caught up in the hernial sac. Fascial
edge are attenuated, and the peritoneum and skin are greatly
stretched.
The surgical approach in this procedure differs from other re-
."1_. '
~" .," ':<:.
'~"'····r···-------···~
PREVIOUS INCISION .--.:.::.:. ...../
FIGURE 99.8. In a paracolostomy or paraostomy hernia, bowel and omen- FIGURE 99.9. Anatomical situation usually encountered in a recurrent
tum are usually found within the hernial sac. paraostomy hernia.
670 P.H. Sugarbaker
-----~-~--------------------
( A 'J ..
f11111thtl't'l'l'O ll-f+
...... ::: ..... .
FIGURE 99.12. The abdomen is closed with the hernia repaired.
FIGURE 99.10. A peritoneal approach is taken to expose the paraostomy

hernia. Usually this means opening an old midline or paramedian incision. Our experience with prosthetic mesh repair of paraostomy her-
nias has been excellent. In long-term follow-up the prosthetic
mesh has not become infected. The fibrous ingrowth that sur-
4-year follow-up. Prosthetic mesh repair has provided good func- rounds the mesh in time prevents recurrence of a hernia at all os-
tion. No other ostomy problems such as prolapse, fistulization, tomy sites. Other problems such as prolapse and stenosis have not
stenosis, or retraction have resulted from the repair of these seven occurred. In the urostomy patient no urine stasis within the con-
paraostomy hernias. duit or increase in the frequency of urinary tract infections oc-
curred. Our unusually low incidence of recurrence may be related
to the flap-like valve that exists over the bowel as it passes from
Discussion the peritoneal cavity to exit at the skin. In this situation, an in-
crease in intraabdominal pressure is exerted on the mesh and then
In a small paraostomy hernia in which a small fascial defect leads on the bowel. The oblique course of the bowel behind the over-
to the accumulation of bowel and omentum in a subcutaneous lying prosthetic mesh prevents intraabdominal forces from sepa-
pocket, hernia repair is often accomplished by a direct surgical at- rating the bowel from the lateral portion of the ostomy. Our
tack on the problem. The hernia is opened, the fascial defect is favorable results suggest that prosthetic mesh repair is indicated
closed with nonabsorbable suture material, and the hernia defect for recurrent enterostomy hernias or enterostomy hernias with a
adjacent to the bowel wall is carefully obliterated.5 Although this large fascial defect.
simple surgical procedure meets with success in some patients, this
is not always the case. Patients with recurrent paraostomy hernias
tend to have a large fascial defect that can only be closed under
Summary
great tension. Even with the most meticulous technique, repair of
Enterostomies are usually well tolerated if they function optimally.
these hernias usually fails, and recurrent hernias can be seen some-
A common problem is a hernia at the enterostomy site. Separa-
times just weeks after repair. In this report we present a method of
tion of the lateral aspect of the enterostomy tunnel from the sero-
hernia repair utilizing prosthetic mesh. The dangers of infection
muscular layer of the intestine permits a space to occur. With time,
of this mesh are kept at a minimum because the contamination of
intraabdominal pressure gradually enlarges this space to bring
the operative field is prevented by positioning the prosthetic mesh
about the hernia.
in the hernia defect through a peritoneal approach. 8
To prevent a hernia from developing after an enterostomy, a
Paraostomy hernias occur almost exclusively on the lateral side
new principle of enterostomy construction is demonstrated. Mter
of the bowel brought out through the abdominal wall. The initial
proper positioning of the intestine within the tunnel, it is returned
defect is caused by failure of the bowel serosa to adhere to the tis-
to the abdomen to allow accurate placement of sutures.
sues of the abdominal wall. Sutures are difficult to position lateral
These sutures bring together the lateral aspect of the tunnel
to the exiting segment of bowel.
and the remote side of the intestine. IT no space is allowed, no
hernia will occur.
A new method for repair of large hernias at stoma sites is pre-
sented. The old abdominal incision is reopened, and prosthetic
mesh is sutured in place aseptically. The bowel is positioned above
the mesh. The mesh is secured to the lateral abdominal wall, cre-
ating a flap valve. The peritoneal approach for insertion of pros-
thetic mesh into the hernia defect is recommended especially for
recurrent paraostomy hernias or hernias that possess a large fas-
cial defect.
References
MESH
1. Kronborg 0, KramhoftJ, Backer 0, et al. Late complications follow-
FIGURE 99.11. Prosthetic mesh is used to close the hernia defect. The bowel ing operations for cancer of the rectum and anus. Dis Colon Rectum.
loop exiting at the ostomy site is secured lateral to the mesh. 1974;17:750-753.
2. Marks CG, Ritchie JK. The complications of synchronous combined 6. RosinJD, Bonardi RE. Paracolostomy hernia repair with Marlex mesh:
excision for adenocarcinoma of the rectum at St. Mark's Hospital. Br a new technique. Dis Colon Rectum. 1977;20:299.
] Surg. 1975;62:901-905. 7. Abdu RA. Repair of paracolostomy hernias with Marlex mesh. Dis Colon
3. Harshaw DH, Gardner B, Vives A, et al. The effect of technical factors Rectum. 1982;25:529-53l.
upon complications from abdominal perineal resections. Surg Gynecol 8. Garnjobst W, Sullivan ES. Repair of paraileostomy hernia with poly-
Obstet. 1974;139:756--758. propylene mesh reinforcement. Dis Colon Rectum. 1984;27:268-269.
4. Goligher JC. Surgery oftke anus, rectum and colon, 3rd ed. London: Bail- 9. Sugarbaker PH. Prosthetic mesh repair of large hernias at the site of
liere Tindall; 1975:737. colonic stomas. Surg Gynecol Obstet. 1980;150:576--578.
5. Thorlakson RH. Technique of repair of herniations associated with 10. Sugarbaker PH. Peritoneal approach to prosthetic mesh repair of
colonic stomas. Surg Gynecol Obstet. 1965;120:347. paraostomy hernias. Ann Surg. 1985;201:344-346.
100
Hernia and Obesity
Harvey J. Sugerman
An increased risk of hernia in obese patients has been reported time because of the potential for postoperative incarceration and
in many studies. 1,2 We have found a 20% risk of incisional hernia the need for a second general anesthetic.
following gastric bypass surgery compared with 4% in patients who Two primary operations for the treatment of severe morbid obe-
underwent a total abdominal colectomy, proctectomy, and ileoanal sity are the vertical banded gastroplasty and the Roux-en Y gastric
pouch anastomosis for ulcerative colitis, involving a much larger bypass. The latter operation has been shown in several random-
incision. 3 Of the latter group, 60% of these patients were taking ized, prospective and retrospective studies to achieve a significantly
an average of 32 mg prednisone a day, which is thought to de- better short-term and long-term weight loss. At 1 year after gastric
crease the rate of wound healing. In the colitis group, four of the bypass, the average patient loses two-thirds of the excess weight,
seven incisional hernia patients had a body mass index of 30 kg/m2 60% at 5 years and 50% at 10 years. This is associated with cor-
or more. Additional risks for hernia in this study included a prior rection or marked amelioration of multiple obesity comorbidity
incisional hernia (41 % vs. 19%), type 2 diabetes mellitus (28% vs. problems, including obstructive sleep apnea, obesity hyperventi-
15%), wound infection (35% vs. 18%), sleep apnea (33% vs. 14%), lation, systemic hypertension, venous stasis ulcers and edema,
and obesity hypoventilation (35% vs. 17%).3 Others have found a pseudotumor cerebri, gastroesophageal reflux, type 2 diabetes
similar rate of incisional hernia following obesity surgery.4-6 Fur- mellitus, weight-bearing joint pains (hip, knees, ankles, lower
thermore, there appears to be an increased risk of recurrent in- back), stress urinary incontinence, and so on. Unfortunately, there
cisional hernia following their repair in obese patients. 7,8 Thus, are no published data on the effectiveness of weight reduction
obesity appears to be a much greater risk for hernia formation surgery on the risk of incisional hernia recurrence apart from
than the use of steroids. the fact that the risk of incisional hernia is much higher in this
What causes this increased risk of incisional hernias in severe population.
obesity? We have found that individuals with central, also known We believe also that these hernias need to be repaired with
as android, obesity have a marked increase in intraabdominal polypropylene (Prolene®) onlay mesh (Fig. 100.3) because the
pressure as measured by urinary bladder pressure, a surrogate for myoaponeurotic tissues of the abdominal wall are usually quite at-
intraabdominal pressure (Table 100.1).9,10 These pressures are of- tenuated and risk of recurrent hernia is high. 7,8,14 We believe that
ten as high as, or higher than, the pressures seen in patients with there is a lower risk of mesh-bowel contact, with its attendant prob-
an acute abdominal compartment syndrome who are intention- lems of adhesions and fistula formation, if the mesh is placed well
ally taken back to the operating room for abdominal dec om- away from the intestines, and less dissection is needed when it is
pressiony,12 Urinary bladder pressure was found to correlate placed in the prefascial rather than the retromuscular location.
significantly (p < 0.001) with sagittal abdominal diameter, a mea- Our data compare favorably with those of Stoppa15 and Wantz.I 6
surement of central obesity (Fig. 100.1). Following surgically in- In addition to incisional and recurrent hernias, severely obese
duced weight loss, there is a significant decrease in both sagittal patients are also at an increased risk for hiatal herniasp,18 Pre-
abdominal diameter and urinary bladder pressure (Fig. 100.2) .13 sumably, this also is secondary to increased intraabdominal pres-
Severely obese patients (body mass index ~35 kg/m2) should sure. One study noted decreased risk of obesity in women with an
have a gastric procedure for obesity at the same time their inci- inguinal hernia. 19 The only spigelian hernia the author has seen
sional hernia is repaired, unless it is an incarcerated hernia with was in a severely obese patient. This type of hernia is usually dif-
gangrenous bowel. Although these patients are still at significant ficult to diagnose, especially in severely obese patients; the use of
risk for developing another incisional hernia, it is much more ultrasound is helpful in identifYing the location of the hernia be-
likely to be permanently repaired following gastric surgery-in- fore surgery.20 Others have found computed tomography helpful
duced weight loss. It would be a mistake to do a weight reduction in diagnosing abdominal wall hernias in obese patients. 21
procedure, such as gastric bypass, and not repair the hernia, as The method of closure of abdominal wounds has been inten-
the incision would probably include the hernia in most instances, sively debated: running versus interrupted sutures, absorbable ver-
and, even if the gastric incision did not include the hernial sac, it sus nonabsorbable sutures, absorbable polyglactin mesh versus
is my opinion that the hernia still should be repaired at the same nonabsorbable polypropylene mesh reinforcement, subcutaneous
672
100. Hernia and Obesity 673
TABLE 100.1. Sagittal abdominal diameter and urinary bladder pressures 40

in morbidly obese patients versus nonobese ulcerative colitis controls
.-
Weight BMI SAD Bladder pressure 0N
(kg) (kg/m2) (em) (em H 2O)
:c
-
30
Morbidly obese E
patients (n = 84) 142 ± 4 52 ± 1 31 ± 0.5* 18±0.7** 0
Control, nonobese
patients (n = 5) 62 ± 6 24 ± 2 19 ± 1.9 7 ± 1.6
~
:::J
en 20
BMI, body mass index; SAD, sagittal abdominal diameter. en
*p< 0.005. ~
**p< 0.001. a..
L..
Q) #
-0
-0
10
i
drains, and subcutaneous sutures. Several randomized, prospec- J2
tive trials have found that a running, absorbable suture has a lower CO
rate of incisional hernia than interrupted, nonabsorbable su-
tures. 22- 26 One study noted that overweight was a significant risk 0
factor for incisional hernia but that this was eliminated when the Pre-Op Post-Op
suture length to wound length ratio of the running suture was be-
tween 4.0 and 4.9. 27 The use of subcutaneous drains in the ab- FIGURE 100.2. Urinary bladder pressure before and 1 year after surgically
sence of a wide wound dissection for placement of polypropylene induced Weight loss. e, individual patient; _, mean ± standard error of
mesh or subcutaneous sutures increases the risk of wound infec- the mean; *p< 0.0001. (Reprinted from Sugerman et al.,13 with permis-
tions in randomized prospective trials. 28-30 The type of incision sion.)
has also been studied in relation to transverse, midline, or para-
median incisional hernias. management), 5% major wound infections, 5% seromas, and 5%
Theoretically, these patients are also at increased risk for wound hematomas with a 4% risk of recurrent hernia. 4 One nonran-
infections and seromas due to incisions through deep subcuta- domized study noted increased risk of wound infection when sub-
neous fat. We believe that patients who undergo the Prolene mesh cutaneous drains were placed; their use when polypropylene mesh
repair should have large Hemovac® drains placed to reduce the was placed did not decrease the frequency of fluid collections or
risk of blood and fluid accumulation that would increase the risk infection. 31 However, this study also found, as would be expected,
of wound infection. 3,14 We leave these drains in place for about 7 that polypropylene mesh repairs were used for more complex and
days even if they are not draining much fluid in order to main- larger hernias, which increased the risk of wound complications.
tain apposition of the subcutaneous fat to the mesh and further In a randomized, prospective trial, placement of preperitoneal ab-
reduce the risk of seroma formation and infection. In our series sorbable polyglactin mesh did not reduce the frequency of inci-
of 98 prefascial mesh repairs, we had a 12% frequency of minor sional hernia in obese patients. 32
wound infections (defined as not requiring rehospitalization for Finally, laparoscopic surgery has come to incisional hernia re-
pair for severely obese patients. The technique involves lysis of all
adhesions to the abdominal wall and inserting DualMesh® through
50 a laparoscopic port, unrolling it, and tacking it to the fascia around
the circumference of the defect. The hernial sac itself is not ex-
cised. The DualMesh is expanded polytetrafluoroethy1ene (Gore-
•
•
•
• •
..... .
• ••••• •
••
. • •
.ifII ••
•••\i.1 •
~.
O~------,-------~------~------~
10 20 30 40 50
Sagittal Abdominal Diameter (em)
FIGURE 100.3. The method of extrafascial placement of polypropylene
FIGURE 100.1. Correlation between urinary bladder pressure and sagittal (Prolene) mesh for incisional herniorrhaphy. The second set of No.1
abdominal diameter in 84 morbidly obese patients (_, men; e, women) polypropylene sutures are placed through the fascia and subsequently
and 5 "control" nonobese patients (0, men; 0, women) with ulcerative passed without needles, directly through the mesh after the fascia has been
colitis, r = 0.67, P < 0.0001). (Reprinted from Sugerman et al.,lO with per- reapproximated in the midline. (Reprinted from Wagman et al.,14 with
mission.) permission. )
674 H], Sugerman
Tex®) , which is rough on its external surface and smooth on the pressure using a transurethral bladder catheter: clinical validation of
side facing the peritoneal cavity. Of 30 patients repaired using this the technique. Anesthesiology. 1989;70:47-50.
technique in one study, there were two complications: cellulitis, 13. Sugerman H, Windsor A, DeMaria E, et al. Effects of surgically induced
which resolved with antibiotics, and skin breakdown, which re- weight loss on urinary bladder pressure, sagittal abdominal diameter
quired mesh removal, which was followed by the only hernia re- and obesity co-morbidity. Int] Obesity Metab Disord. 1998;22:230-235.
14. Wagman LD, Barnhart GR, Sugerman HJ. Recurrent midline hernia
currence in the study.33 The authors concluded that the
repair. Surg Gynecol Obstet. 1985;161:181-182.
laparoscopic approach was associated with decreases in length of 15. Stoppa R, Louis D, Verhaeghe P, et al. Current surgical treatment of
hospital stay, postoperative pain, wound complications, and re- postoperative eventrations. Int Surg. 1987;72:42-44.
currences. However, there has been no randomized, prospective 16. Wantz GE. Incisional hernioplasty with Mersilene. Surg Gynecol Obstet.
trial supporting these conclusions. 1991;172:129-137.
In summary, incisional, recurrent, and other hernias are much 17. HagenJ, Deitel M, Khanna RK, et al. Gastroesophageal reflux in the
more common in severely obese patients. It is likely that this is sec- massively obese. Int Surg. 1987;72:1-3.
ondary to increased intraabdominal pressure present in central 18. Stene-Larsen G, Weberg R, Froyshov Larsen I, et al. Relationship of
(android) obesity. Incisional hernia repair in severely obese indi- overweight to hiatus hernia and reflux oesophagi tis. Scand] Gastroen-
viduals is associated with a high risk of recurrence, which may be teroL 1988;23:427-432.
19. Liem MS, van der GraafY, Zwart RC, et al. Risk factors for inguinal
reduced by placement of mesh reinforcement, either by a
hernia in women: a case-control study. The Coala Trial Group. Am]
polypropylene onlay technique or by a Gore-Tex DualMesh lapa- EpidemioL 1997;146:721-726.
roscopic preperitoneal method. 20. Losanoff JY, Igossev KT. Incarcerated spigelian hernia in morbidly
obese patients: the role of intraoperative ultrasonography for hernia
localization. Obesity Surg. 1997;7:211-214.
21. Rose M, Eliakim R, Bar-Ziv Y, Vromen A, et al. Abdominal wall her-
References nias. The value of computer tomography diagnosis in the obese pa-
tient. ] Clin GastroenteroL 1994; 19:94-96.
1. Pitkin RM. Abdominal hysterectomy in obese women. Surg Gynecol Ob- 22. McNeil PM, Sugerman HJ. Continuous absorbable vs interrupted non-
stet. 1976;142:532-536. absorbable fascial closure. A prospective, randomized comparison.
2. RegnardJF, Hay jM, Rea S, et al. Ventral incisional hernias: incidence, Arch Surg. 1986;121:821-823.
date of recurrence, localization and risk factors.] Ital Surg Sci. 1988;18: 23. Wissing J, van Vroonhoven TJMV, et al. Fascia closure after midline
259--265. laparotomy: results of a randomized trial. Br] Surg. 1987;74:738-741.
3. Sugerman HJ, KellumJMJr, Reines HD, et al. Greater risk of incisiona1 24. Gys T, Hubens A. A prospective comparative clinical study between
hernia with morbidly obese than steroid-dependent patients and low monofilament absorbable and non-absorbable sutures for abdominal
recurrence with prefascial polypropylene mesh. Am] Surg. 1996;171: wall closure. Acta Chir Belg. 1989;89:265--270.
80-84. 25. Trimbos JB, Smit IB, Holm JP, et aI. A randomized clinical trial com-
4. Cleveland RD, Zitsch RP III, Laws HL. Incisional closure in morbidly paring two methods of fascia closure following midline laparotomy.
obese patients. Am]Surg. 1989;55:61-63. Arch Surg. 1992;127:1232-1234.
5. Deitel M, Alhindawi R, Yamen M, et al. Dexon plus versus Maxon fas- 26. Sahlin S, AhlbergJ, Granstrom L, et al. Monofilament versus multifil-
cial closure in morbid obesity: a prospective randomized comparison. ament absorbable sutures for abdominal closure. Br] Surg. 1993;80:
Can] Surg. 1990;33:302-304. 322-324.
6. Brolin RE. Prospective, randomized evaluation of midline fascial clo- 27. Israelsson LA,Jonsson T. Overweight and healing of midline incisions:
sure in gastric bariatric operations. Am] Surg. 1996;172:328-331. the importance of suture technique. Eur] Surg. 1997;163:175-180.
7. Hesselink '\]", Luijendijk RW, deWiltJHW, et al. An evaluation of risk 28. Shaffer D, Benotti PN, Bothe A Jr, et al. A prospective, randomized
factors in incisional hernia recurrence. Surg Gynecol Obstet. 1993;176: trial of abdominal wound drainage in gastric bypass surgery. Ann Surg.
228-234. 1987;206:134-137.
8. Manninen MJ, Lavonius M, Perhoniemi '\]". Results of incisional her- 29. Gallup DC, Gallup DG, Nolan TE, et al. Use of a subcutaneous closed
nia repair. A retrospective study of 172 unselected hernioplasties. Eur drainage system and antibiotics in obese gynecologic patients. Am] Ob-
] Surg. 1991;157:29--31. stet Gynecol. 1996;175:358-361.
9. Bump RC, Sugerman HJ, Fand JA, et al. Obesity and lower urinary 30. DeHoll D, Rodeheaver G, Edgerton MT, Edlich RF. Potentiation of in-
tract function in women: effect of surgically induced weight loss. Am fection by suture closure of dead space. Am] Surg. 1974;127:716--720.
] Obstet Gyneco/. 1992;167:392-399. 31. White TJ, Santos MC, Thompson JS. Factors affecting wound compli-
10. Sugerman HJ, Windsor ACj, Bessos MK, et al. Abdominal pressure, cations in repair ofventraI hernias. Am] Surg. 1998;64:276--280.
sagittal abdominal diameter and obesity co-morbidity. ] Intern Med. 32. Pans A, Elen P, Dewe W, Desaive C. Long-term results of polyglactin
1997;241:71-79. mesh for the prevention of incisional hernias in obese patients. World
11. Harman PK, Kron IL, McLachlan HD, et al. Elevated intra-abdominal ] Surg. 1998;22:479-482.
pressure and renal function. Ann Surg. 1982;196:594-599. 33. Costanza MJ, Heniford BT, Area MJ, et al. Laparoscopic repair of re-
12. Iberti lJ, Lieber CE, Benjamin E. Determination of intra-abdominal current ventral hernias. Am] Surg. 1998;64:1121-1127.
101
Pneumoperitoneum in the Treatment of Giant
Hernias, with Special Reference to Obesity
Edward E. Mason
Pneumoperitoneum, the injection of air into the abdominal cav- Surgical Treatment of Severe Obesity
ity, is an accessory treatment that should be considered in the suc-
cessful and permanent repair of giant hernias. Pneumoperito- If severe obesity was a significant factor in the development of a
neum was used for the treatment of pulmonary tuberculosis from giant hernia and the patient's weight appears likely to cause fail-
1931 until the introduction of streptomycin. Increased pressure ure of repair, the obesity must be treated before repair of the her-
within the abdomen caused elevation of the diaphragm, decreased nia is undertaken (Fig. 101.1). Repeated attempts at weight loss
the intrathoracic space, and thus assisted in the obliteration of cav- through dieting have usually failed such a patient. This will have
ities. Ivan Gani-Moreno, l in Argentina, first used pneumoperi- contributed to the size of the hernia because of the additional
toneum in 1940 to reestablish space in the abdominal cavity of time taken for repeated attempts at an impossible task. It has been
patients with giant hernias. Koontz 2 reported his experience with a standard but ineffective practice over the years to give severely
pneumoperitoneum in 1954 with four patients and again in 1958 obese patients with hernias a weight reduction regimen and a tar-
with five more patients. The experience with pneumoperitoneum get reduced weight and to tell them to return when they have
in patients with giant hernias at the University of Iowa Hospitals reached the desired operative weight. Because diet does not work
and Clinics began in 1953. 3 in patients who are 100 pounds or more overweight, this approach
There are several problems to be considered in the manage- serves only to allow the hernia to reach a larger size and to be-
ment of giant hernia. Of utmost importance is the loss of ab- come even less operable, without reestablishment of abdominal
dominal space. Viscera are forced out into the hernial sac over domain for the viscera from this "second abdomen." Koontz2 com-
time, and the abdominal cavity shrinks around the viscera that re- mented in his paper that "most of the patients who reported [with
main within it. Abdominal space can be regained through the giant hernia] were excessively fat ... most fat people get that way
stretching effect of,intraabdominal air. The abdominal wall may by disgusting self-indulgence.... There are exceptions but most
require a prosthesis even after the preparation of the patient with fat people are liars." [Editor's Note: Such statements seem to us
pneumoperitoneum. The final decision about the use of a pros- today grotesquely unprofessional, reflecting an attitude that may
thesis or reinforcement is usually made at the time of operation, have hindered our progress toward understanding the physiology
although it should be anticipated and planned. Raynor and Del of obesity.] There are still many physicians who feel that the se-
Guerci04 observed that penumoperitoneum and a prosthesis are verely overweight could correct their obesity by simply exerting
not mutually exclusive. They may both be needed in some patients. their willpower. They are not able, however, to control their weight,
Severe obesity adds a third dimension to the plan for repair. and for this reason operations were developed to assist them.
Obesity may be etiological in the occurrence, recurrence, and Our first step at the University of Iowa Hospitals and Clinics
large size of a hernia. Severe obesity does not respond to diet or (UIHC) was to search the records for patients with inoperable her-
other nonsurgical measures, and, when it does respond, there is nias. At the time, we had no experience with the surgical treat-
likely to be recurrent weight gain. 5 If the hernia has been unsuc- ment of obesity. One of these patients had been severely obese
cessfully repaired, excessive weight may well have contributed to and had lost weight because of partial bowel obstruction from in-
the recurrence. Operative treatment of the obesity may take prece- carceration, as well as ulceration over the edematous hernial sac.
dence over the hernia repair. When she again felt well after a pneumoperitoneum-assisted re-
These three branches of the decision tree (effective treatment pair, she began to regain weight, and the hernia recurred. It was
of obesity with an operation to facilitate weight loss, pneu- at this stage in our experience that Kremen et al. 6 suggested we
moperitoneum, and prostheses) are reviewed in the order in which use intestinal bypass in such patients. This and one other patient
they must be considered when planning treatment. Time is re- had very unsatisfactory experiences with intestinal bypass in 1954.
quired to accomplish all that needs to be corrected in the elective This led to the use of a gastric bypass in 19667 and vertical banded
situation. In an emergency, a giant hernia requires the same plan- gastroplasty (VBG) in 1980.8 Vertical banded gastroplasty is at pres-
ning for ultimate repair, but the emergency should be dealt with ent the only operation used for the treatment of obesity at UIHC.
in a safe manner even if the size of the hernia makes an emer- Vertical banded gastroplasty is a simple operation that is effec-
gency repair impossible. This also is reviewed. tive when performed with a measured pouch and stabilized with
676 E.E. Mason
FIGURE 101.1 In some patients, a gastric bypass or ver-

tical banded gastroplasty is needed to ensure weight re-
duction before hernia repair can succeed.
a measured Bard® mesh collar that is sewn to itself and not to the excessive pressure on the vena cava and renal veins and an intol-
stomach wall. It is important to fashion a small, narrow pouch so erable elevation of the diaphragm. The surgeon must make an ed-
that the intraluminal pressure in the pouch approaches that of ucated judgment about this, and the fascia is left open, closed
the normal esophagogastric junction. In this procedure, the pouch partially, or closed completely. The patient should then be ob-
becomes an antireflux mechanism with a limiting capacity for a served closely, postoperatively. If intraabdominal pressure is un-
meal. If the stapled partition is angled out on the fundus or if the duly elevated and blood pressure falls or dyspnea develops, it is
pouch is made too large in the juxtaesophageal area, the opera- important to take the patient back to the operating room, open
tion actually produces reflux. The collar around the outlet should the fascia, restore the hernia for decompression, and close only
measure 5 cm in circumference to avoid obstructing flow of fluid the skin. At a later date, the patient can have the hernia repaired,
and food into the greater portion of the stomach. The collar following weight loss and a period of pneumoperitoneum.
should be placed with the cut edge orad and the selvage abroad
so that when a bolus of food reaches this area, there will be some
relaxation into a funnel-shaped outlet. The Bard® mesh is cut and Pneumoperitoneum
placed so that the circumference is in the direction of the weave,
for the same reason. Three sutures are placed serially along the The chest and abdomen share their space and pressures through
middle of the overlapped ends of the mesh. Again, this is designed the diaphragm. The lungs, heart, liver, spleen, intestines, and blad-
to allow compliance of the upper edge with passage of food. The der vary between individuals and within the individual in their
objective is not to cause obstruction but to prevent progressive in- space requirements. When a giant hernia develops, a new space
crease in the diameter of the outlet. The partition is stapled in enters the picture. There is a shift of abdominal viscera into this
continuity with a TA90B vertical stapler that places four rows of new cavity. Sudden reduction of such a hernia with a tight repair
staples 1 mm apart to provide maximum security for the partition. may be incompatible with life because of the pressure on the vena
The partition must not be divided. Division allows contamination cava, renal veins, and diaphragm.
of the area and a certain incidence of low-grade infection, which We had a 62-year-old patient in the hospital who had just com-
may result in stenosis or erosion by the Bard mesh.® pleted her third attempt at preparation with pneumoperitoneum
When the operation is performed as recommended,9 stenosis for repair of a very large right lower quadrant incisional hernia.
and erosion have been very infrequent. Likewise, the incidence of On each of the earlier occasions she disappeared before we could
staple line breakdown is low when there is no obstruction and complete her treatment. This is often an important factor in the
when tension on the staple line is low due to the smaller diame- development of giant hernias: Either the patient or the surgeon
ter of the pouch. Attempts to make the outlet smaller, to use a postpones treatment. This time, her relatives convinced her that
larger pouch, or to divide the partition or otherwise change the she should stay the course. We admitted her to hospital instead of
operation from what is recommended will likely lead to reflux, trying to manage with outpatient refills, and in the course of 13
stenosis, and erosion by the Bard mesh. The use of an operation days she had a total of 24 L of air injected in daily increments of
to control severe obesity in a patient with a giant hernia requires 1500 to 2200 cc. At the beginning of each injection, the pressure
a surgeon who has had experience with this particular operation. was 3 to 10 mm Hg, and at the end of each injection the pressure
It may be possible to repair a hernia in conjunction with VBG. measured 18 to 24 mm Hg. The decision about when to stop each
Usually, the hernia is at least explored, and all adhesions are di- refill was made on the basis of the tension of the abdomen by pal-
vided. The hernia can be repaired if there is not too much ten- pation and the patient's feeling of fullness. This patient had been
sion placed upon the intraabdominal viscera. There can be walking, eating, and breathing well throughout the period of
101. Pneumoperitoneum in Giant Hernia and Obesity 677
preparation, and there had been no shoulder pain, which was ing is continued for several weeks until there appears to be suffi-
unusual. cient distention of the abdomen and hernial sac so that the sac
Toward the end of the preparation, it became apparent that contents are reduced or can be reduced when the remaining ad-
there was a second fascial defect located at the opposite end of hesions are lysed. This determination is not an exact science. A
the transverse lower abdominal scar. Thus, the pneumoperi- cross-table lateral radiograph with the hernia positioned upper-
toneum acted as a diagnostic test in this patient as it does in chil- most should show only air in the hernial sac, and the bowel dis-
dren who present with a unilateral inguinal hernia. lO Injection of placed into the adbominal cavity, when the patient is ready for
air intraoperatively with a catheter in the neck of the sac of an in- repair. Anterior and lateral radiographs of the chest and di-
guinal hernia is a simple and accurate method of identifying a her- aphragm may be more useful because much of the abdominal air
nia. Our patient appeared to have had a very thin abdominal wall. will be located below the diaphragm when the patient is upright.
It is possible that the newly detected hernia was actually produced At the time of induction, anesthesia should not include nitrous
by the pneumoperitoneum. If so, it demonstrated a need for re- oxide, as it will diffuse rapidly into the abdominal cavity and may
pair and reinforcement in this area as well as in the area of the gi- distend the abdomen to a degree that is incompatible with life.
ant hernia. There is need in such a patient to seriously consider The abdominal gas can double in volume in 15 minutes with the
reinforcement of the repair even though the edges of the abdom- patient breathing 80% nitrous oxide. The surgeon can, of course,
inal wall may be approximated easily after evacuation of the air. remedy such an occurrence with an incision into the sac and evac-
Not all patients with giant hernia are severely obese. If they have uation of the trapped gas.
lost weight as a result ofVBG in preparation for hernia repair, they It is important that the hernial sac and overlying skin be pre-
may have adequate intraabdominal room from the loss of ab- served during the operation so that if it becomes necessary to cover
dominal fat without the preliminary use of pneumoperitoneum. a remaining hernia there will be tissue available. The skin is elas-
If there is any doubt about the need for restoration of abdominal tic and surprisingly strong. Evisceration is less likely with a one-
domain, a trial of pneumoperitoneum should be attempted. layer skin closure than with fascia closed under excessive tension,
Should the surgeon fail to anticipate this need and discover at op- allowing early use of pneumoperitoneum to prepare for the next
eration that there is inadequate abdominal space, there are two and probably final stage of the repair. In most instances the bowel
options: The defect can be closed with a prosthesis, or the hernial will be found to rest within the abdominal cavity, and there is a
sac can be closed with the overlying skin and the fascial defect left laxity of the fascial edges that allows primary repair without ten-
for a later repair after pneumoperitoneum has been used for an sion. The repair is usually started at the lower end of the incision
adequate period of time. It is often possible to perform a partial so that if there is not enough room in the abdomen a defect can
repair of the fascial defect and leave a smaller defect for closure be left superiorly for repair at a later session. It may be the sur-
at a later, final stage of repair. geon's choice to complete the repair with a prosthesis. Usually, a
Pneumoperitoneum is more effective when the fascial defect is complete repair is possible using the abdominal wall.
not too large. Partial repair provides an anchorage of the ab- GOlii-Moreno,1 in 1947, presented most of the reasons for use
dominal wall for countertraction when the distension from the air of pneumoperitoneum, but the observations of others are needed
stretches the wall. If the fascial defect is large, the air stretches the to encourage surgeons to make use of this technique. Astudillo
sac but has little effect in increasing intraabdominal space. The et al. ll compared their experience with the repair of 24 large her-
possibility of staged repair should be explained to the patient be- nias using pneumoperitoneum with another group where pneu-
fore any operation. moperitoneum was not used and found in their own group a less
The initial injection of air is usually from just below the costal bloody dissection with fewer enterotomies, less prolonged post-
margin in the left midclavicular line. If the patient is obese, this operative ileus, shorter hospital stay, and an absence of pulmonary
area will have a thinner layer of fat. The edge of the rectus sheath complications. The operative time averaged 50 minutes compared
is another landmark commonly used for injections. A site must be with 150 minutes without pneumoperitoneum. Fascial substitutes
chosen away from any previous scar where there might be adher- were avoided. There was less splinting and greater comfort. Pneu-
ent bowel. A local anesthetic is used. A spinal needle or long plas- moperitoneum was of special value in the poor-risk patient and
tic catheter on a guide needle is used with a three-way stopcock was recommended as a trial to determine the feasibility of elective
and a length of tubing between this and a 60 ml syringe. The nee- hernia repair in borderline situations. A number of authors have
dle is reinserted. There is usually a palpable, popping sensation referred to the patient with chronic obstructive pulmonary disease
as the needle enters the peritoneal cavity. First, 100 ml of air is in- in this regard. This can be a situation where the pneumoperi-
jected, and the side arm of the stopcock is then temporarily at- toneum is more of a test of the patient's tolerance of distension
tached to the bedside mercury manometer and an initial pressure than a means of developing abdominal room for displaced viscera.
reading taken. It will usually be around 4 to 8 mm Hg. Air is then The objective is still one of preventing the complications of
injected until the patient is aware of a feeling of fullness. If the surgery.
hernial sac is located superiorly it will usually become distended Perhaps there will be greater willingness to use pneumoperi-
and tympanitic. toneum now that surgeons are familiar with the use of insufflation
It is often asked why the air distends the abdominal cavity and as a part of laparoscopic surgery. One cannot read the literature
not just the hernial sac. The sac is limited in its elasticity, and af- on pneumoperitoneum without discerning a similarity between
ter it is tense the air begins to stretch the abdominal wall. At the the benign postoperative course in these patients and the course
end of the injection, another reading is taken using the bedside after laparoscopic operations. Could it be that the relaxation of
blood pressure mercury manometer. A chart should be kept of the the abdomen from the overdistension of pneumoperitoneum is
beginning and ending pressures and the amount of each refill. the common denominator and that even open operations with in-
Refills are performed daily until the patient refuses to have any cisions might be followed by an easier and more rapid recovery if
more or until the pressure fails to fall between refills. The stretch- there was a temporary distension of the abdomen with air?
678 E.E. Mason
Buddee et al. 12 recommended pneumoperitoneum as an alter- Emergency Operations in the

native to the use of a prosthesis and emphasized this in the title
of their paper. Other advantages were also noted, such as safer re-
Presence of Giant Hernias
pair of a large hernia in the presence of a fecal fistula, the ease
of dissection, and the absence of any postoperative dyspnea. Thus, Giant hernias become giant because the patient or the surgeon or
Goni-Moreno's original enthusiasm for the method has been re- both are reluctant to undertake an operation for repair. There is
peated in this and many other papers on the use of pneumoperi- usually an old scar over the middle of the hernial sac. This should
toneum. Unfortunately, it is still not sufficiently known or used. be opened, the bowel freed, and the abdomen explored to make
sure there are no adhesions or sites of obstruction within the ab-
domen. Mter all adhesions have been lysed and the emergency
Prostheses problem appropriately dealt with by resection of gangrenous
bowel, the sac and skin can be closed in one layer. This represents
There are two common uses of prostheses in the repair of giant a safe and simple method of dealing with the emergency. Too of-
hernias. One is to close an area that cannot be safely closed with ten in the past, an emergency operation has led surgeons to at-
abdominal tissues. The other is to reinforce a closure that is inse- tempt a repair that they would not have attempted electively,
cure because of the tension and/or weakness of the surrounding primary closure of a defect with too much tension on the ab-
abdominal wall. If there has been actual loss of abdominal wall dominal wall and, consequently, an unacceptable increase in in-
substance because of wound infection or resection of a desmoid, traabdominal pressure. Should this occur, the patient must be
or for other reasons, it is possible that a prosthesis is needed. IT reoperated on and a decompressive hernia reestablished. A timely
the wound cannot be closed because of contraction of the ab- preparation can then be made.
dominal wall, then preparation with pneumoperitoneum may be Swelstad and Caprini13 mention the use of pneumoperitoneum
preferable. The choice of pneumoperitoneum is easier to make as preparation for a second stage in the closure of omphalocele
preoperatively than when it becomes apparent during an at- or gastroschisis. These are conditions in which a surgical emer-
tempted closure of the abdominal wall. At operation, preplace- gency exists at birth because of failure of the abdominal cavity to
ment of all sutures and then lifting them up and crossing a few develop. A temporary plastic silo is used as a container for the ab-
just ahead of the ones being tied will often demonstrate that the dominal viscera to protect and keep them sterile while an ab-
closure is surprisingly easy and that no prosthesis is needed. Re- dominal cavity is created by continuous pressure. It is eventually
laxation of the abdominal wall occurs as the edges are approxi- possible to close the skin and discard the prosthesis. Mter some
mated when the anesthetist provides muscle relaxation. If a years of growth and development, it is possible to use pneu-
prosthesis is sewn into a wound that could have been brought to- moperitoneum to complete the expansion of an abdominal cavity
gether, the abdominal wall loses some of its function as a muscu- sufficiently for closure of the musculofascial layers.
lar organ. The objective should be to avoid the use of foreign These embryological failures of development of the abdomen
material when possible. Should a prosthesis be needed, it is bet- are mimicked by long-standing giant hernias in which the viscera
ter to use it as reinforcement than to replace abdominal wall. It move out of the abdominal cavity and the abdominal space dis-
is desirable to have omentum between bowel and Bard mesh® be- appears. The peritoneum is a strong layer that can be used like a
cause bowel may become densely adherent to the mesh. A Gore- tissue expander, which a surgeon might introduce for temporary
Tex Soft Tissue Patch® is less likely to become adherent than Bard cover, forcing the gradual development of sufficient tissue to cover
mesh-mesh but is less secure at the edges. a particular area. In cases of emergency, the experience with om-
IT the defect is to be covered with Bard mesh, the edges are sewn phalocele should be remembered.
in place with mattress sutures of polypropylene, with the cut edges On occasion, a surgeon may begin an operation for giant hernia
of the mesh and the knots of the sutures on the upper side away without the benefit of pneumoperitoneum and be confronted by
from the bowel. Suction catheters are placed over the mesh and the impossible return of the hernial contents to a shrunken ab-
used for 2 days, then removed before the space can be contami- dominal cavity. The temptation arises to resect omentum and most
nated through the catheter(s). IT the prosthesis is used to rein- of the colon in the hope that this will correct the situation. Abdu14
force an area where the abdominal wall is approximated, the describes this incident in a patient with a large scrotal sliding her-
polypropylene sutures should be placed all around the edge of the nia that contained omentum, colon, much of the small bowel, and
wound and tagged before the wound edges are closed. The wound half of the bladder. The mesentery was very large and edematous.
edges are then approximated with running No.1 Maxon®, and a Subtotal colectomy and omentectomy did not provide enough room
sheet of Bard mesh® is cut to fit the area. The tagged polypropyl- despite the fact that the specimen weighed 23 pounds! The inguinal
ene sutures are then passed through the edges of the mesh and defect was repaired with the lower end of a long sheet of Bard mesh.
tied down to give a smooth surface of the mesh on top of the The abdomen was closed without need of pneumoperitoneum.
closed wound. Ziffren and Womack15 also reported a patient with a giant scrotal
If the abdominal wall is of poor quality and substance, a layer hernia in whom they repaired the hernia but created a defect higher
of Bard mesh can be sutured to the preperitoneal side of the in the abdominal wall (a new hernia) to decompress the abdomen.
wound around the edges with interrupted polypropylene sutures. These are alternative procedures that may be recalled in the man-
Then, after the wound has been closed (or left open if it cannot agement of large scrotal hernias when urgency precludes the ben-
be closed), the stiff ends of the sutures are passed through a sec- efit of pneumoperitoneum. The latter can be instituted after the
ond layer of Bard mesh-mesh placed on the outer surface of the initial operation and continued until it appears that there is enough
fascia. When these are tied, there is a Bard mesh-mesh "sandwich" room to allow a repair of the fascial defect.
with the abdominal wall between the two layers of mesh. Whelan and Eaker16 were the first to use pneumoperitoneum be-
Commentary 679
fore a secondary staged repair of a large omphalocele in a child. 14. Abdu RA. Urgent management of a giant scrotal hernia. Am] Surg.
Whelan and Eaker began with 150 ml of air as an initial pneu- 1990;56:624-627.
moperitoneum and continued the preparation for 6 months, at 15. Ziffren SE, Womack NA. An operative approach to the treatment of
which time injections of 1500 ml were tolerated in a child who was gigantic hernias. Surg Gynecol Obstet. 1950;91:709-710.
16. Whelan TJ, Eaker AB. Pneumoperitoneum in preparation for second
then 6 years of age. In adults, the duration is usually only a few weeks.
stage omphalocele repair. Pediatr Surg. 1993;52:263-269.
Summary
The management of giant hernias requires planning so that there Commentary
is adequate room for the contents of the hernial sac and adequate
abdominal wall for repair. Correction of severe obesity, when pres- Robert Bendavid
ent, should be a first step and may require a gastric reduction op-
eration followed by a year of weight reduction before a definitive Jorge and Goni-Moreno! reported the use of pneumoperitoneum
repair can be attempted. The abdominal right of domain can be to the Argentine Surgical Association in 1940. Goni-Moren0 then
2
restored through the use of pneumoperitoneum for a few weeks published the results in 1947, acquiring the honors due for such
before the repair. A prosthetic patch is helpful when there remains an important contribution.
a defect that cannot be repaired with the patient's own tissues. However, George Kelling, a German surgeon, was measuring the
Gastric reduction operations, pneumoperitoneum, prostheses, size of stomachs by inflating intragastric balloons in 1890, noting
and staged repair are all potential adjuncts to the successful and that the intraabdominal pressure changed with gastric distension.3.4
permanent repair of giant abdominal hernias. Their selection, tim- In 1901, he became interested in the treatment of gastric hemor-
ing, and effective use require experience with the procedures and rhage by inducing a pneumoperitoneum to apply pressure on the
education of the patient regarding the various options, some of organ in the hope that the tamponade would arrest the bleeding.3,5
which may be introduced during an operation when it is not pos- He did achieve his desired result-at intraabdominal pressures of
sible to explain to the anesthetized patient the reasons behind a 50 to 60 mm Hg! He called this procedure celioscopy. Subsequent
choice of action. Giant hernias are often the result of poor com- uses and techniques were reported for diagnostic purposes by H.C.
munication and inability to comply with a poorly explained, pro- Jacobeus (Sweden, 1911), O.P. Steiner (Switzerland, 1924), H. Kalk
longed, and complex course of treatment. (Germany, 1929), andJ,C. Ruddock (U.S.A., 1937).3 In 1938, Ver-
ess, a Hungarian thoracic surgeon, introduced a spring-loaded
blunt stylet-type of needle with a side hole, which became an im-
References portant adjunct in the creation of a pneumoperitoneum. 3
A hero is never alone in his achievements!
1. Goiii-Moreno I. Chronic eventrations and large hernias. Surgery. 1947; Professor Mason reveals himself to be an abdominal wall surgery
22:945-953. tactician, as he discusses the armamentarium of available thera-
2. Koontz AR. Hernias that have forfeited the right of domicile: use of pies (bariatric surgery, pneumoperitoneum, and the use of pros-
pneumoperitoneum as an aid in their operative cure. South Med J theses at various layers). It is a logical progression that must be
1958;51:165-168. kept in mind at all times. Of particular significance is the approach
3. Mason EE. Pneumoperitoneum in the management of giant hernia. to the problem of obesity, which is in sharp contrast to the propo-
Surgery. 1956;19:143-151.
sitions of Professor Sugerman, who treats hernia and obesity as
4. Raynor RW, Del Guercio LRM. The place of pneumoperitoneum in
one entity at the same session, providing qualified evidence and
the repair of massive hernia. World] Surg. 1989; 13:581-585.
5. National Institutes of Health Consensus Development Conference support for his approach.
Statement. Gastrointestinal surgery for severe obesity. Am J Clin Nutr. Dr. Herszage provides us with rare and important information
1992;55:6158-6198. on how actually to perform a pneumoperitoneum. He has un-
6. Kremen AJ, Linner JH, Nelson CH. An experimental evaluation of the equalled experience in the field of hernia surgery, tackling the
nutritional importance of proximal and distal small intestine. Ann Surg. most daunting surgical problems with great skill and resourceful-
1954; 140:439-448. ness. It is important that our theoretical understanding be fleshed
7. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967; out with the practical experience and know-how of such dedicated
47:1345-1351. practitioners, and it was for me a privilege to visit and operate with
8. Mason EE. Vertical banded gastroplasty for obesity. Arch Surg. 1982; 117:
Dr. Herszage in Buenos Aires, to share firsthand his approach to
701-706.
giant incisional hernias.
9. Mason EE. Morbid obesity: use of vertical banded gastroplasty. Surg
Clin North Am. 1987;67:521-537.
10. Christenberry DP, Powell RW. Intraoperative diagnostic pneumoperi- References
toneum (Goldstein test) in the infant and child with unilateral her-
nia. Am] Surg. 1987;154:628-630. 1. Jorge JM, Coiii-Moreno I. Discussion; XIIth Congress. Arg Cir Bs Ass. 1940.
11. Astudillo R, Merrill R, Sanchez J, et al. Ventral herniorrhaphy aided 2. Coiii-Moreno I. Pneumoperitoneum. Surgery. 1947;22:945.
by pneumoperitoneum. Arch Surg. 1986;121:935-936. 3. Rosenthal RJ, Friedman RL, Phillips EH. The pathophysiology of pneumo-
12. Buddee FW, Coupland GAE, Reeve TS. Large abdominal wall herniae: peritoneum. Berlin: Springer-Verlag; 1999:1-6.
an easy method of repair without prosthetic material with the induc- 4. Kelling G. Uber die ermittelung der magengroesse. Dresden: Reichel; 1890.
tion of pneumoperitoneum. Aust NZ] Surg. 1975;45:265-270. 5. Kelling G. Die tamponade der bauchhoehle mit luft zur stillung lebens-
13. Swelstad J, Caprini JA. Use of progressive pneumoperitoneum in the gefaehrlicher intestinal blutungen. Munch Med Wochenschr. 1901;48:
treatment of giant abdominal hernias. Am] Surg. 1978;44:337-341. 1480-1535.
102
Umbilical Hernias
Maximo Deysine
Umbilical hernias are intimately related to the embryological de- umbilical vein. These structures are located in the inferior half of
velopment of humans; as such, they have probably occurred the umbilical orifice and, together with the remnants of the ura-
throughout primate evolution, producing significant morbidity chus and the round ligament, tend to protect this area from
and mortality. The first recorded mention of an umbilical hernia changes in intraabdominal pressure. The upper half of the um-
was made by Celsus, who in 100 AD called it "an indecent promi- bilicus is composed of a thinner aponeurosis, part of the trans-
nence of the navel." versalis fascia, which, being thin and unprotected, is vulnerable to
Initially, the surgical repair of umbilical hernias included the changes in abdominal pressure changes and prone to herniation. 8
ligature and transfixion of the sac, which led to necrosis. Later, Laparoscopic surgery, which utilizes the umbilicus as one of its
Paulus Aegineta excised the umbilical protuberance, ligating the operative ports, is responsible for a number of incisional hernias
neck.1 In 1740 Cheselden2 reported a repair, and in 1894 Stoser in the vicinity of the umbilicus. 9
performed the first umbilical hernia repair in the United States. 3
In 1898, Mayo delivered a paper in which he described his own
technique for the repair of these defects, first by direct fascial ap- Anatomy
proximation, advancing later to the overlapping technique previ-
ously described by Lucas Championniere. In 1901, Mayo published The superior aspect of the umbilicus is susceptible to changes in
the results of his transverse overlapping "vest-over-pants" tech- the intraabdominal pressure, which may drive forward gobbets of
nique in 19 patients. 4,5 This operation remained in vogue until preperitoneal fat or an incipient sac, stretching and deforming the
the late 1950s, when some surgeons realized that the level of ten- fascia before it into a small funnel. This triangular cone is the be-
sion led to a high recurrence rate. Following this observation, ginning of an umbilical hernia (Fig. 102.1).1 0 Some patients can
Maingot6 repaired small umbilical hernias by transverse fascial ap- describe the development of this bud-like hernia, which, over the
proximation and used a dam technique or a mesh prosthesis for years, may develop into impressive proportions. The neck of this
the larger ones. defects may range from a few millimeters to more than 20 cm. The
inferior and lateral margins of the hernia ring are well demarcated
by relatively strong fascia; superiorly, however, the decussations of
Development Anatomy the rectus sheath separate around the umbilical orifice, creating
weaker areas with potential for postrepair recurrence.
The complicated embryology of the abdominal wall has been thor- The contents of umbilical hernial sacs can vary from small seg-
oughly studied by many investigators and masterfully explained by ments of omentum to any of the abdominal viscera, except, per-
Cullen,7 who in 1916 published a landmark volume on diseases of haps, the spleen, in every possible state of viability. The omentum
the umbilicus. Umbilical hernias occur through defects in the clo- is often adherent to the inner surface of the sac, preventing re-
sure of the embryo's abdominal orifice from which the umbilical duction. In addition, a variety of organs and tumors can be found
cord emerges after the obliteration of the celomic sac. At 3 weeks, occupying umbilical sacs. 11- 21
the somatopleura formed from the embryonic mesoderm and ec-
toderm infolds and fuses, creating the fascial and skin coverings
of the abdominal wall. This is followed by extrusion of the devel- Incidence and Demographics
oping intestines into the celomic sac and their subsequent and fi-
nal reintegration into the forming abdominal cavity. Failure of this The female to male ratio is 3:1, occurring particularly in females
step leads to varius neonatal abdominal wall defects such as om- over 40 years old, obese, and diabetic. Umbilical hernias may fol-
phaloceles. low any condition producing increased intraabdominal pressure
Between the fifteenth and sixteenth weeks, there is an involu- such as ascites, malignancies, and pregnancy. The relationship of
tion of the allantois and the vitelline duct that will eventually oblit- infantile and adult umbilical hernias is unclear, as only 10% of
erate, together with the paired umbilical arteries and the single adults with umbilical hernias exhibited them as children. 22
680
102. Umbilical Hernias 681
Natural History and Conaplications

Hernia
Because of the pressure increase inside the sac during daily activ-
ities such as straining, coughing, and defecation, umbilical her-
nias tend to continue to enlarge with time. Consequently, small
defects may grow to very large proportions.
Many patients do not seek assistance for their umbilical hernias
Urachus until a complication occurs. In addition, clinicians may not be
aware of the high rate of complications and mortality associated
Vesica urinaria with incarceration and strangulation and have a tendency to de-
lay referral of these patients unless there is a dramatic change.
Thus, it is not unusual for a patient to harbor an enlarging um-
Aa. umbilicales bilical hernia for 10 or 20 years. This procrastination turns a sim-
ple operation into a major reparative procedure with its associated
FIGURE102.1. Development of umbilical hernia. (Reprinted from Anson
morbidity and mortality. Large umbilical hernias may become life
and McVay,IO with pennission.)
threatening in morbidly obese diabetic females, in whom incar-
ceration often leads to massive bowel resections associated with
Syrnptonaatology high mortality.
The literature is replete with case reports describing the large
The symptoms of umbilical hernia are directly related to the spe- variety of organs found in umbilical hernias, including full-term
cific organs contained and their status. Some patients will seek as- pregnancies culminating in successful vaginal deliveries. Such
sistance only because of associated skin infections, while others fruitful outcomes are in the minority, however, and these reports
feel little discomfort even with large herniations. tend to remind us that procrastination can lead to veritable
Small umbilical hernias with incarcerated omentum can pro- tragedies. 11-21
duce intermittent or constant pain, sometimes associated with nau- Although general surgeons operate on a great number of these
sea and vomiting probably due to vagal stimulation. Larger hernias hernias, large series are absent from the literature. Most are men-
may be asymptomatic, but they can be very uncomfortable, re- tioned as case reports when an unusual presentation occurs. In
quiring frequent manual reduction by the patient. Incarcerated 1971, Baccari et al. 14 studied the onset of umbilical hernias in ma-
omentum constricted either by the neck of the sac or by its own turity in 146 patients, reaching the conclusion that it was difficult
torsion may lose its circulation and produce an aseptic inflamma- to correlate these defects with the presence of other intraabdom-
tory process that fills the sac with hemorrhagic fluid that irritates inal pathology.
and discolors the adjacent skin and causes pain. This condition Although congenital umbilical hernias seem to be more
seldom leads to systemic symptomatology, and the patient remains common in infants of Mrican-American descent, the incidence
well despite the local discomfort. of adult hernias was not found to be higher in this ethnic
Larger hernias containing portions of small or large bowel are group.27
often associated with intermittent episodes of abdominal disten- Depending on their size and contents, umbilical hernias can
sion and crampy abdominal pain. If the bowel cannot be reduced, present with a wide variety of signs and symptoms. Regardless
a variety of symptoms related to incomplete or complete bowel of the hernia's size, incarceration and strangulation are always
obstruction may ensue, with associated vomiting and abdominal a dangerous possibility; unless there are strenous contraindica-
distension. tions, they should be operated on electively as soon as they
The prognosis of umbilical hernia changes drastically whenever are discovered. It is not unusual to find some degree of patient
there is circulatory compromise of the incarcerated viscus. In sharp resistance; the surgeon should seek the cooperation of the
contrast to the foregoing, bowel strangulation is a serious, life- family and document the importance of immediate surgical
threatening complication of umbilical hernia, with characteristic correction.
local and general symptoms. The severe local and generalized ab-
dominal pain, focal to the now irreducible hernia, is associated
with fever and leukocytosis, with symptoms of incomplete or com-
plete bowel obstruction with vomiting. This condition is poten- Diagnosis
tially lethal and requires fast and decisive action. The transluminal
fluid that exudes from the now necrotic incarcerated bowel con- Most umbilical hernias can be diagnosed by simple inspection
tains a high concentration of toxic bacterial by-products that en- and palpation. When they are present in morbidly obese patients,
ter the circulating blood, triggering an interleukin cascade and however, the size and location of the neck and sac can be diffi-
other mediators that precipitate sequential organ failure. 23 ,24 cult to determine because of the thick adipose panniculus. In
These by-products are lethal to many cell organelles and may lead these patients, sonograms and computed tomographic scans are
to septic shock, which, despite modem critical care, still carries a very useful both in the diagnosis and as an aid to precise place-
mortality rate of 5 to 25%.25 ment of the incision. These tests simplify the approach to these
If only a segment of intestinal wall is strangulated, as in a defects, and I strongly support their use. A direct relationship
Richter's hernia, the symptoms tend to be local, as bowel transit with the radiologists, including them as active partners in the care
is not altered, misleading the surgeon into a wait-and-see period of these patients, greatly simplifies the interpretation of the
that can have serious consequences. 12.26 results. 28 ,29
682 M. Deysine
Surgical Technique
Evolution
There are no reports on long-term follow-up of umbilical hernior-
rhaphy. However, perusal of the literature reveals a tendency
among surgeons to prefer tension-free techniques.
This evolution seems to have occurred in a sequential fashion.
Before the introduction of the Mayo repair, umbilical herniorrha-
phy was associated with inordinately high mortality and morbidity.I
The Mayo procedure was a veritable technical breakthrough that
offered reasonably good results during an era when anesthesia and
antisepsis were still developing (Figs. 102.2 and 102.3).
Subsequently, surgeons used a variety of techniques, but their
reporting lacked adequate long-term follow-up. Pilling22 recom-
mended a vertical closure with stainless steel wire, whereas
Harmel8 and Champault22 utilized a transverse closure or a pros-
thesis. Maingot6 seems to have undergone a technical evolution; FIGURE 102.3. The Mayo procedure for closure of the hernial opening at
he initially used a transverse repair without overlapping on small the umbilicus. The first row of sutures has been tied, and the second is
hernias and fascia lata darn for larger ones, before finally switch- nearly completed.
ing to polypropylene meshes.
Initially, we used the Mayo technique but, because of its inher-
ent tension, soon replaced it by the direct approximation of fascial Technical Considerations
edges with polypropylene sutures. A short-term 40% recurrence
rate persuaded us to abandon both techniques, and we proceeded One hour before surgery patients are given 1 g of a second gen-
to repair all umbilical hernias regardless of their size with inlaid eration cephalosporin intravenously. If allergic to penicillin, they
meshes (Figs. 102.4 and 102.5). We began with expanded polytet- do not receive any antibiotic.33,34
rafluoroethylene patches, switching later to polypropylene. Some Umbilical hernias with necks measuring from 1 to 4 cm in di-
small hernias were repaired with preshaped plugs trimmed to fit ameter can be safely operated on under local infiltrative anesthe-
the orifices without tension. Our recurrence and infection rate has sia, utilizing 1% lidocaine without epinephrine. The larger ones
now virtually disappeared. 31 ,32 may require general endotracheal anesthesia.
We use a curved infraumbilical incision, making an effort to pre-
serve the umbilicus unless the skin is necrotic. The subcutaneous
tissue is separated from the sac, and dissection continues until the
neck is reached. This maneuver is facilitated by elevating the skin
with Allis clamps. The fascia around the neck of the sac is cleared
of fat for at least 3 cm in every direction. The sac is opened; if the
contents are found to be viable, they can be replaced in the peri-
FIGURE 102.2. The Mayo procedure for closure of the hernial opening at
the umbilicus. Arow of mattress sutures are so placed that the lower flap FIGURE 102.4. Placement and anchoring of polypropylene mesh.
(a) is drawn well under the upper flap (b). (Reprinted from Abrahamson,3 with permission.)
102. Umbilical Hernias 683
disappear. Infections should be treated like any other purulent

collection.
If a wound infection is followed by a recurrence, the already
healed wound should be percutaneously tested for the presence
of bacteria. Positive cultures require the administration of a spe-
\
cific antibiotic until the wound test is negative. If this fails and the
wound still contains bacteria, it should be opened, debrided, and
allowed to heal by secondary intention. The wound is again tested,
and only when it becomes free of bacteria can a new prosthesis be
inserted.
'. If bowel had to be resected, the patient and family should be
made aware that the ensuing wound contamination negatively in-
fluences the prognosis of the operation in terms of both recovery
of health and the ultimate success of the repair, because the sur-
geon must avoid the use of a permanent mesh in the contami-
nated field. It has to be emphasized that absorbable meshes are
temporary measures associated with high recurrence rate. 35
FIGURE 102.5. Section to show overlap of mesh with margins of abdomi-

Postoperative Activities
nal wall defect and placement of sutures. (Reprinted from Abrahamson,3
Patients ask when they may return to their occupational and recre-
with permission.)
ational activities. There are no data in this respect, and I empiri-
cally allow a period of relative rest-no weight-lifting and no
toneal cavity. If there is omentum adherent to the sac, it can be
straining-of 2 weeks for small hernias and 4 weeks for large ones.
divided between ligatures or dissected free and replaced. If bowel
An effort should be made to tailor this policy to each patient in-
is present and compromised, a resection with anastomosis may
dividually, taking into consideration body weight, age, and the de-
have to be performed after adequate enlargement of the ring.
gree of straining they will undertake. Walking is perhaps the safest
Excess sac is excised, and the resulting peritoneal defect is closed
form of exercise and can be recommended freely.
with a running suture. The preperitoneal fat and the peritoneum
are separated from the deep surface of the posterior rectus sheath
to create a space for the insertion of a prosthesis. During this ma-
neuver it is convenient to divide a set of lateral small veins that Our Experience
will bleed annoyingly and should be controlled before the mesh
is inserted. Between 1980 and 1998, we repaired III umbilical hernias. The
A polypropylene mesh measuring at least 3 em larger than the first 10, by the Mayo technique, and the subsequent 20, by direct
circumference of the neck is inserted in preperitoneal position fascial approximation, were followed by a recurrence rate of 42%.
and secured with interrupted sutures of polypropylene. In patients This high failure rate prompted us to begin performing prosthetic
with bowel strangulation requiring a resection, the defect must be repairs. Seven hernias were operated on using expanded polytet-
closed with a Vicryl® absorbable mesh. Throughout the procedure rafluoroethylene patches, 34 with preformed or handmade poly-
the wound is thoroughly irrigated with a solution of 80 mg of gen- propylene plugs and the remaining 40 with a preperitoneal
tamincin diluted in 250 ml of normal saline solution, which is also polypropylene mesh. No infections or recurrences were observed
used to soak the laparotomy pads utilized during the procedure. in the prosthetic group. The use of tension-free techniques has
After complete hemostasis, the deep surface of the umbilicus is significantly reduced the recurrence rate and the short-term and
anchored to the midportion of the repair with a single absorbable long-term postoperative wound discomfort.
suture. The subcutaneous tissue is closed with interrupted sutures
of 3-0 polypropylene. The skin is approximated with staples. On
occasion, we insert a rubber band drain to allow the excess serum References
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8. Hannel RP Jr. Umbilical hernia. In Nyhus LM, Condon RE (eds): Her-

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W.B. Saunders; 1984:569-575. I am thankful to Dr. Deysine for an interesting discussion of um-
11. Cameron CTM. Strangulation of a benign mesenchymoma at the umbilical hernia, but also for the opportunity to differ, for the record.
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16. Bhandari NS, Shastri KD, Shanna AK. Spontaneous rupture of um- to be answered. With a history of an infected wound, should a re-
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1972;59:243-244. have seen mesh become infected 7 months after an indsional re-
17. Dietel M, Friedman I. Strangulated umbilical hernia with external fe- pair and 2 years after an inguinal repair.2 Flament et al. 3 reported
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18. McDermott M, Tanner A, Hourihane D. Abdominal actinomycosis fol-
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sized that organisms adhere to sutures, particularly between the
19. Chan MYP, Ng BK Intrahernial tumor-a case report. Singapore Med strands of twisted or braided types. The organisms reinfect a re-
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20. Sampaio R, Ferreira M. Umbilical hernia of stomach. Eur RadioL peared to be perfectly healed for many years. The persistence of
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22. Pilling GP IV. Umbilical hernia. In Nyhus LM, Condon RE (eds): Her- The concept of needling the site of a previously infected hernior-
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23. ZimmermanJL, Taylor RW. Sepsis and septic shock. In CivettaJM, Tay-
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ment. 7 Aspirates will be Gram stained and cultured. In six attempts,
24. Luster AD. Chemokines--chemotactic cytokines that mediate inflam- DeysineB has not been able to obtain a positive culture, but this is
mation. N Engl] Med. 1998;338:436-445. not to say that it should not be attempted. Often at reoperation, I
25. Deitch EA. Multiple organ failure. Pathophysiology and basic concepts of ther- have seen "sterile abscesses" associated with polypropylene sutures;
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surgery of the abdominal waU, 2nd ed. Paris: Springer-Verlag; 1998:280- 1. Bendavid R E.E. Shouldice: a biography. Probl Gen Surg. 1995; 12 (1): 1-5.
284. 2. Bendavid R The merits of the Shouldice repair. Probl Gen Surg. 1995;
31. Deysine M. Hernia repair with expanded polytetrafluoroethylene. Am 12(1):105-109.
] Surg. 1992;163:422-424. 3. Flament JB, Palot]p, Burde A. Treatment of major incisional hernias.
32. Deysine M. Ventral herniorrhaphy: treatment evolution in a hernia ser- Probl Gen Surg. 1995;12(1):151-158.
vice. Hernia. 1998;2:15-18. 4. Abrahamson]. Factors and mechanisms leading to recurrence. In Ben-
33. Classen DC, Evans RS, Pestonik SL, et al. The timing of prophylactic david R (ed): Prostheses and abdominal waU hernias. Austin: RG. Landes
administration of antibiotics and the risk of surgical wound infections. Company; 1994: 138-170.
N Engl] Med. 1992;326:281-286. 5. Davis jM, Wolff B, Cunningham TF. Delayed wound infection. An
34. Abramov D, Jeroukhimov I, Yinnon AM, et al. Antibiotic prophylaxis eleven-year survey. Arch Surg. 1982;117:113-117.
in umbilical and incisional hernia repair; a prospective randomised 6. Houck]P, Rypins EB, Safeh Ij, et al. Repair of incisional hernias. Surg
study. Eur] Surg. 1996;162:945-948. GynecolObstet. 1989;169:397-399.
35. Deysine M. Pathophysiology, prevention and management of pros- 7. Deysine M. Pathophysiology, prevention and management of prosthetic
thetic infections in hernia surgery. Surg Clin North Am. 1998;78:1105- infections in hernia surgery. Surg Clin North Am. 1998;78(6):1105-1115.
1115. 8. Deysine M. Personal communication, August 19, 1999.
103
Epigastric Hernias
Maximo Deysine
Epigastric hernias have probably existed since the genesis of hu- The understanding of the gross and microanatomy of the linea
manity, for they are linked to defects in the anatomical configu- alba was enhanced by the work of Askar (Chapter 6), who em-
ration of the linea alba where they occur. The understanding of phasized the importance of fiber decussation across the midline
the natural history of these hernias closely follows the clarification reinforcing the linea alba. Moreover, dissecting a large number of
of the embryology of the region.1· 2 cadavers, Askar demonstrated that epigastric hernias were more
common in individuals in whom the fibers decussated only once
and not three times, as in the majority.
Historical Perspective This band is constantly exposed to the stretching forces pro-
duced by coughing, defecating, and recreational and occupational
Epigastric hernias were first described in 1285 by Amauls de Ville- activities, but it cannot change both its length and breadth at the
neuve; in 1742, Rene de Garengeot clearly defined this entity, as- same time; expansion in one direction necessitates reduction in
cribing to it a variety of symptoms probably related to pathology the other. During episodes of great abdominal distension, the linea
of the underlying intraabdominal organs. This misconception was alba may be forced to elongate in both directions, a process that
further reinforced by GUllZ, who believed and popularized the may tear some of its fibers, precipitating the onset of a hernia.
idea that these hernias always contain the stomach, calling them Askar6 also demonstrated anatomical attachments between the di-
gastroceles. This issue was latter clarified by Richter in 1785. The aphragm and the linea alba that he believed could produce inor-
term epigastric hernia was coined by Leveille in 1812, and Bernitz dinate tension during coughing, vomiting, and straining. Most
and Cruveilhier described their anatomy in 1848 and 1849, re- importantly, and probably the real etiological culprit, approxi-
spectively. 3 mately 10 paired neurovascular bundles perforate this fascia
In 1802, Maunior described the first successful repair of an epi- anteroposteriorly, creating small orifices through which preperi-
gastric hernia, but the procedure fell into disrepute because of the toneal fat can insinuate itself, starting incipient hernias that grow
high incidence of postoperative peritonitis probably due to stran- with age and increased weight? These anatomical characteristics
gulation or iatrogenic injury to the contents. 4 In 1887, Luecke5 explain why these hernias are multiple in 20% of patients.
reported two patients in whom the repair of an epigastric hernia The linea alba is narrowest and strongest at the level of the um-
relieved their peptic ulcer symptoms. This prompted a wave of op- bilicus, while it can be as wide as 2.5 cm at the xyphoid level. Epi-
erations aimed at the relief of such symptomatology, with the ex- gastric hernias are extremely rare below the umbilicus.
pected failure. Such misconceptions continued until 1956, when it The linea alba is subjected to a variety of different tensions dur-
became clear that gastrointestinal symptoms could not be ascribed ing daily activities and may be overstretched to the point of de-
to the herniation except when a specific organ was incarcerated. veloping defects through which hernias may protrude. The most
commonly seen effect of such excessive strain in the later adult
years is in diastasis recti.
Developmental Anatomy
Epigastric hernias are hernias of the linea alba, which is embry- Physiopathological Anatomy
ologically formed by the midline junction of the rectus abdominis
sheaths. As they join, these structures form a triple layer of inter- Epigastric hernias probably start as small protrusions of preperi-
digitating collagenous fibers, firmly uniting the anterior and pos- toneal lipomas, which, during episodes of increased intraabdom-
terior rectal sheaths. The consolidation of these two elements inal pressure, enter the fascial openings of the perforating
produces a strong fascial complex that maintains the anteropos- neurovascular bundles (Fig. 103.1). When the components of a
terior diameter of the abdominal wall and resists the powerful bundle are compressed, particularly the nerve, pain can be pro-
lateral pulling of the external oblique, internal oblique, and trans- duced. As the intraperitoneal pressure increases, the protrusion
versus abdominis muscles. increases the size of the hernia neck until it allows the passage of
686 M. Deysine
During an episode of irreducibility, any doubt about the viabil-

ity of the contents should lead to emergent surgery to prevent or
minimize organ necrosis. Strangulation is associated with increas-
ing pain, fever, and leukocytosis, all progressing to more serious
manifestations of sepsis and sequential organ failure, which is still
associated with a 20% mortality rate. 9
Diagnosis
The diagnosis is easily made in thin patients, particularly if a mass
can be palpated. Otherwise, the pinpoint location of the pain may
allow the surgeon to mark the site of the offending lipoma, facil-
itating its discovery during surgery. However, in obese patients the
FIGURE 103.1. Diagrammatic representation of the defects in the linea alba
produced by the perforating neurovascular bundles. Preperitoneal lipo- palpation of a lipoma or a sac may be extremely difficult. Recently,
mas penetrate these small orifices, single, larger defect (a) or cluster of sonography and computed tomography have been successfully
defects (b) producing pain and creating defects through which hernial used to diagnose these defects. Familiarization with the resulting
sacs may emerge. (Reprinted from Anson and McVay,' with permission.) images by both radiologist and surgeon readily increases the di-
agnostic accuracy of these tests, which we utilize almost routinely.
Large epigastric hernias are easily detected. However, it is not
a peritoneal sac. Subjected to such pressure and tension, the di- unusual to see patients with very large herniations who can carry
ameter of the neck that starts at 2 mm may reach or exceed 20 on a seemingly normal life and who seem surprised when surgery
cm over a period of years, permitting at some point in their evo- is suggested. 10-12
lution the passage of any of the movable intraperitoneal organs.
The viability of the contents of these sacs varies with the constric-
tion at the defect; the hernia can easily progress to incarceration Treatment
and/or strangulation with its associated morbidity and mortality.s
Surgical Technique
Incidence and Demographics Methods vary, depending on the size of the hernia. We operate on
small and medium-sized defects (up to about 7 cm in diameter)
According to Robin,4 epigastric hernias are found in 5 to 10% of with local infiltrative anesthesia (1 % lidocaine without vasocon-
autopsies, accounting for 0.5 to 5% of all surgically treated her- strictors), supplemented with intravenous sedation administered
nias. They seem to be frequent among the sepoys of India,l rais- by an anesthesiologist. The larger hernias are operated on under
ing the possibility of genetic predisposition. general endotracheal anesthesia.
Most epigastric hernias should be approached through a verti-
cal incision, as this helps to rule out or treat the presence of mul-
Symptoms tiple defects. In small hernias, less than 3 mm in diameter, after
the offending lipoma is located, it is excised and the neck orifice
Symptoms are directly related to the size of the defect and the is closed with a few transverse sutures of polypropylene. If the
contents of the sack. Small hernias often produce significant pain nerve is found-and it can be very thin-it is divided to avoid post-
because of nerve compression by the preperitoneal lipoma. This operative neuralgia.
pain can be sudden, excruciating, disabling, and without prodro- In larger hernias, the simplest way to start the dissection is to
mal symptoms. Some patients describe it as "stabbing" and made identify the dome of the sac, which is often found in the subcu-
worse by motion. Its abrupt onset may immobilize the individual. taneous tissue close to the skin, and then bluntly separate it from
The pain mayor may not be associated with a palpable epigastric the fat on all sides. This approach is simple, eliminates time-con-
mass, and this is particularly uncertain in obese individuals. Be- suming dissection, and readily leads to the neck without produc-
cause of its epigastric location, the pain has been confused with ing unnecessary lateral increases in wound size. Once the neck is
episodes of acute and chronic cholecystitis or peptic ulcer disease reached, the fascia surrounding it is cleared of subcutaneous fat
and treated as such, with poor results. 4 In the past this symptom- for a distance of at least 3 cm around its circumference. Most re-
atology led some surgeons to perform unnecessary intraab- ducible sacs can be invaginated without opening them; however,
dominal surgery. On the other hand, larger epigastric hernias con- an irreducible sac must be opened and its contents closely in-
taining parts of intraabdominal organs, or even whole organs, may spected. Omentum can be reduced into the peritoneal cavity if it
produce minimal discomfort, particularly if they are easily re- is viable; if not, it should be resected after ligation. Bowel should
ducible. Some patients may harbor large and virtually asympto- be dealt with according to its viability.
matic herniations for many years before seeking medical attention. Epigastric hernias ofless than 3 mm in diameter can be repaired
Sudden irreducibility, with its associated pain and/or intestinal with single polypropylene stitches. Some surgeons use transverse,
symptoms, usually brings the patient to the doctor, by which time others vertical, sutures; Askar recommends oblique closures. These
his or her condition will dictate the need for elective or urgent techniques all approximate the defect edges under tension in an
surgery. The variety of possible hernia contents produces a symp- area known to be exposed to a great deal of motion. 13-16 In our
tomatological rainbow of organ involvement and viability. experience the introduction of a mesh, plug, or Kugel patch pro-
103. Epigastric Hernias 687
duces a tension-free repair with minimal chances of recurrence is positive, the patient should receive the appropriate antibiotics,
and significantly less disability and pain. We utilize a prosthesis in and the percutaneous testing should be repeated in due course.
all epigastric hernias 0.4 cm and over. If still positive, the wound should be opened, and all suspicious
The choice of mesh needs careful consideration. If the peri- areas should be debrided and bacteriologically tested. Only after
toneum is intact, these defects can be repaired with a preshaped a negative percutaneous test should the insertion of a new mesh
polypropylene plug, an inlaid polypropylene mesh, expanded be entertainedP
polytetrafluoroethylene, or Kugel patch. However, there are scant
data about the long-term results of the latter device.
If the peritoneum is not intact or is missing, it can be replaced
by an absorbable Vicryl® mesh over which a polypropylene mesh
References
is laid. All meshes except the Kugel patch are secured to overly- l. Iason AH. Hernia. Philadelphia: Blakiston; 1941.
ing fascia with interrupted U stitches of 2-0 polypropylene. If the 2. McCaugham lJ. Epigastric hernias: results obtained by surgery. An:h
defects are multiple and contiguous, the fascial bridges between Surg. 1956;73:972.
the necks should be left in place, and a single mesh measured and 3. Stoppa R, Wantz GE, Munegato G, et al. Hernia healers. Paris: Arnette;
trimmed to exceed the entire herniated surface is inserted and su- 1998.
tured in the preperitoneal position. 4. Robin AP. Epigastric hernia. In Nyhus LM and Condon RE (eds): Her-
During the procedure, the wound is frequently irrigated with a nia, 3rd ed. Philadelphia: J.B. Lippincott; 1989:354-359.
solution of 80 mg of gentamicin dissolved in 250 ml of normal 5. Luecke. Operative Beseitigung von sog. Fetternien wegen gastralgie.
saline solution, which in our hands has contributed to a 0% in- Chirurgie. 1887;14:68.
6. Askar OM. A new concept of the etiology and surgical repair of para-
fection rateP The subcutaneous tissue is drained with an aspira-
umbilical and epigastric hernias. Ann R Coll Surg. 1978;60:42-48.
tion device and approximated with a running suture of 3-0 7. Anson BJ, MacVay CB. In McVay CB (ed): Abdominal wall. Surgical
polypropylene. The skin is approximated with staples. anatomy, 6th ed. Philadelphia: W.B. Saunders; 1984:498-506.
8. Dennis C, Enquist IF. Strangulating external hernia. In Nyhus LM,
Condon RE (eds): Hernia, 2nd ed. Philadelphia:J.B. Lippincott; 1978:
Postoperative Care 279-299.
9. ZimmermanJL, Taylor RW. Sepsis and septic shock. In CivettaJM, Tay-
The drain is removed in 24 to 48 hours. Staples come out in 1 lor RW, Kirby RR (eds): Critical care, 3rd ed. Philadelphia: Lippincott-
week. After the repair of large hernias, patients are advised to use Raven; 1997:405-412.
an abdominal binder during their daily activities, except when sit- 10. Yeh H, Lehr:Janus C, Cohen C, et al. Ultrasonography and CT of ab-
dominal and inguinal hernias.] Clin Ultrasound. 1984;12:479-486.
ting or reclining. As there is no hard and fast rule about the best
1l. Hodgson 1], Collins MC. Anterior abdominal wall hernias: diagnosis
time to return to preoperative activities, we encourage walking and by ultrasound and tangential radiographs. Clin Radiol. 1991;44:185-
discourage straining for 2 weeks for small hernias and 3 to 4 weeks 188.
for large ones. 12. Harison CS. A case of strangulated epigastric hernia. S Afr Med J
1965;39:679.
13. Briggs TP, Tyler X, Dowling BL. Gastric abscess-an unusual presen-
Complications tation. Eur] Surg. 1991;157:365-366.
14. Gupta AS, Bothra VS, Gupta RK. Strangulation of the liver in epigas-
Hematomas and ecchymoses are usually inconsequential. Seromas tric hernia. Am] Surg. 1968;115:843-844.
are observed for 10 days, and if not apparently resolving they are 15. Stoppa R. Hernia of the abdominal wall. In Chevrel JP (ed): Hernias
and surgery of the abdominal wal~ 2nd ed. Paris: Springer-Verlag; 1998:
aspirated under aseptic conditions in the office once a week. Usu-
264-266.
ally two aspirations are necessary. 16. Abrahamson J. Hernias. In Schwartz SI, Ellis H (eds): Maingvt's ab-
Infections should be dealt with appropriately. Insertion of a dominaloperations. Norwalk, CT: Appleton & Lange; 1989:261-266.
mesh in a previously infected hernia site should be preceded by 17. Wantz GE. Atlas of hernia surgery. New York: Raven Press; 1991:167-172.
percutaneous bacteriological wound testing to rule out the pres- 18. Deysine M. Pathophysiology, prevention and management of pros-
ence of bacteria that contraindicate prosthesis insertion. If the test thetic infections. Surg Clin North Am. 1998;78:1105-1115.
104
Acquired Lumbar Hernias
Parviz K. Amid and Robert Bendavid
Acquired lumbar incisional hernias appear following flank inci- sacrospinalis muscle. Superiorly, sutures may go around ribs
sions for renal pathology or retroperitoneal procedures. It is im- (sometimes the lowest rib was previously partially resected) or may
portant to establish that a defect is in fact present. The previous be inserted into the diaphragm.
surgical intervention may have interrupted the anterior branches One has to keep in mind that the patient is lying on his or her
of the anterior primary divisions of nerves T6 to T12, resulting in side, usually on sandbags, so that, when suturing is begun, the pa-
"neurological pseudo-hernias," as can also be seen, though rarely, tient should be straightened out to gauge the tension on the mesh.
in diabetic radiculopathy. The umbilicus in such neurological le- It it is too loose, a bulge may result; if too tight, discomfort and
sions may be drawn to the unaffected side. If the anterior branch avulsion of the mesh are possibilities.
of T10 is affected, the umbilicus moves upward when the patient Results before the use of prosthetic implants were notoriously
attempts to sit up from the supine position (Beevor's sign). Un- poor. The results have now improved, although very few surgeons
fortunately, little can be done for these pseudo-hernias resulting have enough cases to provide meaningful statistics.
from nervous interruptions.
Conclusion
Diagnosis
Incisionallumbar (flank) hernias are notoriously difficult to treat
Acquired incisional flank hernias are usually large, measuring 10 by primary tissue repair. The addition of prosthetic materials, in
to 20 cm in diameter, and often associated with the loss of sup- conjunction with a sound knowledge of the anatomy, will go a long
porting muscle and fascia near the defect. They are usually asymp- way toward achievement of excellent results.
tomatic, and it is the unsightly deformity that usually brings the
patient to seek treatment. Computed tomographic scans and ul-
trasound imaging are excellent tools for investigating these her-
nial defects (Fig. 104.1).
Treatment
Simple pure tissue closure of the defect and onlay mesh do not
provide a permanent cure. Surgery invariably requires a general
anesthetic. A transverse incision, sometimes removing the previ-
ous scar, is made between the twelfth rib and the iliac crest. The
dissection proceeds through the external oblique aponeurosis, the
internal oblique, and the transversus abdominis muscles until the
preperitoneal space is entered. A large polypropylene mesh is in-
serted, extending generously beyond the margins of the defect
(Fig. 104.2). Sutures are inserted as far circumferentially as possi-
ble to include innervated muscle. This means that, anteriorly, the
sutures may have to pass through the rectus sheath and muscle.
Posteriorly, sutures may include the latissimus dorsi and even the FIGURE 104.1. Lumbar incisional hernias with muscular margins.
688
104. Acquired Lumbar Hernias 689
FIGURE 104.2. Cross-section showing the

placement of a prosthesis for lumbar (flank)
hernias. Note the extent anteriorly (rectus)
and posteriorly (latissimus) of the prosthesis.
Part XVII
Complications of Hernia Repairs
105
Complications of Groin Hernia Surgery
Robert Bendavid
Introduction scopic). Clinical manifestation occurs within 24 to 72 hours as

painful enlargement of the testicle (two or three times normal
Nothing goes as far toward preventing complications as the sur- size), woody hard in consistency, and associated low-grade fever.
geon's awareness and fear of them. On this premise, an overview The fever may precede physical findings by 24 to 72 hours. The
of current perceptions of the complications of groin hernia pain associated with ischemic orchitis is severe and may last up to
surgery should aid in the development of a balanced and informed 6 weeks, requiring aggressive and effective analgesia, although for
view. Peripheral issues, apart from anesthesia, will not be delved a few patients pain may not be a significant feature.
into; rather, the direct complications of the act of hernia repair, Ischemic orchitis may progress to testicular atrophy, a process
whether it be pure tissue, tension-free, plug, or laparoscopic re- that may be observed over several months. The outcome cannot
pair, are outlined. be clinically predicted; in some situations, normal postoperative
testicles become unquestionably atrophied by 12 months, whereas
enlarged, painful, firm testicles accompanied by low-grade fever
Anesthesia have resumed normal appearance and function. How many pa-
tients with ischemic orchitis develop testicular atrophy? In a series
Relevant to the safety of hernia surgery is the wide use of local of 10 cases of enlarged and painful testicles investigated with color
anesthesia, popular because patients do not require tedious Doppler sonography, 6 were found to have ischemia or infarction
scrutiny, extensive laboratory examination, and preoperative con- within 48 to 72 hours; the remaining 4 showed normal blood
sultants. In a series of 7159 patients at the Shouldice Hospital, flow. At reexamination 6 months later, these four had returned to
52.1 % of all patients were over 50 years of age. Associated car- normal, whereas the six with ischemia or infarction had not
diovascular factors of these patients included anticoagulation ther- improved. 2
apy (aminosalicylic acid, ticlopidine, warfarin) (12%), history of The incidence of testicular atrophy following open pure tissue
myocardial infarction (15%), history of angina (15%), therapy for repairs was studied at the Shouldice Hospital. Between the years
congestive heart failure (17%), hypertension (20%), and cardiac 1986 and 1993, 52 patients were identified: 33 of 7169 recurrent
arrhythmias (50%).1 inguinal repairs (0.46%) and 19 of 52,583 primary inguinal re-
Epinephrine is never included with the local anesthetic agents pairs (0.036%).3
because it may precipitate substernal tightness, palpitations, ele- The mechanism of ischemic orchitis finds its best evidence from
vated blood pressure, and tachycardia. Epinephrine "reversal" has Fruchaud4 and Wantz5; it derives from an intense venous conges-
also been documented and manifests itself in hypotension, hy- tion within the testicle secondary to thrombosis of the veins within
poventilation, and shock. the spermatic cord. The initiating trauma is seen during dissec-
All open hernia techniques lend themselves ideally to local anes- tion of the cord from the hernial sac, whether direct3 or indirect. 5
thesia. Laparoscopy, however, still requires general anesthesia, a Testicular pain, swelling, epididymitis, and atrophy can complicate
drawback and limiting factor in patient recruitment. laparoscopic hernia repairs, with an incidence of 0.3 and 5.0%,
respectively, although testicular atrophy has been least reported
in relation to laparoscopic technique.6-11
Organ Involvement
Testicle Vas Deferens
The two major complications involving the testicle are ischemic Trauma to the vas deferens may be transection or rough handling
orchitis and testicular atrophy. Orchitis can be defined in this resulting in obstruction. Transection is a mishap that usually oc-
context as postoperative inflammation of the testicle following incurs through open repairs, particularly in recurrent herniorrha-
guinal hernia repair (usually open, far less commonly laparo- phies. Reanastomosis should be attempted with 0 Prolene® as a
693
694 R. Bendavid
stent, which can be pulled out after 3 days. Transection can, how- needle (open technique) or vigorous scissors and forceps dissec-
ever, occur with all techniques. tion (laparoscopy).1 9
Obstruction can result from handling of the vas with forceps, An aberrant obturator artery originating from the inferior epi-
with eventual fibrosis of varying severity through the muscular wall gastric artery can be the source of bleeding when blind sutures
of the vas. 12 .13 Following hernia repair, the vas deferens may be- are inserted in the lagament of Cooper without prior splitting of
come adherent to the posterior inguinal wall in sinuous pattern the transversalis fascia for visibility or when the lacunar ligament
and form kinks that may obstruct outflow. This condition, known is incised from below the inguinal ligament while an attempt is
as dysejaculation, was first reported in 1992 14.15 and involves a sear- made to free an incarcerated femoral hernia. This dangerous step
ing, burning, painful sensation throughout the groin preceding, has earned the artery the unenviable designation "artery of death."
during, and/or just following ejaculation. The symptoms have Injuries to the femoral vein may be caused by suture of the an-
been ascribed to sudden distension of the healed vas and its terior wall of the vein during the inclusion of the shelving edge
smooth musculature. of Poupart's ligament in the repair or by compression of the vein
A spermatic granuloma has been reported as an uncommon by a suture placed too far laterally on the ligament of Cooper.
complication of tension-free repair.16 These situations have complicated the Cooper's ligament repair
too frequently (0.35 to l.6%) and contributed to a lessened pop-
ularity of that technique. 20.21 Injury to the femoral artery can also
Lymphatics mar an inguinal herniorrhaphy. This may occur during recon-
struction of the posterior inguinal wall near the deep inguinal ring,
Hydroceles complicating inguinal hernia repair have been re- where the iliofemoral artery is situated, 1 to l.5 cm deep to the
ported in 0.7% of patients following 14,442 operationsP Although transversalis fascia.
the etiology is unknown, it has been associated with overzealous All control of bleeding must be done under direct vision; deep
skeletonization of the spermatic cord and tissue dissection from sutures and blind clamping must be proscribed. Careful postop-
the sac and at the internal ring. The common mechanism may be erative observation must be instituted for early detection of vas-
severance of lymphatic drainage vessels. cular impairment and its sequelae of thrombosis, embolization,
Seromas are collections of exudate (solutes, water, and plasma and gangrene. Delayed complications are seen, such as stenosis,
proteins, including fibrin and neutrophils). Seromas result from false aneurysm, and arteriovenous fistula. 22
the trauma of scalpels, scissors, cautery, and foreigh bodies, such The introduction of prosthetic materials originally raised some
as sutures and prostheses. In the groin, seromas are seldom sig- concerns with regard to their proximity to arteries and veins. Flat
nificant or clinically noticeable, in contradistinction to incisional sheets of prosthetic materials have not been associated with vas-
hernias; however, with the introduction of various prostheses, the cular erosion and thrombosis. In only one case, to the author's
incidence of seromas now ranges from 0 to 17.6%.18 knowledge, has the plug been associated with iliac artery erosion
Seromas vary in size and may be sufficiently large to stimulate and thrombosis. 23
a postoperative eventration. They must be allowed to resorb slowly, A minor but not uncommon complication is thrombophlebitis of
particularly if prosthetic material has been used during the in- the penis, with an incidence of 0.65% of operations done person-
guinal repair, as repeated aspiration depletes serum proteins and ally. Patients are asymptomatic after 6 to 8 weeks without treat-
increases the risk of infection. Most seromas resolve spontaneously, ment. 24 Three cases have been observed among our patients with
and the author allows 6 to 8 weeks to elapse before needling and thrombosis of the superficial ascending inferior epigastric vein, with
draining. Rarely, a seroma may become encysted with strong fi- a palpable "cord" extending to the right upper quadrant and mim-
brotic capsule and require resection. icking cholecystitis. Vascular injuries from laparoscopic hernior-
rhaphy have been to the deep inferior epigastric and spermatic
vessels,25.26 but also to the external iliac, deep circumflex iliac, ob-
Vessels (Arteries and Veins) turator vessels, and the aorta. 27- 29 Trocar site bleeding is a relatively
new complication to be remembered while introducing trocars.
Bleeding from either arteries or veins can occur at all anatomical
levels during an inguinal hernia repair and in all types of repairs.
Superficially, subcutaneous hematoma or severe ecchymoses can Nerves
result from careless ties or cautery to the superficial vessels (ex-
ternal pudendal, circumflex iliac, and superficial epigastric). Residual neuralgia following herniorrhaphy is the most vexing
On a deeper plane, during resection of the cremaster, careless complication of the inguinal region. The absence of convincing
ligature of the external spermatic artery can result in a tense objective tests and the subjective nature of the complaints do not
hematoma and ecchymosis that extends to the scrotum. Division favor an easy resolution to the problem. It has often been observed
of the transversalis fascia (posterior inguinal wall) requires atten- that pain syndromes improve when litigation and workmen's com-
tion at the medial edge of the deep inguinal ring to avoid lacera- pensation claims are settled. 3o
tion of the inferior epigastric vessels (one artery, two veins). These Essential to understanding the neuralgia is the recognition that
vessels can be divided with impunity, particularly during recurrent the anatomy of the ilioinguinal, iliohypogastric, and genitofemoral
hernia surgery, when they may be encased in scar tissue. Within nerves displays a marked variation that is not widely recognized. 31
the space of Bogros, a venous circle is present that can be the In a study by Moosman and Oelrich,32 only 60% of dissections
source of brisk bleeding (iliopubic, rectusial, and rectusioepigas- showed a "normal" ilioinguinal nerve. Neuropraxia and hypes-
tric veins); less commonly, an iliopubic artery is present. Bleeding thesia have been reported in 15 to 20% of patients following open
results from the inadvertent penetration of those vessels with a hernia repair.33-36 whereas chronic pain was seen in 5%.37-39
105. Complications of Groin Hernia Surgery 695
Four types of neuralgias have been described by Chevrel and because marked fibrosis can obliterate planes of cleavage. On rare
Gatt,31 as follows: occasions, a diverticulum of the bladder may be lacerated.
Laparoscopic surgery is associated with urinary complication
Neuroma pain: Neuroma pain is the most common type, caused
with an incidence of 1.5 to 5% and consists of retention, infec-
by proliferation of nerve fibers outside the neurilemma fol-
tion, and hematuria. 8,24,26,43 Laceration of the urinary bladder was
lowing complete or partial nerve section. Hypesthesia is seen
seen in 2 of 3229 open herniorrhaphies. 46 Sutures accidentally
along the corresponding dermatome. Pain is exquisite at the
inserted within the wall of the urinary bladder have resulted in
site of the neuroma and simulates an electric shock.
paravesical suture granulomas and have been mistaken on com-
Deafferentation pain: Deafferentation pain is a burning pain fol-
puted tomographic scans for bladder carcinomas. 47
lowing partial or complete nerve section or entrapment in a
ligature with chronic paroxysmal exacerbations. Initially, an
area of anesthesia is followed by spreading adjacent areas of
hypesthesia, then hyperesthesia and contact dysesthesia in the
Bowel (Small, Large)
corresponding dermatome.
Complications relating to bowel during open techniques of her-
Projected pain: The intact nerve is encased in a callus or en-
nia repairs are limited to two situations: (1) the freeing of an in-
trapped in a ligature. Pain is elicited by light touch along the
carcerated or strangulated segment of bowel and (2) inadvertent
course of the nerve.
laceration of large bowel in cases of sliding hernia. The sites of
Referred pain: The lesion is at a distance, such as an inflamma-
strangulation are usually the superficial inguinal ring and the
tory granuloma around a suture or the stump of a peritoneal
femoral ring. Early and accurate recognition of femoral hernias is
sac.
crucial, because operative mortality correlates directly with the
In many cases, the pain undoubtedly can be debilitating, and pathological condition of the strangulated viscus and the time
reexploration of the wound and division of the three nerves is de- elapsed before treatment is instituted. Mortality has ranged from
sirable. The neurological deficit is minimal and consists of a loss 6 to 23%.42,48-52 Release of the constriction of a femoral hernia
of cremasteric reflex and an area of anesthesia of the inguino- must be carried out under direct vision within the retroinguinal
scrotal fold no larger than 3 to 5 cm in diameter. In the case of space of Bogros using a medial incision through Gimbernat's lig-
genitofemoral neuralgia, Tons et al. 40 were able to reduce the in- ament and ascertaining the absence of an aberrant obturator ves-
cidence from 5 to 2% by cutting the genitofemoral nerves. Re- sel. Sliding hernias demand constant vigilance on the part of the
section of the genital branch of the genitofemoral nerve is done surgeon. The publications of Ryan53 and Welsh54 have conclusively
routinely during the course of a Shouldice repair. 4o In women, validated the new attitude that opening of a sac is not necessary,
however, the genital branch of the genitofemoral nerve must be that the high ligation of a sac is also unnecessary, and that the
preserved, as it is the sensory nerve to the labium m~us. countless, complicated maneuvers to reperitonealize bowel and
In a personal review of 100 patients with chronic pain at the abdominal cavity are confusing and possibly dangerous and should
Shouldice Hospital, the operative protocol was examined: In 90% be discarded in favor of simple reduction of the hernial sac and
of the cases, "the ilioinguinal and iliohypogastric nerves were care- contents into the preperitoneal space. In female children, sliding
fully preserved." components within indirect inguinal hernias can consist of fal-
Laparoscopic herniorrhaphies have created a new type of neu- lopian tubes, ovaries, and even the uterus; thus ligating the sac "as
rological injury caused by dissection, division of the nerves, or sec- high as possible" may result in the loss of these organs.55
ondary to stapling of a prosthesis. The specific nerves are the Laparoscopic approaches to hernia repair have brought about
femoral branch of the genitofemoral nerve and the lateral femoral a new class of complications and language. It may be too soon to
cutaneous nerve of the thigh, which is involved in meralgia pares- determine the incidence of these complications; most series em-
thetica of Roth.41 Femoral nerve injuries, caused by pressure dur- phasize a "learning curve" of variable duration.
ing manipulation and stapling, have been reported. The incidence Though medical centers of excellence exist, standards have yet
of complications varies with the technique: intraperitoneal onlay to be established and evaluated for the average general surgeon
mesh (IPOM), 0.5 to 4.5%; transabdominal preperitoneal (TAPP) , performing laparoscopic procedures. Severe complications are not
1.2 to 2.2%; and totally extraperitoneal (TEP), 0 to 0.6%.26,42-45 common, vary with the technique, and range from 0.06 to 0.2%.
Persistence of postoperative symptoms such as numbness and pain They include laceration of large bowel or small bowel, trocar site
necessitates exploration and removal of the offending staples or herniation with a Richter type of hernia, adhesion of viscus to mesh
sutures. with resulting ileus, obstruction, adhesion formation, erosion, and
transmigration of mesh into esophagus, duodenum, small bowel,
large bowel, and bladder.56-62 In his doctoral thesis, Dufilh063 re-
Visceral Complications ported 16 cases of intraperitoneal Dacron® mesh insertions that
resulted in four enterocutaneous fistulas. Two patients died sub-
Urinary Bladder sequently. Internal herniations have been reported when the peri-
toneum has separated from suture or staples ("shower curtain"
Trauma to the urinary bladder may occur with open or laparo- effect); the clinical presentation is usually one of acute bowel
scopic techniques. The bladder is posterior and medial to the pos- obstruction.
terior inguinal wall and may adhere to or "slide" into a direct or The trend in laparoscopic herniorrhaphy is away from the
femoral hernia. Recognition of the injury and repair in two layers IPOM. This is welcome news because the use of intraperitoneal
will correct the complication. Care must be taken when there has prostheses can no longer be justified.56-62
been a history of therapeutic irradiation in prostatic carcinoma Finally, a situation involving viscera must be dealt with, namely,
696 R. Bendavid
the "loss of right of domain." Some patients may procrastinate un- interstices 1 to 2 /Lm in diameter, which keep out macrophages
til the hernia becomes in effect a second abdominal cavity too large and provide nests for bacteria; this is why they must be removed
for reintegration in the shrunken abdomen proper. Elevated in- when they become infected. The presence of infection does not
traabdominal pressure fixes the diaphragm in an elevated position. necessitate the removal of a polypropylene or polyester mesh un-
This can lead to acute respiratory distress in the immediate post- less the mesh is sequestered and bathed in a purulent exudate.
operative period and recurrent respiratory infections afterward. Management in the presence of sepsis should be quite aggressive:
The cornerstone of treatment is weight loss through diet or sur- culture and sensitivities, exposure of the prosthesis, antibiotics sys-
gical treatment of severe obesity, pneumoperitoneum (2 to 4 temically, local irrigation with Dakin's solution, and partial resec-
weeks), pulmonary function studies, pulmonary toilette, and phys- tion of the mesh. Failure to be vigorous leads to the formation of
iotherapy. Surgery will likely make use of generous relaxing inci- chronic sinuses and enterocutaneous fistulas. In nearly 3000 mesh
sions and prosthetic materials. 64 The surgical care of patients with operations at the Shouldice Hospital, only two patients had to have
"loss of right of domain" can be quite intricate; it calls for so- their infected mesh entirely removed.
phisticated intraoperative measurements of esophageal pressure, Delayed infections can also be seen associated with prosthetic
rectal pressure, and muscular tension at the time of abdominal meshes, months or years later. Although the mechanism of this
closure. Appropriate postoperative care is crucial. 65 delay is not understood, the treatment does not vary. The pres-
ence of infection or contamination at surgery generally precludes
the use of prostheses. Even the presence of a "sterile" abscess about
Bone a suture from previous surgery should be Gram stained and cul-
tured. The use of antibiotics for prophylaxis when prostheses are
Osteitis pubis as a complication of hernia repair seems to have disinserted has been a common practice in the past, more out of fear
appeared with the elimination of suture through the periosteum; than proven efficacy. A study by Gilbert and Felton,72 which cov-
however, the generous use of staples into the ligament of Cooper ered 2493 patients, showed no difference in infection rate between
(and the underlying pubic ramus and tubercle) may contribute to those who received antibiotics (0.9%) and those who did not
a resurgence of this complication. With tension-free repairs, em- (0.95%). There was no significant difference in patients with or
phasis is placed on securing prostheses at the level of the pubic without prostheses. Still, antibiotics are indicated for some patients
crest, a common area for recurrence. and should be given intravenously 30 to 60 minutes preoperatively.
Skin Prostheses
Exclusive of infectious complications that are common to all in- As recently as 1985, Ravitch 73 stated that "there is no justification
cisions, no skin manifestation is of major concern. Laparoscopic for using foreign material to repair ventral hernias." In 1956, Elek
techniques have, however, been implicated in some severe ecchy- and Conen 74 reported in their classic contribution that "the
moses and extensive subcutaneous emphysema, both of which are virulence of Staphylococcus pyogenes for man is enhanced ten
self-limited and without significance. thousand-fold by the presence of a foreign body reaction to su-
tures." Despite these alarming bugle calls, the surgical landscape
today is dominated by monofilament polypropylene (Bard mesh,
Infections Prolene, Trelex), braided polypropylene (Surgipro), braided poly-
ester Dacron (Mersilene, Lars®), polytetrafluoroethylene (PTFE)
Infection is a major complication in all types of surgery. Certain (Teflon®), and expanded PTFE (Gore-Tex®), to mention a few.
factors particular to groin hernias have been recognized. Women Victor Hugo would smile, remembering his own statement that
have a statistically higher infection rate than do men: 2.1 times. 66 "no army in the world can stop an idea whose time has come."
The presence of a drain and the duration of that presence in- The upsurge in the use of prostheses brings with it heightened
creased infections by a factor of nine. Incarcerated, recurrent, um- awareness of their drawbacks and liabilities, as well as the conse-
bilical, and femoral hernias also showed increases of infection rate, quences of their unthinking application. A collection of observa-
namely, 7.8%, 10.8%,5.35%, and 7.7%, respectively.51 Duration of tions over the years yields some very strange uses of mesh indeed,
surgery also was a significant factor, as seen in operations that such as mesh as an onlay over the external oblique aponeurosis,
lasted 30 minutes or less (2.7%) or 90 minutes (9.9%).66 a stamp-sized mesh applied at the external ring, a cigarette-sized
The introduction of prosthetic mesh in an inguinal hernior- and -shaped roll of mesh laid along the inguinal ligament, and a
rhaphy is becoming a standard procedure, and, as always, famil- cuff of mesh 2 cm long around the spermatic cord into the in-
iarity breeds complacency. Prostheses should be accorded due ternal ring.
respect, for when complications occur they can be challenging and The following general observations should be noted:
taxing to the extreme. One of these complications is infection,
which is reported to occur in 0 to 0.6% of patients. 8•26.68-70 Dif- No prosthetic appliance, however sophisticated, can supplant a
ferentiation should be made between superficial and deep-seated good knowledge of anatomy.
sepsis. The superficial subcutaneous collection does not play Because meshes are eventually "inhabited" by fibroblasts and
the same role in the incidence of recurrence as that of deeper will fibrose, they reveal a rigidity and buckling that is often
collections. 71 felt by the patient. The author has known one such patient
The use of monofilament biomaterial (Bard® mesh, Prolene, who requested the removal of the mesh.
Trelex®) rather than braided biomaterials (Mersilene®, Surgipro®) Because of the fibrosis permeating the interstices of meshes,
confers a theoretical advantage. Braided yams contain microscopic contraction of the scar tissue, and hence the mesh, eventu-
ally occurs. A 20% shrinkage has been measured by Amid. 75 Pathology

When laid in place, prostheses should never be taut.
Contact between severed nerve ends and polypropylene mesh Herniation must be considered the end result of a collagen defi-
creates a typical late postoperative pain that is presently be- ciency, the co-called metastatic emphysema of Read,79 so that re-
ing investigated by Bocchi (personal communication, 1998). pair must encompass areas beyond the immediate defect (children
A total of 7.6% of 1000 patients were affected. excluded).
All prostheses, absorbable and nonabsorbable, for adhesions.
Gore-Tex probably forms the least fibrotic adhesions within
the peritoneal cavity. Use and Misuse of Mesh
Whether any of the prosthetic materials in vogue are carcino- A review of the literature on the results of inguinal herniorrha-
genic remains a favorite question at conferences when all else has phies with regard to recurrences is summarized in Table 105.1. 77
been discussed. Polypropylene was synthesized in 1954 by Italian The most remarkable results from the use of prosthetic material
scientist and Nobel laureate Natta. Usher pioneered its use in 1958. have been noted in femoral herniorrhaphies, primaries, and
Polytetrafluoroethylene was accidentally discovered in 1938 by recurrences.
Plunkett and made clinically available in 1982. Mersilene has been For the laparoscopic surgeon, it may be too early to assess re-
available since 1960. The author is not aware of any convincing currences because most of the reports are coming from individu-
evidence showing carcinogenicity of any of the above prostheses als with a keen interest in herniology and hence are not reflections
in the past 40 years. This subject is most competently reviewed by of general surgery at large. Causes of recurrences include a mesh
Kossovsky and Freiman. 76 size that is too small, staple misplacement, inadequate placement
of mesh, and rolling of the mesh. The laparoscopic group must
be reassessed on a longer-term basis and preferably in medical cen-
ters that do not specialize in hernia surgery, to evaluate laparo-
Recurrences scopic techniques as a means of herniorrhaphy in the hands of an
average general surgeon in any general hospital.
Ironically, recurrences remain the most common complication of
hernia surgery and range from 2.3 to 20.0% for inguinal hernias
and from 11.8 to 75% for femoral hernias. 77 There are several rea- Laparoscopic Considerations
sons for such disappointing results.
Integral to laparoscopy is the insuffiation of carbon dioxide and
the concomitant possibility of venous air embolism. If a di-
Anatomy aphragmatic defect exists, a pneumothorax may result, requiring
Knowledge of anatomy is no doubt a weak point with many sur-

TABLE 105.1. Results of inguinal herniorrhaphies with regard to
geons, as can be gleaned from a publication by Obney and Chan,78 recurrences
which reviewed 1057 recurrent inguinal hernias. A total of 37%
were indirect inguinal hernias, 8% were femoral hernias, and 10% Percent Percent
had two or more hernias present. These hernias are referred to Operations recurrences re-recurrences
as "missed" or "retained" hernias by the laparoscopic surgeon. 78 Without mesh
Statistics from the Shouldice Hospital reveal that 13% of patients Bassini 2.9-25.0 6.5-13.4
have a second hernia that requires surgery. Division of the floor Shouldice 0.2-2.7 2.9-6.4
of the canal (posterior wall) allows not only adequate examina- McVay 1.5-15.5 2.4-5.5
tion of the floor but also the exposure of the proper myoaponeu- Nyhus 3.2-21.0 9.5-27.0
rotic layers necessary for a good repair, but this step is often With mesh
omitted in open groin repairs. Nyhus buttress 0-1.7 0-1.7
Rives 0-9.9 1.7-3.2
Stoppa 0-7.0 0-8.0
Tension-free repairs 0-1.7 0-3.4
Experience of the Surgeon Plug repairs 0-1.6 0.5-1.6
Femoral without mesh
Experience is a valuable asset, as can be observed in the results of Bassini 2.3
surgeons who limit their practice to hernia surgery, as at the Bassini-Kirschner 2.0-6.5
Shouldice Hospital and several other centers around the world. Moschowitz 0.9
Nyhus 0-0.9
McVay 0-3.1
Femoral with mesh
Corruption Stoppa, Wantz, Bendavid, 0-1.1
Lichtenstein, Rutkow
Corruption of a technique is a common error perpetrated by many Laparoscopic repairs BO
Intraperitoneal onlay mesh 0-4.5
surgeons. No one does a Bassini, a Shouldice, or a Stoppa. Instead,
Transabdominal preperitoneal 1.0-4.3
surgeons do a modified Bassini, a modified Shouldice, or a mod-
Totally extraperitoneal 1.0-0.4
ified Stoppa.
698 R Bendavid
thoracocentesis or a chest tube. Hypercarbia and peritoneal trac- 17. Obney N. Hydroceles of the testicle complicating inguinal hernias.
tion may result in cardiac arrhythmia. Excessive pneumoperi- Can Med Assoc J. 1956;75:733.
toneum and a reverse Trendelenburg position may reduce venous 18. Bendavid R Seromas (part I). In Bendavid R (ed): Prostheses and ab-
return and, if sustained, produce cardiac arrhythmias. dominal wall hernias. Austin: RG. Landes Company; 1994:367-369.
19. Cooke RV. Discussion of small bowel obstruction. Proc R Soc Med.
Contraindications to laparoscopic surgery include severe cardiac
1958;51 :503-508.
or pulmonary disease, extremes in age (children and the elderly),
20. Barbier J, Carretier M, Richer JP. Cooper's ligament repair: an update.
the nature and extent of previous operations, incarceration or W(ffldJ Surg. 1989; 13:499-505.
strangulation, sliding inguinal hernias, scrotal hernias, bleeding 21. Brown R, Kinateder RJ, Rosenberg N. Ipsilateral thrombophlebitis and
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to open techniques range from 0.1 to 0.6%81 Recurrences from 1980;87:230-232.
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1997;(suppll):S5.
Groin hernias are among the most common procedures performed 24. Loh A, Leopold P, Taylor RS. Laparoscopic preperitoneal patch her-
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in general hospitals. The rapid changes that have been witnessed
European Congress of the European Association for Endoscopic
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techniques have made hernia surgery a most interesting field of 25. Favrettu F, Valetta S, DaRold A. Laparoscopic herniorrhaphy: trans-
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62. ThompsonJS, Williams SM. Fistula following continent ileostomy. Dis 80. Ryberg AA, Quin TH, Filipi Cj, et al. Laparoscopic herniorrhaphy:
Colon Rectum. 1984;27:193-195. transabdominal preperitoneal and intraperitoneal onlay. Probl Gen
63. Dufilho A. Les complications des protheses en tulle de Dacron: a pro- Surg. 1995;12:173-184.
pos de 414 observations. These medicale, 1981. 81. Phillips EH, Friedman RL. Laparoscopically-guided total extraperi-
64. Mason EE. Prostheses and pneumoperitoneum. In: Bendavid R (ed). toneal inguinal hernioplasty. In Maddern GJ, Hiatt JR, Phillips EH
Prostheses and abdominal wall hernias. Austin: R G. Landes Company, (eds): Hernia repair, open versus laparoscopic approaches. New York:
1994:224-229. Churchill Livingstone; 1997:161-175.
106
Complications of Laparoscopic
Inguinal Hernioplasty
Steven M. Fass and Edward H. Phillips
Introduction nantly cardiovascular. Problems such as aspiration, deep vein

thrombosis, pulmonary embolus, and even loss of teeth due to in-
All surgical procedures are subject to complications such as bleed- tubation occasionally occur. General anesthesia may be con-
ing and infection,just as each type of operation has complications traindicated for patients with significant cardiac and pulmonary
that are unique to the specific procedure. For example, a gas- disease. The cardiovascular effects of pneumoperitoneum are usu-
trectomy can result in dumping syndrome, and inguinal hernio- ally minimal and rarely cause hypotension or arrhythmia. l During
plasty can result in testicular ischemia. Laparoscopic inguinal insufflation only about 0.2% of patients experience hemodynamic
hernioplasty also is associated with nonspecific complications such problems that are associated with vasovagal reflexes and/or de-
as bleeding and infection, but problems due to the creation of creased return of blood to the heart. 2 These problems are usually
pneumoperitoneum and complications related to the specific minor and can be corrected with fluid or atropine. Rarely signif-
technique of hemioplasty are unique. Laparoscopic approaches icant arrhythmias occur, and the abdomen must be desufflated
to the repair of inguinal hernias vary from completely new tech- immediately.
niques to laparoscopic adaptations of existing ones. It is necessary The basic technique of laparoscopy is associated with compli-
to understand these techniques to appreciate the potential com- cations other than hemodynamic. Creation of a pneumoperi-
plications associated with each of them. toneum is performed either with "closed" technique utilizing a
One of the benefits of laparoscopic hernioplasty is that both in- Veress needle or "open" technique that involves making an inci-
guinal and femoral regions can be inspected without an additional sion through the linea alba just below the umbilicus. Sutures are
incision; unsuspected hernias can be repaired during the same placed on each side of the fascial incision. A trocar with a blunt
procedure with minimal increase in morbidity. Laparoscopic tip and a cone-shaped adapter around it is inserted into the peri-
hernioplasty avoids the area previously operated on in patients toneal cavity. The cone is then fitted into the incision to provide
with recurrent hernias, which should decrease the incidence of a gas seal. The sutures are then affixed to the cone to hold it and
nerve injury and ischemic orchitits, and it may be associated with the trocar in place. Use of the "closed" technique decreases the
less postoperative pain and disability. However, there are compli- risk of injury to the m.yor vessels but does not eliminate injury to
cations that are both specific to the type oflaparoscopic technique the intestines.
employed and common to laparoscopy and hernia repair in gen- Bowel punctures with the Veress needle usually do not require
eral. These must be taken into consideration when performing or intervention. Only rarely do Veress needle blood vessel injuries re-
recommending a laparoscopic hernioplasty. sult in significant hemorrhage. On the other hand, trocar injuries
The three aspects of the laparoscopic technique that concern to the bowel always require intervention, and trocar injuries to the
most surgeons are the requirement of general anesthesia, the need major vessels have been associated with fatal hemorrhage. Thank-
for mesh even in primary repairs, and the violation of the peri- fully, major hollow viscus injuries are rare and only occur in ap-
toneum in some techniques. proximately 0.16% of cases, while major vascular injuries occur in
only 0.067%. 3 Patients who have had prior abdominal surgery have
a greater risk of inadvertent enterotomy when pneumoperitoneum
Pneumoperitoneum is created regardless of technique. Special procedures must be em-
ployed in these patients to minimize problems. 4
Laparoscopic hernioplasty requires general anesthesia to control The use of trocars in laparoscopic surgery results in the risk of
pain and acidosis due to absorbed C02' In healthy people, mod- trocar site hernia, possible bowel obstruction (Fig. 106.1), and/or
em general anesthesia is extremely safe, but as long as the lapa- additional procedures to repair these hernias. The most trouble-
roscopic technique requires general anesthesia the risks of some potential complication of transperitoneal or intraperitoneal
anesthesia must be taken into account when weighing its risks and laparoscopic hernioplasty is the creation of intraabdominal adhe-
benefits. The complications of general anesthesia are predomi- sions. Any approach that violates the peritoneal cavity can cause
700
106. Complications of Laparoscopic Inguinal Hernioplasty 701
FIGURE 106.1. Trocar site hernia. A, incarcerated segment of small bowel FIGURE 106.3. Bladder injury. A, Foley balloon; B, bladder wall mucosa.
after reduction; B, anterior abdominal wall; C, surgeon's gloved finger re- (Photo courtesy of Robert W. Sewell, MD, FACS. Surgical Associates of the
ducing hernia in trocar site. (Photo courtesy of Robert W. Sewell, MD, Mid-Cities, 350 Westpark Way, Suite 205, Euless, TX 76040.)
FACS. Surgical Associates of the Mid-Cities, 350 Westpark Way, Suite 205,
Euless, TX 76040.)
adhesions. Converting an extraperitoneal operation to an in-

Simple Closure of the Internal Ring
traperitoneal one puts the patient at risk to develop adhensions
Dr. Ralph Ger was the first to report the repair of an inguinal her-
and a subsequent bowel obstruction (Fig. 106.2). This risk, plus
nia by laparoscopy in 1982.5 He closed the internal ring with a large
the risks inherent in creating a pneumoperitoneum and inserting
staple or suture without the dissection of the sac. This procedure
trocars, are the added risks of the laparoscopic technique. These
is associated with little discomfort but with occasional hydrocele
risks must be offset by reduction in the risks inherent in the tra-
formation. This repair has been associated with a 25% recurrence
ditional anterior approach to hernia repair and/ or in the decrease
rate when performed during open surgery. Theoretically it should
in postoperative pain, disability, and recurrence to justify the lap-
be more successful when performed in young patients with a small
aroscopic approach (complications associated with the repair of
indirect hernia. Complications are few with this approach.
inguinal hernia regardless of technique are discussed in detail in
Chapter 105). Additionally, the dissection of the inguinal region
can result in injury, especially during the learning phase. Vascu-
lar, nerve, colon, and bladder injuries can occur (Fig. 106.3). Also,
Plug and Patch Repairs
the different techniques of laparoscopic repair have unique com-
The plug and patch technique was pioneered by Dr. Leonard
plications and a different incidence of specific complications. The
Schultz and published in 1989. 6 The technique underwent several
following is a discussion of the basic techniques.
modifications because of early recurrences in great part due to the
lack of fixation devices at that time. The basic technique involves
placing a mesh plug into the defect. In subsequent modifications
an additional piece of mesh is placed in the preperitoneal space
across the direct and indirect portions of the floor and fixed in
place with staples. Occasionally, if the mesh plugs are not fixed in
place (as in the early technique) they may migrate and become
palpable on examination. This is the unique complication associ-
ated with this type of repair. Ultrasound, computed tomography,
or magnetic resonance imaging can differentiate between a
seroma, hematoma, and "meshoma." A small recurrence can be
difficult to differentiate or detect because of the mesh plug. As
this repair becomes more like the transabdominal preperitoneal
repair (TAPP), the complications will be similar to those associ-
ated with the TAPP repair.
Transabdominal Preperitoneal
FIGURE 106.2. Small bowel obstruction secondary to hernia through peri-
toneal closure. A, proximal dilated small bowel; B, small bowel in preperi- Prosthetic Repair
toneal space; C, staples approximating peritoneal edges. (Photo courtesy
of Robert W. Sewell, MD, FACS. Surgical Associates of the Mid-Cities, 350 The TAPP prosthetic repair is the most commonly performed lap-
Westpark Way, Suite 205, Euless, TX 76040.) aroscopic technique. The peritoneum is incised and the hernia
702 S.M. Fass and E.H. Phillips
defects dissected. Usually, but not necessarily, the indirect sac is TABLE 106.1. Laparoscopic hernia repairs by technique
reduced. Indirect hernia sacs are occasionally transected and left
No. of Percentage
in situ, which may be associated with hydrocele formation but de- No. of repairs of repairs
Repair type patients
creased hematoma creation. Mesh is fixed to the underside of the
conjoined tendon (aponeurotic sling), Cooper's ligament, lateral Transabdominal 1553 1944 60
to the internal ring and anterior to the inguinal ligament. Varia- preperitoneal
tions include mobilization of the spermatic cord, slitting the mesh Extraperitoneal 367 578 18
laterally, and placement of the mesh around the cord in the Intrapertoneal 295 345 11
preperitoneal space. onlaymesh
Plug and patch 278 286 9
The TAPP repair is associated with the use of more staples than
Closure of ring 66 76 2
the totally extraperitoneal (TEP) repair. Staples placed lateral to
Total 2559 3229 100
the epigastric vessels are associated with ilioinguinal and/or lat-
eral femoral cutaneous nerve injuries.
the laparoscopic approach. Overall, there were 336 complications

Intraperitoneal Repair (10%), including 54 (2%) recurrences (Table lO6.2). Recurrences
were considered complications. Major complications were defined
Intraperitoneal onlay mesh (IPOM) of Prolene® (Ethicon, Inc.) as any complication that required surgical intervention or resulted
had been advocated by Fitzgibbons. 7 The IPOM technique fixes in disability (i.e., recurrence, testicular ischemia, nerve entrap-
the mesh to either the peritoneum or Cooper's ligament with sta- ment, removal of mesh). Minor complications were those that
ples. Toy and SmootS use e-polytetrafluoroethylene (Gore-Tex®). spontaneously resolved or were treated with a short course of an-
Fitzgibbons7 experienced several failures in direct hernias but tibiotics (i.e., seromas, hematomas, trocar site infections).
found it effective in indirect hernias. Complications unique to this Most major complications (especially recurrence) occurred dur-
approach are associated with adhesion formation to the mesh. ing the developmental period and led to changes in the surgical
Also, a sliding direct hernia that contains bladder may be difficult techniques employed. Table lO6.3 shows the incidence of recur-
to identify with this approach. Hematomas are less likely with this rence associated with the different laparoscopic techniques. Re-
technique as the dissection is minimized. Fitzgibbons has aban- currence occurred in 2% of patients (average follow-up 1.5 years).
doned the IPOM technique because of adhesion formation. Mor- There were 71 (2%) major complications. If recurrence is ex-
ris Franklin and Jose Antonio Diaz-Elizondo (Chapter 67) cluded, there were 282 (9%) complications. Only 17 (1 %) major
continue to use a modification of this technique with good results. complications occurred (using the number of patients operated
on as the denominator). There was one vascular injury and no
complications due to the creation of the pneumoperitoneum. The
laparoscopic technique did result in eight serious injuries (0.2%),
Total or Near Total all within the surgeons' first 50 cases. There were two (0.06%)
Extraperitoneal Repair bladder injuries and one (0.03%) colon injury. There were five
(0.2%) small bowel obstructions due to internal hernias in the
To avoid intraperitoneal adhesions and to perform a hernioplasty peritoneal closure (three) and trocar site hernias (two). Two
that has a track record, our surgical group began performing a (0.06%) deaths occurred. One death was due to a myocardial in-
laparoscopic Stoppa-like preperitoneal prosthetic mesh repair in farction, and the other was due to liver failure and variceal bleed-
1990.9-11 We use a laparoscopic Cheatle-Henry-type approach 12,13 ing in a patient with cirrhosis.
to place mesh between the peritoneum and the underside of the There were 265 (8%) minor complications. Hematomas of mi-
abdominal wall, fixing the mesh to Cooper's ligament. McKernan nor significance that might not even be mentioned in other re-
and Law14 accomplish this technique completely avoiding the peri- ports developed in 84 patients (2.6%). Transient neuralgias
toneal cavity. They use an operating laparoscope to develop the occurred in 53 (1.6%), but one patient required reoperation to
preperitoneal space. This type of repair is perceived by some as remove a clip and was counted as a major complicaiton. Testicu-
technically more difficult. A balloon dissecting device is also avail- lar pain occurred in 31 (1.0%). There were no cases of testicular
able to create the preperitoneal space but increases the cost of the ischemia or atrophy. Thirty-seven (1.1 %) patients developed uri-
procedure. nary retention. This complication occurs in traditional ap-
proaches, but urinary catheter drainage of the bladder to increase
the safety of creating the pneumoperitoneum in the laparoscopic
Results approach exacerbates this problem. Nine patients developed
chronic pain (0.3%). Four patients (0.1%) developed infections.
Complications
A multi-institutional survey was undertaken among some of the pi- TABLE 106.2. Cumulative results oflaparoscopic hernioplasty
oneers in laparoscopic hernioplasty.15 This was published in 1995. No. Percent
The longest follow-up was 4 years, and the average was 1.4 years.
There were 3229 inguinal hernioplasties performed in 2559 pa- Recurrence 54 2
tients (Table 106.1). Some patient selection undoubtedly oc- Complications 282 9
Major 17
curred. Patients with significant medical illness or with multiple
Minor 265 8
prior lower abdominal surgeries were not commonly chosen for
TABLE 106.3. Complications by technique

TAPP TEP IPOM Plug/patch Ring closure Total
Number 1944 578 345 286 76 3229

Recurrence 19 (1 %) 0 7 (2%) 26 (9%) 2 (3%) 54 (2%)
Complications 141 (7%) 60 (10%) 47 (14%) 24 (8%) 10 (13%) 282 (9%)
Hematomas 45 21 9 3 6 84
Neuralgias 35 6 9 2 1 53
Urinary retention 20 5 7 5 0 37
Testicular pain 11 9 5 4 2 31
Chronic pain 6 2 0 0 9
Small bowel obstruction 4 0 0 0 5
Trocar site infection 3 1 0 0 0 4
Transfusion 2 0 0 0 3
Bladder injury 0 0 0 1 2
Colon i~ury 0 0 1 0 0 1
Vascular injury 0 0 0 0 2
Other 10 16 13 9 0 48
Trocar site hernia 2 0 0 0 0 2
Death" 2 0 0 0 0 2
Total 160 60 55 50 12 336
TAPP, transabdominal preperitoneal; TEP, totally extraperitoneal; IPOM, intraperitoneal onlay mesh.
·Myocardial infarction, 1; liver failure, 1.
Two were minimal and occurred in the umbilical trocar site, but in 295 patients. There were 54 complications (15.7%). These com-
one involved the mesh, which was removed. There were 52 other plications were mostly minor but included seven recurrences
complications (1.6%), which included hydroceles, seromas, ileus, (2.0%). There were seven seromas (2.0%) and four hydroceles
transfusions, and trocar site hernias (Table 106.3). (1.2%). One colon and one bladder injury occurred in this group,
The complications specific to laparoscopic hernioplasty were but no small bowel obstructions occurred as one might have
few. There were no complications from the creation of pneu- expected.
moperitoneum. There were five bowel obstructions. Two were due Plug and patch techniques were used to repair 286 hernias in
to incarcerated trocar site hernias. The others were due to small 278 patients. There were 50 complications (17.5%), which in-
bowel becoming entrapped in gaps in the peritoneal closure. cluded 26 recurrences (9.1%). Not including recurrences, the
Clearly, great care must be taken to carefully close the peritoneum. complications were 24 (8.4%). Urinary retention was the most fre-
If closed with staples, they must be placed no more than 5 mm quent problem, occurring in five (1.7%) patients. Testicular pain
apart. There were also 53 neuralgias; all were transient except one. was present after four repairs (1.4%). Small bowel obstruction oc-
Many were lateral femoral cutaneous nerve abnormalities that curred in one patient (0.3%).
seem unique to the laparoscopic technique. Again, experience Simple closure of the internal ring was performed the least fre-
with the various techniques has shown that avoidance of stapling quently and in highly selected patients. Seventy-six repairs (2.4%)
in the region just lateral to the epigastric vessels and below the were performed in 66 patients. Complications occurred in 12
level of the inguinal ligament will prevent these injuries. (15.8%) patients of which two were recurrences. Six hematomas,
Transabdominal preperitoneal repair was the most frequently two testicular pains, one neuralgia, and one bladder injury oc-
performed laparoscopic technique: 1944 repairs (60%). There curred in this group.
were 160 complications (8%), including 19 recurrences (1.0%). Laparoscopic surgeons have been increasingly performing TEP
If recurrences are excluded, only 12 (0.6%) experienced major repairs. The major complication rate in these collected series is
complications and 129 (6.6%) had minor complications. extremely low. The minor complication rate ranges from 0 to 10%,
The preperitoneal approach was used in 578 patients, 18% of with seromas and hematomas predominating. Table 106.4 shows
the entire series. The preperitoneal approach is unique in that the recurrence and complication rates from each of these re-
there are no recurrences to date. There were 60 complications spective series.I6-21
(10%). Inguinal hematomas occurred in 21 patients (3.6%). This
was higher than seen with other techniques. Seromas occurred in
15 repairs (2.6%). Seromas seemed to be more frequent in the Recurrences
preperitoneal and IPOM techniques, perhaps because the defect
is not closed or filled with mesh as in other repairs, thus creating An additional multi-institutional study was undertaken to determine
a potential space for fluid to collect. The peritoneal incision in the reasons for recurrence following laparoscopic hernioplasty. The
the TAPP repair probably allows fluid to escape into the peri- basis of the study is a patient group of 57 with 60 recurrent hernias.
toneum, where it is absorbed. Tables 106.2 and 106.3 show the in- The average age of the patients was 49 years, and five patients (9%)
cidence of complications seen after laparoscopic preperitoneal had significant comorbid illness. The recurrences were noted on
hernioplasty. the average 5.1 months postoperatively (range 0 to 30 months).
Intraperitoneal onlay mesh repairs were performed 345 times Technical factors were responsible for nearly all early recur-
TABLE 106.4. Cumulative incidence of complications rences. The most common reason for recurrence was that the
mesh was too small: 36 (60%). The mesh was never stapled in 19
Type No. Percent
cases (32%), and the hernia was never repaired in 12 patients
Recurrence 54 1.7 (20%). The clips pulled through the tissues in five cases (8%), and
Hematomas 83 2.6 in nine cases (15%) the repair had not been undertaken or the
Neuralgias 53 1.6 etiology was unclear. There was more than one reason in 19 pa-
Urinary retention 37 1.2 tients (30%) (Table 106.5).22
Testicular pain 31 1.0 Consequently, many recommend using the largest possible piece
Chronic pain 9 0.3 of mesh and stapling it securely and anatomically in place. It is
Small bowel obstruction 5 0.2
also important to cover both the indirect and direct portions of
Trocar site infection 4 0.1
Transfusion 3 0.1
the inguinal floor in all cases.
Bladder injury 2 0.06 Many prospective randomized studies have been published com-
Trocar site hernia 2 0.06 paring laparoscopic to open hernia repair. These vary in the type
Colon injury 1 0.05 of procedure performed. Nevertheless, they do show an equal or
Other 44 1.4 better complication and recurrence rates for the laparoscopic re-
Death 2 0.06 pair. Tables 106.6 and 106.7 list most of these reports.29-50
TABLE 106.5. Complications of laparoscopic extraperitoneal herniorrhaphy: collected series
Felix16 Massad17 Heithold1B Cocks19 Phillips20 McKernan 21
Year 1995 1996 1997 1998 1998 1998

No. of patients 382 316 346 254 278 638
Recurrence 1 (0.2) 5 (1.5) 2 (0.4) 1 (0.3) 1 (0.3) 4
Complications
Seromas/hematomas 38 (10) 4 (1.2) 0 19 (7) 22 (8) 45 (7)
Urinary retention 0 8 (2.5) 7 (2.0) 1 (0.3) 11 (4) 21 (3)
Neuralgia (transient) 0 1 (0.3) 0 2 (0.7) 3 (1) 4 (0.6)
Bleeding 0 0 3 (0.7) 0 0 4 (0.6)
Wound infection 0 1 (0.3) 0 2 (0.7) 0 1 (0.1)
Testicular swelling/pain 0 2 (0.6) 0 0 2 (0.7) 19 (3)
Postoperative pain 0 0 0 15 (5.5) 12 (4) 0
Hydrocele 2 (0.5) 0 0 0 4 (1.5) 0
Enterotomy 0 0 2 (0.2) 0 0 0
Cystotomy 0 1 (0.3) 2 (0.2) 1 (0.3) 0
Numbers in parentheses are percentages.
TABLE 106.6. Open versus laparoscopic herniorrhaphy: prospective randomized studies 1994-1996
No. of Percent
patients complications Recurrence Follow-up
Reference Year Technique (O/Lap) (O/Lap) (O/Lap) (months)
Stoker29 1994 D/TAPP 75/75 21/8' 0/0 7t

Payne 30 1994 L/TAPP 52/48 18/12 0/0 lOtt
Maddern31 1994 D/TAPP 44/42 47/40 0/2 8tt
Vogt32 1995 B/V/IPOM 31/30 16/17 2/1 8t
Barkun33 1995 SC/TAPP 49/43 12/22 1/0 14tt
Lawrence 34 1995 D/TAPP 66/58 2/12' 0/1 1.5
Leibl 35 1995 S/TAPP 48/54 6/4 0/0 16t
Schrenk36 1996 S/TAPP/TEP 34/28/24 6/8/6 0/1/0 3t
Besse1l37 1996 S/TEP/TAPP 72/29/3 10/12 0/2 7tt
Filipi38 1996 L/TAPP 29/24 10/8 2/0 Ut
Tschudi39 1996 S/TAPP 43/44 26/16 2/1 7tt
Lap, laparoscopic; 0, open; TAPP, transabdominal preperitoneal repair; TEP, totally extraperitoneal; IPOM, intraperitoneal onlay mesh; S, Shouldice;
D, dam; L, Lichtenstein; B, Bassini; V, McVay; SC, surgeon's choice of repair; P, plug and patch; ST, Stoppa; PPO, preperitoneal open; ND, no differ-
ence; NR, not reported; 'p < 0.05 open vs. lap; tvalues are means; ttvalues are medians.
TABLE 106.7. Open versus laparoscopic herniorrhaphy: prospective randomized trials 1997-1999.
No. of
patients Complications Recurrence Follow-up
Reference Year Technique (O/Lap) (O/Lap) (O/Lap) (months)
Liem40 1997 SC/TEP 507/487 20/15 31/17' 20tt

Tanphiphat41 1997 B/TAPP 60/60 ND 0/1 32t
Kald42 1997 S/TAPP 100/100 ND 3/0' 12
Champault43 1997 SC/TEP 49/51 30/4' 1/3 36t
Zieren44 1998 S/P/TAPP 80/80/80 ND 0/0/0 25t
Heikkinen45 1998 L/TAPP 20/20 40/25' 0/0 17tt
Paganini46 1998 L/TAPP 56/52 ND 0/2 28 tt
Aitola47 1998 PPO/TAPP 25/24 8/21 2/3 18tt
Dirksen 48 1998 B/TAPP 87/88 ND 22/7' 24t
Khoury49 1998 P/TEP 142/150 23/13" 4/3 17tt
juul50 1999 S/TAPP 130/138 ND 3/4 12tt
Lap, laparoscopic; 0, open; TAPP, transabdominal preperitoneal repair; TEP, totally extraperitoneal; IPOM, intraperitoneal onlay mesh; S, Shouldice;
D, dam; L, Lichtenstein; B, Bassini; V, McVay; SC, surgeon's choice of repair; P, plug and patch; ST, Stoppa; PPO, preperitoneal open; ND, no differ-
ence; NR, not reported; 'p < 0.05 open vs. lap; tvalues are means; ttvalues are medians.
Discussion References
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22. Phillips et al. Reasons for early recurrence following laparoscopic 38. Filipi Cj, Gaston:Johnson F, McBride Pj, et al. An assessment of pain
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23. CorbittjD. Laparoscopic herniorrhaphy. Surg Laparosc Endosc. 1991;1: tension-free repair. Surg Endosc. 1996;10(10):983.
23-25. 39. Tschudij, Wagner M, Klaiber C, et al. Controlled multicenter trial of
24. Gazareli MM. Anatomical laparoscopic hernia repair of direct or in- laparoscopic transabdominal preperitoneal hernioplasty vs. Shouldice
direct inguinal hernias using the transversalis fascia and iliopubic tract. herniorrhaphy. Early results. Surg Endosc. 1996;10(8):845.
Surg Laparosc Endosc. 1992;2:49-52. 40. Liem MSL, Van Der GraafY, Zwart RC, et al. A randomized compari-
25. Ger R, Monroe R, Duvivier R, et al. Management of indirect inguinal son of physical performance following laparoscopic and open inguinal
hernias by a laparoscopic closure of the neck of the sac. Am] Surg. hernia repair. Br] Surg. 1997;84:64.
1990;159:370. 41. Tanphiphat C, Tanprayoon T, Sansubhan C, et al. Laparoscopic ver-
26. Schultz L, Garber j, Pietrafittaj, et al. Laser laparoscopic herniorrha- sus open inguinal hernia repair: A randomized, controlled trial. Surg
phy: a clinical trial preliminary results. ] Laparoendosc Surg. 1990; Endosc. 1998;12:846.
1:41. 42. Kald A, Anderberg B, Carlsson P, et al. Surgical outcome and cost-
27. Fitzgibbons R, Annibali R, Litke B, et al. A multicentered clinical trial minimization analyses of laparoscopic and open hernia repair: a ran-
on laparoscopic inguinal hernia repair: preliminary results. SAGES An- domized prospective trial with one year follow up. Eur]Surg. 1997;163:505.
nual Meeting. Phoenix, Arizona. April 1993. 43. Champault GG, Rizk N, Catheline jM, et al. Totally preperitoneallap-
28. Macfadyen BV, Arregui M, Corbitt j, et al. Complications of laparo- aroscopic approach versus Stoppa operation: randomized trial of 100
scopic herniorrhaphy. Surg Endosc. 1993;7(3):155-158. cases. Surg Laparosc Endosc. 1997;7(6):445.
29. Stoker DL, Spiegelhalter Dj, Singh R, et al. Laparoscopic versus open 44. Zieren j, Zieren HU, jacobi CA, et al. Prospective randomized study
inguinal hernia repair: randomised prospective trial. Lancet. 1994;343: comparing laparoscopic and open tension-free inguinal hernia repair
1243. with Shouldice's operation. Am] Surg. 1998;175:330.
30. PayneJHjr, Grininger LM, Izawa MT, et al. Laparoscopic or open in- 45. Heikkinen T, Haukipuro K, Leppaiaj, et al. Total costs oflaparoscopic
guinal herniorrhaphy? A randomized prospective trial. Arch Surg. 1994; and Lichtenstein inguinal hernia repairs: a randomized prospective
129:979. study. Surg Laparosc Endosc. 1997;7(1):1.
31. Maddern Gj, Rudkin G, BesselljR, et al. A comparison oflaparoscopic 46. Paganini AM, Lezoche E, Carle F, et al. A randomized, controlled clin-
and open hernia repair as a day surgical procedure. Surg Endosc. ical study of laparoscopic versus open tension-free inguinal hernia re-
1994;8:1404. pair. Surg Endosc. 1998;12:979.
32. Vogt DM, Curet~, Pitcher DE, et al. Preliminary results of a prospec- 47. Aitola P, Airo I, Matikainen M. Laparoscopic versus open preperitoneal
tive randomized trial of laparoscopic onlay versus conventional in- inguinal hernia repair: A prospective randomised trial. Ann Chir Gy-
guinal herniorrhaphy. Am] Surg. 1995;169:84. naecoL 1998;87:22.
33. Barkun jS, Wexler Mj, Hinchley Ej, et al. Laparoscopic versus open 48. Dirksen CD, Beets GL, Go PMNYH, et al. Bassini repair compared with
inguinal herniorrhaphy: preliminary results of a randomized con- laparoscopic repair for primary inguinal hernia: a randomized con-
trolled trial. Surgery 1995;118:703. trolled trial. Eur] Surg. 1998;164:439.
34. Lawrence K, McWhinnie D, Goodwin A, et al. Randomized controlled 49. Khoury N. A randomized prospective controlled trial of laparoscopic
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35. Leibl B, Daubler P, Schwarz j, et al. Standardisierte laparoskopische 50. juul P, Christensen K Randomized clinical trial oflaparoscopic versus
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107
Complications of the Use of Prostheses: Part I
Parviz K Amid
In the early 1800s, the degenerative nature of inguinal hernia was patches (Gore-Tex®, MycroMesh®, DuaIMesh®), and Dacron®
suspected by Astley Cooper. l In the latter part of the nineteenth mesh (Mersilene®). Although from the chemical point of view, all
century, Billroth realized the need for prosthetic reinforcement of these synthetics are completely biocompatible, some physical
of the inguinal floor, musing that, if only the proper material could and structural properties of the prostheses are associated with
be created to "artificially produce tissue of the density and tough- certain complications. However, these complications are entirely
ness of fascia and tendon, the secret of the radical cure of hernia preventable if their causes are recognized in advance and com-
would be discovered."2 The earlier generations ofbiomaterials for pensated for.
hernia repair such as tantalum mesh, stainless steel mesh, poly- Evaluation of the clinical aspects of biomaterials requires in-
ester cloth, polyester sheeting (Mylar®), nylon mesh, acrylic cloth depth knowledge and understanding of the physical properties of
(Orlon®), polyvinyl sponge (Ivalon®), polytetrafluoroethylene prostheses, of which the porosity and the pore size of the materi-
(PTFE) (Teflon® mesh and cloth), and carbon fiber mesh resulted als are the most important. Classification of available biomaterials
in disastrous complications such as infection, rejection, fragmen- for hernia surgery is essential for the everyday practical use of pros-
tation, adhesion, erosion, and transmigration. theses. Based on their pore size, the most frequently used bioma-
However, in 1959, Billroth's dream was realized when polyeth- terials in hernia surgery can be grouped into four types:
ylene mesh was introduced by Usher et al. 3 In the decades since,
Type I: totally macro porous meshes, such as Atrium, Marlex,
there has been a transition to polypropylene, and the introduc-
Prolene, Surgipro monofilament, and Trelex. These prosthe-
tion of additional synthetic materials. Currently, a variety of ab-
ses contain pores larger than 75 p,m, which is the required
sorbable and nonabsorbable synthetic materials are available.
pore size for admission of macrophages, fibroblasts (fibro-
Absorbable meshes include polyglycolic acid (Dexon®) and
plasia), blood vessels (angiogenesis), and collagen fibers into
polyglactin (Vicryl®). Absorbable biomaterials are recommended
the pores. 7- 9
only for temporary abdominal closure in contaminated cases. In
Type II: totally microporous prostheses, such as ePTFE (Gore-
1991, experiments with the rat model suggested possible benefit
Tex) and DualMesh. These prostheses contain pores that are
from implantation of polyglactin mesh in the groin for repair of
less than 10 p,m in at least one of their two surface dimen-
inguinal hernias. 4 According to this study, the mesh becomes re-
sions.
placed by polarized collagen bundles oriented along the lines of
Type III: macroporous prostheses with multifilament or micro-
stress. Morphologically, this implies that the newly formed colla-
porous components, such as PTFE mesh (Teflon), braided
gen bundles should be as strong as normal connective tissue. How-
polyester mesh (Mersilene), braided polypropylene mesh
ever, it is doubtful that in hernia patients the resulting fibrous
(Surgipro multifilament), and perforated ePTFE patch (My-
tissue can resist the inevitable collagen metabolic disorder with
croMesh).
the passage of time. Furthermore, our animal experimentation
Type N: biomaterials with submicronic pore size, such as Silas-
showed that such fibrous tissue could not withstand intraabdomi-
tic, polypropylene films, Preclude® Pericardial Membrane and
nal pressure or prevent hernia formation. 5
Preclude Dura-Substitute. These are nONuitable prostheses
In this study, a 4 by 6 cm piece of polyglactin was used to patch
for hernia repair; however, in combination with type I bio-
a 3.5 by 5.5 cm defect that was created in the abdominal wall of a
materials, they can be used as a physical barrier between mesh
rabbit. Figure 107.1 shows a large hernia sac formed by the fibrous
and viscera in the form of adhesion-free composites.lO,ll
tissue that replaced the absorbable mesh after 22 weeks. The same
has been reported by other authors. 6 From the clinical point of view, concerns associated with uti-
Currently available nonabsorbable biomaterials include poly- lization ofbiomaterials in hernia surgery are infection, seroma for-
propylene meshes (Atrium®, Marlex® [now called Bard® mesh], mation, intestinal adhesion, bowel obstruction, erosion of the
Prolene®, Surgipro® monofilament, Surgipro multifilament, and prostheses into an adjacent hollow viscus, and failure of the repair
Trelex®) expanded polytetrafluoroethylene (ePTFE) soft tissue due to contraction of the prosthesis.
707
708 P.K. Amid
FIGURE 107.1. A large hernial sac at the site of polyglactin implantation FIGURE 107.3. Computed tomographic scan of infected Gore-Tex® patch.
(rabbit model) .
Infection tion and growth of bacteria not only by admitting macrophages but
also by allowing rapid fibroplasia and angiogenesis within their wide
Surgical infection promoted by implantation ofbiomaterials, such pores. 6,19
as sutures and prostheses, is caused by infiltration and prolifera- Frequently, sinus tract formation and chronic infection follow-
tion of bacteria in the pores and interstices of these synthetic ma- ing type I prosthetic repair of hernias are caused by multifilament
terials. When interstices or pores are less than 10 f.Lm, in each of suture material used in fixation of the mesh, although they are
their two surface dimensions, as in braided sutures 12 and pros- mistakenly believed to be caused by the mesh itself. 15,20,21 Although
thetic materials,13 bacteria averaging 1 f.Lm cannot be eliminated infection rates associated with type II and III prostheses are within
by macrophages and neutrophilic granulocytes, which are too an acceptable range,10 higher rates of 9.6%22 to 50%23 associated
large to enter a 10 f.Lm pore. 12- 14 By admitting both microphages with their utilization have been reported. Such numbers have not
and bacteria, biomaterials with pores larger than 10 f.Lm create a been encountered in association with type I biomaterials.
major challenge for the proliferation of bacteria and thus do not More importantly, in connection with surgical infection from
contribute to the development of surgical infection. 15- 18 other causes, the totally macro porous prostheses (type I) do not
Type II and III prostheses are similar to braided suture materi- have to be explanted; drainage of the infected area, followed by
als and by harboring bacteria can promote their growth, likewise local wound care, is all that is necessary to manage the infec-
resulting in biomaterial-related infection. 12,13 Figures 107.2 and tion (Figs. 107.5 and 107.6) .24-26 In contrast, total removal of
107.3 show examples of an infected and partially extruded type II the type II prosthesis 1o,20,22 and at least partial removal of the
prosthesis; Figure 107.3 shows examples of infected type III bio- type 11127 is required to manage infection associated with their
materials. Unlike types II and III, type I prostheses deter infiltra- utilization.
FIGURE 107.4. Macroscopic view of an infected multifilament Surgipro

FIGURE 107.2. Infected and partially extruded Gore-Tex patch. mesh.
107. Complications of the Use of Prostheses: Part 1 709
tion is reduced. 25 Sufficient molecular permeability also results

in formation of the proper scaffolding for future host tissue
incorporation,9 which, by filling the pores of the mesh and mak-
ing them inaccessible to bacteria, further decreases the chance of
biomaterial-related seroma formation and infection. 6,19
Because of their inadequate pore size, type II biomaterials lack
sufficient molecular permeability for the host fibrinous and pro-
teinaceous materials. The resulting slow elimination of the dead
space between the prosthesis and the host tissue fosters the for-
mation of seroma. 28,29 Figure 107.7 (left) from our animal research
shows a 4 by 6 cm piece of polypropylene implanted between two
layers of abdominal muscle of the rabbit. The patch was fixed in
place with plain catgut, and the rabbit was sacrificed after 8 weeks.
The polypropylene patch retained its original square shape be-
cause of its rapid fixation to the host tissue during the short life-
time of the plain catgut. Figure 107.7 (right) shows a 4 by 6 cm
piece of ePTFE that was similarly implanted on the opposite side
of the same rabbit. Incomplete fixation of this biomaterial during
FIGURE 107.5. Three-day postincision and drainage of a massive wound in-
the same period of time is apparent from its wrinkling and curl-
fection, following repair of a large incisional hernia. The mesh is com-
ing on itself.
pletely covered by granulation tissue.
The reported rate of seroma formation associated with type II
prostheses has been as high as 14.6% in incisional hernia repair22
and 9.6% in inguinal hernia repair.3o No such increased rates of
Seroma seroma formation have been cited in the surgical literature in con-
nection with properly implanted type I and type III prostheses.
Postoperative prosthesis-related seroma formation is caused by a
host inflammatory reaction to the prosthesis and by the dead space
created between the prosthesis and host tissues. Adequate pore
size gives types I and III prostheses sufficient molecular perme-
Intestinal Adhesions
ability to allow penetration of host proteinaceous material into
The most important characteristics of ideal prostheses for ab-
their pores. 6 Because this results in a rapid fibrinous fixation of
dominal wall hernia surgery are macroporosity7,9,16 and rough sur-
the mesh to the tissue and elimination of the dead space between
face texture. 3l These qualities combine to create the degree of
the prosthesis and the host tissue, the chance of seroma forma-
host tissue infiltration into the prosthesis that is critical to a strong
and secure hernia repair. However, an undesirable attribute of
macroporosity is the adherence of macro porous mesh to the bowel
when it comes in direct contact with the intestinal tract.J I ,32,33 At
the present time, all available prostheses (absorbable and nonab-
sorbable) adhere to the intestines (Figs. 107.8 to 107.10).11,32,33
Covering the mesh on its intestinal side with a layer of absorbable
FIGURE 107.7. (Left) Polypropylene patch retained its original square

shape because of its rapid fixation to ihe host tissue. (Right) Expanded
FIGURE 107.6. Complete healing of the wound after secondary closure with- PTFE, similarly implanted on opposite side. Incomplete fixation is evident
out removing the mesh. from its wrinkling and curling.
710 P.K. Amid
FIGURE 107.8. Adhesion of the intestines to Gore-Tex®. FIGURE 107.10. Adhesion of the intestines to Marlex®mesh.
material such as Vieryl (Fig. 107.9),33 or with ePTFE (Fig. 107.8) model and human subjects. To prevent mesh-related intestinal
patch, does not entirely eliminate this risk. complications, we suggested covering the visceral side of the mesh
with a layer of nonabsorbable and tissue-impervious biomaterial.
Our animal experimental study proved this refinement to be suc-
Hollow Viscus Erosion and cessful. lI A variety of tissue-impervious biomaterials, such as
polypropylene film and submicronic pore size ePTFE (Preclude
Fistula Formation Pericardial Membrane and Preclude Dura-Substitute, manufac-
tured by Gore) are available for this purpose. Currently, the po-
Another undesirable attribute of macroporous mesh is erosion and tential biomaterial-related intestinal complications can be avoided
migration of the prosthesis into the gastrointestinal tract when in
by utilization of composites, such as those described above, or the
direct contact. This complication is even more common when the
commercially available product (Bard mesh composite, Com-
prosthesis is in direct contact with organs without serosal cover- posix®, manufactured by Davol, Inc.). These composites offer ex-
ing: the distal esophagus,34 rectum,35 bladder28.36 and denuded in-
cellent tissue ingrowth within the outer layer of polypropylene,
testinal tract. Direct contact of the prosthesis with the normal while the inner ePTFE surface prevents intestinal adhesion and
intestine covered by an intact serosal layer can also lead to fistula concomitant complications. II
formation (Fig. 107.11).28,32,38-41 Covering the intestinal side of
the mesh with a layer of absorbable material does not prevent ero-
sion and migration of prostheses. 33 In 1993, we pointed out that Contraction of the Prosthesis
the intended purpose of such combination could not be substan-
tiated by our rabbit model experimentation. II More importantly, Shrinkage of the Prosthetic Plug (Mesh Plug)
a report by Soler and co-workers,33 based on their animal experi-
mentation as well as on clinical observation, indicated that such Mter implantation, mesh plugs shrink up to 75% in size, de-
composite meshes resulted in intestinal fistulization in both rat pending on their looseness, thus failing to secure the repair. 42 ,43
FIGURE 107.11. Intestinal fistula from direct contact of the bowel with Mar-
FIGURE 107.9. Adhesion of the intestines to Vicryl-MarJex®composite. lex®mesh.
107. Complications of the Use of Prostheses: Part I 711
FIGURE 107.12. Shrinkage of a "Perfix" mesh plug 4 months after its im-
FIGURE 107.14. Microscopic view of erosion of Marlex mesh plug into the
plantation (removed during an operation for recurrence of the hernia). bladder wall.
There is 70% shrinkage compared with the unused plug and more than
30% shrinkage compared with the plug after its insertion into the hernia
defect. for the preperitoneal mesh repair of incisional hernias made 10
months after implantation reveal a contraction of approximately
20% (Figs. 107.15 and 107.16) compared with measurements
A loose or soft plug that can be collapsed by pinching it between taken shortly after the procedure. Furthermore, comparison
two fingers shrinks during the patient's own scarring process (Fig.
between mesh removed from patients and processed through an
107.12).28,42 As a result, the anchoring sutures of the plug pull
alcohol-methyl salicylate clearing sequence with that of a control
through the margin of the hernia defect, leading to recurrence
demonstrates that the pore sizes of the removed mesh are ap-
of the hernia and migration of the plug into the scrotum (Fig.
proximately 20% smaller.28
107.13).28,43 More importantly, after scarification and shrinkage,
even a soft plug assumes a cartilage-like consistency and can
erode into the bladder (Fig. 107.14), intestines,44,45 and major Key Principles of
blood vessels. 46 In addition, need for explantation of the plugs
for the treatment of infection 47 ,48 and neuralgia 49 has been
Biomaterials Application
reported.
The following are the key principles of biomaterials application
for effective repair of abdominal wall hernias.
Shrinkage of the Mesh Patch 1. Avoid subcutaneous placement of mesh over an incisional her-
nia defect to avoid seroma collection and fibrous cyst forma-
Contraction of the mesh fibers during the scarring process leads tion . If not covered by at least one aponeurotic layer, the mesh
to shrinkage of the mesh after implantation in vivo. Radiographic is vulnerable to displacement due to intraabdominal pressure,
measurements of the distances between the metallic staples used with increased risk of recurrence.
2. Use intraabdominal pressure to the advantage of the repair
by covering the mesh with a myoaponeurotic layer of the ab-
dominal wall such as the rectus sheath for midline incisional
and external oblique aponeurosis for inguinal hernia repair.
This myoaponeurotic layer keeps the mesh tightly in place un-
til incorporation can occur.
FIGURE 107.13. Shrunken Perfix mesh plug removed after its migration to FIGURE 107.15. Abdominal wall radiograph 1 day after implantation of
the patient's scrotum. polypropylene mesh.
712 P.K. Amid
biomaterial-related intestinal obstruction and fistula formation ,

and failure of the repair due to shrinkage of the mesh. When the
mechanisms of these problems are understood and proper pre-
cautions are taken, prostheses can be used with minimal or no com-
plications. These precautions include the following:
1. The risk of infection can be avoided by utilization of type III
and particularly type I prostheses.
2. The risk of seroma formation can be virtually eliminated by sub-
aponeurotic and retromuscular implantation of type I and type
III prostheses and drainage of the surgical field whenever a
large sheet of mesh is used.
3. The possibility of mesh-related intestinal adhesion, bowel ob-
struction and fistula formation can be eliminated by avoiding
direct contact between the mesh and the intestinal tract or uti-
lization of adhesion-free composites.
4. Finally, problems associated with contraction of the mesh patch
and mesh plug can be circumvented by using a sufficiently large
FIGURE 107.16. Abdominal wall radiograph of the same patient as in Fig.
piece of mesh to provide adequate mesh/tissue interface be-
107.1510 months after implantation of polypropylene mesh.
yond the boundary of the hernia defect, by maintaining ade-
quate laxity of the mesh while it is being fixed to the abdominal
wall tissue, and by avoiding utilization of mesh plugs for the re-
3. Maintain adequate overlap between the mesh and the ab-
pair of abdominal wall hernias.
dominal wall tissue beyond the margins of the defect. The rec-
ommended amount of overlap is 2 to 4 cm for inguinal hernia
repairs, requiring a mesh of 6 to 8 cm in width, and 8 cm for
incisional hernia repairs. Mter incorporation is complete, this
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tions in abdominal wall hernia surgery. Hernia. 1997;1:15-21. 45. Danelli PG, Kurihara H, Montecamozzo G, et al. Le complicanze dei
29. Amid PK, Shulman AG, Lichtenstein IL, et al. The goals of modern plugs: Infezioni e recidive. Hernia. 1997;1(1):55.
hernia surgery. How to achieve them: open or laparoscopic repair? 46. Cristaldi M, Pisacreta M, Elli M, et al. Femoro-popliteal by-pass occlu-
?rob Gen Surg. 1995;12:165-171. sion following mesh-plug for prevascular femoral hernia repair. Her-
30. Law NW, Ellis H. Preliminary results for the repair of difficult recurrent nia. 1997;1:197-199.
inguinal hernias using expanded PTFE patch. Acta Chir Scand 1990; 1-4. 47. Wantz GE. Prosthetics: their complications and management (part I).
31. Taylor SR, Gibbons DF. Effect of surface texture on soft tissue response In Bendavid R (ed): Prostheses and abdominal wall hernias. Austin: R.G.
to polymer implants.] Biomed Mater Res. 1983;17:205-227. Landes Company; 1994:326-339.
32. Crist D, Gadasz T. Complications of laparoscopic surgery. Surg Clin 48. Graham MF. Formal classification of groin hernia and indications
North Am. 1993;73:265-289. for operative therapy. In Leistenhernienchirurgie Heute, Interna-
33. Soler M, Verhaeghe P, Essomba A, et al. Treatment of postoperative tionales Symposium, Klinik fur Chirurgie Kantosspital St. Gallen, April
incisional hernias by a composite prosthetics (polyester-polyglactin 1998.
910). Clinical and experimental study. Ann Chir. 1993;47:598--608. 49. Palot JP, Avisse C, Cailliez-Tomasi JP, et al. The mesh plug repair of
34. Schneider R, Herrington JL Jr, Granada AM. The mesh repair of a di- groin hernias: a three year experience. Hernia. 1998;2(1):31-34.
108
Complications of the Use of Prostheses: Part II
Gianfranco Francioni, Prospero Magistrelli, and Mario Prandi
Introduction Polypropylene
Absorbable and nonabsorbable prostheses have been used in re- Polypropylene had been used in 42 patients. We observed compli-
constructive surgery of the abdominal and thoracic walls for the cations due to the use of rigid prosthesis in a deep abdominal lo-
past four decades. These synthetic materials have made the treat- cation. Adhesion to bowel was frequent, causing some degree of
ment of parietal defects simple and effective, and they have espe- obstruction to transit in 50% of cases (21 patients), occlusion in
cially altered the type, frequency, and severity of complications 15%, the need for ileal resection in 35% of cases (15 patients), and
associated with treatment of abdominal wall hernias. 1- 5 occurrence of pain in 7% (3 patients). The prostheses directly pen-
We have looked closely at the behavior of prostheses in terms etrated the bowel in two cases (one ileum, one colon) and caused
of host tissue reactions, comparing polypropylene (Bard® mesh fistula in three other cases (one ileum, one colon, one bladder).
[Marlex®], Prolene®), polyester (Mersilene®), and expanded poly- Two patients had resection of a bladder diverticulum adherent
tetrafluoroethylene (Gore-Tex®). to the prosthesis and resection of a pseudo tumor of the bladder
dome following an infected multiple relapse with urinary fistula.
Studies Dacron®
Animal Model Dacron showed complications caused by infection and/or pe-

ripheral sequestrations around the fixation sutures. Three chronic
We tried to duplicate clinical conditions in an animal model in abscesses, following median alloplastic repair, required the re-
the hope of arriving at a better understanding of infection, adhe- moval of the prostheses. In six cases major complications were doc-
sion, erosion, and transmigration through viscera. Some of these umented: one colic fistula on peristomal hernia (the prosthesis
complications were well simulated in the animal model and pro- was located in the subcutaneous tissue); three occlustions follow-
vided us with interesting macroscopic as well as microscopic illus- ing Rives technique; two cases where Dacron was used as a sling
trations. Ultimately, the animal experiments were discontinued on within the pelvis: One, on the rectum, was complicated by occlu-
ethical grounds, as the results were in perfect agreement with clin- sion, and the other was a hysterectomy causing a chronic abscess
ical experience. fistulizing into the vagina, which required excision through a com-
bined laparotomy and transvaginal approach.
Clinical Observations Expanded Polytetrafluoroethylene

Our clinical experience occurred between 1982 and 1997 and in- Expanded polytetrafluoroethylene (ePTFE) was preferred in the
volved 54 patients (38 males and 16 females) ranging in age from treatment of incisional hernias. Complications observed were in-
35 to 76 years, who underwent reoperation for prosthetic com- fection, including three chronic abscesses (two of which occurred
plications. Most of this group were referred patients. Eighteen pa- after extensive surgery for colon cancer), and in each case the
tients had had more than one operation, seven patients more than prosthesis was removed without complications.
three operations, and three patients more than six operations. A new type of ePTFE, the DuaIMesh®, is now used to minimize
Twenty-five had incisional hernias and 27 inguinofemoral hernias; adhesion to adjacent organs as the inner surface of the mesh is
2 patients, operated on through a transperitoneal approach, un- made of low porosity ePTFE. Our preliminary experience shows
derwent hysterectomy and hysteropexy. encouraging results.
714
108. Complications of the Use of Prostheses: Part II 715
Discussion
Polypropylene
Polypropylene has been commonly used to repair minor and ma-
jor parietal defects. 6,7 When there are no complications, it induces
similar reactions in different tissues. Cell colonization is the clas-
sic foreign body reaction. Tissue integration generally takes 3
months; after 6 months minimal fibroblastic activity can be ob-
served, and the scar is healed. The connective tissue around the
prosthesis, which we call "periprosthetic sclerosis," is due to dif-
ferent factors but is directly proportional to the thickness and stiff-
ness of the prosthesis. Stiff, thick prostheses induce severe
periprosthetic sclerosis, just under 1 mm thick on both surfaces.
Striated muscle has revealed a tolerance for this type of mesh, and
the space between the aponeurosis and the muscle guarantees FIGURE 108.2. Prosthesis adhesion within the left colonic flexure.
quick integration even if the prosthesis is not perfectly flat. Inte-
gration is much more difficult when the mesh is rolled into a plug.
This often presents sequestration areas within, with decreased re-
sistance to infection (Fig. 108.1). When the tissue around the mesh
is in continuous movement (pulsation of an artery, gastric, intes-
tine, ureteral, or bladder peristalsis), the adhesion of prosthesis is
not superficial but tends to be deeply seated (Figs. 108.2 and
108.3). When an irregular part of the prosthesis is in contact with
viscera, migration and penetration of the organ is commonly seen.
In our experience as well as in that of others,6 polypropylene
was a favorable material in terms of tissue integration (Fig. 108.4);
it showed resistance to infections but a high risk of displacement,
adhesions, and visceral erosions (Fig. 108.5).
Dacron
Dacron, used alone or in a composite mesh,8 induces a minor re-
action compared with polypropylene, probably due to the reduced
thickness of the prosthesis. It shows limited resistance to infec-
tions, either because of its structure or because it tends to create FIGURE 108.3. Microscopic section showing adhesion between prosthesis
peripheral areas of sequestration (Fig. 108.6). Near the periphery and wall of small intestine.
of the mesh there is an increased risk of chronic abscesses and fis-
tulas. This type of prosthesis is soft and thin and needs to be well
anchored to avoid displacement. All complications we observed
FIGURE 108.4. Polypropylene monofilament prosthesis contacting the

smooth muscle and perfectly integrated 3 months after implant in the pig
FIGURE 108.1. Rolled polypropylene prosthesis. (hematoxylin-eosin stain).
716 C. Francioni et al.
A B
FIGURE 108.5. (A) Rolled preperitoneal mesh. Adhesion of the intestinal loops with total wall erosion after 3 months from prosthesis placement in a
35 kg pig. (B) Evidence of prosthesis inside the intestine.
(three chronic abscesses, three occlusions, two intestinal fistulas) the literature is limited,6 our preliminary results on the risks of
were caused by the rejection of the mesh, which was found folded complications are encouraging.
and infected around its nonabsorbable peripheral sutures. The use of DualMesh shows that, without infection, this pros-
thesis induces limited endoperitoneal adhesions. In case of infec-
tion the tissue reaction is comparable to that for any foreign body,
Expanded Polytetrafluoroethylene with adhesions between the loops rather than between an intesti-
nal loop and the prosthesis.
There is clear evidence that ePTFE shows a tissue integration con- The association of polypropylene and 0.1 mm ePTFE gives good
siderably different from that of polypropylene and Dacron 4 ,9,l0 acceptance and integration.!l
(Figs. lOS.7 and 10S.S). It is colonized by a connective layer that
tends to pervade it deeply, and when it is used to support a serosal
wall it is covered by a sort of mesothelium. Expanded PTFE has Prosthesis Location
been shown to be extremely effective for prosthetic repair oflarge
abdominal parietal defects. 9 It is to be used when the mesh has to A further step of our study was to identify appropriateness of types
be in contact with bowel, diaphragm, and pericardium to guar- of prostheses to specific anatomical sites.
antee a very limited production of adhesions 2 (Fig. 10S.9).
We have never observed migration and organ or vascular ero-
sions with this material. The only complications were chronic in-
fections, which required the removal of prostheses (Figs. lOS.lO
and 10S.11).
We tested the Composix® mesh as well. Although experience in
FIGURE 108.6. Chronic seroma following the use of a Dacron prosthesis. FIGURE 108.7. Microscopic section of well-tolerated ePTFE.
FIGURE 108.8. Expanded PTFE placed in the abdominal wall with serum FIGURE 108.11. Infected PTFE (stained with hematoxylin and eosin).
collection.
Abdomen
The Subcutaneous Space
The subcutaneous space shows good tolerance of prostheses. This
location is to be avoided when the adipose tissue is scarce or ab-
sent, as the mesh may cause infection, necrosis, or seroma for-
mation. In superficial locations, mesh is quickly and easily
accepted if we use soft monofilament knitted polypropylene di-
rectly in contact with the superficial aponeurosis.
Dacron gives good results provided that the surgeon fixes the
peripheral sutures to prevent folding of the prosthetic borders.
Premuscular Subaponeurotic Space

We consider the pre aponeurotic space an ideal site for a polypropyl-
ene prosthesis whose thickness, size, and stiffness are well toler-
ated in this location. In the inguinal region, prostheses are
tolerated, although a rigid prosthesis in contact with the spermatic
FIGURE 108.9. Expanded PTFE 0.1 mm well integrated and without in-
testinal adhesions.
cord may induce severe periprosthetic sclerosis (Fig. 108.12).
Dacron prostheses may be used successfully, but the difficulty of
fixation, with risk of folds around the peripheral sutures, makes it
suitable only in the hands of experienced surgeons.
FIGURE 108.12. Microscopic section showing adhesion of polypropylene

FIGURE 108.10. Infected ePTFE (stained with AgNo3). (white spaces) with spermatic cord vessels.
71S G. Francioni et al.
A B
FIGURE lOS.13. (A) Polypropylene plug inside the colon. (B) Macroscopic and microscopic section.
Preaponeurotic Median Submuscular Space compared with a flat prosthesis. Plugs have been shown to be more
subject to infection and central sequestrations, and they tend to
The classic median submuscular localization, described by Rives, migrate like a foreign body. They are to be used with selected in-
remains the best location for a prosthesis. A polypropylene pros- dications, specific technique, and adequate fixation (Fig. 108.13).
thesis is easily placed in this space without significant risk of com-
plications. In contrast, Dacron prostheses required reoperation for
chronic infection in four cases, two of which were further com- Retroperitoneal Space
plicated by hernia recurrence and intestinal occlusion.
Iliac/Femoral Vessels
Preperitoneal Space Polypropylene and Dacron prostheses in direct contact with a ves-
sel wall adhere so tenaciously that they cannot be dissociated.
We think Stoppa's technique, although effective, should be re- When a rigid fold of polypropylene adheres, we may observe the
considered. We now criticize the extensive dissection, which car- progressive penetration of prosthesis into the wall (Fig. 108.14),
ries risks of severe complications. The excess of prosthetic material the innermost layer, causing stenosis in the large veins and throm-
within the preperitoneal space causes extensive periprosthetic scle- bosis in the small vessels. To avoid this severe complication, a large,
rosis that will hinder later surgery in the abdomen or pelvis. soft, knitted prosthesis should be used, leaving 2 to 3 mm of adi-
In the preperitoneal space we use thin, soft monofilament pose tissue between the prosthesis and the organ for protection.
polypropylene prostheses to avoid or reduce contact with any peri- We advise against dissecting away the lymphatic and adipose tis-
toneal organ. sue along the iliac/femoral axis and the thin fascia that covers it.
At the level of the deep inguinal ring the use of plugs has be- For this reason, it is of fundamental importance to preserve the
come a common procedure for reinforcement in the anterior ap- integrity of the transversalis fascia and the iliopubic tract covering
proach. Their incorporation by tissues is slower and more difficult the femoral vessels.
A B
FIGURE 10S.14. Polypropylene prosthesis penetrating the iliac artery wall. (A) Macroscopic section. (B) Microscopic section.
FIGURE 108.15. Microscopic section showing a polypropylene adherent to

ureter (hematoxylin and eosin, X 200).
Ureter
Similarly, a prosthesis in direct contact with the ureters will involve
the ureteral wall and can reach the submucosa (Fig. 108.15). Once
the adhesion is consolidated, it is impossible to isolate the ureter or
FIGURE 108.16. Monofilament polypropylene prosthesis located in the me-
do any maneuver without destruction "en bloc" with the prosthesis. dian preperitoneal space. Macroscopic evidence of adhesion between
ileum and prosthesis.
Bladder Colon
The bladder wall shows a similar reaction to that described below
Colon behaves similarly to ileum, and the thickness of its wall
for bowel. Both Dacron and polypropylene, once in contact with
makes its separation from a slowly eroding prosthesis impossible.
the wall, become inextricable without extensive resection. For this
reason, we consider fixing a prosthesis at the midline objection-
able, especially if there is a coexisting subumbilical incisional her-
nia. We prefer to anchor sutures to Cooper's ligament bilaterally, Spleen
avoiding the contact between the mesh and the bladder wall.
Pieces of polypropylene may be used to avoid lacerating the splenic
capsule when suturing the parenchyma. The underlying tissue is
not damaged by the prosthesis. When the suture reaches the in-
Peritoneal Cavity ferior pole, it is best to avoid contact between pieces of mesh and
the wall of the colon or ileum.
Esophagus and Stomach
The reaction of the esophagus and stomach to prostheses is sim- Liver
ilar to that described below for the ileum.
The same considerations apply to the liver as to the spleen.
Ileum
Whenever polypropylene is used, adhesions reach the muscular Thorax
plane within 3 months. At this stage, when the wall is not too thin
and the zone of contact is not large, the prosthesis can be safely Lung
removed. If the adhesion is irregular (rigid folds, protrusions), the
prosthesis tends to penetrate progressively into the wall, even en- Polypropylene adheres quickly and tenaciously to the lung. This
tering the lumen of the bowel. This happens not only in case of peculiarity may be used successfully for parenchymal mechanical
endoperitoneal prostheses, with direct contact with intestinal suture. Interposition of a sheet of thick knitted polypropylene
serosa, but also when the mesh is covered by a very thin peritoneal between the stapler jaws improves the efficacy of the suture. Com-
layer, especially where abdominal pressure is higher, as in the um- pression through the clips guarantees a good aerostasis, particu-
bilical area (Fig. 108.16). larly in patients with emphysematous and bullous disease, effective
720 G. Francioni et al.
lung expansion, and further tenacious adhesion of the sutured References

zone to the chest wall.
1. Levasseur JC, Lehn E, Rignier P. The repair of extensive evisceration
using an absorbable prosthesis. Khirurgiia. 1995;48:34-37.
Chest Wall 2. Trupka AW, Schweiberer L, Hallfeld K, et al. Management of large ab-
dominal wall hernias with foreign implant materials (Gore-Tex patch).
We have used a double polypropylene mesh for anterolateral chest Zentralbl Chir. 1997;122:879-884.
wall reconstruction. It is easily anchored, its integration is quick 3. Validire J, Imbaud P, Dutet D, et al. Large abdominal incisional her-
and complete, and this material is stiff enough to guarantee late nias: repair by fascial approximation reinforced with a stainless steel
stability. mesh. BrJ Surg. 1986;73:8-10.
4. Colombo PL, Roveda S, Belisomo M, et al. Large abdominal incisional
hernias, use of prosthesis. Our experience. Minerva Chir. 1992;47:161-
Conclusions 170.
5. Dayton MT, Buchele BA, Shirazi SS, et al. Use of an absorbable mesh
The different tissues (e.g., muscle, aponeurosis, periosteum, to repair contaminated abdominal wall defects. Arch Surg. 1986;121:
954-960.
peritoneum, parenchyma) react on the microscopic level in
6. Amid PK, Shulman AG, Lichtenstein II, et al. Experimental evaluation
the same way to the same or similar prostheses.
of a new composite mesh with the selective property of incorporation
The reaction correlates with thickness and stiffness of the mesh to the abdominal wall without adhering to the intestines. ] Biomed Mater
and may be influenced by a chronic inflammation. Res. 1994;28:373-375.
Scar stability correlates with the type of tissue, its pliability, the 7. Seelig MH, Kasperk R, Tieze L, et al. Enterocutaneous fistula after Mar-
type and shape of prostheses, and previous infection. lex net implantation. A rare complication after incisional hernia re-
Polypropylene is an excellent material for prosthetic repair, but, pair. Chirurgie. 1995;66:739-741.
when it comes into contact with moving or pulsating organs, 8. Soler M, Verhaeghe P, Essomba A, et al. Treatment of postoperative
it tends to adhere deeply, to the point of penetrating the struc- incisional hernias by a composite prosthesis (polyester-polyglactin
ture, causing severe complications. 910). Clinical and experimental study. Ann Chir. 1993;47:598-608.
9. Balyen EM, nyiez-Caballero A, Hernyandez-Lizoyain JL, et al. Repair
Tissue reaction to ePTFE is quite peculiar: This material adheres
of ventral hernia with expanded polytetrafluoroethylene patch. BrJ
to tissues without real integration. Expanded PTFE can be
Surg. 1988;85:1415-1418.
placed relatively safely inside the peritoneal cavity. 10. Christoforoni PM, Kim YB, Preys Z, et al. Adhesion formation after in-
Composix mesh may be a satisfactory solution for large parietal cisional hernia repair: a randomized porcine trial. Am] Surg. 1996;
defects. 62:935-938.
Complications of prosthetic repair are potentially serious, and 11. Bendavid R Composite mesh (polypropylene-ePTFE) in the intra-
their surgical treatment is reserved for experienced surgeons. peritoneal position. A report of 30 cases. Hernia. 1997;1(1):5-8.
109
Infected Abdominal Wall Prosthesis
Donald E. Fry
During the past 30 years, prosthetic materials have been used with perior end of the repair and is sutured to the shelving edge of
increasing frequency in the management of ventral 1,2 and groin the inguinal ligament or to Cooper's ligament. The mesh may be
hernias. 3,4 Various permanent prosthetic meshes have been used used in a preperitoneal repairll and may not even require su-
in the repair of these hernias with polypropylene (Bard® mesh, tures. 12 Mesh is used both in the purely elective repair and in
Prolene®)5 and expanded polytetrafluoroethylene (Gore-Tex®)6 emergencies.
being the most frequent mesh materials employed. The use of Second, mesh is used to repair ventral hernias. This is usually re-
mesh is thought to be very desirable in the repair of these various served for very large hernias that cannot be repaired by primary
abdominal wall hernias because (1) it minimizes tension in the suture or when primary repair is under excess tension and mesh
hernia repair, (2) it permits repair of extraordinarily large defects affords a relatively tension-free reconstruction.
that cannot be repaired by primary fascial approximation, and (3) A third use of mesh is as temporary replacement of the ab-
it also can be used to replace attenuated abdominal wall fascia that dominal wall in emergency circumstances when primary closure
would otherwise result in a recurrence. cannot be achieved because of the severity of trauma and the at-
Unfortunately, synthetic mesh materials are associated with tendant intestinal edema. The temporary mesh is usually removed
higher rates of infection than in comparable surgical procedures when the edema resolves. The intention of mesh placement at this
where mesh is not employed. Overall infection rates even when point is to remove it when the edematous circumstance resolves.
mesh is used are quite low, so the presumed slight increase in rates Finally, mesh is used when infection or abdominal wall injury
of infection associated with these prosthetic materials has not dis- has resulted in the acute loss of abdominal wall substance. The
couraged their use. 7 Some reports would indicate that mesh re- emergency use of mesh in the face of severe external contamina-
pairs are not associated with increased infection rates at all. 8 tion from injury, severe contamination from acute intestinal dis-
However, when infection of the mesh repair does occur, all would ruption, or in the face of infection of the fascia or abdominal cavity
agree that the infection is commonly recalcitrant to management. is controversial. l 3-15
Mesh infection creates a clinical dilemma of mesh removal with
all the attendant problems of recurrent hernia and technical mor-
bidity associated with removal of the infected mesh. This chapter
attempts to provide a rationale for the management of these dif-
Biology of Prosthetic Infection
ficult infections.
Infection in a surgical wound results from the summed effects of
(1) the inoculum of bacteria within the wound, (2) the virulence
of the bacterial contaminant, (3) the presence of adjuvant vari-
Clinical Setting of the ables in the wound, and (4) the integrity of the host's inflamma-
Abdominal Wall Prosthesis tory/immune response. In clean wounds such as elective groin or
abdominal wall hernia repair, the inoculum is usually low and orig-
Abdominal wall prosthetic materials have been increasing in pop- inates from the patient's skin. Especially virulent organisms are
ularity during the 1990s and include polypropylene, expanded uncommon (Table 109.1). Despite the ubiquitous presence of cul-
polytetrafluorothylene (ePTFE) , polyester,9 and several types of ab- turable bacteria in every hernia repair, the low inoculum, and the
sorbable meshes (e.g., Vicryl®).10 For permanent reconstruction, modest virulence of most organisms, infection rates are likely to
either polypropylene or ePTFE is used because absorbable meshes be at or less than 2%.8,16
provide only transient support and are inevitably associated with Infection rates in clean hernia wounds are most likely affected
hernia recurrence. by the presence of adjuvant effects. Hemoglobin is a potent adju-
Nonabsorbable mesh prostheses are used in the abdominal wall vant for local infection because of the increased iron that is pres-
in several situations. First, they are commonly used in tension-free ent in the surgical woundP Wound hematoma about a mesh will
repair of a direct inguinal hernia, primary and recurrent. The use increase the probability of infection from a number of bacterial
of the mesh usually extends from the transversus arch at the su- contaminants that would otherwise not cause clinical infection.
721
722 D.E. Fry
TABLE 109.1. The likely pathogens to be identified in infected mesh
Pathogen Virulence factor Comments
Staphylococcus aureus Coagulase Most common pathogen associated with infected mesh that causes an acute infection that is usually
identified within 10 days of the procedure
Staphylococcus epidermidis Glycocalyx Associated with delayed sinus infections; cultures of the exudate are commonly negative. Removal
production of knot or redundant mesh at the edge of the repair can be curative of the infection without
complete mesh removal
Streptococcus pyogenes M proteins Rare acute infection (24 to 48 hours) after mesh placement; rapidly evolving infection that
commonly has a necrotizing fasciitis; requires immediate reoperation, removal of necrotic tissue,
and removal of mesh
Escherichia coli Endotoxin An occasional pathogen in inguinal hernia mesh repair because of proximity to the groin area;
infections identified within first 2 weeks after mesh placement; these infections tend to be locally
pyogenic processes
Pseudomonas aeruginosa Endotoxin A rare pathogen usually seen in exposed mesh from an intensive care unit setting; will commonly
have other associated resistant pathogens with it
Bacteroides fragilis Capsular Anaerobic infection is nearly always associated with an associated aerobic pathogen in a mixed
polysaccharide infection following intestinal contamination of the wound; is seen with gram-negative organisms
with fistulas through the mesh
Necrotic tissue in a wound, perhaps from the use of electrocautery, tion of the surgical site will usually reveal evidence of inflamma-
will increase infection rates. Foreign bodies in a wound also in- tion. Erythema is usually present; and induration can be felt. The
crease infection rates. Elek and Conen 18 showed that silk sutures diagnosis of infection is confirmed by the discharge of pus from
in a wound reduced by 100-fold the numbers of bacteria neces- the wound.
sary to cause experimental wound infection. Braided materials In obese patients, infection can be difficult to confirm because
have a greater adjuvant effect than monofilament material. of the thickness of the subcutaneous tissue. A very important key
Braided material is thought to provide interstices that harbor mi- to diagnosis is persistent pain and palpable induration. Cutaneous
croorganisms from phagocytes. erythema in the obese patient may be totally absent and may only
Prosthetic mesh material is presumed to have a foreign body ad- become evident if the process remains unresolved for many days
juvant effect in the wound. The coarse weave of polypropylene or weeks after infection is suspected. Aspiration of the indurated
mesh with interdigitated monofilament cords should favor lower area of the wound can be attempted, but, in the absence of pal-
infection rates than would the fine mesh weave of ePTFE, which pable fluctuation, it is frequently not productive and risks the in-
has characteristics more akin to silk braid. Adherence of bacteria troduction of contaminants into the wound. In selected cases,
on the surface of the polypropylene probably results in an ineffi- computed tomographic imaging of the area may assist in the di-
cient inflammatory response and poor bacterial clearance from agnosis by identifying fluid about the mesh.
the prosthesis. Proliferation of the microbe on the surface of the Delayed infection can occur months to years after the mesh is
mesh then results in invasion of the bacteria into the adjacent soft placed. Small abscesses can develop and present as areas of pal-
tissue and results in a pyogenic response. pable induration and erythema. These areas commonly disrupt
Infection arising from the body of the mesh appears to be an and drain spontaneously because the patient is beyond the period
infrequent event in the experience of this author. Most commonly, of follow-up with the surgeon and are not recognized as abscess
infection and sinus tracts arise from the edge of the mesh, at the by the patient. These delayed abscesses, which are either drained
site of the knot employed to suture the mesh in place, or at the by the surgeon or drain spontaneously, often lead to a persistent
edge of the mesh where redundant or "bunched" mesh is identi- draining sinus that will usually require specific management.
fied. Large numbers of knots even in monofilament suture creates These draining sinuses usually track to the edge of the mesh and
a "braiding" effect that may increase infection rates. Redundant, communicate with a suture.
folded, or crinkled mesh creates dead space within this foreign The bacteriology of mesh infection varies widely. Most com-
body that may increase infection rates. monly, mesh infection will be with Staphylococcus aureus. The staphy-
Accumulation of pus in and about the foreign body results in lococci will have been in the skin contaminants that were seeded
clinical evidence of inflammation on the surface of the closed into the wound during the procedure. It is generally accepted that
wound and ultimately the discharge of pus from the wound. Di- fewer staphylococci are required to cause infection when mesh is
gestion of soft tissues and fascia about the edges of the mesh re- used because of the adjuvant effects of the foreign body. Because
sults in failure of the hernia repair as the sutured mesh separates. 19 of the proximity of the inguinal area to the perineum, gram-
Occasionally, infection will dissect along the perifascial plane and negative infections such as Escherichia coli will occasionally be seen.
result in necrotizing fasciitis. When mesh is used to replace abdominal wall fascia at the time
of bowel resection or when active peritonitis is present, polymi-
crobial infection can take place. Aerobic gram-negative bacteria
Diagnosis with obligate anaerobes (Bacteroides fragilis) will be the pathogens
following colonic contamination of the wound. Delayed infections
The diagnosis of infection in prosthetic mesh is for the most part with a particularly putrid odor are polymicrobial and are often as-
a clinical one. The patients usually complain of pain in the wound sociated with a fistula into the intestine. Others will reflect sinuses
disproportionate to that which is ordinarily expected. Examina- developing usually to the edge of the mesh as a suture sinus.
109. Infected Abdominal Wall Prosthesis 723
The Infected Mesh necessity. When confronted with this possibility, preoperative
counseling with the patient is necessary on the issue of the risks
When infection of the mesh is confirmed, management must be and potential necessity of orchiectomy.
based on the specific circumstances of each patient. Options in- A small stitch sinus from the edge of the mesh may declare it-
clude local drainage of the infected area, vigorous irrigation strate- self months to even years after repair. In these circumstances, re-
gies with or without antimicrobials, systemic antibiotics, and partial moval of the mesh is unnecessary. Local exploration of the wound
or complete removal of the mesh. with a crochet hook may allow retrieval of the stitch at the mar-
gin of the mesh. It is interesting that these delayed sinus infec-
tions do resolve after the infected suture at the margin of the mesh
Inguinal Hernia Infection is removed. In selected circumstances, a local exploration of the
sinus may be necessary to retrieve the suture. Unincorporated
Wound infection after groin hernia repair with mesh requires an mesh in the local soft tissues should be resected. Sinus tracts sec-
initial assessment about mesh involvement. Many infections after ondary to suture knots that lead down to the shelving portion of
inguinal hernia repair arise from simple processes within the sub- the inguinal ligament or to Cooper's ligament cannot safely be re-
cutaneous layer. Simple drainage of the focus is sufficient, and moved by probing with a hook. These deep sinus tracts need open
these patients have a quick resolution of the process and do quite exploration. Sinus tract infections at the level of Cooper's ligament
well. However, when infection tracks deep into the area of mesh usually require complete removal of the mesh.
repair, the surgeon is then faced with a far more difficult situation
that may require treatment over several months.
Infection of mesh from groin hernia repair inevitably leads to Infection of Ventral Hernia Repair
total removal of the mesh. The amount of mesh used for repair
of an inguinal hernia is small and seldom exceeds 25 cm 2 de- Infection of the mesh after ventral hernia repair poses an inter-
pending on the type of repair. Infection of the groin mesh initially esting problem requiring a judicious approach. Infection after
requires opening and drainage of the wound, but the usual results elective repair is infrequent (:51 %), and management must be in-
with this treatment are either draining sinuses or open draining dividualized. Early infection within the first several weeks follow-
wounds of variable size. Partial removal of the mesh while trying ing mesh placement initially requires opening of the wound and
to preserve a portion of it has proven foolhardy in my experience. drainage of the infection. In many situations, the mesh will then
It is futile, also, because the small portion of mesh that is used in granulate, and secondary closure is achieved with full-thickness
the groin hernia repair nearly always involves the knotted sutures flap closure. It is important not to place split-thickness skin grafts
about the edge of the mesh. over the granulated mesh bed because continued wound con-
The patient must be returned to the operating room and have traction results in extrusion of the mesh. Exposed sutures about
the wound fully explored and all mesh and sutures removed. Sys- the margin of the granulating mesh should be removed because
temic antibiotics do not eradicate the infection but only delay the failure to be incorporated into the granulation is predictive of fu-
inevitable need to remove the foreign material. When the mesh ture sinus formation. As noted in groin hernia infections, redun-
is out, the wound will heal. The recurrent hernia can be managed dant, folded, or bunched mesh about the edge of the repair will
by a second attempt at mesh placement in 6 months or later fol- not heal, and the redundant mesh must be excised.
lowing resolution of the infection. A preperitoneal approach is Localized areas of persistent infection in the ventral hernia re-
preferred in the severely scarred groin following infection and pair may present in several fashions. Persistent draining sinuses
mesh removal. Laparoscopic repair should certainly be enter- through the surgical wound used for the initial repair when probed
tained for the recurrent groin hernia following infection and mesh or explored will lead to suture material or to areas of redun-
removal. dant/buckled mesh. If the sinus infection is due to the suture ma-
Antibiotics for the management of an infected mesh within a terial, then removal of the suture with a crochet hook or local
groin hernia wound have limited value. I have never seen antibi- exploration may be sufficient to resolve the process and gain sec-
otics alone solve the problem. When an infected sinus is present, ondary healing. Probing with the crochet hook for a large ventral
antibiotics may result in a transiently and seemingly healed wound, hernia repair may be difficult because the tendency is to "catch"
but when antibiotics are withdrawn the draining sinus inevitably the mesh rather than necessarily the suture itself. With local ex-
resumes its purulent discharge. At the time of mesh removal, an- ploration for removal of the suture, redundant mesh or nonin-
tibiotics are useful in the presence of cellulitis or soft tissue necro- corporated mesh should be resected. Some late infections present
sis from infection. In addition to removal of the mesh, severely as abdominal wall abscesses at remote periods of time from the
infected wounds requiring systemic antibiotic therapy also require original procedure. These too should be incised and drained, with
aggressive and complete debridement of all nonviable elements removal of sutures and redundant/buckled/unincorporated
of tissue within the groin. Bleeding can be problematic about the mesh. It is unnecessary to remove those areas of the mesh that are
area of the shelving portion of the inguinal ligament and around fully incorporated into the soft tissues unless future failure of the
Cooper's ligament, but usually can be managed by pressure and wound to heal by secondary intention dictates otherwise. Cata-
specific suture ligation. Anatomical relationships can be seriously strophic infections will have mesh extruding through the wound
distorted in the infected groin, and care must be exercised to avoid (Fig. 109.1). Excision of all mesh within the wound is commonly
a femoral vessel injury. Occasionally, the spermatic cord may be necessary in these infections.
necrotic, and testicular viability may be in question. If the initial Several reports have advocated the use of mesh in open and
hernia repair resulted in manipulation of the testicle from the even infected abdominal wall wounds. 13,14,20,21 In my experience,
scrotum, then loss of blood supply from the necrosis of the sper- this can be successfully done if the wound edges have been de-
matic cord leaves no collateral perfusion, and testicular infarction brided back to healthy, viable tissue; if the deep-seated infection
may be a resulting complication. Orchiectomy may be an eventual within the abdominal cavity is under control; and if no intestinal
724 D.E. Fry
When a fistula develops, all mesh in and about the fistulous tract
must be removed. I know of no case where an enteric fistula has
spontaneously healed through intact mesh. Efforts at debridement
of the mesh around the fistulous tract are extraordinarily difficult,
and I have usually found it necessary to resect bowel and fistula.
This requires resection of all exposed mesh about the perimeter
of the wound to avoid a recurrent fistula. The wound is then man-
aged in an open fashion with the inevitable recurrence of a ven-
tral hernia. Split-thickness skin grafts can be used over granulated
intestine and omentum for temporary wound closure.
The subsequent ventral hernias can be unsightly, but such is the
price for closure of the fistula. Reconstruction of these ventral her-
nias may be forsaken because of the extreme complexity of fur-
ther surgery. Having the patient fitted with an abdominal wall
binder may be preferable to additional and hazardous surgery.
This decision may depend on the age of the patient, the patient's
FIGURE 109.1 . Illustrates extruding mesh from an infected repair of a large wishes for repair of the ventral hernia, and the operative risk posed
ventral hernia following a Pfannenstiel incision. Redundant mesh within by the patient's associated conditions.
the wound was the major variable in this infection, which required com- In the overall management of the infected mesh of the ab-
plete removal of all mesh. dominal wall, systemic antibiotics have a limited role. Exposed
mesh that is expected to granulate for subsequent closure will not
benefit from systemic prophylactic antibiotics, nor will topical an-
tibiotics or antiseptics facilitate the process. Systemic antibiotics
suture lines are in proximity to the mesh. The open wound with simply promote the emergence of resistant bacterial strains. Local
mesh can then be allowed to granulate, and full-thickness cover- antiseptics are commonly irritating to tissue and may interfere with
age can then be employed to cover the wound. Split-thickness skin prompt granulation formation.
grafts should not be used. Localized drainage of remote abscesses Systemic antibiotics will not facilitate eradication of infection in
and local debridement of redundant mesh may be required at a redundant mesh, nor will such treatment facilitate fistula closure.
late date, but many patients have an excellent result from this dif- In patients with continued necrotizing infection of soft tissues or
ficult situation. with evidence of cellulitis, antibiotics specific for the pathogen(s)
The most severe complication in mesh reconstruction of the ab- involved are appropriate. Infection about suture material or re-
dominal wall is an infection as a consequence of an enteric fistula. dundant/buckled mesh requires management of the problems of
Fistulas through the mesh, in my experience, occur because mesh the foreign body, not antibiotics.
is used for the restoration of abdominal wall integrity at the same Yet another difficult problem in the patient with a fistula
time that fresh suture lines are placed in the intestine or when re- through mesh is management of the fistula drainage. It is advis-
dundant mesh results in folding and buckling. The buckled or able to construct a specially contoured stomal appliance to fit
folded mesh provides an edge for erosion of the intestinal serosal about the margins of the fistula. Suction catheters can successfully
surface and delayed fistula formation . In my experience, I have be used to control the excoriation and digestive action of enteric
not seen acute or delayed fistula formation when suture lines of drainage on the patient's skin. Aluminum-based pastes can be ap-
the intestine are present with a smooth mesh surface. plied to the skin to minimize excoriation.
TABLE 109.2. Preventive strategies necessary to avoid mesh infections, following hernia repair
Method Comment
Preoperative shower/bathing Having the patient cleanse and scrub the area of the surgical site
reduces the cutaneous colonization at the site; also enhances
patient awareness that infection is an issue
Antiseptics at the surgical site Topical preparation must be thorough to further reduce bacterial
colonization of the wound and the mesh
Preoperative systemic Recommended but without prospective randomized data to
antibiotics demonstrate efficacy; cefazolin 1 g preoperatively covers
staphylococci and common gram-negative rods; no postoperative
antibiotics should be used
Avoid adjuvant effects Precise intraoperative hemostasis to avoid hematoma, but also
avoid excessive necrotic tissue from electrocautery; no braided
suture material in the wound
Avoid technical problems Avoid redundant mesh in the wound; contour the mesh to fit the
defect without tension but without excessive laxity that will
result in wound contraction and buckling of the mesh; avoid
excessive knots for each suture that is placed to secure the mesh
109. Infected Abdominal Wall Prosthesis 725
The timing of reoperation to repair the fistula through mesh 3. Usher FC. Technique for repairing inguinal hernias with Marlex mesh.
requires patience on the part ofthe surgeon and the patient. These Am] Surg. 1982;143:382-384.
fistulas will not close when mesh is still in the tract; waiting for a 4. Amid PI{, Shulman AG, Lichtenstein IL: A critical evaluation of the
long period of time in anticipation is unrewarding. However, pre- Lichtenstein tension-free hernioplasty. Int Surg. 1994;79:76-79.
5. Kark AE, Kurzer M, Waters K. Tension-free mesh repair: review of 1098
mature reoperation in the face of extreme and persistent soft tis-
cases using local anesthesia in a day unit. Ann R Col Surg Engl. 1995;
sue inflammation will only beg the issue of recurrent or additional
77:299-304.
fistulas. In general, I wait 5 to 6 months before proceeding with 6. Koller R, MiholicJ,Jakl RJ. Repair ofincisional hernias with expanded
repair of a fistula through mesh. polytetrafluoroethylene. Eur] Surg. 1997;163:161-166.
Nutritional support becomes an important issue for the patient 7. Deysine M. Pathophysiology, prevention, and management of pros-
who is awaiting repair of the fistula. Parenteral nutrition is com- thetic infections in hernia surgery. Surg Clin North Am. 1998;78:1105-
monly necessary on an ambulatory basis. If fistula drainage is con- 1115.
trolled well, some oral intake of calories is advisable. If the fistula 8. Gilbert AI, Felton LL. Infection in inguinal repair considering bio-
is sufficiently proximal in the jejunum, enteral feeding through materials and antibiotics. Surg Gynecol Obstet. 1993;177:126-130.
the fistula tract distally into the bowel can be achieved in an oc- 9. Leber GE, Garb JL, Alexander AI, Reed WP. Long term complications
associated with prosthetic repair of incisional hernias. Arch Surg. 1998;
casional patient. Regardless of the route of feeding, nutritional
133:378-382.
support is essential so that an adequate period of time can elapse
10. Pans A, Desaive C. Use of an absorbable polyglactin mesh for the pre-
before any attempt at resection of the fistula. vention of incisional hernias. Acta Chir Belg. 1995;95:265-268.
11. Mozingo DW, Walters MJ, Otchy DP, Rosenthal D. Properitoneal syn-
thetic mesh repair of recurrent inguinal hernias. Surg Gynecol Obstet.
Summary 1992;174:33-35.
12. Stoppa RE. The treatment of complicated groin and incisional her-
Infected prosthetic mesh in groin and abdominal wall hernia re- nias. World] Surg. 1989;13:545-554.
pairs is fortunately an infrequent event. Care must be exercised at 13. Voyles CR, RichardsonJD, Bland Kl, Flint LM. Emergency abdominal
the time of mesh placement to minimize the risk of this compli- wall reconstruction with polypropylene mesh. Ann Surg. 1981;194:219-
cation (Table 109.2). For infected groin hernias, the mesh usually 223.
must be removed. A judicious approach is required for abdomi- 14. Fansler RF, Taheri P, Cullinane C, et al. Polypropylene mesh closure
nal wall infections that complicate mesh reconstruction of ventral of the complicated abdominal wall. Am] Surg. 1995;170:15-18.
15. Brandt CP, McHenry CR, Jacobs DG, et al: Polypropylene mesh clo-
hernias. without redundancy and buckling of the mesh, conserv-
sure after emergency laparotomy: morbidity and outcome. Surgery.
ative management can be successfully applied. Local sinus tract in-
1995;118:736-740.
fections usually lead to an area of infected suture at the margin 16. Lazortes F, Chotasso P, Massip P, et al. Local antibiotic prophylaxis in
of the mesh and can be removed with a local probing of the wound inguinal hernia repair. Surg Gynecol Obstet. 1992;175:569-571.
using a hook or by local exploration and removal of the offend- 17. Polk HC Jr, Miles AA. Enhancement of bacterial infection by ferric
ing suture. Mesh complicated by enteric fistula is a problem re- iron: kinetics, mechanisms, and surgical significance. Surgery. 1971;70:
quiring complete removal of the mesh from the fistula tract and 71-77.
surgical repair of the fistula 5 to 6 months later. 18. Elek SD, Conen PE. The virulence of Staphylococcus fryogenes for man:
a study of the problem of the wound. Br] Exp PathoL 1957;38:573-
596.
References 19. Glassow F. Is postoperative wound infection following single inguinal
herniorrhaphy a predisposing cause of recurrent hernia. Can] Surg.
1. Usher FC. New technique for repairing incisional hernia with Marlex 1964;91:870-871.
mesh. Am] Surg. 1979;138:740-741. 20. Mathes SJ, Stone HH. Acute traumatic losses of abdominal wall sub-
2. Liakakos T, Karanikas I, Panagiotidis H, Dendrinos S. Use of Marlex stance.] Trauma. 1975;15:386-391.
mesh in the repair of recurrent incisional hernia. BrJ Surg. 1994;81: 21. Fry DE, Osler T. Abdominal wall considerations and complications in
248-249. reoperative surgery. Surg Clin North Am 1991;71:1-11.
110
Chronic Pain Following Repair of a Groin Hernia
PJ. O'Dwyer and M.G. Serpell
Introduction Frequency of Chronic Groin Pain

Chronic pain is the most serious long-tenn complication that oc- Although chronic groin pain following repair of a groin hernia is
curs following repair of a groin hernia. Not only does it affect the well recognized, there is little infonnation in the literature on its
individual's employment status but it also has significant effects on exact frequency. In the study by Cunningham et al., 1 63% and 54%
sexual and social activities. Although precise figures for the preva- complained of some form of groin pain at 1 and 2 years, respec-
lence of this complication are not available, Cunningham and col- tively, after their hernia repair. However, not all patients in that
leagues! indicate that over 10% of patients will have moderate to study had undergone Bassini, McVay, or Shouldice repairs, and no
severe pain at 2 years following hernia repair. infonnation was given on tension-free mesh repairs using either
The most common type of pain in this context is nociceptive open or laparoscopic techniques. Since 1994, we have been en-
(related to tissue damage), with tenderness at the point of inser- tering patients into a multicenter randomized trial oflaparoscopic
tion of the inguinal ligament to the pubic tubercle. This pain, versus open mesh repair. This trial closed in March 1997 with 928
which often radiates to the ipsilateral scrotum or thigh, is made patients randomized, 468 to laparoscopic repair and 460 to open
worse by stretching and activity and is similar to that reported by repair. At I-year follow-up, when asked by questionnaire if they
patients suffering from groin strain. Recently, Heise and Starling2 had any pain in their groin in the last week, 29% of the laparo-
described mesh inguinodynia as a new clinical syndrome after in- scopic patients had pain while 37% of the open group had pain
guinal hernia repair using mesh. However, it would seem from (Table nO.I). In most patients this pain was mild; however, 4% of
their description of its distribution and our personal experience patients in the laparoscopic group and l.5% in the open repair
that it is similar to the nociceptive pain described after nonmesh group described their pain as severe. In addition, 1% of patients
repair. in the open repair group had very severe pain while none in the
In our experience, testicular pain is the second most common laparoscopic group experienced this (Table 1l0.2).
type of chronic pain patients complain of, and this is more likely to In a more detailed study of 379 of my own patients entered into
occur after preperitoneal (open or laparoscopic) hernia repair. Neu- the same study and examined on an annual basis by an indepen-
ropathic pain localized to the ilioinguinal, iliohypogastric, and gen- dent observer, 33 (8.7%) when questioned admitted to groin or
itofemoral nerves after open hernia repair and in the distribution testicular pain at I-year follow-up. All patients in the laparoscopic
of the lateral cutaneous nerve of the thigh (meralgia paresthetica) group had a totally extraperitoneal (TEP) repair, while patients
after laparoscopic hernia repair is less common than nociceptive randomized to open repair had a Lichtenstein repair if they had
pain. It is characterized by transient electrical, jabbing, or burning a primary unilateral inguinal hernia and a Stoppa repair if their
pain that occurs with or without provocation. Finally, pain follow- hernia was bilateral or recurrent. In all patients with a Lichten-
ing ejaculation has also been described and is the least frequent stein repair insertion of periosteal sutures at the pubic tubercle
type of chronic pain encountered after either open or laparoscopic was avoided. Of the 33 patients with pain, 23 complained of groin
hernia repair. It is not unusual for patients to have combinations of pain, 9 complained of testicular pain, and 1 had both groin and
any or all of the above types of pain, and indeed some who start out testicular pain.
with untreated nociceptive pain may progress to neuropathic pain There was no correlation between the type of hernia repaired
as a result of chronic stimulation of sensory nerves. or the subsequent development of chronic pain (Table 1l0.3). In-
Because the results from treatment strategies to help patients terestingly, patients with a preperitoneal mesh repair were more
with chronic pain after hernia repair can be poor, surgeons need likely to have pain at 1 year than those undergoing a TEP or a
to concentrate on trying to prevent this problem in the first in- Lichtenstein repair (Table 1l0.4). However, part of this increase
stance. This review concentrates on nociceptive pain, its frequency in incidence of pain can be accounted for by the type of hernia
after open and laparoscopic hernia repair, its effect on social ac- repaired in this manner, that is, bilateral and recurrent hernias.
tivities and employment, treatment strategies, and steps that can There was no association between the development of chronic
be taken to prevent it. pain and the presence or absence of any postoperative complica-
726
110. Chronic Pain Following Repair of a Groin Hernia 727
TABLE 1l0.I. Incidence of any groin pain at 1 year following different TABLE 110.3. Relationship between type of hernia and pain at 1 year
types of hernia repair
Nyhus type No. No. with pain (%)
Type of repair No. of patients Percent with pain
20 1 (5%)
Nonmesh 315 62.9 II 138 14 (10%)
Mesh 362 36.7 III 83 9 (11%)
Laparoscopic 394 28.7 IIIB 73 5 (7%)
mc 13 0(0%)
IV 52 4 (8%)
Total 379 33 (8.7%)
tion such as seroma, hematoma, or wound infection. All patients
with testicular pain as their predominant symptom had either a
TEP or open preperitoneal repair, while patients with a Lichten-
time of his attendance to the pain clinic, and he has since re-
stein repair were more likely to have groin pain as their main symp-
mained asymptomatic. Of the remaining four, all have had gen-
tom. All patients with testicular pain had normal testicular size and
eral concerns regarding their health in addition to their groin
blood flow on ultrasonography.
and/ or testicular pain. One was concerned that he might have
All patients have now been followed up for a minimum of 2
cancer, one complained of persistent pain at his intravenous in-
years and a maximum of 5 years. Five of the 33 patients with groin
jection site where anesthetic drugs were administered and had a
or testicular pain required referral to a specialized pain clinic for
past history of constant headaches for 3 years, while the third suf-
ongoing symptoms. In one of these the pain had resolved at the
fered from chronic perianal and back pain, asthma, and possible
sleep apnea. The fourth patient had a past history of headaches
TABLE 1l0.2. Responses to patient questionnaire at 1 year following requiring neurologic investigation and had been treated for
hernia repair trigeminal neuralgia just before his admission for hernia repair.
All patients' groin or testicular pain either has now resolved or is
Laparoscopic Open
controlled with amitriptyline (Table 110.5).
No. % No. % Nine patients who did not have pain at the year 1 follow-up com-
plained of pain at year 2, while a further two patients complained
Pain in groin of pain at year 3. One of these required referral to a specialized
All the time 6 1.5 3 0.8
pain clinic, while in all the others the pain resolved when they
Most of the time 9 2.3 9 2.5
37 10.3
were reassured that they had no recurrence of their hernia. The
Some of the time 30 7.6
A little of the time 68 17.2 84 23.3 patient who required referral to the pain clinic indicated that his
None of the time 282 71.4 227 63.1 pain commenced after the scar was "prodded" during his first year
Pain level in groin follow-up examination. This responded to injection of local anes-
No pain 283 72.4 231 64.2 thetic and steroids and he now experiences tolerable pain on ex-
Very mild 50 12.8 66 18.3 ercise 4 years after his initial repair (Table 110.5).
Mild 43 11.0 55 15.3 Both leisure and sexual activity were significantly affected in all
Severe 15 3.8 5 1.4 but one of the six patients who attended the pain clinic with
Very severe 0 0.0 3 0.8 chronic pain. Three were retired from work, and one was unem-
Numbness around groin
ployed. Of the two in employment, one returned to work 6 months
Not at all 322 81.9 216 60.2
after his hernia repair, and the other refused to go from part-time
Slightly 45 11.5 96 26.7
Moderately 16 4.1 27 7.5 to full-time employment 5 years after his hernia repair.
Quite a bit 8 2.0 16 4.5
Extremely 2 0.5 4 1.1
Numbness down thigh Treatment
Not at all 338 85.8 318 88.8
Slightly 39 9.9 24 6.7 There are no prospective controlled studies concerning the man-
Moderately 9 2.3 10 2.8 agement of chronic pain following hernia repair.3 The manage-
Quite a bit 6 1.5 5 1.4 ment is therefore based on empirical evidence from other chronic
Extremely 2 0.5 0.3
painful conditions. 4 The treatment strategies are based on man-
Pain in testicles
All of the time 5 1.3 11 3.2
aging the component parts of the condition, namely, the nocicep-
Most of the time 9 2.4 7 2.0 tive (tissue damage) and neuropathic (nerve damage) constituents.
Some of the time 23 6.2 14 4.0 It would be too simplistic to regard chronic hernia pain as being
A little of the time 46 12.3 36 10.4
None of the time 290 77.7 279 80.4
TABLE 110.4. Relationship between type of repair and pain at 1 year
Change in day-to-day life so far
Much better 218 55.5 189 52.8 Type of repair No. No. with pain (%)
Slightly better 47 12.0 43 12.0
No change 108 27.5 112 31.3 Totally extraperitoneal 151 12 (8%)
Slightly worse 13 3.3 11 3.1 Lichtenstein 153 13 (8.6%)
Much worse 7 1.8 3 0.8 Stoppa 41 8 (19.5%)
728 PJ. O'Dwyer and M.G. Serpell
TABLE 110.5. Outcome of patients with chronic pain*

Date and
Patient type of repair Symptom Examination Treatment Outcome
TEP 4/94 Groin and Tender over Injection, TENS, 4/98, pain conrolled
testicular pain epididymis amitriptyline on amitriptyline
2 LICT 4/94 Groin pain Normal Injection, TENS 7/98, pain free
3 LICT 5/94 Groin pain Normal Injection 5/98, pain free
4 LICT 8/94 Groin pain Tender over Injection, TENS, Died 3/97, bronchial cancer,
pubic tubercle amitriptyline pain controlled on amitriptyline
5 TEP 9/94 Testicular pain Normal Resolved without treatment
6 LICT 6/95 Groin pain Tender over
pubic tubercle Injection 6/98, occasional mild pain
*while over 90% of all Lichtenstein repairs were supervised by a consultant, three of the four that required treatment at the pain clinic were not.
LICT, Lichtenstein repair; TEP, totally extraperitoneal; TENS, transcutaneous nerve stimulation.
caused by either one or the other of these two mechanisms. In At our pain clinic, injection therapy is often the quickest to im-
truth, it is often a combination of the two, although frequently one plement. We use local anesthetic (plain bupivacaine 0.5%) for di-
plays the predominant role. agnostic evaluation. Complete or very good pain relief is regarded
The treatments available fall into the following groups: physical as a positive response. A good response would be one in which
(e.g., acupuncture), drug, nerve block, and psychological. There is the effect outlasts the pharmacological action of the drug. This is
no strong evidence that one form of therapy is any more effective not an uncommon feature and is explained by the fact that the
than another. The exact order of implementation often depends hyperactivity of the nerve has been suppressed to a level at which
on local availability, side effect profile, and patient preference (most it requires a certain amount of time to fully reestablish itself. If
would like to avoid medication). A logical and ordered approach is there is a positive response, injections can be repeated with steroid
required that must be initiated as rapidly as possible so as to avoid or clonidine added to the anesthetic. Steroid reduces inflamma-
prolonging the patient's suffering (Table 110.6). There is also evi- tion and also has a conduction blocking effect that occurs by an
dence that rapid control of pain symptoms can reduce the proba- unknown mechanism different from local anesthetics. Clonidine
bility of development of resistant chronic pain. 5 is an alpha receptor antagonist that can block sympathetic medi-
Acupuncture and transcutaneous nerve stimulation are simple, ated neuropathic pain. A neuroma or myofascial "trigger spot" of-
inexpensive, and low-risk physical therapies and thus are popular ten presents as a single point of exquisite tenderness and can be
with patients. Acupuncture works by stimulating endogenous opi- injected directly. I~ections of nerves are first done at a peripheral
oid secretion. Transcutaneous nerve stimulation can, depending on site (genitofemoral or iliohypogastric and ilioinguinal nerves) but
the stimulation frequency, work by the same mechanism as acupunc- if unsuccessful are then performed at progressively more central
ture or by large nerve fiber stimulation, "closing the gate," as pro- sites (spinal root at the paravertebral site or epidural).
posed by the gate control theory. This is the mechanism by which, We often combined injection therapy with drug therapy. 6 Most
for example, we get pain relief by rubbing our arm after injuring patients will have appropriately tried nociceptive analgesics such as
our elbow. Rubbing stimulates low threshold mechanoreceptors, paracetamol, nonsteroidal antiinflammatory drugs, and compound
which activate inhibitory interneurons in the substantia gelatinosa weak opioid analgesics. For both nociceptive and neuropathic pain,
and reduce activity in the second order nociceptive neurons. Stim- our first line drug is amitriptyline (tricyclic antidepressant drug). It
ulation of large nerve fibers "closes the gate" to pain transmission. works by increasing central nervous system serotonin and nor-
adrenaline levels, which are fundamental to the endogenous pain
inhibitory pathway in the descending dorsal columns of the spinal
TABLE 110.6. Treatment strategies of hernia pain based on cord. Due to its sedating effect, the drug is taken at night and grad-
prevailing component
ually increased to the optimal range of 50 to 100 mg. This effect is
Nociceptive pain Neuropathic pain quite distinct from any antidepressant effect. Other better tolerated
(tissue damage) (nerve damage) but unproven agents in this class of drug include imipramine and
venlafaxine. It is doubtful whether serotonin selective reuptake in-
Injection: "trigger spot" Injections: neuroma, peripheral nerves
hibitors provide analgesia, and we therefore do not use them.
paravertebral, epidural
Transcutaneous nerve Transcutaneous nerve stimulation For nociceptive pain, the next agent is tramadol, an opiate ana-
stimulation and/or and/or acupuncture logue that works by a combined opioid and amitriptyline-like ef-
acupuncture fect. There is a great reluctance among both medical personnel
Paracetamol Topical capsaicin/Emla cream and the public to use opioids such as morphine for nonmalignant
Nonsteroidal pain, although these are often used early and with good effect for
antiinflammatory drugs Membrane stabilizers cancer pain. This stance is not rational from a pharmacological
Weak opioids Tricyclic antidepressant perspective. The risk of addiction in suitably selected and regu-
Tricyclic antidepressant Anticonvulsants larly monitored individuals is very low, and opioids have proved
Opiate analogues to be effective analgesics. 7 Even neuropathic pain, previously
(e.g., tramadol) Systemic local anesthetics
thought to be resistant to opioids, can sometimes be improved,
Strong opioids Strong opioids
and it is worth trying opioids as a last resort.
110. Chronic Pain Following Repair of a Groin Hernia 729
Specific agents for neuropathic pain include topical local anes- staple into the lateral cutaneous nerve of the thigh. Since January
thetic (Emla) and capsaicin creams. Emla cream will produce 1995, we have used staples only to secure the mesh to Cooper's
short-term anesthesia of superficial nerves, which may bring worth- ligament in select cases, that is, those with a large direct hernia
while relief for the patient but needs to be applied several times encroaching on the femoral canal or those with a femoral hernia.
per day. Capsaicin is applied three times per day and is gradually Although follow-up is still short, we have not had a recurrence
absorbed and transported centrally along the nerve fibers. It is a from over 200 TEPs performed in this manner. More importantly,
neurotoxin and depletes substance P from the nerve, thus reduc- however, we have not had any patient with severe groin or testic-
ing pain transmission. Other agents are termed membrane stabiliz- ular pain using this approach.
ers, as they reduce the activity of hyperexcitable or spontaneously Ejaculatory pain9 is rare following hernia repair, and we have
active nerve transmission. These include anticonvulsant drugs such encountered it only once in our prospective study. This occurred
as carbamazepine and gabapentin and systemic local anesthetics following a combined TEP and vasectomy and resolved sponta-
such as intravenous lignocaine or oral mexiletine. neously after 6 months. Cunningham and colleaguesl also de-
If all therapeutic medical therapies fail, the patient may be con- scribed this syndrome in a single patient and thought that it was
sidered for a pain management program that employs primarily probably not caused by development of a stricture in the spermatic
psychological and physiotherapy techniques for improving their cord but related to dysfunction of periurethral structures involved
overall function and ability to cope with their condition. in ejaculation. However, given that almost 1 % of patients have
some form of cord iryury at open or laparoscopic hernia repair,
it would be difficult to discount complete occlusion or a stricture
Role of Surgery of the vas as a potential source of this pain.
The role of surgery in the management of chronic groin pain is

controversial. Some authors report good to excellent results in up Summary and Conclusions
to 60% of patients treated by neurectomy or neurectomy plus mesh
removal for those with a mesh repair. 3,8 The use of selective nerve Although one in three patients will admit to some form of groin
blocks is thought to be of little value in predicting a response to or testicular discomfort when assessed by questionnaire at 1 year
surgical neurectomy, however, while the presence of testicular pain following hernia repair, less than 1 in 10 will indicate discomfort
is said to be a relative contraindication of genitofemoral neurec- when assessed at the same time by an independent observer. In 1
tomy. Although the TEP laparoscopic approach would appear to to 2% of all patients, the pain will be of such severity as to war-
be ideal for genitofemoral nerve neurectomy after open hernia rant treatment at a specialized pain clinic. Referral to such a clinic
repair, many still favor an open approach and combine it with il- should be made as soon as infective or ischemic sources for the
ioinguinal and iliohypogastric neurectomy. pain have been excluded. These patients will often have anxieties
It is interesting to note that the success rates of 50 to 60% seem about their general health, and the groin and/or testicular pain
to be consistent irrespective of the operative procedure per- will have a significant impact on their social activities and em-
formed, which suggests that such responses may be largely a ployment. The pain is usually nociceptive, with maximal tender-
placebo effect. Cunningham and colleagues! advise against ilioin- ness at or medial to the pubic tubercle. All will have either a partial
guinal, iliohypogastric, or genitofemoral nerve resection for noci- response to medical treatment, with mild to moderate pain
ceptive pain. The finding from our prospective study supports this brought on by prolonged exercise several years after the repair, or
in that all patients treated medically responded and returned to a complete response allowing them to return to normal activities.
employment or normal activities. Rarely, surgery in the form of neurectomy may be required for in-
tractable cases.
Prevention of Chronic Groin Pain

References
Hernia repair performed outside major hernia centers has often
been relegated to the junior surgical trainee. This should no 1. Cunningham], Temple~, Mitchell P, et al. Cooperative hernia study.
longer be the case; all groin hernias should be supervised by a Pain in the postrepair patient. Ann Surg. 1996;224:598-602.
2. Heise CP, Starling]R Mesh inguinodynia: a new clinical syndrome af-
consultant or an experienced surgeon who has performed at least ter inguinal herniorrhaphy? JAm Coll Surg. 1998;198:514-518.
100 hernia repairs. The hernia repair should be performed with- 3. Callesen T, Kehlet H. Postherniorrhaphy pain. Anesthesiology. 1997;87:
out tension irrespective of the method of repair used, and the 1219-1230.
placement of periosteal sutures at the pubic tubercle should be 4. McQuay HJ, Moore RA. An evidence-based resource for pain relief. Oxford:
avoided. The decision to divide the genital branch of the gen- Oxford University Press; 1998.
itofemoral nerve or the ilioinguinal nerve should rest on whether 5. Bwosher D. Pathophysiology of post-herpetic neuralgia: towards a ra-
undue traction is likely to be placed on them or whether they are tional treatment. Neurology. 1995;45:s56-557.
likely to be injured during the repair. In obese patients or patients 6. Wall PD, Melzack R (eds). Textbook ofpain. Edinburgh: Churchill Living-
with large combined defects, it is sometimes easier to divide the stone; 1989.
7. Zenz M, Strumpf M, Trybe M. Long-term oral opioid therapy in patients
nerves rather than risk their incorporation into the repair by a su-
with chronic nonmalignant pain. J Pain Symp Manag. 1992;7:69-77.
ture or cause a traction injury by the retraction that is sometimes
8. Kennedy EM, Harms BA, Starling JR Absence of maladaptive neuronal
necessary to obtain adequate exposure in these patients. plasticity after genitofemoral-ilioinguinal neurectomy. Surgery. 1994; 116:
In patients undergoing laparoscopic hernia repair, fixation of 666-671.
mesh using staples is largely unnecessary. The rare cases of mer- 9. Bendavid R "Dysejaculation": an unusual complication of inguinal
algia paresthetica reported are almost all related to insertion of a herniorrhaphy. Postgrad Gen Surg. 1992;4:139-141.
III
Neuralgia Following Hernia Repair
C. Tons, J. Hoer, and V. Schumpelick
Chronic inguinal pain following hernia repair can be a severe lateral scrotum. 22 These results demonstrate that irritation of the
handicap, often leading to problems in both home and working genital branch of the genitofemoral nerve has been underesti-
life. Permanent disability is not rare. 1 Nevertheless, Devlin 2 as- mated as a direct cause of chronic neuralgia after hernia repair.
serted in 1995 that chronic neuralgia after hernia repair by a spe- The irritation of this nerve may be caused by the surgical mani-
cialist is nonexistent. Other studies by reputable hernia surgeons pulation of the internal inguinal ring and resection of the cre-
show that the incidence of chronic inguinal pain after hernia re- master muscle. 22- 24
pair ranges from 2 to 7%, regardless of the surgical technique The causal mechanisms for chronic inguinal pain after mesh
used.3--8 The risk of chronic neuralgia is signjficantly higher after hernia repair with either the open anterior or endoscopic ap-
repair of a recurrent hernia than after primary hernia repair.9-11 proach are still under debate. The application of clips or sutures
Most data about chronic inguinal pain have referred to the con- in the proximity of the nerves was once thought responsible
ventional anterior approach repairs without prostheses; now stud- for chronic inguinal pain.14 Two further causes are discussed
ies dealing with chronic neuralgia following endoscopic and here: mesh migration and mesh shrinkage near the nerves and
anterior mesh hernia repairs are beginning to reveal a compara- the persistent inflammatory reaction caused by the implanted
ble clinical picture.1,3,12-17 biomaterials. 17
Causes Diagnosis
As a rule, chronic inguinal pain is the consequence of a disorder Chronic inguinal pain as a consequence of surgical hernia repair
of the sensory and motor nerves of the inguinal region: the il- can be assessed only after a clinical follow-up of at least 6 months.
ioinguinal and iliohypogastric nerves and the genitofemoral nerve, This follow-up should include a neurological examination (tactile
particularly its genital branch (Fig. 111.1).18 Neuroma formation hypo- and hyperesthesia, two-point discrimination, cremaster re-
on these herves may be caused by complete or partial nerve sec- flex), a standardized interview about the character of the pain,
tion, contact with foreign material, compression by scar tissue, or and, eventually, infiltration with local anesthetic.
nerve ligation. Sinus formation around a suture, with concomitant To achieve optimal diagnosis and therapy, the interpretation of
irritation of the adjacent nerves, was often reported in the past. the character of the pain seems to be of central importance. Chevrel
Since the elimination of multifilament nonabsorbable suture ma- et al. 25 have listed pain characteristics and their clinical significance:
terial in hernia surgery, this complication has become rare. 19 The
painful persisting periostitis of the pubic bone is rarely seen nowa- Hyperesthesia or hyperpathia, either fixed or transitory, with an
days, primarily because the Bassini procedure is practiced to a exquisite shooting type of pain resembling an electric shock
much lesser extent, but also because surgeons are aware of the may point to a neuroma after partial or total division of one
problems caused by suturing periosteal tissue. 8,20 of the three nerves in the region of the groin.
In a follow-up study, 367 of our patients (237 primary hernia re- A constant burning sensation appearing after several weeks post-
pairs, 130 recurrent) were examined 1 year after a conventional operatively with paroxysms in the corresponding region may
Shouldice repair. The-follow-up rate was 91.2% for primary her- indicate a partial section of inclusion of a nerve in a ligature.
nias and 87.7% for recurrent hernias. The incidence of chronic Contact does not produce sharp pain.
inguinal pain was 4.2% for primary hernia patients and 6.2% for A permanent hyperalgesia without reported paroxysms may be
patients with recurrent hernias. Although 11 % of these patients due to irritation of a nerve without interruption of its conti-
showed signs and symptoms of direct involvement of the ilioin- nuity due to involvement in a fibrous mass or a ligature.
guinal nerve,21 39% of the patients with chronic inguinal pain A fixed hyperalgesia without paroxysms in an area that may
showed the classic irritation of the genital branch of the geni- cover various dermatomes may be due to a lesion at some dis-
tofemoral nerve, with radiation of pain into the medial thigh and tance from the affected nerve. The cause can be muscular ir-
730
111. Neuralgia Following Hernia Repair 731
to the old scar. A surgical approach through the old inguinal scar
is not recommended because of the high incidence of scar-induced
exacerbation of nerve disorders.
In the case of a severe genital branch syndrome, an extraperi-
toneal proximal neurotomy of the genital branch of the geni-
tofemoral nerve through a flank incision is possible. 28 The nerves
in the retroperitoneum should be identified (Fig. 111.2), and the
genital branch of the genitofemoral nerve should be coagulated
just beyond the bifurcation. There have been successful endo-
scopic proximal neurectomies of the genital branch 29.30 ; the open
approach may lose adherents.
A distinct diagnosis and indication for surgical intervention is
obtained in only 40% of patients with chronic inguinal pain. 9.3!
Most of these patients are treated conservatively with repeated in-
jections of local anesthetics or steroids,27 with systemic analgesics,
nonsteroidal antiinflammatory drugs, and often with adjunct psy-
chiatric therapy. Additional supportive therapy with transcuta-
neous electric nerve stimulation showed no satisfactory long-term
results in patients with chronic neuralgia after hernia repair. 32
The therapeutic results of chronic inguinal pain are further im-
paired by the mechanisms of spinal pain facilitation. This occurs
through spinal afferent fibers especially in the inguinal region and
may lead to persistent pain even when no local nerve disorder is
demonstrable. 33-35
Prevention
FIGURE 111.1. Nerves of the inguinal region to be respected: 1, iliohy-
pogastric nerve; 2, ilioinguinal nerve; 3, genital branch of the genito- The 50% success rate after therapy of chronic inguinal pain is un-
femoral nerve. satisfactory.25.27 It underlines the importance of taking preventive
precautions. Preemptive analgesia, as a preventive measure, was
tested in prospective randomized studies but proved ineffective;
ritation due to inflammatory granuloma or visceral adhesions neither the postoperative local infiltration of the operative field
caused by the stump of the peritoneal sac. with ropivacaine nor the systemic therapy with ibuprofen showed
The diagnosis of chronic inguinal pain is based on history and any significant advantage.!5.36
clinical criteria. Nerve conduction velocity measurements and imag- In our experience, attention to detail is effective in preventing
ing procedures such as ultrasonography or x-ray of the pubic bone the development of chronic inguinal pain. The subtle preparation
are not as helpful. The repeated trial infiltration of the involved of the ilioinguinal nerve, and especially of the genital branch of
nerve with local anesthetic is the most important diagnostic test for the genitofemoral nerve, seems to be very important for postop-
chronic inguinal neuralgia. The limitation of this method is the in-
accessibility of the genital branch of the genitofemoral nerve to
direct infiltration. To verify a suspected genital branch syndrome,
a computed tomography-directed paravertebral root block is
feasible. 26
Therapies and Results

The therapeutic results of both surgical and drug treatment of
chronic inguinal pain have not proved satisfactory.25.27 The results
of surgical interventions, especially through the scar of the pri-
mary operation, are poor. 25 Unequivocal signs and symptoms for
neuromas or nerve compression should be confirmed by trial in-
filtration with local anesthetics before surgical intervention. The
surgical approach should be carried out through proximal scar-
free anatomical areas, and the affected nerve must be either mo-
bilized or resected and electrocoagulated with full energy to avoid
recurrence of neuroma formation. In some cases a proximal il-
ioinguinal or iliohypogastric neurectomy is necessary. It is our ex- FIGURE 111.2. Nerves in the retroperitoneum: a, lateral cutaneous nerve
perience that this should be carried out through a new transverse (of the thigh); b, genitofemoral nerve; c, femoral branch; d, genital
incision medial to the anterior superior iliac spine and proximal branch; e, obturator nerve.
732 C. Tons, J. Hoer, and V. Schumpelick
TABLE 111.1. Follow-up studies of Aachen Medical University: Results of References

physical examination 1 year after Shouldice repair of groin hernia of
patients in first series compared with those of patients in pain 1. Schrenck P, Woisetschlager R, Reiger R, et al. Prospective randomized
prophylaxis program trial comparing postoperative pain and return to physical activity af-
ter transabdominal preperitoneal, total preperitoneal or Shouldice
First series Follow-up study technique for inguinal hernia repair. BrJ Surg. 1996;83:1563-1566.
2. Devlin HB. Chronic pain after hernia repair. In Schumpelick V, Wantz
Primary hernia
GE (eds): Inguinal hernia repair-expert meeting on hernia surgery.
Number 237 621
St. Moritz Basel: Karger; 1995:365-367.
Local anesthesia 13.0% 93.1%
3. Callesen T, Bech K, Andersen], et al. Pain after primary inguinal
Follow-up rate 91.2% 89.2%
herniorrhaphy: influence of surgical technique. ] Am Colt Surg. 1999;
Testicular atrophy 0.5% 0.5%
188:355-359.
Chronic inguinal pain 4.2%* 1.5%·
4. Condon RE, Nyhus LM. Complications of groin hernia and of hernial
Recurrences 0.5% 1.5%
repair. Surg Clin North Am. 1971;51:1325-1336.
Recurrent hernia
5. Glassow F. Inguinal hernia repair using local anaesthesia. Ann R Colt
Number 130 258
Surg EngL 1984;66:382-387.
Local anesthesia 3.0% 68.2%
6. Rutledge RH. Cooper's ligament repair: a 25-year experience with a
Follow-up rate 87.7% 85.6%
single technique for all groin hernias in adults. Surgery. 1988;103:1-10.
Testicular atrophy 1.5% 1.2%
7. Schumpelick V (ed): Hernien, 3rd ed. F Enke Verlag; Stuttgart. 1996.
Chronic inguinal pain 6.2% 2.7%
8. Stulz P, Pfeiffer KM. Peripheral nerve injuries resulting from common
Recurrences 3.2% 3.1%
surgical procedures in the lower portion of the abdomen. Anh Surg.
•p< 0.05. 1982;117:324-327.
9. Cunningham], Temple \\1, Mitchell P, et al. Cooperative hernia study.
Pain in the postrepair patient. Ann Surg. 1996;244:598-602.
10. Ungeheuer E, Herrmann F. Komplikationen nach Leisterhernienop-
erative results. Operation under local anesthesia facilitates the erationen. Chirurgie. 1984;55:564-568.
identification and protection of the genital branch in the region
of inguinal hernioplasty. Surg Clin North Am. 1993;73:571-581.
of the internal inguinal ring. In surgical interventions with pros-
12. Chevallier ]M, Wind P, Lassau ]P. Damage to the inguino-femoral
thetic meshes, sutures and other fixation devices should be placed nerves in the treatment of hernias. An anatomical hazard of traditional
at a safe distance from nerves. The avoidance of relaxing incisions and laparoscopic techniques. Ann Chir. 1996;50:767-775.
in the rectus sheath, which cause irritation of the iliohypogastric 13. Gurleyik E, Gurleyik G, Cetinkaya F, et al. The inflammatory response
nerve, and of wound drainage further reduces incidence of pain to open tension-free inguinal hernioplastyversus conventional repairs.
after groin hernia repair. AmJSurg.1998;175:179-182.
An early postoperative anodyne may prevent the development 14. Kraus MA. Nerve injury during laparoscopic inguinal repair. Surg Lajr
of chronic inguinal pain mediated by spinal facilitation. Ninety- arosc Endosc 1993;3:342-345.
three percent of our patients with primary groin hernia and 68% 15. Mixter CG III, Meeker LD, Gavin 'IJ. Preemptive pain control in pa-
tients having laparoscopic hernia repair: a comparison of ketorolac
with recurrent hernias are now operated on under local anesthe-
and ibuprofen. Arch Surg. 1998;133:432-437.
sia and treated postoperatively by early mobilization and guided
16. Pugliano G. Preliminary experience in prosthetic hernia surgery. Acta
extension of trunk muscles. In recognition of the effective patient- Biomed Ateneo Parmense. 1995;66:229-232.
controlled intravenous analgesia after laparotomies, all patients af- 17. Schumpelick V, Klinge U, Welty G, et al. Meshes in der Baiichwand.
ter hernia surgery receive four "cocktails" (tramadol-metamizol Chirurgie.70(8):876-887.
drops) to be taken on demand. 18. Lanz T. Praktische anatomie der bauchwand. Langenbecks Anh Chir.
Follow-up studies after the introduction of this postoperative 1963;304:250-274.
pain prophylaxis program showed that subtle preparation and fac- 19. Solhaug ]H. Polyglycolic acid (Dexon) versus Mersilene in repair of
ultative neurectomy of the genital branch of the genitofemoral inguinal hernia. Acta Chir Scand. 1984;150:385-387.
nerve, in combination with the postoperative pain therapy, is ef- 20. Mettler M, Kupfer K, Stirnemann H. Disorders of sensation following
inguinal hernial operations. Helv Chir Acta. 1988;54:777-780.
fective in preventing chronic inguinal pain. The clinical follow-up
21. Mumenthaler A, Mumenthaler M, Luciani G, et al. Das ilioinguinalis-
at 1 year after the surgical treatment of 621 primary hernias (fol-
syndrom. Deutch Med Wochenschr. 1965;90:1073-1078.
low-up rate 89.2%) and 258 recurrent hernias (follow-up rate 22. Tons C, Kupczyk:Joeris D, Rotzscher VM, et al. Cremasterresektion bei
85.6%) showed promising results: The incidence of chronic pain Shouldice-Reparation. Eine prospektiv kontrollierte Bicentes-Studie.
after primary hernia repair was significantly reduced from 4.2 to Chirurgie. 1990;61:109-111.
1.5% (P < 0.05), while the incidence of chronic pain after recur- 23. Laha RK, Rao S, Pidgeon CN, et al. Genito-femoral neuralgia. Surg
rent hernia repair fell markedly but not significantly from 6.2 to NeuroL 1977;8:280-282.
2.7% (Table 111.1). 24. Starling ]R, Harms BA, Schroeder ME, et al. Diagnosis and treatment
We may conclude that while hernia recurrence after primary of genitofemoral and ilioinguinal entrapment neuralgia. Surgery. 1987;
hernia repair is between 0.1 and 3%,5,7,22 the quality of the her- 102:581-586.
25. Chevrel]P, Gatt MT, Sarfati E. Les nevralgies residuelles apres cure de
nia surgery has to be judged by complications of the intervention.
hernie inguinale. GREPA, 4e reunion, St. Tropez. Boulogne-Bi11ancourt;
Of all the patients in our study, 22 suffered recurrence or re-
Bruneau: 1982:29.
recurrence, but 34 patients suffered from severe chronic inguinal 26. Harms BA, DeHaas DRJr, StarlingJR Diagnosis and management of
pain. Five of these had to change their jobs, and one remains dis- genitofemoral neuralgia. Arch Surg. 1984;119:339-341.
abled by persistent pain in the inguinal region. Quality of life, in- 27. Gatt MT, Chevrel]P. Treatment of neuralgia after surgical repair of in-
cluding freedom from pain, is the true measure of the success of guinal hernia. A propos of 47 cases. Chirurgie. 1991;117:96-103.
a surgical intervention. 28. Tons C, Kupczyk:Joeris D, Ratzscher VM, et al. Chronic inguinal pain
111. Neuralgia Following Hernia Repair 733
following Shouldice repair of primary inguinal hernias. Contemp Surg. 33. Plaghki L, Bragard D, Le Bars D, et al. Facilitation of a nociceptive
1990;37:24-30. flexion reflex in man by nonnoxious radiant heat produced by a laser.
29. Krahenbuhl L, Striffeler H, Baer HU, et al. Retroperitoneal endoscopic ] NeurophysioL 1998;79:2557-2567.
neurectomy for nerve entrapment after hernia repair. BrJ Surg. 1997; 34. Urban MO, Zahn PK, Gebhart GF. Descending facilitatory influences
84:216-219. from the rostral medial medulla mediate secondary, but not primary
30. Perry CPo Laparoscopic treatment of genitofemoral neuralgia. JAm As- hyperalgesia in the rat. Neuroscience. 1999;90:349-352.
soc Gynecol Laparosc. 1997;4:231-234. 35. Yanez AM, Peleteiro-Ramos R, Camba MA, et al. Pharmacology of
31. Choi PD, Nath R, Mackinnon, SE. Iatrogenic injury to the ilioinguinal spinal facilitation: the basis for preventive analgesia. Rev Exp Anestesiol
and iliohypogastric nerves in the groin: a case report, diagnosis and Reanim. 1998;45:17-23.
management. Ann Plast Surg. 1996;37:60-65. 36. Johansson B, Hallerback B, Stubberod A, et al. Preoperative local in-
32. Smedley F, Taube M, Wastell C. Transcutaneous electrical nerve stim- filtration with ropivacaine for postoperative pain relief after inguinal
ulation for pain relief following inguinal hernia repair: a controlled hernia repair. A randomised controlled trial. EurJ Surg. 1997;163:
trial. Eur Surg &so 1988;20:233-237. 371-378.
112
Mesh Inguinodynia Mter
Inguinal Herniorrhaphy
James R. Starling
Complications after inguinal herniorrhaphy are relatively rare. no correlation between pain or numbness and the preservation or
Postherniorrhaphy chronic inguinodynia (neuralgia) occurs in 1 sacrifice of the peripheral nerves. They have never operated on
to 2% of patients. I4i These patients report severe, debilitating pain any of their patients for chronic inguinodynia. They believe that
and pose a difficult ongoing management problem. Treatment chronic postherniorrhaphy inguinodynia is due to the sequelae of
modalities have included local analgesics and steroid injections, suturing under tension rather than to frank nerve entrapment. I6-IS
various drugs, behavioral therapy, cryotherapy, alcohol or phenol A further development is the enthusiastic use of mesh in lapa-
injections, and neurectomy or neurolysis. Postherniorrhaphy pain roscopic hernia repairs. Recently, reports of entrapment syndromes
syndromes are thought to be caused by injury to or entrapment began appearing in the literature; these have included, particularly
of the ilioinguinal, iliohypogastric, genitofemoral, or lateral cuta- in earlier reports, entrapment of the lateral cutaneous nerve of the
neous nerves. Onset is usually immediate, although delayed onset thigh (lateral femoral cutaneous nerve) and, more recently, injuries
can occur, possibly due to scarring or neuroma formation. to the ilioinguinal and iliohypogastric nerves,II-I4,I9 Injury to the
The use of prosthetic mesh is well accepted and is rapidly be- femoral nerve has also been described. The incidence of chronic
coming a standard approach to hernia repair. Lichtenstein has inguinal neuralgia has been reported to be 0.3 to 2.6% after lap-
done much to popularize its use; using his "tension-free hernio- aroscopic herniorrhaphy, depending on the technique employed:
plasty," his clinic has reported a 0.2% recurrence rate. 7,s Never- "Intraperitoneal onlay mesh (IPOM), 0.5 to 4.6%; transabdomi-
theless, patients still present with chronic inguinodynia, and steps nal preperitoneal (TAPP), 1.2 to 2.2%; and total extraperitoneal
to avoid this problem have been recommended. I,5 (TEP), 0 to 0.6%."20 Seid and Amos reported nine such cases, but
Mesh is used in laparoscopic herniorrhaphy with increasing fre- others have given case reports only,u,I3,I9 Three patients in our
quency and good results in terms of recurrences. 9,IO Among the own initial series and 13 additional patients developed chronic
advantages of laparoscopic herniorrhaphy are less postoperative pain after laparoscopic herniorrhaphy. The involvement of mesh
pain, earlier return to normal activities, and a novel approach to plugs as a possible cause of chronic inguinodynia has not been re-
difficult recurrent or bilateral repairs. However, chronic inguinal ported or denied. I6
pain is among the reported complications of this procedure,II-14 Nerves can become tightly incorporated into the interstices of
In addition, there have been some unusual neurological findings the mesh, making separation impossible (Fig. 112.1). Following
after laparoscopic hernia repairs involving inadvertent stapling incorporation by fibrotic material, mesh tends to contract, possi-
of peripheral sensory nerves. ll Entrapment of the lateral cutan- bly causing kinking or entrapment of nerves (Fig. 112.2). Bocchi
eous nerve of the thigh results in the syndrome known as meralgia reported a 7.6% incidence oflate postoperative pain after inguinal
paresthetica. herniorrhaphy, which he attributes to contact between frayed
nerves and the polypropylene mesh. 2o
Why some patients with mesh herniorrhaphy develop such de-
Reports bilitating pain remains an enigma. Although the cause may be ob-
vious, as when a surgical clip is placed around a nerve or when
Initial reports of inguinodynia date back to the 1940s, describing direct injury results in a traumatic neuroma, granuloma, or severe
genitofemoral causalgia. I5 Hagen and co-workers reported that perineural fibrosis (Fig. 112.3), there are times when nothing ab-
10.6% of patients who had open inguinal herniorrhaphy, espe- normal can be found.
cially McVay's repair, complained of moderate or severe pain 2
years after the operation. 6 These early reports predate the intro-
duction of prosthetic mesh for hernia repair; now that use of mesh Treatment
implants of all kinds is becoming commonplace, one would ex-
pect a corresponding increase in the incidence of chronic in- Most early surgical treatments of chronic inguinodynia were per-
guinodynia following these forms of inguinal hernia repairs. formed on patients without mesh repairs. 21 Many of these patients
Robbins and Rutkow have the largest experience with mesh plug experienced pain relief following exploration and neurectomy. As
herniorrhaphy. Their experience with over 3000 patients indicates there are so few reports on treatment of pain after mesh hernior-
734
112. Mesh Inguinodynia After Inguinal Herniorrhaphy 735
FIGURE 112.1. Ilioinguinal and iliohypogastric nerve incorporated into FIGURE 112.3. Ilioinguinal nerve neuroma incorporating mesh fragments.
mesh.
neurectomy. However, in the current study of mesh inguinodynia,

rhaphy, proper management remains unclear. In relation to lap-
clinical outcomes of patients reporting relief with selective pre-
aroscopically induced neuralgia, Seid and Amos 19 recommend
operative nerve blocks were not different from those of patients
treating with local injection, reporting 100% success in nine cases.
who did not respond to nerve blocks. 21 Neither did it make any
They reserve operative exploration for those cases that fail to re-
difference whether mesh was removed at the time of neurectomy
solve after 4 to 6 weeks. Broin et al.1 1 suggested a transabdominal
or not. Because of these clinical observations, preoperative nerve
laparoscopic approach, with staple removal, for meralgia pares-
blocks are no longer recommended as part of treatment of in-
thetica. Others describe operative intervention through an open
guinodynia after mesh herniorrhaphy.
transabdominal or extraperitoneal approach, with mesh removal,
neurectomy, or both.1 2,13 These authors report favorable out-
comes. In my experience, pain relief with mesh removal and pos-
sible neurectomy will be 60 to 70%. This lower percentage may be Clinical Experience
attributable to the severity of chronic inguinodynia. Patients
should not undergo remedial surgery for at least 3 months and The author's initial published experience with chronic inguino-
preferably at more than 6 months to allow time for spontaneous dynia in patients with mesh hernioplasty consisted of20 patients. 21
resolution of the many causes of neuralgia not attributable to nerve Seventeen had had open mesh herniorrhaphy and 3 laparoscopic
entrapment. repair (TAPP). In addition to chronic inguinodynia, 13 patients
Earlier publications by the author have stressed the importance reported pain in the scrotum or labia majora, and 2 had pain in
of a multidisciplinary approach to the problem of treating chronic the anterolateral thigh (meralgia paresthetica of Roth). Eight of
inguinodynia following inguinal herniorrhaphy.22 The use of pre- the 20 patients had had two or more previous surgeries related to
operative nerve blocks is recommended to determine the location their complaints. Eleven had preoperative nerve blocks with mod-
of the nerve injury and help in planning the approach for specific erate or complete relief of pain. Seven were workmen's compen-
sation cases.
Treatment consisted of mesh removal in 4 patients, with im-
provement in 50%, and mesh removal combined with neurectomy
in 16 patients, 62% of whom were improved. Overall, 60% of pa-
tients reported good or excellent results. In those without scrotal
or labial pain, 71 % improved. Good results were also reported by
75% of those who had had previous surgery. Two of three patients
who underwent primary laparoscopic repair had favorable out-
comes when their mesh was removed.
Complications following treatment for inguinodynia were min-
imal: One patient developed a wound hematoma and one has
short-term orchialgia. None of the 16 who had neurectomies ex-
perienced anesthesia dolorosa.
Previous reports have suggested a link between workmen's
compensation cases and postoperative recovery after inguinal
herniorrhaphy. Compared with patients with commercial med-
ical insurance, workmen's compensation cases had a longer du-
ration of postoperative pain and recovery. Of the seven work-
men's compensation cases of chronic mesh inguinodynia in our
FIGURE 112.2. Portion of ilioinguinal nerve entrapped in shrunken mesh. initial study, none reported an "excellent" outcome.
736 J.R. Starling
Since this preliminary series, an additional 35 patients have un- 6. CunninghamJ, Temple V\j, Mitchell P, et al. Cooperative hernia study.
dergone mesh removal, most with concomitant neurectomy. In Pain in the postrepair patient. Ann Surg. 1996;224:598-602.
three patients with obvious stapled nerves, the staples were re- 7. Lichtenstein IL, Shulman AG, Amid PK, et al. The tension-free hernio-
moved and the mesh left in situ. Seven patients had mesh plug re- plasty. Am] Surg. 1989;157:188-193.
moval; their pain, which occurred during bending or lifting, was 8. Shulman AG, Amid PK, Lichtenstein IL. The safety of mesh repair for
primary inguinal hernias: results of 3,019 operations from five diverse
not affected by preoperative nerve blocks. Complete relief of pain
surgical services. Am] Surg 1992;58:255-257.
occurred in all of these patients when plug and mesh sheets were 9. Fitzgibbons RJ Jr, Camps J, Comet DA, et al. Laparoscopic inguinal
removed. herniorrhaphy: results of a multicenter trial. Ann Surg. 1995;221:3-13.
10. Memon MA, Rice D, DonohueJH. Laparoscopic herniorrhaphy.] Am
Coll Surg. 1997;184:325-335.
Summary 11. Broin EO, Homer KM, Derin MJ, et al. Meralgia paraesthetica fol-
lowing laparoscopic inguinal hernia repair. Surg Endosc. 1991;9:76-78.
Mesh inguinodynia should be considered an entity in itself, which 12. Choi PD, Nath R, Mackinnon SE. Iatrogenic injury to the ilioinguinal
can be anticipated in increasing numbers as mesh placement in and iliohypogastric nerves in the groin: a case report, diagnosis, and
inguinal herniorrhaphy becomes commonplace. Although mesh management. Ann Plast Surg. 1996;37:60-65.
13. Sampath P, Yeo Cj, CampbellJN. Nerve injury associated with laparo-
excision with or without neurectomy appears to offer relief to
scopic inguinal herniorrhaphy. Surgery. 1995;118:829-833.
many patients, the task of extricating the mesh can be difficult and
14. Tucker JG, Wilson RA, Ramshaw BJ, et al. Laparoscopic herniorrha-
tedious. Prevention of this uncommon but debilitating complica- phy: technical concerns in prevention of complications and early re-
tion depends on improved understanding of those causes related currence. Am] Surg. 1995;61:36-39.
specifically to the use of mesh in inguinal herniorrhaphy. 15. Magee RK. Genitofemoral causalgia (a new syndrome). Can Med Assoc
J 1942;46:326-329.
16. Rutkow 1M, Robbins AW. Mesh plug repair: a follow-up report. Surgery.
References 1995;117:597-598.
17. Robbins AW, Rutkow 1M. Mesh plug repair and groin hernia surgery.
1. Lichtenstein IL, Shulman AG, Amid PK, et al. Cause and prevention Surg Clin North Am. 1998;78:1007-1023.
of postherniorrhaphy neuralgia: a proposed protocol for treatment. 18. Rutkow 1M, Robbins AW. The mesh plug technique for recurrent groin
Am] Surg. 1988;155:786-790. herniorrhaphy: a nine-year experience of 407 repairs. Surgery. 1998;
2. Wantz GE. Complications of inguinal hernia repair. Surg Clin North Am. 124(5):844-847.
1984;64:287-288. 19. Seid AS, Amos E. Entrapment neuropathy in laparoscopic hernior-
3. Gilbert AI. Inguinal herniorrhaphy: reduced morbidity, recurrences, rhaphy. Surg Endosc. 1994;8:1050-1053.
and costs. South MedJ 1979;72:831-834. 20. Bendavid R. Complications of groin hernia surgery. Surg Clin North Am.
4. Pollak R, Nyhus LM. Complications of groin hernia repair. Surg Clin 1998;78: 1089-11 03.
North Am. 1983;63:1363-1371. 21. Heise CP, StarlingJR. Mesh inguinodynia: a new clinical syndrome af-
5. Tons C, KupczykJoeris D, Rotzscher VM, et al. Chronic inguinal pain ter inguinal herniorrhaphy.] Am Coll Surg. 1998;187:514-518.
following Shouldice repair of primary inguinal hernia. Contemp Surg. 22. StarlingJR, Harms BA. Diagnosis and treatment of genitofemoral and
1990;37:24-30. ilioinguinal neuralgia. World] Surg. 1998;13:586-591.
113
Ilioinguinal/Iliohypogastric Neuropathy
R. Graham Vanderlinden, Rajiv Midha, and Loren Vanderlinden
Introduction guinal areas and found a "normal" course in only 60%. In 35%
the ilioinguinal nerve appeared as a branch of the iliohypogastric
Persistent pain following inguinal hernia repairs is a significant or genitofemoral nerves.
problem. Marsden1 reported a series of 939 inguinal hernia re- The genitofemoral nerve arises from Ll and L2 and consists
pairs in which 2.8% of patients still suffered significant wound pain mainly of sensory fibers with a motor branch to the cremasteric
at 1 year and 1.4% were substantially disabled at 3 years. Entrap- muscle (efferent component of the cremasteric reflex). It travels
ment of the ilioinguinal or the iliohypogastric nerves may be obliquely through and over the psoas muscle, emerging in the
caused by suture placement, tendinous bands, fibrous adhesions, retroperitoneal space opposite the L4 vertebral body. It divides
or neuroma formation. into the genital (external spermatic) and femoral (lumboinguinal)
Lumbar plexus lesions were recorded by Osler2 in 1910, but the branches, which travel separately behind the ureter and across the
syndromes of genitofemoral and ilioinguinal/iliohypogastric neu- base of the broad ligament. The genital branch crosses the lower
ralgia were first reported by Magee 3 and Lyon4 as being surgically end of the external iliac artery and enters the inguinal canal
correctable. These authors and others5-l0 have noted that the il- through the internal ring. It follows the spermatic cord or round
ioinguinal/iliohypogastric nerves can be entrapped following ap- ligament and supplies sensation to the scrotum or labia and me-
pendectomies, blunt trauma, or urological operations as well as dial upper thigh. The femoral branches descend lateral to the ex-
inguinal herniorrhaphies. Purves and Miller7 believe strongly that ternal iliac artery behind the inguinal ligament; passing through
injury to the genitofemoral nerve occurs at the time of pelvic the fascia lata, they enter the femoral sheath where they lie literal
surgery. to'the femoral artery. These branches supply sensation to the up-
per anterior thigh.
Anatomy
Diagnosis
The cutaneous branches of the lumbar plexus give rise to the il-
iohypogastric, ilioinguinal, and genitofemoral nerves, the lateral Ilioinguinal and iliohypogastric neuralgia and entrapment may oc-
femoral cutaneous nerve of the thigh, and the obturator nerves. cur spontaneously, as a result of congenital bands, or as a )ZOm-
The iliohypogastric is a motor and sensory nerve arising from plication from operations on the lower abdominal wall and
the Tll, T12, and Ll nerve roots. It emerges from behind the lat- inguinal region (Table 113.1). The ilioinguinal clinical triad is
eral edge of the psoas muscle and pierces the transversus abdo-
l. Pain-sharp, stabbing, or aching and burning, in the groin with
minis muscle above the iliac crest. Its anterior branch runs forward
radiation to the pubic tubercle and proximal inner thigh
between the internal oblique muscle and the external oblique
2. Sensory abnormalities-hypoesthesia, hyperalgesia, or allody-
aponeurosis, which it penetrates to supply the skin above the pu-
nia in the ilioinguinal dermatome
bis. Its posterior branch supplies an area of the buttock just pos-
3. A circumscribed trigger point medial to and below the anterior
terior to the iliac crest.
superior iliac spine, where pressure reproduces the character-
The ilioinguinal nerve is also a mixed nerve arising primarily
istic pain radiation
from Ll but also receiving branches from T12 that emerges be-
hind the psoas muscle below the iliohypogastric nerve. It passes Iliohypogastric pain is distributed above the pubis, and the point
obliquely across the quadratus lumborum and iliac muscles and of maximum tenderness is often above the midpoint of the in-
perforates the transverse abdominal and internal oblique muscles guinal ligament. Genitofemoral pain is more medial than ilioin-
medial to the anterior superior iliac crest. It runs along the inguinal pain, and the point of maximum tenderness is at the pubic
guinal canal and emerges through the external ring. It provides tubercle or external inguinal ring. Distinguishing genitofemoral
sensation to the upper medial aspect of the thigh and the base of neuralgia from ilioinguinal neuralgia can be difficult and at times
the scrotum and labia. Mossman and Oelrichll studied 424 in- impossible.
737
738 R.G. Vanderlinden et al.
TABLE 113.1. Etiology of ilioinguinal/iliohypogastric neuralgia bercle. The external oblique aponeurosis was opened parallel to
its fibers down to the external inguinal ring. The ilioinguinal and
1. Inguinal hernias or postherniorrhaphy
2. Previous abdominal surgery iliohypogastric nerves were identified and dissected along their
a. Appendectomy (McBurney) courses from the internal oblique to the external ring and rectus
b. Gynecological (Pfannenstiel) sheath, respectively. There was considerable anatomical variability
c. Retroperitoneal in the course of these nerves. If the nerve was obviously entrapped
3. Congenital tendinous bands by tendinous bands at the point of exit from the internal oblique
muscle, a decompression or neurolysis was done.
Successful pain relief was achieved in 34% of patients, while 50%
of cases were failures and 16% were lost to follow-up. Three of
Local blocks of the ilioinguinal/iliohypogastric nerves with
these patients required repair of an unsuspected direct hernia at
bupivacaine at the trigger point medial to the anterior superior il-
the time of surgery.
iac spine and of the genital nerve at the external ring can usu~lly
differentiate between these two neuralgias and confirm the diag-
nosis. The addition of steroids did not produce prolongation of
pain relief. Differential paravertebral blocks of the TIl, T12, Ll,
Neurectomy (29 Patients)
and L2 nerve roots were also used in some patients.
Neurectomy was done in patients who had failed decompression
There is no "typical" case history, although the following is il-
or where previous surgery had invested the nerve in extensive scar-
lustrative of some of the difficulties experienced by both patient
ring. Successful pain relief was obtained in 60% of patients, fail-
and physician in dealing with this entity. A 31-year-old woman de-
ures were observed in 38%, and one patient was lost to follow-up.
veloped intermittent right lower quadrant pain following a mis-
carriage in 1983. In 1986, a right inguinal hernia was repaired and
the symptoms subsided. The hernia recurred 5 months later fol-
lowing childbirth. The hernia was re-repaired in 1987, and the il-
Dorsal Root Ganglionectomy (14 Patients)
ioinguinal nerve was explored and scar tissue removed. Her pain
This procedure was offered to patients who failed the above pro-
was not relieved but progressed in severity and radiated to the an-
cedures and demonstrated good relief of pain from paravertebral
teromedial thigh and sometimes to the posterior superior iliac
blocks. The microsurgical resection of the sensory components
spine. There was constant discomfort, but, at times, the pain was
of TIl, T12, and Ll nerve roots was done through a paraspinal
sharp and she graded it as 8 out of 10 on the visual analogue scale.
muscle-splitting incision about 1 cm lateral to the lateral portion
The severe pain was precipitated by coitus, and she was unable to
of the intervertebral foramina. Permanent anesthesia in the groin
lie supine without flexing her hips.
area was produced, but in four patients it was subsequently nec-
Assessment by three gynecologists, two laparoscopic examina-
essary to extend the ganglionectomies up to T9 and T10 or down
tions, abdominal ultrasound, barium enema, and colonoscopy
to L2. The success rate was 50%, while failure to produce pain re-
showed no abnormalities. Examination demonstrated focal ten-
lief was observed in 30%. Twenty percent of patients were lost to
derness medial to the anterior superior iliac spine and at the
follow-up (Table 113.2).
external inguinal ring, mild hyperalgesia in the ilioinguinal der-
matome, and restriction of back extension and left lateral bend-
ing due to right lower quadrant pain. Two ilioinguinal nerve blocks
relieved the pain.
Discussion
In 1992, an attack of periumbilical pain resulted in laparoscopic
Injury to peripheral nerves often produces a neuritic pain syn-
removal of a fibrotic, noninflamed appendix. There was no change
drome.l 2 This, at times, can be further complicated by autonomic
in her pain following this surgery. In 1993 the inguinal region was
dysfunction, and in some cases, by sympathetically mediated pain
explored, and the ilioinguinal nerve was found to be invested in
(autonomic dysreflexia). Although these severe and difficult to
dense scar tissue necessitating removal of a 5 cm length of the
manage pain syndromes usually follow damage to major limb or
nerve.
plexus nerve elements, injury to cutaneous peripheral nerves may
The patient did well for 6 months, but the pain recurred and
also produce similar severe neurogenic pain syndromes. Moreover,
began to interfere seriously with her life. Paravertebral blocks of
injured cutaneous nerves have a propensity to regenerate and of-
the TIl, T12, and Ll nerve roots relieved her pain and, in June
ten form painful neuromas.
1994, microsurgical dorsal root ganglionectomies were done. The
The iliohypogastric, ilioinguinal, and genitofemoral nerves are
patient resumed her normal activities and remained pain free 5
all at risk for iatrogenic injury in lower abdominal wall, inguinal,
years later.
and groin operations. I~ury to these nerves is best avoided by
Surgical Treatment of TABLE 113.2. Overall results of surgical treatment (follow-up for
Ilioinguinal Neuropathy 1 to 28 years)
Percent No. of patients
Decompression or Neurolysis (38 Patients)
Successful 60 37
The inguinal area was explored by means of an incision beginning Failed 24 15
Lost to follow-up 16 10
superior and medial to the anterior superior iliac spine, extend-
Total 100 62
ing parallel to the inguinal ligament and ending at the pubic tu-
113. Ilioinguinal/Iliohypogastric Neuropathy 739
careful exposure and protection during the procedure. If acci- achieve reasonable results where the nerve is primarily entrapped
dental damage occurs, intraoperative management should be di- and not injured, as demonstrated in about one-third of the pa-
rected toward avoidance of painful neuroma development. tients in this series. However, the results of neurolysis appear to
Because an injured nerve has tremendous potential for attempted be poor for long-term pain control in over half the patients. This
regeneration, two general forms of surgical treatment are indi- is similar to the generally poor results of neurolysis for cutaneous
cated. Either the nerve should be immediately repaired, directing nerve injuries that result in painful neuromas. I3 In circumstances
axons toward the end-organ, or the proximal stump of the nerve of excessive nerve scarring and painful neuroma, a neurolysis pro-
should be placed in an environment where a neuroma will not cedure is probably doomed to failure.
form or will be clinically innocuous. First, a wide excision of the Nerve repair and grafting has some theoretical merit in that re-
proximal nerve is performed. Some authors consider coagulation generating axons can be directed away from the zone of nerve in-
of the nerve stump.13 The proximal stump is then buried or jury and scar.14 However, patients have been reported who develop
allowed to retract deep to muscular tissue,14 far from the skin in- a neuroma within the suture line, resulting in an equally in-
cision and superficial tissue. In the case of iliohypogastric, ilioin- tractable recurrence of pain. I3 Also, grafting requires harvesting
guinal, and genitofemoral nerves, proximal excision to the level of a donor nerve, and this has obvious drawbacks. The most reli-
where the nerves can retract into a retroperitoneal location would able procedure remains a neurectomy. The patient must accept
suffice. Although not advocated by us, some inguinal hernia sur- the trade-off: loss of sensory function for probable relief of pain.
geons intentionally divide these nerves. I5 In these circumstances, Because the ilioinguinal and iliohypogastric nerves do not supply
we would recommend a wide excision of the nerve to allow re- sensation to a critical area, the sensory deficit is well tolerated.
traction of the proximal stump into a retroperitoneal site.
Ongoing pain or a new onset of pain (especially neuralgic) fol-
lowing inguinal hernia surgery should alert the clinician to the
possibility of injury or persisting entrapment of the ilioinguinal References
and/ or iliohypogastric nerves. A careful history and clinical ex-
amination, aided by appropriate nerve blocks, often allows the di- 1. Marsden AJ. Ilioinguinal hernia: a three-year review of two thousand
agnosis to be made. cases. Br] Surg. 1962;49:384-394.
2. Osler W. Modern medicine. Philadelphia: Lea & Febiger; 1910:768-786.
The majority of these patients have a painful neuropathic con-
3. Magee RK. Genitofemoral causalgia (a new syndrome). Can Med Assoc
dition. Sensory loss is not clinically important; in this circumstance J 1942;46:326-329.
the goal is to eliminate the patient's pain problem. The initial ap- 4. Lyon EK. Genitofemoral causalgia. Can Med Assoc J 1945;53:213.
proach may be conservative, using one or a combination of phys- 5. Hameroff SR, Carlson GL, Brown BR Ilioinguinal pain syndrome.
ical modalities, psychotherapy and pharmacotherapy. Many of Pain. 1981;10:253-257.
these patients have already visited a pain clinic and been treated 6. Harms BA, DeHaas DRJr, Starling JR. Diagnosis and management of
with various medications. If not, a course of tricyclic agents is genitofemoral neuralgia. Arch Surg. 1984;119:339-341.
worthwhile, such as amitriptyline (Elavil®). An alternative to 7. Purves JK, Miller JD. Inguinal neuralgia: a review of 50 patients. Can
amitriptyline is the newer generation of serotonin selective in- ] Surg. 1986;29:43-45.
hibitors, such as sertraline (Zoloft®). Other medications that are 8. StarlingJR, Harms BA. Diagnosis and treatment of genitofemoral and
ilioinguinal neuralgia. World] Surg. 1989;13:586-591.
occasionally beneficial include anticonvulsant agents such as car-
9. Hahn L. Clinical findings and results of operative treatment in ilioin-
bamazepine (Tegretol®), phenytoin (Dilantin®), and gabapentin guinal nerve entrapment syndrome. Br] Obstet GynaecoL 1989;96:
(Neurontin®), as well as newer generation nonsteroidal antiin- 1080-1083.
flammatory drugs such as ketorolac (Toradol®). Narcotic medica- 10. Melville K, Schultz EA, Dougherty JM. Ilioinguinal-iliohypogastric
tions should be avoided and discouraged in these situations. nerve entrapment. Ann Emerg Med. 1990;19:925-929.
For those patients with an obvious painful neuroma, and oth- 11. Moosman DA, Oelrich RM. Prevention of accidental trauma to the il-
ers with a painful nerve injury not responding to conservative ioinguinal nerve during inguinal herniorrhaphy. Am] Surg. 1977;133:
treatment, especially where a nerve block has been successful in 146-148.
ameliorating pain, a peripheral nerve surgical procedure is war- 12. Devor M. The pathophysiology and anatomy of damaged nerves. In
ranted. Intraoperative management is dictated by the generally ac- Wall PD, Melzack R, Bonica lJ (eds): Textbook of pain. New York:
Churchill Livingstone; 1984:49-64.
cepted principles of neuroma surgery.13 There are three general
13. Kline DG, Hudson AR Nerve injuries: operative TliSUlts from major nerve
procedures available for painful cutaneous nerve injury condi- injuries, entrapments, and tumors. Philadelphia: W.B. Saunders; 1995.
tions: neurolysis, nerve repair (primary suture or grafting), and 14. Mackinnon E, Dellon AL. Surgery of the peripheral nerve. New York:
neurectomy. Thieme Medical Publishers; 1988.
Neurolysis carries the benefit of preservation of sensory func- 15. Bendavid R Complications of groin hernia surgery. Surg Clin North Am.
tion (if, in fact, this is retained postinjury). Neurolysis appears to 1998;78(6):1088-1103.
114
Sexual Dysfunction Following
Inguinal Hernia Repair
Jerald Bain
One would not expect sexual dysfunction, characterized by erec- sexual function. There may also be a concomitant decline in testos-
tile dysfunction, decreased libido, or ejaculatory disorders, to oc- terone production. Matsumoto and colleagues3 tested this hy-
cur after an inguinal hernia repair because the operation does not pothesis by measuring plasma testosterone levels in 20 chronically
appear to induce an anatomical disturbance related to sexual func- ill men who underwent one of several surgical procedures. Testos-
tion. Despite this apparent lack of physical relationship, surgeons terone was measured preoperatively, immediately after surgery,
should be aware of the possibility that a male patient may experi- and then 2 and 6 days later. Significant decreases were found im-
ence some type of sexual complaint after such an operation. l Al- mediately and 2 days after surgery. Those who underwent a ma-
though this disturbance is more likely to have a psychogenic basis, jor operation still did not have baseline testosterone levels at 6
rarely inguinal hernia repair may be followed by true organicity days, whereas those with moderate surgery did.
that mayor may not be attended by sexual dysfunction. This transient dip in postoperative testosterone secretion, how-
ever, is not likely to explain any significant or sustained sexual dys-
function. Testosterone affects primarily libido, and this may be
Nonorganic Sexual Dysfunction reduced simply on the basis offocusing one's attention on the op-
eration and convalescence rather than on engaging in sexual ac-
after Hernioplasty tivity. Even if reduced testosterone was playing a role, one would
expect the endocrine status to have reverted back to baseline
Sexual dysfunction, particularly erectile dysfunction, may be asso- within the week after surgery.
ciated with a number of etiological factors that can conveniently An interesting approach to assessing sexual consequences of
be categorized under the acronym PENIS2: hernia repair was taken by Libman and colleagues. 4 These work-
Psychogenic ers compared psychosexual changes after both transurethral
Endocrine prostatectomy (TURP) and inguinal hernia repair. Prostatectomy
Neurological might induce a certain incidence of erectile dysfunction, not be-
Insufficiency of blood cause the erectile innervation is disturbed but because of the pow-
Substance or structural damage erful psychological response to surgical manipulation of the penis.
It is surprising to note, however, that in a review of studies carried
There is little or no impact by hernia repair on the endocrine out between 1960 and 1985 the incidence of sexual disturbances
system, the neurological control of erection, vascular factors (with after a TURP ranged from 0 to 100%.5
the possible exception of ischemic orchitis and testicular atrophy, Libman and colleagues4 compared 67 men who had undergone
which are considered below), substance abuse by the patient, or a TURP with 24 men of equivalent social characteristics who had
a structural abnormality of the penis such as Peyronie's disease. had an inguinal hernia repair. There was no difference between
The only mechanism, therefore, that is likely to initiate most forms the two groups with regard to sexual consequences. Both groups
of sexual dysfunction after hernioplasty is the psychogenic. experienced a minor deterioration in sexual function, suggesting
There are multiple possible contributing psychological factors. that the mechanism of this deterioration is less likely to be related
One of these is the proximity of the operative site to the genital to the operation directly and more likely to be a psychological re-
area. There may be the subconscious fear that any impingement sponse induced by undergoing surgery.
on the genitals will result in some form of interference with re-
productive and sexual functioning. This fear may be aroused or
exacerbated by postoperative pain, wound swelling, ecchymosis, Dysejaculation
or paresthesias. l
There is evidence to suggest that endocrine changes may occur Dysejaculation, a painful or burning sensation with ejaculation,
as a consequence of the stress of an operation. The most notable was first reported by Bendavid6 in 1992. Of the 17 patients in his
change is an adrenocorticotropic hormone rise inducing a tran- original description, 15 had had an inguinal hernia repair, with
sient increase in cortisol secretion. This should have no impact on the onset of this troublesome symptom occurring either immedi-
740
114. Sexual Dysfunction Following Hernia Repair 741
ately postoperatively or as long as 23 months later. The mean du- in response to a few questions. The following are some sample
ration between surgery and onset of dysejaculation was 9.4 months. questions:
Most patients experienced complete recovery within 1 year of the
1. Are you currently sexually active with a partner?
herniorrhaphy, while a few patients recovered only after 4 to 5 years.
2. Do you currently masturbate?
No clear etiological mechanism for this symptom has emerged,
3. How would you rate your interest in sexual activity-high,
although Bendavid speculated that it must arise within the vas def-
medium, low, absent?
erens from the level of the superficial inguinal ring to the deep
4. Are you able to get erections?
inguinal ring, perhaps as a consequence of stretching of the vas
5. If yes, are they firm enough for penetration?
by a rush of semen during ejaculation. A vas that becomes ad-
6. How often do you have sexual activity with a partner?
herent to the floor of the inguinal canal or to the posterior in-
7. How often do you masturbate?
guinal wall after hernioplasty might not have sufficient flexibility
8. If you do have intercourse and are able to penetrate, can you
to stretch in response to ejaculation, hence the pain.
maintain your erection until ejaculation?
Bendavid7 studied a further 13 cases and estimated that there
9. Can you have an ejaculation?
is a 0.04% incidence of this phenomenon.
Ischemic Orchitis and Testicular Atrophy Serum Testosterone Level

If a patient develops postoperative erectile dysfunction, investiga-
A testis that undergoes atrophy, regardless of etiology, ceases to
tion might reveal a low serum testosterone level. Was the patient's
function with respect to both spermatogenesis and testosterone
testosterone reduced preoperatively, or is this reduction a conse-
production. A reduction in testosterone secretion may induce sex-
quence of the operation?3
ual dysfunction primarily because of a diminution in libido and
One might argue that this dilemma could be solved by obtain-
secondarily because of erectile dysfunction. For testosterone pro-
ing a preoperative serum testosterone level and comparing the
duction to fall to very low levels, however, both testes would have
to be affected; sexual dysfunction associated with unilateral tes- pre- and postoperative levels. The difficulty with this approach is
that testosterone levels fluctuate, and it would not be possible to
ticular atrophy is less likely to be associated with hypoandrogene-
implicate the hernia repair as a causative factor of a reduced post-
mia and more likely to be associated with some other cause,
operative serum testosterone (unless a large-scale study used
whether organic or psychogenic.
This also holds true of the rare complication of hernioplasty, is- enough patients to establish this point). Although there is evi-
dence to show that a moderate operation may reduce testosterone
chemic orchitis, and, even more rare, ischemic orchitis progress-
levels transiently,3 these levels are not necessarily associated with
ing to atrophy.
Ischemic orchitis, which can occur after hernioplasty, is char- symptomatology, and, even if they were, the symptoms should be
acterized by a painful, swollen testicle and spermatic cord, fever, reversed by the sixth postoperative day.
It would require several pre- and postoperative testosterone
and increased white blood count. 2 This syndrome has its onset 2
or 3 days postoperatively. The fever is usually short lived, but it determinations to ascertain whether a real difference exists. In
may take several months for the testis and spermatic cord to re- the context of the small incidence of sexual dysfunction after
turn to normal size. In approximately one-third of patients the or- herniorrhaphy, it does not seem fruitful to order a preoperative
serum testosterone level unless there is a clinical suspicion that
chitis progresses to frank atrophy, which usually becomes apparent
within a few months of the operation. The precise pathophysio- the patient already has a hypogonadal state.
logical mechanism of the ischemia is unknown.
Ischemic orchitis occurs in about 1 in 2500 cases of primary in-
guinal herniorraphy and is about 12 times more common in re- Reassurance
current repair.B,g
Sexual dysfunction is not a common consequence of hernioplasty
because there are no physical or mechanical pathways by which
Preoperative Assessment the operation could induce this. Most forms of sexual dysfunction
that do occur postoperatively are probably psychogenically medi-
Surgeons who perform inguinal hernia repair operations will be ~ted. Even if patients do not ask about the impact of the opera-
faced with patients who will have either erectile dysfunction or Uon on sexual activity, the doctor, by bringing it up, discussing it
some other form of sexual concern postoperatively. Surgeons can openly and giving reassurance, will likely prevent many instances
both minimize the possibility of this complication and avoid un- of postoperative sexual disturbances.
necessary recrimination from patients should this occur by spend-
ing a few short minutes preoperatively on some simple preventive
measures. Treatment with Testosterone
Adequate testosterone production is a major factor in the estab-
Sexual History lishment and maintenance of libido. Erectile function is much less
reliant on testosterone. The occasional decrease in libido after in-
It is important to determine the status of the patient's sexual func- guinal hernia repair is likely due to psychogenic factors, but the
tioning before the operation. A detailed sexual history need possibility of reduced testosterone secretion should be considered
not be taken, but a reasonable sexual activity profile can emerge either as a consequence of testicular atrophy or as a consequence
742 J. Bain
of the andropause (androgen deficiency in the aging male with cidence and degree of postoperative sexual dysfunction by (1) pre-
sexual distress and a decreased sense of well-being) . operatively measuring serum testosterone levels if there is clini-
Testicular atrophy would have to be bilateral in order for testos- cally apparent hypogonadism, (2) preoperatively determining
terone levels to fall low enough to induce a reduction in libido. whether a sexual concern or problem already exists, and (3) re-
Men who have unilateral testicular atrophy preoperatively can be assuring patients that there is no physical or mechanical way in
reassured that treatment with testosterone is available if postop- which hernia repair would impinge on sexual function (except in
erative atrophy occurs in the remaining healthy testicle. Treatment the rare instance of testicular atrophy and then only if the other
is necessary not only to bolster libido but also to maintain a vari- testicle was already compromised).
ety of important metabolic functions, including normalization of
hemoglobin, maintainence of normal muscle mass, and avoidance
of osteoporosis. Although the adrenal glands do produce testos- References
terone, the concentrations achieved are far less than those of the
testes and would not be enough to ward off the adverse conse- 1. Wantz GE. Complications of inguinal hernia repair. Surg Clin North Am.
quences of bilateral testicular failure. 1984;64:287-297.
2. Bain J. Erectile dysfunction: help is available. Patient Care. 1999;10:
The classic approach to testosterone treatment is the intramus-
62-73.
cular injection of about 200 mg of testosterone in oil usually every
3. Matsumoto K, Takeyasu K, Mizutani S, et al. Plasma testosterone levels
2 weeks. This regimen is safe and effective. Other forms of ad- following surgical stress in male patients. Acta EndocrinoL 1970;65: 11-
ministration are available, but these vary from country to country. 17.
Common alternatives to the intramuscular route are the safe oral 4. Libman E, Fichten CS, Rothenberg P, et al. Prostatectomy and inguinal
form, testosterone undecanoate, and the testosterone patch. Both hernia repair: a comparison of the sexual consequences. ] Sex Marital
of these latter approaches require daily administration. Testos- Tiler. 1991;17:27-34.
terone in oil remains the treatment of choice. 5. Libman E, Fichten CS. Prostatectomy and sexual function: a review. Urol-
ogy. 1987;29:467-478.
6. Bendavid R "Dysejaculation": an unusual complication of inguinal
Conclusion herniorraphy. Postgrad Gen Surg. 1992;4:130-141.
7. Bendavid R Dysejaculation. Prabl Gen Surg. 1995;12:237-238.
8. Hamilton P, Murphy j, Bendavid R Color Doppler ultrasound in the
The exact incidence of erectile dysfunction or some other form assessment of ischemic orchitis after inguinal herniorrhaphy. Prabl Gen
of negative sexual adjustment is not known, but it is known that Surg. 1995;12:229-232.
sexual concerns do follow inguinal hernioplasty. 4 The concerns 9. Bendavid R, Andrews DF, Gilbert AI. Testicular atrophy: incidence and
are relatively minor and virtually always related to psychogenic fac- relationship to the type of hernia and to multiple recurrent hernias.
tors rather than organic ones. Surgeons might well reduce the in- Probl Gen Surg. 1995;12:225-227.
115
Vascular Injuries from Hernia Surgery
James R. DeBord
As a first-year surgical resident in 1974, during one of my first her-epigastric artery and the accessory obturator artery, which then
nia operations, I was personally instructed by Dr. Lloyd Nyhus on courses across Cooper's ligament to the obturator foramen. This
the anatomy of the iliopubic tract and its relationship to the anatomical variant or some derivative of it occurs in 2 and 25% of
femoral vessels. Mter he cautioned me about injury to the vessels the population and was feared as a source of fatal hemorrhage in
and what to do if I should inadvertently penetrate the artery or earlier times when hernia repair was performed by less skilled sur-
vein with the needle, I promptly and confidently placed a suture geons in a more blind fashion than today.2,3 More commonly, the
to approximate the transversus abdominis aponeurotic arch to the obturator artery comes directly off the internal iliac artery and
iliopubic tract and shelving portion of inguinal ligament and was proceeds through the obturator foramen. Condon4 described the
rewarded with considerable oozing of blood from the injured arteria corona mortis as a branch of the pubic artery that courses
femoral vein. Looks (but not words) were exchanged, and I reg- medially on the surface of Cooper's ligament. Some surgeons ap-
istered one of the first lessons of my clinical surgical education. ply corona mortis to the accessory obturator artery or any large ves-
Given over 500,000 hernia operations performed in the United sel in the area of Cooper's ligament that can be injured by the
States annuallyl and the close proximity of the femoral and iliac needle of a deeply placed anterior suture or during a McVay or
femoral hernia repair. Injury to these vessels should be more read-
vessels to the site of repair, it is surprising that, apparently, so few
m;yor vascular complications occur. It may well be that these in- ily avoided in preperitoneal surgery because they should be easily
juries do occur with greater frequency than surgeons wish to ad- identified under direct vision. Serious bleeding from damage to
mit but that most are recognized and properly handled at the time the corona mortis is probably unusual in modem surgery; how-
of injury with little fanfare and without significant morbidity for ever, if it should occur, these vessels may all be ligated with im-
the patient. Delayed symptomatic presentation usually implies a punity if removal of the suture and pressure does not result in
more significant, unrecognized or initially poorly treated injury to hemostasis. These anatomical relationships are delineated to some
an artery or vein. These more serious injuries may then be prop- degree in Fig. 115.1.
erly treated, but not reported. Avoidance of these accidents is a The inferior epigastric vessels represent one of the most classic
matter of constant awareness of the circumstances in which an iat- of surgical landmarks as they divide the regions of a direct and in-
rogenic vascular injury can occur and thorough understanding of direct inguinal hernia, and their location should be well known
the anatomical environment of the surgical field and its neigh- by all surgeons. Injury to these vessels could only occur during a
boring vascular structures. lapse in concentration, but they may be ligated with impunity and
Three major types of vascular injuries may occur during hernia their exposure is quite easy from the anterior approach, and of
surgery: course, they are completely exposed and often ligated in preperi-
toneal repairs. Unrecognized injury is more likely to occur with
1. Bleeding from the "corona mortis," accessory obturator artery, the accessory obturator artery during a McVay repair or a femoral
inferior epigastric artery, or other "minor" vessels in the in- hernia repair and would be unlikely to occur with the epigastric
guinofemoral area vessels.
2. Bleeding, stenosis, occlusion, or false aneurysm formation of Bleeding from the smaller groin vessels supplying the spermatic
the common femoral or external iliac arteries cord, the internal spermatic (testicular) artery, the artery of the
3. Bleeding, thrombosis, stenosis, or compression of the common vas deferens, and the external spermatic (cremasteric) artery
femoral or external iliac veins should not usually occur with careful dissection; but, when it does,
ligation is usually performed. There exists good communication
between the gonadal and deferential arteries in all patients as well
Corona Mortis and Lesser Vessels as anastomoses with the cremasteric artery in many patients. Thus,
even with division of the cord, collateral circulation is sufficient to
Corona mortis is a term introduced by Hesselbach to refer to a long, prevent infarction in most patients, although some degree of at-
common trunk from the external iliac artery that courses across rophy of the testicle will occur in about 80% of these patients7
the posterior wall of the groin before giving rise to the inferior (Fig. 115.2).
743
744 J.R. DeBord
ormal ryJ
A ------A B
AbnOrmal
le_ry
obtu .. tor lJ1e'Y
B c
FIGURE 115.1. (A) Normal and variant (accessory) obturator arteries with nishes this artery and the inferior epigastric artery.6 (C) The relationship
pubic branches. (B) v, dotted outline indicating usual course of accessory of the iliopubic tract and Cooper's ligament to the abnormal accessory ob-
obturator artery; x, dotted outline indicating course of accessory obtura- turator artery.27
tor artery when there is a long, common trunk (corona mortis), which fur-
The spermatic cord is drained by the pampiniform venous result in significant postoperative bleeding, hematoma, and ec-
plexus, which eventually forms two veins proximal to the internal chymosis and is caused by suture needle penetration of these oc-
ring. These veins drain directly into the vena cava on the right and cult groin vessels. Identification and ligation of the bleeding site
the renal vein on the left. lrUury to those veins is not common in remains the standard remedy, as repair of these veins would not
hernia repair, but careful ligation of these fine blood vessels will be feasible. It is safe to say that most surgeons would consider the
control inadvertent bleeding. It has been well documented that postoperative bleeding complications associated with injuries to
simply adopting a policy of limited distal sac and cord dissection this deep inguinal venous circuit a "bleeding diathesis," "too much
will decrease the incidence of injury to these delicate cord vessels aspirin," or a "failure to get complete hemostasis" rather than a
and any resulting ischemic orchitis or atrophy without altering the discrete technical error of injury to a named blood vessel.
rate of recurrence of the hernia. 8 A thorough knowledge of the subtle vascular anatomy of the
Bleeding from rough handling of tissues or misguided suturing groin will provide safer and more satisfying surgical dissection and
can come from the deep inguinal venous circulation in the space hernia repair with reduced bleeding complications. Careful and
of Bogros9 (Fig. 115.3). This venous pathway is well described in precise placement of sutures and prosthetic materials is the key to
Chapter 5 of this book, and the reader is referred there for fur- avoidance of injury to these "minor" vascular structures of the in-
ther anatomical descriptions. Injuries to these 1 to 3 mm veins can guinal area.
115. Vascular Injuries from Hernia Surgery 745
FIGURE 115.4. The close anatomical relationship of the iliac-femoral ves-

sels to the major fascial structures used in hernia repair. 3?
erations with an array of complications, but not a single injury to

the femoral artery or vein was documented. In 1963, Mendenhall
and Fuson ii described a case of occlusion of the right iliac-femoral
FIGURE 115.2. The collateral blood supply to the testis and epididymis.? 1,
artery due to injury during a recurrent inguinal herniorrhaphy in
Testicular artery; 2, deferential artery; 3, cremaster artery; 4, posterior scro- which brisk bleeding was encountered during placement of the
tal artery; 5, anterior scrotal artery. repair sutures. The bleeding was controlled by additional deep su-
ture ligatures, and immediately postoperatively an acutely ischemic
limb was evident. This was repaired promptly, but formal vascular
reconstruction was required 7 months later. These authors em-
Major Arterial Injuries phasized the critical points that remain in force today; namely (1)
the position of the artery (vein) must be known at all times and
The intimate proximity of the fascial structures to the distal ex- protected by caution while all repair sutures are placed, (2) any
ternal iliac artery and proximal common femoral artery makes arterial bleeding must be precisely controlled under direct vision
these major arteries susceptible to injury during herniorrhaphy rather than with deep suture ligatures, and (3) if damage to the
(Fig. U5.4). In view of the large number of hernia repairs per- femoral artery occurs, it must be recognized early and repaired
formed annually and the anecdotal unpublished reporting of sur- promptly using standard vascular surgical principles.
geons' personal experiences with these injuries, it is surprising how In 1963, Smith et aJ.l2 presented a review of civilian vascular
few major injuries appear to occur. The actual incidence is cer- trauma from the Henry Ford Hospital in Detroit. They identified
tainly higher than reported. 61 vascular i~uries in 59 patients, of which 42 were penetrating
Marsden,1O in 1961, reported a 3-year review of 2000 hernia op- injuries; 8 were iatrogenic injuries due to nonvascular surgical pro-
cedures or diagnostic studies. Three of these cases were due to in-
jury of the external iliac artery during inguinal hernia repair. Two
cases were promptly recognized and appropriately treated, but one
patient treated with blind deep suture ligation of the bleeding site
developed a false aneurysm that became infected and eventually
led to ligation of the artery and leg ischemia. They noted that dam-
age to the external iliac artery during hernioplasty need not be a
serious incident if the source of bleeding is identified and repaired
under direct vision and that blind suturing is not a safe method
of sealing a laceration of a major artery.
In the early 1970s there were several publications in the Euro-
pean literature that reported small groups of patients with injuries
to the iliac or femoral arteries during inguinal hernia surgery.l3-i8
HP.-spel~mallic cord
The frequency of these reports over a short span of years empha-
sizes that while anyone institution may experience a limited num-
ber of these serious complications, it is probable that many
surgeons and institutions have dealt with these potentially limb-
or life-threatening complications at least once during the perfor-
mance of a "minor hernia operation." These reports emphasized
FIGURE 115.3. The deep inguinal vasculature within the space of Bogros.9 that the injury occurs during deep placement of sutures into the
746 J.R. DeBord
anterior femoral sheath or iliopubic tract. This may cause a tear struction, especially in the presence of infection, and also em-
of the artery, resulting in significant blood loss (Fig. 115.5). Ill- phasized the importance of prevention of serious injury by care-
advised attempts at suture control of the bleeding may lead to an ful dissection, use of small needles, and prudent widening of the
arterial stricture. Emboli may originate from the traumatized area, surgical exposure in case of hemorrhage.
or thrombotic occlusion may develop resulting in acute or chronic Iatrogenic vascular trauma was the subject of four reviews from
ischemia. At the site of the vascular injury, a false aneurysm may 1981 to 1983. 21 - 24 Pietri et al. 21 reviewed 46 cases of iatrogenic vas-
develop. cular injury and identified two cases due to Bassini herniorrhaphy.
Surprisingly, most of these lesions were not discovered intraop- Boontje,22 on the other hand, could identify no cases related to
eratively. Postoperatively, the patient may have developed ischemic hernia surgery out of 37 iatrogenic vascular injuries. Adar and col-
symptoms in the affected leg, sometimes with gangrene, but usu- leagues23 published an extensive review of iatrogenic complica-
ally only with intermittent claudication. There was a significant tions in surgery. They identified 286 complications in 3736
amputation rate associated with the sequelae of these vascular com- operations, of which 55 operations were for iatrogenic vascular
plications of hernia surgery in these reports from the early 1970s. trauma. Only four of these operations were for accidental arterial
With modem diagnostic methods and improved antibiotics, vas- damage during nonvascular surgery, and it was not clear if any of
cular surgical techniques, prosthetic vascular grafts, and vascular these were hernia repairs. In a follow-up to an earlier paper,19
sutures, the incidence of delayed diagnosis and limb loss should Youkey et al. 24 reviewed 125 vascular injuries from 1974-1982 at
be significantly reduced today, although this does not lessen the Walter Reed Army Medical Center. They found 34 vascular injuries
gravity of these types of injuries associated with hernia surgery. occurring during nonvascular surgery, but none was due to in-
In 1974, Rich et al.l 9 reported on 87 cases of vascular trauma guinal hernia repair. They implicated the increasing number of
secondary to diagnostic and therapeutic procedures. The signifi- invasive diagnostic and therapeutic procedures in the increase in
cant etiological role of catheterization procedures was empha- iatrogenic vascular injury. They noted that delay in treatment was
sized, but 27% of the injuries were related to nonvascular surgical still occurring due to failure of the attending physicians to recog-
operations. However, there were no vascular injuries due to her- nize leg ischemia in intubated postoperative patients who were re-
nia surgery. ceiving narcotics. Again, a high awareness level that vascular
Melliere et al.,20 in 1980, reported on two additional cases of complications may occur and careful monitoring of lower ex-
femoral artery injury due to inguinal hernia surgery. They rec- tremity perfusion remain paramount.
ommended autologous saphenous vein grafts for vascular recon- Shamberger and co-authors 25 reported four cases of arterial in-
jury during inguinal herniorrhaphy at the Massachusetts General
Hospital in 1984. They noted that the artery is placed in jeopardy
when the transversalis fascia is incorporated into the stitches used
to close the medial aspect of the internal inguinal ring. The depth
of penetration of the needle and the proximity of the iliac-femoral
artery or one of its branches must be accurately judged. This judg-
ment does not necessarily improve with time, since only one of
the four surgeons involved was inexperienced. All of their cases
required complex vascular reconstruction with autologous vein or
prosthetic vascular grafting.
9 In 1991, White 26 reviewed a case of femoral vascular injury oc-
h curring during an inguinal hernia repair. The 53-year-old man pre-
a External oblique fascia
b Conjoined "tendon" sented 1 month after repair of a recurrent right inguinal hernia
c Cremaster muscle with mild paresthesia of the right foot and 100 m claudication of
d Spermotic cord the right leg. He had a diminished right femoral pulse with a loud
e Transversalis fascia right femoral bruit and an ankle/brachial pressure index of 0.64
f Shelving edge of on the right, which dropped further with exercise, and 1.07 on
inguinal ligament
9 Femoral sheath the left, which did not change with exercise. Angiography demon-
h Femoral artery strated a tight stenosis at the junction of the external iliac artery
I Inferior epigastriC artery and the common femoral artery (Fig. 115.6). Exploration revealed
nylon sutures incorporating a large part of the common femoral
artery, and the resulting stricture was repaired by prosthetic patch
angioplasty with a good result. The author also commented that
these injuries are probably much more frequent than the number
of published cases would suggest, and they occur from the "blind"
placement of deep sutures through the muscular layers above the
inguinal ligament. The incidence of vascular injury during hernia
surgery was thought by White to be increased with inexperienced
surgeons, operations for recurrent hernia, and in complex repairs
of femoral hernias.
The actual mechanism of arterial injury has been alluded to ear-
FIGURE 115.5. Cross-sectional view of the inguinal canal showing the areas lier and results from direct puncture of the artery, laceration of
of danger at the external iliac artery, the inferior epigastric artery, and the its wall, or disruption or occlusion of a side branch by the mis-
common femoral artery.25 guided hernia needle, which is often larger, wider, and stouter
In most reported cases, the vascular injury has apparently not

been detected or fully appreciated at the time of the initial oper-
ation, and delayed repair has been required. 3,25 The presence of
a false aneurysm or arteriovenous fistula usually requires exposure
of the damaged segment of artery, which means reoperation
through the scarred hernia field and potential harm to the long-
term success of the original repair. Occlusion or stenosis of the in-
jured artery gives the surgeon the option of a bypass procedure
with dissection proximal and distal to the previously operated re-
gion and placement of a graft to restore flow without disturbing
the original hernia repair (Fig. 115.8). Standard vascular surgical
techniques for repair or bypass of the affected segment of injured
artery are well outlined elsewhere. 29
Major Venous Injury

FIGURE 115.6. Arteriogram demonstrating severe stenosis of the right iliac- Injuries to the smaller veins, such as the inferior epigastrics, the
femoral artery at the site of placement of deep sutures during inguinal veins of the cord, and the venous circulation of the space of
hernia repair. 26 Bogros, have been discussed. Major injury to the distal external il-
iac and proximal common femoral vein cannot be readily dealt
with by ligation, and they must be recognized and formally re-
than most general surgical needles. 27 The chances of arterial in- paired whenever possible to avoid the sequelae of acute and
jury can be reduced by being aware of the position of the artery chronic deep venous thrombosis and chronic venous insufficiency.
at all times and by protecting it with the surgeon's finger or by lift- As with arterial injuries, and probably more so, injuries to the
ing up the fascial structures with a forceps when the needle passes iliac-femoral vein during groin hernia repair occur relatively fre-
through to avoid catching the blood vessels with the stitch. 3,ll Plan- quently but are infrequently reported.
ning the trajectory of needles so they parallel the course of major Direct injury to the vein by the suture needle occurs through
arteries also lessens the chance of direct puncture. 28 If arterial the same technical error as arterial injuries. Sutures placed too
bleeding is observed, the action taken by the surgeon at this point deeply through the anterior femoral sheath traumatize the
is critically important. Certain tendencies must be avoided. Many femoral vein. Copious oozing of venous blood should alert the sur-
surgeons would complete the suture and tie it, thus creating an geon to the problem, and prompt termination of the suture place-
entry and an exit wound in the vessel and a small bridge of vas- ment, backing out of the needle, and focal compression of the
cular wall between that can be torn through by the tied suture bleeding site for several minutes should be successful in almost all
(Fig. 115.7). Another urge by surgeons is to grasp the bleeding cases in achieving hemostasis without further problems. Exposure
site with a clamp or hemostat of some size. However, blind clamp- and direct repair of the vein should rarely be necessary if these
ing is no more prudent than blind suture ligation; both put the steps are followed at the time of injury. Once hemostasis is ob-
femoral vessels in jeopardy. tained after venous injury, one may carefully proceed with the her-
The proper approach to brisk femoral artery bleeding during nia repair, avoiding further injury to the vessels. Attempting to
hernia surgery is to withdraw the needle without completion of "control" the bleeding with blind additional suture ligatures sub-
the stitch and to apply digital pressure over the area for several jects the vein to the same jeopardy as the artery and is to be con-
minutes. The bleeding will stop in almost all cases, but, if it should demned.
not, the transversalis fascia should be opened to permit tissue dis- In addition to direct injury of the vein through the femoral
section surrounding the artery and identification of the precise sheath, the vein can be damaged by the needle during a Cooper's
bleeding site. Usually the small perforation can then be controlled ligament repair. Because of the angle of Cooper's ligament with
with a single 6-0 vascular suture under standard proximal and dis- respect to the vein, avoidance of injury can be technically difficult,
tal vascular control, if needed. but this may be overcome by positioning the needle holder par-
FIGURE 115.7. (A) Suture placed into and out of the

artery. (B) As the suture is tied, the vessel is further in-
jured. (C) The defect in the damaged vessel, a source
of potentially serious hemorrhage. 27
748 J.R. DeBord
FIGURE 115.8. (A) Arteriogram and di-

agram depicting occlusion of right ex-
ternal iliac artery due to injury during
inguinal hernia repair.ll (B) Operative
procedure showing completed iliac-
femoral bypass graft to reconstruct in-
(>celuded - "<IImll'. 'III'~' a. jury depicted in A.ll
,'essel
{kep
Femorola
Sup.
Femora/4
_-.:>o.rmeI1U V.
Sup. Femoral a
A B
allel to Cooper's ligament, a maneuver best achieved on the left aponeurotic arch, Cooper's ligament, and the superomedial edge
side by sewing with the left hand 30 (Fig. 115.9). of the femoral sheath, is particularly likely to cause this compli-
A more subtle, but potentially equally hazardous complication cation if not precisely placed (Fig. 115.11).
is compression or constriction of the femoral vein during the The incidence of significant venous compression is unknown, al-
course of hernia repair. Procedures that incorporate Cooper's lig- though many cases of postoperative deep vein thrombosis or pul-
ament in the repair are most prone to this vascular complication. monary embolism may actually be traceable to this focal surgical
Most notably, this would be a concern in a McVay repair of in- technical error. It is likely that in most patients the venous con-
guinal hernia or in any of several techniques for repair of femoral striction is mild and clinically unrecognized and of little conse-
hernia (Fig. 115.10).27,31 In placing the most lateral suture into quence. Whenever a patient develops acute deep vein thrombosis
Cooper's ligament, it is important to have clearly dissected the lig- or pulmonary embolism following groin hernia surgery, a veno-
ament and the femoral vein free of any preperitoneal fat and are- gram should be obtained (Fig. 115.12). If constriction or throm-
olar tissue so that these structures may be clearly in view. Surgical bosis of the vein is noted, consideration should be given to
judgment is then called on to assess that this most lateral suture, reoperation and removal of the offending suture in addition to
when tied, will completely obliterate the hernia defect without un- possible venous thrombectomy, fibrinolytic therapy, or proper an-
due compression of the femoral vein. The so-called transition su- ticoagulation treatment of the venous thrombosis or pulmonary
ture of the McVay repair, which incorporates the transversus embolus.
The first report to document this problem was that of Nissen32
in 1975. He reported six cases of complications due to venous com-
pression following McVay herniorrhaphy. Pulmonary embolism
was the presenting symptom in four of the cases, and deep vein
thrombosis was the presenting symptom in two of the cases. Five
{~
patients underwent venography, and constriction of the femoral
vein was identified in all five cases. Suspicion that the "transition
suture" was the culprit was proved by reoperation in three cases,
and thus he surmised it to be the cause in all of the cases. Nis-
sen 32 noted that the repairs were performed in three different sur-
~
gical departments, often by senior members of the staff. He
\~' Jr.
proposed that the decreased venous flow during surgery, com-
bined with the stasis caused by the venous constriction, was re-
sponsible for the thrombus formation leading to the pulmonary
embolus. If one adds some venous intimal injury from this trauma,
.,r.r. '\.--
~.
two of Virchow's triad for venous thrombosis are present. The true
. ....-. incidence of thromboembolism from constriction of the femoral
vein is unknown.
In 1980, Brown et al. 33 confirmed Nissen's earlier report when
FIGURE 115.9. Avoiding injury to the femoral vein during a Cooper's liga- they presented five cases of Cooper's ligament hernia repair fol-
ment hernia repair by positioning the needle holder parallel to Cooper's lowed by ipsilateral deep vein thrombosis. Four of the five patients
ligament during suture placement. This maneuver may best be done on developed pulmonary embolism. Again, they postulated the "tran-
the left side by sewing with the left hand. 3o sition suture" as the cause of the compression and resulting throm-
A B
c o
FIGURE 115.10. (A) Relationship of femoral vein to most lateral (transi- repair offemoral hernia with potential to constrict the femoral vein. 27 (D)
tion) suture of a McVay repair of inguinal hernia. Suturing too lateral Preperitoneal femoral hernia repair. Approximation of iliopubic tract to
could result in compression ofthe femoral vein. 27 (B) Moschcowitz repair Cooper's ligament with potential for venous compression. 31 A detailed view
of femoral hernia approximating Cooper's ligament to the inguinalliga- of the transition suture in a Cooper ligament (McVay) herniorrhaphy with
ment with potential to compress the femoral vein. 27 (C) Bassini-Kirschner its potential for femoral vein compression. 6
boembolic complications. None of their patients was reoperated No thrombus was visualized, but the vein was dilated and non-
on, however, and all were treated with standard anticoagulation. compressible. The patient was promptly returned to the operat-
Three additional cases of deep vein thrombosis due to femoral ing room after heparinization; the offending sutures were removed
vein compression during McVay hernia repair were reported by and properly replaced, relieving the problem completely and re-
Klausner et al. 34 in 1986. In 1988, Rutledge 35 published a 25-year turning the venous Doppler examination to normal. The authors
experience with McVay herniorrhaphy. In 1142 repairs in 942 pa- confirmed the value of immediate documentation if the question
tients, he reported only 1 case of femoral vein constriction in an of venous injury arises following hernia surgery, and they pointed
82-year-old patient, who was seen 1 week postoperatively with a out the value of modern duplex ultrasound imaging and Doppler
swollen leg ipsilateral to the repair. A venogram confirmed nar- techniques, which can provide this information at the bedside
rowing of the femoral vein at the operative site. The patient was quickly and noninvasively.
treated medically and improved. Although a direct or indirect venous injury is not common in
In 1992, Normington and colleagues36 reported an additional hernia surgery, clearly it is a potential threat to every surgeon and
case of acute venous compression following McVay hernia repair, patient preparing for a hernia operation. High awareness and sus-
confirming that this serious complication continues to be a threat picion must be present in the surgeon's mind not only during the
to patients undergoing what is perceived to be relatively "minor" performance of the operation but also in the early postoperative
surgery. These authors were prudent to react promptly when a period when subtle signs and symptoms might alert one to a de-
mottled lower extremity was noted in the recovery room. Avenous veloping problem that can be remedied before the not-so-subtle
duplex scan performed in the recovery room revealed no flow in complications of deep vein thrombosis or pulmonary embolism
the femoral vein, a finding consistent with extrinsic obstruction. develop.
750 J.R. DeBord
adherence of the artery or vein to the adjacent mesh, resulting in

partial compression or thrombosis of the vessels. If a prosthetic
mesh is fixed too tightly across a major vessel, direct injury could
also occur. Although there have been no published reports of such
complications, the close proximity of prosthetic mesh to the iliac-
femoral vessels makes the future identification of these potential
vascular complications not unlikely (Fig. 115.13). One of the ma-
jor advantages of prosthetic mesh repair of groin hernia is the re-
duction in tension that can be accomplished when tissues are not
brought together to repair the hernia, but bridged by the pros-
thetic material. Increasing use of "tension-free" repairs with mesh
might decrease the use of repairs like the McVay repair with its at-
tendant risk of venous compression.
Hernia Complications
of Vascular Surgery
FIGURE 115.11. (A) Venogram showing right femoral vein following
As a final note, surgeons need to remember that while vascular
McVay hernia repair. 32 ,34
complications of hernia surgery do occur, so also can hernia com-
plications of vascular surgery develop. These "paravascular" her-
nias occur at the site of prosthetic or autologous grafts that have
been tunneled through tissue planes to reach the recipient artery.
Prostheses and Vascular Injury Most commonly, this occurs at the inguinal ligament with aorta
femoral or bifemoral bypasses that require tunneling anterior to
Modem reliance on and increasing utilization of prosthetic ma- the common femoral artery, which is not infrequently accompa-
terials in hernia repair should not alter the nature or incidence nied by a partial division of the inguinal ligament to allow for such
of vascular injuries in hernia surgery to any significant degree be- passage. If the ligament is not properly reapproximated, or if the
cause sutures are still required to anchor the mesh in place and tunnel is made too large, a potential hernia defect is created. This
it is the suturing that results in most of the injuries. The role and complication is less likely with an axillofemoral graft because the
success of sutureless techniques employing mesh are not clear; femoral component does not pass through the inguinal ligament
however, this theoretically could result in a decrease in the risk of but remains anterior to it. Femoral-femoral bypass also should not
vascular injury. Some prosthetic materials elicit an inflammatory create this potential hernia complication for the same reason.
response that theoretically could result in entrapment or partial Extraanatomical bypasses in vascular surgery are limited only by
FIGURE 115.12. (A) Prosthetic mesh repair of inguinal hernia

with mesh covering the iliac-femoral vessels. 6 (B) Same as Fig.
115.13A only bilateral repair with large preperitoneal pros-
A B thesis abutting both femoral veins. 6
proached anteriorly from below the inguinal ligament, and the uti-
lization of Bendavid's polypropylene "umbrella,"40 or a similarly act-
ing polypropylene "plug," a number of which are commercially
available, after high ligation or reduction of the sac, should suffice.
Munshi and Wantz39 have described an anterior approach to the
preperitoneal space for repair of paravascular hernias that is a mod-
ification of the giant prosthetic reinforcement of the visceral sac
(GPRVS) technique, which employs polyester mesh, with no re-
currence in six patients. They point out the value of this prosthetic
material in that no sutures are required posteriorly and that the
mesh conforms to the femoral vessels and pre peritoneal space with-
out buckling or crimping or compression of the femoral vessels.
The preperitoneal approach to these inguinal paravascular hernias
may prove more satisfactory, although the space of Bogros may be
disturbed by the previous vascular surgery. This approach would
permit a more complete reduction of the hernial sac and a more
precise prosthetic repair of the usually discrete defect under direct
vision. At this time, if any additional groin hernia exists, it could
be incorporated into a more formal preperitoneal repair ofthe en-
tire myopectineal orifice with a larger mesh. This approach with
an oversized, soft, and pliable prosthetic material may more effec-
tively repair the paravascular defect, the margin of which would be
A the femoral vessels or the prosthetic vascular graft, neither of which
is a suitable site for hernia repair suture placement.
Repair of "extraanatomical" hernia defects created by unusual
vascular graft routes would require the creative use of surgical judg-
ment and most likely a strategic placement of a customized pros-
thesis that would cover the defect but permit the passage of the
vascular conduit. Close attention to the careful construction of the
original vascular bypass route to prevent the occurrence of these
hernias is paramount.
Vascular injuries of all types in hernia surgery should, for the
most part, be avoidable through awareness of their potential to
occur, sound knowledge of the vascular anatomy of the groin, and
gentle, precise dissection, and suture placement.
B
References
FIGURE 115.13. (A) Prosthetic mesh repair of inguinal hernia with mesh 1. Rutkow 1M, Zuidema GD. Surgical rates in the United States: 1966 to
covering the iliac-femoral vessels. 6 (B) Bilateral repair with large mesh 1978. Surgery. 1981;89:151.
preperitoneal prosthesis abutting both femoral veins. 6 2. Lippert H, Pabst R. Arterial variations in man. Classification and frequency .
Munich: Bergmann; 1983.
3. Bergertz SE, Bergquist D. Vascular complications of various general
surgical procedures. In Bergertz SE, Bergquist D (eds): Iatrogenic vas-
cular injuries. Berlin: Springer-Verlag; 1989.
the imagination of the surgeon and the arteries of proximal and
4. Condon RE. The anatomy of the inguinal region and its relation to
distal pursuit. Some "extraanatomical" hernias could follow such groin hernia. In Nyhus LM, Condon RE (eds): Hernia, 3rd ed. Philadel-
bypasses as the thoracic aorta-to-femoral bypass or an obturator phia: J.B. Lippincott; 1989:43.
foramen bypass into the medial thigh to avoid an infected femoral 5. Grant JCB. Grant 's atlas of anatomy, 5th ed. Baltimore: Williams &
wound. These subtle hernias that would involve the diaphragm or Wilkins; 1962, Plate 212.
obturator foramen could be potentialty clinically significant, and 6. Madden JL (ed) . Abdominal wall hernias-an atlas of anatomy and repair.
a certain degree of suspicion and awareness of this potential clin- Philadelphia: W.B. Saunders; 1989:127,239,241,301,303.
ical entity is important. Presentation wollin most likely consist of 7. Skandalakis JE, Colborn GL, Pemberton LB, et al. The surgical
intermittent pain or frank bowel obstruction similar to adhesive anatomy of the inguinal area-part 2. Contemp Surg. 1988;38:28.
disease. 8. Fong Y, Wantz GE. Prevention of ischemic orchitis during inguinal
hernioplasty. Surg Gynecol Obstet. 1992;174:399.
The surgical treatment of these hernias may be difficult, and the
9. Bendavid R. The space of Bogros and the deep inguinal venous cir-
concern for compromising the vascular bypass is an added issue. culation. Surg Gynecol Obstet. 1992;174:355 .
Fortunately these hernias are rare, and I am not aware of many re- 10. Marsden AJ. Inguinal hernia: three year review of 2,000 cases. BrJ Surg.
ports published about their occurrence or treatment other than 1961;49:384.
the brief note by Bocchi 38 and the 1996 paper by Munshi and II. Mendenhall E Jr, Fuson R. Femoral artery irUury during inguinal
Wantz. 39 The paravascular hernias of the inguinal area may be ap- herniorrhaphy. JAMA. 1963;186:731.
752 J.R. DeBord
12. Smith RF, Szilagyi DE, Pfeifer JR. Arterial trauma. Arch Surg. 1963;86: JL (ed): Hernias of the abdominal walL Philadelphia: W.B. Saunders;
153. 1980;230, 246, 247, 577, 578.
13. Niemann F, Kovacicek S, Sailer R. Gefassverletzungen bei leistenund 28. Malt RA, Ottinger LW. Arterial injuries during inguinal hernia repair.
schenkelbruchoperationen. Chirurgische sorgfaltspflicht und krite- In Nyhus LM, Condon RE (eds): Hernia, 3rd ed. Philadelphia:J.B. Lip-
rien schuldhaften verholtens. Zbl Chir. 1971;12:408. pincott; 1989:265.
14. NataliJ, Kieffer E, Maraval M, et al. Accidents arteriels au cours du 29. Flanigan EP (ed): Civilian vascular trauma. Philadelphia: Lea & Febiger;
traitement chirurgical des hernies de l'aine: a propos de 7 observa- 1992.
tions. Chirurgie. 1972;98:517. 30. McGuire HH Jr. Complications of abdominal wall surgery. In Green-
15. Gautier R, Bonneton G. Deux observations de lesions arterielles au field LJ (ed): Complications in surgery and trauma, 2nd ed. Philadelphia:
cours de la cure de hernie inguinale. Chirurgie. 1972;98:722. J.B. Lippincott; 1990:496.
16. PilletJ, Albaret P. A propos des accidents arteriels au cours du traite- 31. Nyhus LM. The preperitoneal approach and iliopubic tract repair of
ment chirurgical des hernies de l'aine. Chirurgie. 1973;99:210. femoral hernia. In Nyhus LN, Condon RE (eds): Hernia, 3rd ed.
17. Hofmann KT, Simonis G, MannI HFK, et al. Iatrogene verletzungen Philadelphia: J.B. Lippincott; 1989: 194.
der grossen gefasse und am herzen. Munch Med Wochenschr. 1974;116: 32. Nissen HM. Constriction of the femoral vein following inguinal her-
975. nia repair. Acta Chir Scand. 1975;141:279.
18. Junko MA, Kozak BG. Injury of external iliac artery during operation 33. Brown RE, Kinateder RJ, Rosenberg N. Ipsilateral thrombophlebitis
for inguinal hernia repair. Klin Khir. 1974;0(8):42. and pulmonary embolism after Cooper's ligament herniorrhaphy.
19. Rich NM, Hobson RW, Fedde CWo Vascular trauma secondary to di- Surgery. 1980;87:230.
agnostic and therapeutic procedures. Am] Surg. 1974;128:715. 34. Klausner JM, Noveck H, Skornick Y, et al. Femoral vein occlusion fol-
20. Melliere D, Dermer J, Danis RK, et al. Complications arterielles de la lowing McVay repair. Postgrad MedJ 1986;62:301.
chirurgie inguinale. Interet du remplacement veineux in situ. ] Chir 35. Rutledge RH. Cooper's ligament repair: a 25-year experience
(Paris). 1980;117:531. with a single technique for all groin hernias in adults. Surgery. 1988;
21. Pietri P, Alagai G, Settembrini PG, et al. Iatrogenic vascular lesions. Int 103:1.
Surg. 1981;66:213. 36. Normington EY, Franklin DP, Brotman S1. Constriction of the femoral
22. Boonye AH. Iatrogenic vascular trauma. Vase Surg. 1981;15:266. vein after McVay inguinal hernia repair. Surgery. 1992;111:343.
23. Adar R, Bass A, Walden R. Iatrogenic complications in surgery. Five 37. Nyhus LM, Condon RE, Harkins HN. Clinical experiences with
years experience in general and vascular surgery in a university hos- preperitoneal hernial repair for all types of hernia of the groin. Am]
pital. Ann Surg. 1982;725. Surg. 1960;100:234.
24. Youkey JR, Clagett GP, Rich NM, et al. Vascular trauma secondary to 38. Bocchi P. Paravascular hernias. In Bendavid R (ed): Prostheses and
diagnostic and therapeutic procedures: 1974 through 1982. Am]Surg. abdominal wall hernias. Austin: R.G. Landes Company; 1994:415-
1983;146:788. 416.
25. Shamberger RC, Ottinger LW, Malt RA. Arterial injuries during in- 39. Munshi IA, Wantz GE. Management of recurrent and perivascular
guinal herniorrhaphy. Ann Surg. 1984;200:83. femoral hernias by giant prosthetic reinforcement of the visceral sac.
26. White GH. Femoral vascular injury during hernia repair. Postgrad Vase J Am Coil Surg. 1996;182:417-442.
Surg. 1991;2:57. 40. Bendavid R. A femoral "umbrella" for femoral hernia repair. Surg Gy-
27. PonkaJL. Intraoperative complications during hernia repair. In Ponka neeolObstet. 1987;65(8):153-156.
116
Seromas
Robert Bendavid and Matthias Kux
A seroma is a fluid mass that results when an exudate collects in immunological response. Carbon particles, which are chemically
any tissue plane, potential space, or cavity following surgery. The inert, are capable of inducing intense fibrosis when inhaled or
fluid is made up of water, solutes, plasma proteins including fi- when injected into the peritoneal cavity.8 The physical properties
brin, and neutrophils. 1 of the surfaces of foreign materials, such as interface tension and
The development of a seroma invariably convinces a patient that the ability to be wetted by water, also playa part. 9 Metals can in-
a recurrence has taken place, and the most sympathetic explana- duce tissue necrosis due to the galvanic effect. lO As R.S. Smith ll
tions seldom convince them otherwise. However, a seroma is a gen- says, "The physicochemical characteristics of the surface of foreign
erally benign complication, despite its often dramatic size. It arisesmaterials has much to do with tissue reaction and if water or pro-
from the body's natural inflammatory response to an insult to its teins are adsorbed on the surface of a plastic, the molecular con-
tissues (i.e., the trauma of surgery and the introduction of a for- figuration must necessarily be altered from that of adjacent tissues
eign body within those tissues). The vigor of the inflammatory re- and result in proliferative foreign body reaction and giant cell for-
mation." Lam et al. 4 and Lin and Vargas5 studied the effects of the
action is directly related to the severity of the insult, as well as the
size and quantity of foreign material. Thus, although seromas have use of two different prostheses at the same time; the increased as-
recently been associated with the pervasive use of prostheses, they sociated incidence of seroma was statistically significant. It seems
can occur in the absence of foreign material. possible that each foreign material can evoke its own response,
qualitatively and quantitatively, independent of the other, and
perhaps synergistically intensify each other's antigenic stimulus to
Incidence tissues.
Regardless of the agent of injury, the aspect of inflammation
In simple primary pure tissue repairs, seromas are rarely, if ever, that contributes to seroma formation is the increased permeabil-
reported, whereas in the presence of prosthetic material the inci- ity of the capillaries and other alterations in the microcirculation.
dence ranges from 02 to 17.6%3 (Table 116.1). In incisional her- Normally, capillaries and the smaller venules are freely permeable
nias, where dissection is extensive and the injury compounded by to water, salts, glucose, amino acids, and other substances of
the addition of mesh, the incidence of seroma formation is higher smaller molecular size. Under normal conditions, the hydrostatic
yet (Table 116.2). The incidence is highest when more than one pressure within the microcirculation tends to force fluids out into
type of prosthetic material has been used (e.g., tantalum and fas- the extravascular space while the blood proteins exert a retaining
cia lata4 or Silastic® and Dacron®5 (Table 116.2). Hamilton,6 who osmotic pressure across the capillary walls. When this balance is
studied the use of fascia lata in incisional hernias, reported an in- altered by inflammation, proteins are lost more freely, lessening
cidence of 34% seroma formation at the site of the hernia repair the osmotic pressure. The escape of fluid from an inflamed cap-
and a 13% incidence of seromas at the donor site as well. illary has been estimated to be from five to seven times greater
than normal. 12 Because hydrostatic pressure is increased during
inflammation, filtration pressure will also be affected. Lymphatics
Mechanism can normally resorb blood proteins from the tissue spaces. These
proteins cannot be resorbed against a diffusion gradient. In edem-
Seromas can develop as a result of an inflammatory response to atous tissues, when lymphatics may have been severed, ligated, cau-
mechanical, chemical, or physicochemical trauma to tissues dur- terized, distorted, or sclerosed during surgery, their function is
ing surgery. Mechanical injury is caused by scissors, scalpels, impaired; in chronic situations, the lymphatic valves become in-
cautery, sponges, staples, sutures, and the like, but also by insen- competent. Increased permeability has been extensively studied,
sitive handling and vigorous retraction of fragile tissues. Additives and some of the known mediators of this pathophysiology have
such as plasticizers and coloring matter can leach out of a pros- been identified: from cellular breakdown: histamine, serotonin,
thesis, producing an intense inflammatory reaction. 7 However, prostaglandins, lysosomal enzymes, leukotrienes and cytokines, all
chemical inertness and insolubility do not ensure the absence of affecting vascular leakage; from the macrophages: proteases (col-
753
754 R. Bendavid and M. Kux
TABLE 116.1. Incidence of seromas in groin repairs thetic reinforcement of visceral sac (GPRVS) repairs numbered
32, while Rives' incisional repairs numbered 18, 8 of which were
No. of No. of
Author Year patients Prosthesis seromas Percent
not drained. The Rives incisional repair implies a plane anterior
to the posterior rectus sheath and posterior to the rectus muscle.
Usher2 1959 13 Marlex 0 0 Some accumulation of fluid could be detected by ultrasound in
Mason 3 1961 17 Dura mater 3 17.60 virtually every patient. This fluid appeared in planes adjacent to
Durden l9 1974 96 Dacron 1 1.04 the mesh but also in the subcutaneous space and peritoneal cav-
Peacock23 1984 13 Fascia lata 2 15.0 ity. Seroma formation, as expected, was more extensive in inci-
Holl-A1len3o 1984 137 Porcine dermal 0 0 sional hernioplasties; it is in these patients that fluid and protein
collagen
losses are most threatening. Seromas generally resolved in 2 to 4
Kaufman l7 1985 187 Marlex 2 1.00
Bendavid24 1986 Marlex 4 8.30
weeks. Seromas developing in retained scrotal hernial sac rem-
24
Bendavid25 1987 30 Marlex 2 6.60 nants did not resolve spontaneously but required one or more
Capozzi22 1988 745 Prolene 4 0.53 puncture evacuations, spaced over several weeks. Even closed suc-
Law-Ellis27 1990 52 ePTFE 5 9.60 tion drains did not prevent seroma formation in those retained
LeBlanc28 1992 100 ePTFE 4 4.00 sacs. Six of the 18 Rives incisional hernioplasties developed im-
portant seromas, noted on CT scans 4 to 8 weeks postsurgery. Fig-
ures 116.1 and 116.2 show examples of two late seromas that
resolved spontaneously within 4 months. Seromas detected by ul-
lagenous, elastase, plaminogen activator), platelet activation factor; trasound can be seen in Figure 116.3. Figure 116.4 shows fluid col-
from plasma: kinins and fibrinolytic and complement systems. 13 lections in areas not immediately adjacent to the sites of surgery.
Clinical Manifestations Recommendations

Seromas vary in size, depending on the extent of the surgery and Aspiration of a seroma is tempting once the diagnosis is made, but
the surface area of the prosthetic material in contact with trau- this temptation must at first be resisted. In one case (R.B.), a
matized tissues. Although the onset must immediately follow seroma the size of a soccer ball appeared by the seventh postop-
surgery, clinical manifestation takes days to weeks. The skin is dis- erative day but was completely resorbed without intervention by
tended but without erythema and usually without ecchymosis un- the fourteenth day. Prolonged suction drainage of a cavity, with
less there is an accompanying hematoma. The collection is volumes up to 500 cc per day during the first postoperative week,
fluctuant. The raised area of skin is not warmer than the sur- has led to severe hypoproteinemia, generalized edema, and dis-
rounding skin. The palpable mass is soft and may, if long-stand- turbances of clotting parameters. Drainage volumes, as observed,
ing, become firm due to encapsulation. Investigations would do not decrease during the first 7 days, and drains are often re-
include x-ray, ultrasonography, and computed tomography (CT). moved earlier for fear of ascending infections. When a prosthetic
Rarely, superinfection may take place spontaneously, but can fol- mesh is in place, the fear of introducing infection is quite justi-
low careless and untimely needle aspiration. fied. Delaying needle aspiration for 3 to 6 weeks would seem rec-
In one series,14 50 consecutive operations were followed in ommended clinically. If aspiration is decided upon, proper skin
which prosthetic materials were used. Of these, Stoppa giant pros- cleansing and aseptic techniques must be used. Aspiration may be
TABLE 116.2. Incidence of seromas in incisional hernia repairs
No. of No. of
Author Year patients Prosthesis Position seromas Percent
Lam4 1948 24 Tantalum and fascia lata EP 11 45.8

Flynn33 1951 45 Tantalum ON 5 11.1
(three with fascia lata)
Usher32 1959 65 Marlex ON 25.0
Usher2 1959 16 Marlex P 1 6.0
UsherW 1962 358 Marlex 2LT 21 5.8
Gibson l8 1964 25 Teflon ON 5 20.0
Hamilton6 1968 43 Fascia lata ON 16 34.0
Lin5 1973 9 Silas tic-Dacron ON 50.0
Durden l9 1974 13 Marlex, Mersilene ON 5 38.0
Casebolt34 1975 35 Marlex ON 3 9.0
Kaufman l7 1980 20 Marlex 8IP, 12 EP 4 20.0
McDonald21 1984 50 Marlex IP 2 4.0
Lewis29 1984 50 Marlex ON 3 6.0
Holl-Allen31 1984 11 Porcine dermal collagen ON 3 27.0
DeBord26 1992 62 ePTFE IP 9 14.5
KUX l4 1994 18 Dacron EP 6 33.3
IP, intraperitoneal; EP, extraperitoneal; ON, onlay; 2LT, 2 layer mesh closure.
':
'.
~
..
.. I
-. ~
"- •
~ b
Y ,
'"
A B
FIGURE 116.1. (A) A 52-year-old male patient with a seroma 5 weeks after a supraumbilical incisional hernioplasty. (B) Same patient 4 months later and
without specific therapy. The seroma has almost completely cleared.
,..
, ,ft"s .. ,'"
.
-
,-.
' .
..".•: .-
'. ;v&
-~' ..
.
. # .-.~ ~ J
~
A B
FIGURE 116.2. (A) Postoperative seroma in a 70-year-old man after supraumbilical midline incisional herniorrhaphy. (B) Some patient after sponta-
neous resolution of the seroma 4 months later.
A B
FIGURE 116.3. (A) Seroma detected by ultrasound. The mesh itself is not identifiable, but fluid accumulation can be seen on both sides of the pros-
thesis. (B) Following resolution.
755
756 R. Bendavid and M. Kux
3. Mason MS, RaafJ. Use of homologous dura mater in the repair of her-
nias. Arch Surg. 1961;82:856-862.
4. Lam CR, Szilagyi DE, Puppendahl M. Tantalum gauze in the repair of
large postoperative ventral hernias. Arch Surg. 1948;57:234-244.
5. Lin BS, Vargas A. Use of temporary prostheses to repair difficult her-
nias. South MedJ 1973;66:925-928.
6. Hamilton JE. The repair of large or difficult hernias with mattressed
onlay grafts offascia lata: a 21 year experience. Ann Surg. 1968:167:85-
90.
7. Blaine G. The uses of plastics in surgery. Lancet. 1946:525.
8. Leveen HH, Barberio JR. Tissue reaction to plastics used in surgery
with special reference to Teflon. Ann Surg. 1949;129:74-84.
9. Miller jW, Sayer RR. The response of peritoneal tissue to industrial
dusts. Public Health Rep. 1941;56:264.
10. Venable CS, Stuck WG. Ageneral consideration of metals for buried
" appliances in surgery. Int Abstr Surg. 1943;76:297.
11. Sttlith RS. The use of prosthetic materials in the repair of hernias. Surg
Clin North Am. 1971;51:1387-1389.
FIGURE 116.4. Accumulation of extraperitoneal fluid in the prevesical and 12. Florey HW. General pathology, 4th ed. Philadelphia: W.B. Saunders;
perirectal spaces, following GPRVS. The fluid assumes the "molar tooth" 1970:925-928.
shape of the prevesical space (top dashed line). Fluid accumulation on 13. Kossovsky N, Freiman CJ. Biomaterials pathology. In Bendavid R (ed):
the right side of the perirectal space shows no direct communication with Prostheses and abdominal wall hernias. Austin: RG. Landes; 1994:207-223.
fluid in the prevesical space (bottom dashed line). 14. Kux M. Seromas and prostheses. In Bendavid R (ed). Prostheses and
abdominal wall hernias. Austin: RG. Landes Co: 1994:370-372.
15. Kaufman M, Weissberg D, Bider D. Repair of recurrent inguinal her-
nia with Marlex mesh. Surg Gynecol Obstet. 1985;160:505-506.
repeated. Closed suction drainage, if used, can be safely removed
16. Ponka JL. Hernias of the abdominal walL Philadelphia: W.B. Saunders;
in 24 hours.
1980:391-392.
Surgical removal is unusual unless the seroma becomes encysted 17. Kaufman M, Weissberg D. Marlex mesh in giant ventral hernia repair.
and develops a pseudo-capsule. The injection of steroids may has- Isr] Med. 1980;16:739-742.
ten resolution of a seroma, but this has not been extensively or 18. Gibson LD, Stafford D. Synthetic mesh repair of abdominal defects:
objectively identified and studied. 15 The use of a-chymotrypsin has follow-up and reappraisal. Ann Surg. 1964;30:481-486.
been tried on four patients. 16 The use of pressure dressings to col- 19. DurdenJG, Pemberton LB. Dacron mesh in ventral and inguinal her-
lapse a cavity after aspiration has many adherents, but many de- nias. Am] Surg. 1974;40:662-665.
tractors as well. 17 Prostheses should never be left in a subcutaneous 20. Usher FC. Hernia repair with Marlex mesh: an analysis of 541 cases.
position, especially when there is little subcutaneous fat. Arch Surg. 1962;84:325-328.
21. McDonald S, Gagic N. Intraperitoneal Prolene mesh in hernia repair:
a comparison of two techniques. Can] Surg. 1984;27:157-158.
Conclusion 22. Capozzi JA, Berkenfeld JA, Cherry JK Repair of inguinal hernia in the
adult with Prolene mesh. Surg Gynecol Obstet. 1988;167:124-128.
The French concept of GPRVS has found many adherents and 23. Peacock EE. Internal reconstruction of the pelvic floor for recurrent
groin hernia. Ann Surg. 1984:321-325.
been adapted for laparoscopic interventions. Because it involves
24. Bendavid R The "fletching": a new implant for the treatment of in-
wide dissection of abdominal wall layers and the implantation of guinal hernia. Int Surg. 1986;71:248-251.
very large amounts of mesh, GPRVS is invariably associated with a 25. Bendavid R A femoral "umbrella" for femoral hernia repair. Surg Gy-
considerable amount of seroma formation. For this reason, use of necolObstet. 1987;165:153-156.
drains is routine in this procedure. In incisional GPRVS hernio- 26. DeBord JR, Wyffels PL, Marshall JS, et al. Repair of large ventral inci-
plasty, persistent serous drainage may result in life-threatening sional hernias with ePTFE prosthetic patches. Postgrad Gen Surg. 1992;4:
protein loss before integration of the prosthesis takes place. It is 156-160.
important to maintain perspective when dealing with seromas and 27. Law NW, Ellis H. Preliminary results for the repair of difficult recur-
to bear a few simple facts in mind: that spontaneous resolution of rent inguinal hernias using ePTFE patch. Acta Chir Scand. 1990;156:
609-612.
seromas in GPRVS, without infectious complications, has been well
28. LeBlanc KA, Booth WV. Repair of primary and secondary inguinal her-
verified; that closed suction drains can be safely withdrawn within
nias using ePTFE. Contemp Surg. 1992;41:29-32.
24 hours of GPRVS or even dispensed with entirely, and that those 29. Lewis RT. Knitted polypropylene (Marlex) mesh in the repair of inci-
seromas that do develop need not necessarily be evacuated or sional hernias. Can] Surg. 1984;27:155-157.
drained. Seromas challenge the medical practitioner to resist the 30. Holl-Allen RTJ. Porcine dermal collagen repair of inguinal hernias.
urge to hustle Nature along and to adopt a knowledgeable wait- ] R Coll Surg Edinb. 1984;29(3):154-157.
and-see attitude. 31. Holl-Allen RTJ, Sarmah BD. Porcine dermal collagen repair of inci-
sional herniae. Br] Surg. 1984;71:524-525.
32. Usher FC, Morris GC, SelfM. Lyophilized human and ox fascia in the
References repair of hernias. Surgery. 1954;36:117-124.
33. Flynn V\j, Brant AE, Nelson GG. A 4If2 year analysis of tantalum gauze
1. Anderson WAD. Pathology, vol 1, 6th ed. St. Louis: CV Mosby; 1971: used in the repair of ventral herniae. Ann Surg. 1951 ;134(6):1027-
145. 1034.
2. Usher FC, Hill JR, Ochsner JL. Hernia repair with Marlex mesh. 34. Casebolt BT. Use of fabric mesh in abdominal wall defects. Missouri
Surgery. 1959;46:718-724. Med. 1975;72(2):71-76.
117
Dysej aculation
Robert Bendavid
Introduction had had to give up sexual intercourse altogether; one wife had de-
clared she would leave if matters did not improve, and one pa-
A common reaction among men when the word hernia is men- tient threatened to put a gun to his head if nothing could be done
tioned is a shudder of apprehension; the physical location is to help him.
enough to induce anxiety about the effect of the condition, and The presence in the group of two patients who had not under-
more importantly, its alleviation by surgical intervention, upon the gone herniorrhaphy tended, oddly enough, to clarify rather than
future of his sex life. From the surgeon's point of view, such anx- complicate the picture. A 75% response to the questionnaire dis-
iety, while understandable, has little scientific basis. Yet there does closed no correlation with other postoperative complications such
exist a pathology directly traceable to the corrective operation, as infection, testicular atrophy, swelling, or evidence of hernia re-
which, through no known fault of the surgeon, can have a devas- currence or entrapped nerves; the date of onset varied widely be-
tating effect on the patient's quality of life. This is the entity now tween 1 month and more than 2 years. Two patients had had
known as dysejaculation. vasectomies, but dysejaculation did not appear until after their
herniorrhaphy. There was no correlation with type of hernia (in-
direct, direct, recurrent or not), except that there were (as one
Definition would expect in such a small sample) no femoral hernias. Of the
two nonsurgical patients, one was a 53-year-old man who had had
Dysejaculation is a condition involving episodes of brief but often a painful chronic recurrent epididymitis for 7 years; the other
severe pain in the groin upon ejaculation, occurring on the same was a 68-year-old man whose dysejaculation had begun 3 days af-
side as a hernia repair. Typically, the pain lasts from a few seconds ter the end of a 7-week course of radiation therapy for his prostate
to a full 30 seconds, during ejaculation and variably before and cancer.
afterward. The quality of the pain is described as a burning or The clinical course of the entity is ultimately benign, although
"searing" sensation. it may take anywhere from 2 months to 5 years for gradual subsi-
dence of the symptom to occur, without intervention.
History
Mechanism
The first recorded case was in 1983 at the Shouldice Hospital in
Toronto; by 1991, a total of 17 patients had reported the com- Both of the nonsurgical patients in the investigation had histories
plaint. All but two had been operated on at the Shouldice for in- suggestive of traumatic involvement of the vas, one by chronic in-
guinal hernia. A personal investigation was launched, consisting flammation and infection and the other by radiation. In the other
of a questionnaire and review of the charts of the 17 patients. This patients, the localization of the pain to the field of surgical inter-
small study led to publication of a paperl in 1992 introducing the vention and its typical occurrence only during the ejaculatory
term dysejaculation and offering a conjecture as to the mechanism phase of sexual intercourse pinpointed the vas as the source of
of this unusual complication. Between 1992 and 1995, a further the pain.
13 cases were identified, leading to a second publication. 2 There Longitudinal stretch and circumferential distension of the vas
were a few word-of-mouth confirmations from surgeons at other are known causes of pain in this hollow organ. 3 "Ejaculation be-
institutions. On the basis of the Shouldice experience, it is begins with peristaltic contractions in the testis, the epididymis and
lieved that the frequency of this complication is in the region of the vas deferens to cause expulsion of sperm in the urethra. Si-
0.04%. In terms of incidence, it is clearly not an epidemiological multaneously, rhythmic contractions occur in the seminal vesicles
threat; it is, however, a complication of herniorrhaphy that has un- and the muscular coat of the prostate gland to expel seminal fluid
pleasant-even grave-potential consequences for patients and and prostatic fluid along with the sperm."4 Innervation of the vas
their partners. As reported earlier, one man complained that he is through the genital branch of the genitofemoral nerve and in
757
758 R. Bendavid
sympathetic fibers from the pelvic and testicular plexuses accom- pain to which he had been subject for about 7 years. Another pa-
panying the spermatic artery and the ductus deferens. In the tient reported constant and severe pain at the site of his inguinal
healthy vas, the sudden and forceful rush of fluid does not trig- surgery during a month of forced abstinence while on a camping
ger pain, but this might be expected to occur in a vas that has trip.
been. A common finding on reoperation is a vas separated from
the spermatic vessels, although deliberate separation of these
structures is not part of operative procedure in any modem Conclusion
herniorrhaphy; this suggests that the vas may be injured during
herniorrhaphy by traction or application of instruments. The rel- With a probable occurrence of 1 in 2500 herniorrhaphies, this
atively late onset of symptoms indicates that the pathology may it- complication is rare but not inconsequential. Rough treatment of
self be part of the healing process, as the vas becomes kinked and the vas during surgery, chronic infection, radiation, and the use
adherent to the floor of the inguinal canal or develops intralumi- of onlay mesh may contribute to kinking, stricture, and adhesions
nal stricture and scarring. Strictures may also follow radiation or of the vas deferens, the apparent cause of pain during ejaculation.
inflammation due to infection (prostatitis, orchitis, epididymitis). Treatment must remain conservative, consisting mainly of en-
Symptoms in the two patients with vasectomies can be explained couraging patience and perseverance. Patients who report pain
by retrograde distension of the vas. This retrograde filling of the during sexual intercourse should be followed up closely in the
vas is known to occur and contributes to the etiology of orchitis hope that a clearer clinical picture may emerge with better indi-
and epididymitis. Secretions from the prostate and seminal vesi- cations of what may be recommended to avoid exacerbation of
cles account for most of the volume of the ejaculate; reflux into the condition and to promote its timely resolution.
a bound, kinked or stenotic vas could account for the pain at ejac-
ulation in these patients.
References
1. Bendavid R. "Dysejaculation": an unusual complication of inguinal
Treatment herniorrhaphy. Postgrad Gen Surg. 1992;4(2):139-141.
2. Bendavid R. Dysejaculation. Prohl Gen Surg. 1995;12(2):237-238.
Prognosis is favorable, although prolonged. Surgery is not indi- 3. Bell GH, Davidson IN, Scarborough H. Textbook of physiology and bio-
cated unless there are other indications. One patient developed chemistry, 5th ed. Edinburgh: E & S Livingstone Ltd.; 1961:989-990.
cancer of the prostate and had bilateral orchidectomies that co- 4. Guyton AC. Textbook of medical physiology, 2nd ed. Philadelphia: W.B.
incidentally resulted in the disappearance of the burning groin Saunders; 1982.
Part XVIII
Other Considerations
118
Medicolegal Issues Relating to Herniorrhaphy
Erle E. Peacock
Introduction law) are a function of the state, and usually a malpractice suit is
a matter for state courts to decide. It is prudent, therefore, for
Patients who have been operated on for an abdominal wall her- surgeons to be familiar with the Medical Practice Act and any med-
nia are not generally as litigious as some other categories of sur- ical malpractice statutes in the state where they practice. Differ-
gical patients. The major reason is, of course, that most patients ences between states are often not great, but some attention to
obtain an excellent result from herniorrhaphy and are grateful to local details is needed to construct a successful defense. Generally,
their surgeon for making them feel structurally intact again. There a plaintiff in a medical malpractice action has the burden of prov-
are exceptions, however, and surgeons who perform abdominal ing that a surgeon had a definable duty to the patient, that the
wall reconstruction face the same potential liability allegations as duty was not fulfilled, and that failure to fulfill such duty was a
other surgeons. Unfortunately, surgical procedures are viewed as foreseeable and direct cause of injury. These basic principles of li-
a consumer product to be purchased like any business commod- ability for negligence appear in most statutes or common law de-
ity under a warranty that can be exercised any time the result is cisions as a statement that a doctor must (1) possess the same
perceived by the consumer to be different from that expected. degree of knowledge and skill as other physicians with similar cre-
The most common such differences in outcome include post- dentials in the same or similar communities; (2) apply such knowl-
operative pain, causalgia, anesthesia, tenderness, recurrence, tes- edge and skill with diligence; and (3) use his or her best judgment
ticular atrophy, sexu~ dysfunction, and urinary and bowel (not necessarily perfect judgment or even good judgment, but per-
abnormalities. The last two, before introduction of the laparo- sonal best judgment). The "similar community" criterion is dis-
scope, were practically never the result of surgical malpractice but, appearing rapidly in favor of national standards.
because of anatomical proximity, are sometimes associated with A plaintiff must prove by a preponderance (51%) of evidence
the repair of adjacent abdominal wall defects and therefore "must (contrasted with "clear and convincing evidence" as in some other
have been caused by the surgeon," even though specific causation civil trials and "beyond reasonable doubt" as in a criminal trial)
could not be determined. Finally, anesthetic complications, hem- that all of the elements of negligence existed. The only way a plain-
orrhage, infection, and other complications that can occur dur- tiff can achieve this goal in most cases is by having an expert wit-
ing or following surgery on any part of the body comprise the basis ness testifY that a duty existed for the defendant doctor, that the
for malpractice allegations following abdominal herniorrhaphy. duty was breached, and that the breach resulted in the damage
The use of laparoscopy in performing both simple and compli- claimed by the patient. Such an expert witness, who has to be ac-
cated transabdominal reconstructions has increased the possibil- cepted as an expert by the court, in most states has to be a sur-
ity of m,yor vascular, neurological, bowel, and genitourinary tract geon whose training and experience equals or is equal to that of
injuries. Thus, even the surgeon who specializes in hernia repair the defendant and, in some states, practicing the same specialty
must be prepared for both frivolous and meritorious malpractice at least 50% of the time. States do vary in the qualifications they
allegations. This chapter is written to place such allegations in require for expert witnesses in medical malpractice litigation; mer-
proper perspective and to help defendants deal with them grace- cifully, the requirements are becoming more strict to eliminate
fully. This means winning frivolous lawsuits decisively and settling professional medical malpractice expert witnesses who go from
bona fide allegations with fairness to all. The key to reaching such trial to trial testifYing for plaintiffs for a fee commensurate with
a goal is realization that neither the times, greedy plaintiffs, un- what they can say with a straight face.
principled attorneys, nor any combination thereof can take away Failure to find an expert witness is grounds for a directed ver-
a surgeon's hard-earned competence. dict or nonsuit in favor of the defendant surgeon. If a plaintiff is
willing to pay the high fee some professional expert witnesses com-
mand, it is almost always possible to find someone who will testify
Medical Malpractice according to a plaintiff's needs to avoid summary judgment and
at least get the case put in front of a jury. Faced with expert testi-
In the United States, medical malpractice law, both common law mony of this type against them, surgeons must obtain expert tes-
(judge- and/or jury-made law) and statutory law (legislature-made timony that no duty existed, that the duty that existed was not
761
762 E.E. Peacock
breached, or that, even if a duty existed and was breached, the changed! A surgeon must not doubt that any change made in the
breach did not directly or foreseeably cause the damage claimed medical record after it has been completed and a patient dis-
by the patient or that no damage occurred. When both such ex- charged from the hospital can and will be detected. Once such a
perts can be enlisted and settlement is not possible, the case goes change is discovered, the case is over and will be settled in favor
to trial. The purpose of trial is to have a jury decide which expert of the plaintiff by any insurance company. It is very tempting to
witness is the most credible-or even which one is telling the truth. add to the record when an open space in the margin or an extra
The evidence that both sides will use to support expert testimony blank space on a page can be filled with a few words that the sur-
includes qualifications and past records of the expert witnesses, geon wishes had been put in during the original entry. This must
the basis for the expert's testimony, testimony of the surgeon and never be done; it can always be detected! When a surgeon looks
testimony of the patient, and, most important, in most cases, the over a record after a complaint has been filed and discovers an er-
medical record. In reality it is usually the medical record that ends ror in the record, the proper thing to do is to tum to the last
up being tried, and the evidence in the record is what usually in- progress note, add a new page if necessary, place the date the new
fluences the jury to find for a plaintiff patient or a defendant sur- entry is made in the margin and then write a progress note stat-
geon. The lesson for physicians is that the medical record is ing, for example, "in reviewing this chart an error was discovered.
absolutely critical in the outcome of a medical malpractice lawsuit. The anterior fascia was closed with interrupted four zero silk su-
Practical considerations based on the principles stated above for tures rather than with a continuous 5-0 plain catgut suture as er-
surgeons performing herniorrhaphy are (1) dictate operative roneously stated in the operative note." If the surgeon remembers
notes immediately after performing surgery, not days or weeks seeing a patient on a day the patient claims not to have been vis-
later; and (2) dictate operative notes defensively. Many lawsuits filed ited, a progress note dated for that day should not be inserted af-
by patients after herniorrhaphy allege failure of the surgeon to ob- ter the previous day's progress note. The missing note should be
tain informed consent (a separate problem to be discussed in de- placed at the end of the record, dated properly with the date it
tail later) . Others are the results of complications of the operative was written, and stating simply that the note was omitted at the
procedure such as postoperative pain, analgesia, anesthesia, mus- time the patient was seen.
cle weakness alleged to be the result of damage to a major nerve, Pathological findings such as excessive scar from previous
recurrence of the hernia, vascular injury because of failure of he- herniorrhaphy, attenuated fascia, previously placed permanent su-
mostasis or thrombosis, hematoma or testicular atrophy, infection tures, and involvement of bowel, bladder, major nerves and blood
causing prolonged drainage, extrusion of prosthetic material, and vessels, all are important defensive observations that when noted
painful scars. Therefore, the operative note dictated defensively appropriately in the medical record cast the burden of proof on
following a repair of a groin or ventral hernia should specifically the defendant and prevent a skilled plaintiff's lawyer from utiliz-
state that the genitofemoral, iliohypogastric, and femoral (or ing a less than ethical expert witness to shift the burden of proof
other) nerves were identified and some reasonable protective mea- to the defendant.
sures were taken. Some notation of identification and protection A history of smoking, pulmonary disease, excessive muscular ac-
of the vas deferens, position of the testicle, and normal pulsations tivity, coughing, straining for urinary and bowel action and sexual
in the testicular artery also are useful defensive measures. dysfunction, can all be valuable defensive items in the preopera-
When a note in the record can be introduced as evidence that tive history.
the surgeon recognized and accepted the duty to protect impor- The discharge summary always should contain a notation about
tant structures, it implies that such duty was not breached during the appearance of the wound at the time the patient left the hos-
surgery. The burden of proof, if such evidence can be introduced, pital or ambulatory care unit. Such an observation shows that the
then lies squarely upon the plaintiff to prove otherwise, an ex- wound was examined and implies that any complications such as
tremely difficult task in most cases. However, if there is no men- hematoma, infection, dehiscence, and so forth, occurred after dis-
tion of any important structures and no mention of any measures charge and therefore were not under the direct control of the sur-
taken to protect them, a plaintiff's expert witness can have a field geon. Consistency is an important defensive tool. The hastily
day creating implications that the duty to recognize and protect dictated (sometimes weeks or months after discharge) discharge
such structures was not recognized or carried out, thereby shift- summary with statements that are not consistent with the history,
ing the burden of proof to the surgeon, who must try to convince physical examination, operative note, or progress notes carries a
the jury that the structures were identified and protected. Where strong suggestion of negligence that can be amplified out of all
the burden of proof ends up may determine the extremely im- proportion in the summary statement of a skilled plaintiff's attor-
portant instructions which the judge gives the jury before it retires ney. Even the often boring and voluminous nurses' notes should
to decide th'e case. Such instructions may actually be crucial to the be reviewed before dictating the discharge summary to be certain
outcome of a jury trial. It should not be forgotten that if expert that there are no erroneous or contradictory statements that might
witness testimony and/or other evidence results in a tie, the loser suggest to a jury some years later that the surgeon "may not have
is the side that had the burden of proof. known what was really going on."
An operative note can be skillfully dictated defensively that is An occasional exception to the need for expert testimony to
not excessively long or burdensome, but still contains critical evi- find a surgeon liable for negligence is a case that the court will
dence necessary to place the burden of proof on a plaintiff who accept under the doctrine of res ipsa loquitur. Translated, res ipsa
claims a deviation from the standard that the patient had a right loquitur means "the thing speaks for itself' and qualifies for pre-
to expect. All that is required is some written reference to the sur- sentation to a jury without an expert witness contributing profes-
geon's recognition and reasonable protection of three or four sional scientific explanations. Res ipsa (as it is known for short)
nerves, the testicular blood supply and vas deferens, hemostasis usually means that expert testimony is not necessary because the
and protection from infection such as preparation of the skin, and issue is so obvious that even laypersons are as qualified as an ex-
so forth. pert to decide the issue of liability. The test for res ipsa is some-
It is extremely important that the medical record never be times referred to as the "Oh, my God!" test. Such cases for surgeons
118. Medicolegal Issues Relating to Herniorrhaphy 763
performing herniorrhaphy will usually be limited to operation on Failure to obtain legally valid informed consent is classified as
the wrong side, foreign bodies such as sponges or instruments left negligence in all states but Pennsylvania, which still considers fail-
in the wound, or an operating room explosion. Prevention of res ure to obtain informed consent as battery.5 Battery is an inten-
ipsa cases is obvious. A res ipsa case, however, does not mean that tional tort, and all other states permit a battery allegation on
a jury necessarily will find for the plaintiff. A defendant doctor can matters of informed consent only when consent of any kind is to-
win a res ipsa case by proving that the accident was not under his tally absent. Many medical malpractice insurance companies do
control, was not the result of negligence, or did not result in dam- not cover intentional torts in their policies so it is important for
age. Res ipsa cases therefore should be defended vigorously if the practitioners in Pennsylvania to take special precautions in ob-
surgeon does not honestly believe that he was negligent and is not taining consent and to purchase malpractice insurance with a
willing to admit liability. If the surgeon does admit liability, how- broader coverage than might be needed elsewhere.
ever, an out of court settlement is desirable, provided an equitable Although verbal consent and implied consent have been ruled
settlement can be structured and agreed to by both sides. adequate by the courts under some conditions, there is no ques-
tion about the superiority of written consent. Some state statutes
cover implied consent by stating that, if a reasonable prudent per-
Informed Consent son would have opted for a procedure, regardless of the risk, or
if an emergency exists that makes obtaining informed consent dan-
The courts vigorously defend a patient's right to self-determina- gerous to the patient's welfare or, if the patient is a minor with an
tion about what can be done to his or her own body. In a land- emergency, implied consent can be a defense as a matter of law.
mark New York case in 1914, Justice Cardozo declared, "every The surgeon should, however, beware the patient who brushes off
human being of adult years and sound mind has a right to deter- attempts to explain possible complications and outcome by mak-
mine what should be done with his own body."1 The requirements ing such statements as "Anything you want to do is okay with me"
of such self-determination have changed over the years, however, or "I don't want to hear about those things." It is wise to ip.sist that
and vary to some extent among the various states of the United the patient listen to whatever the surgeon wants to explain and
States. Again, state law prevails; it is incumbent, therefore, upon that a witness to the discussion be enlisted. Waiver can be a de-
surgeons to know the law of the state or province they practice in. fense to inadequate consent claims but it is not a strong defense
Pure consent, as such, is based on English law, which primarily and often will not be sufficient to protect a defendant surgeon. 6
required that the patient give permission for whatever treatment A hospital attorney should be consulted or surgery postponed, if
was proposed. The concept of informed consent grew out of com- it can be done without endangering the patient's health, before
mon law decisions that since the mid-twentieth century began to accepting a verbal waiver and proceeding on that basis rather than
require that patients be informed of broader concerns than just obtaining the usual written consent after informing the patient of
permission, such as risks, alternative treatment, and outcome. In the basic steps of the proposed procedure as well as any risks, al-
about 1972, courts became less active in defining common law of ternatives, and expected results. Expected results, of course,
informed consent largely because state legislatures began to take should never be in the form of a contract or guaranteed outcome;
over by passing statutes defining the requirements and the stan- only a statement of the usual outcome of the procedure in simi-
dard of informed consent in their respective states. 2 Not all state lar patients should be offered.
legislatures have passed statutes covering informed consent. Those General consent for a patient undergoing abdominal wall
that have not depend on common law handed down by the vari- herniorrhaphy should, of course, include the usual warnings of
ous state courts through the years. Informed consent statutes gen- the risk of postoperative hemorrhage and infection. The general
erally state the standard of informed consent and may contain a rule concerning the risks that should be included in the written
paragraph covering implied consent as well. consent is that any complication that occurs relatively often, even
The standard of informed consent is very important in that it though minor, and any complication that occurs rarely, but is se-
controls whether or not a plaintiff will need an expert witness to rious, should be included. General risks, applicable to any major
prevail in a claim that informed consent was deficient. There are operation, of course, include hemorrhage, infection and allergic
two prevailing standards: the physician standard and the reason- reactions. The special risks that apply to herniorrhaphy vary with
able person standard. In physician standard states, informed con- the site of the hernia. Recurrence definitely should be included
sent is defined by the medical profession. Successful litigation for as a special risk of ventral herniorrhaphy; wound tenderness and
a plaintiff claiming deficient informed consent in these states re- prolonged groin discomfort should be included in the written con-
quires that an expert witness, usually a surgeon practicing in the sent for groin herniorrhaphy. Note that it is not necessary to name
same medical specialty in the same or a similar community, testify all of the nerves and blood vessels encountered during inguinal
that in that community the standard is to provide the patient with or femoral herniorrhaphy, and it is not necessary to outline in-
certain information needed to make an informed decision and, juries that occur to each one of these structures as possible com-
second, that the defendant doctor failed to meet that standard. 3 plications. In all probability, a plaintiff's expert witness can be
Without such testimony, allegations of inadequate consent will be expected to testify that major injury to the iliohypogastric, gen-
dismissed by the court as a matter of law. In some states, however, itofemoral, or femoral nerves constitutes deviation from the stan-
an expert witness is not required; the standard of informed con- dard of practice the patient had a right to expect when deciding
sent is that the patient must be told everything that a "reasonable to have herniorrhaphy. Moreover, listing injuries to such structures
prudent person" would need to make a rational decision to have in the informed consent document does not absolve the surgeon
or not to have a proposed treatment or diagnostic procedure. 4 In of liability if these structures are i~ured negligently. There is no
a reasonable prudent person state, it is much easier and consid- point, therefore, in raising the specter of major nerve and/or ves-
erably less expensive, therefore, for a plaintiff to avoid summary sel i~ury or injury to the bowel and bladder when obtaining in-
judgment and get the matter of informed consent placed before formed consent for herniorrhaphy.
a jury. Either the recurrence rate or the successful repair rate should
764 E.E. Peacock
be included in what the patient is told, however. The recurrence In summary, informed consent allegations are found in ap-
rate, if significantly high, such as in a patient who has already ex- proximately 16 to 20% of medical malpractice complaints. The
perienced multiple recurrences, should be stated in the written record, as usual, is what gets tried. As new procedures such as lap-
consent. It is not necessary to put in the written consent that the aroscopy make their way into the field of herniorrhaphy, the ba-
patient was informed that there is a 96% success rate, but a warn- sic principle remains that the patient must be informed and a
ing that there is a 20% recurrence rate if the hernia is a secondary record kept of the discussion of diagnosis, important risks, and
direct inguinal hernia or even higher in recurrent ventral hernia outcome of inguinal herniorrhaphy sufficient for any reasonable
definitely should be placed in the written consent. The courts use person to make a decision. It is, in essence, an application of the
the term framing to describe the way consent is obtained, and in- golden rule.
formed consent cases have been won and/or lost over the way con-
sent information was framed. A different result may be obtained if
a surgeon tells a patient that there is a 30% recurrence following Being an Expert Witness
repeated unsuccessful direct herniorrhaphy than if the same patient
is told that there is a 70% success rate from the same procedure. An expert witness is the most important actor in a medical mal-
The written consent should take framing into consideration when practice lawsuit. It is a duty all physicians owe themselves, their
the exact words or phrases are chosen for the written record. colleagues, the judicial system and their profession during these
A young surgeon deciding on the wording for consent to distressingly litigious times. Every master surgeon should be pre-
herniorrhaphy should take one of two approaches. If practicing pared to be an expert witness occasionally and should not be re-
in a reasonable patient standard state, the surgeon should simply luctant to serve the judicial system in this way when called on to
use the test, "what would any average reasonable prudent person do so. If good surgeons refuse to lend the courts their expertise,
need to know in order to make an intelligent decision to have not-so-good surgeons can be found, some of whom, for a suffi-
herniorrhaphy?" Hworking in a physician standard state, it is def- ciently enticing fee, actually become professional plaintiffs wit-
initely worthwhile for a new surgeon to seek the advice of senior nesses. Such individuals are well known to the plaintiff's bar and
surgeons or the hospital librarian about what usually is put in the may actually advertise their services and availability. But good sur-
record in that community and has by common usage, therefore, geons should be pleased to help a deserving. colleague, particu-
become the legal standard for informed consent. Hemorrhage and larly when a frivolous lawsuit has been filed. Good surgeons,
infection, generally, pain and tenderness and recurrence rates, however, are not automatically effective expert witnesses; if un-
specifically, will be the standard in most geographical areas. prepared, they may not be able to help a jury arrive at truth even
Testicular torsion, and/ or atrophy, injury to the vas deferens and though their intentions are good.
injury to bowel and bladder usually are not found. These compli- The majority of surgeons are reluctant to testifY for a plaintiff,
cations are usually the result of dropping below the prevailing stan- particularly in the geographic region where they practice. The ju-
dard of care, and nothing is really gained, from a legal standpoint, dicial system is dependent upon good expert witnesses for plain-
by putting them in the preoperative record. Practically, if these tiffs as well as for defendants and, again, if good surgeons leave a
complaints are really frequent enough to justifY a surgeon in- void for plaintiffs in need of expert testimony, professional expert
forming the patient about them, the patient probably ought to witnesses will fill that void, often to the detriment of the judicial
seek a second opinion and possibly even a different surgeon. system trying to arrive at truth. Nevertheless, certain practical con-
A disquieting factor creeping into informed consent law in some siderations cannot be ignored. Young surgeons building a prac-
states is the need to include the experience of the surgeon and/or tice should not be called on to give testimony for a plaintiff. In
any outcome data that apply specifically to him or his institution. 7 most instances, a plaintiff should go outside of the community
Outcome data ("batting average") in herniorrhaphy has previously where the lawsuit has been filed to obtain expert testimony. Some
been limited to the general population or experience of all sur- surgeons have adopted strict rules when deciding whether to tes-
geons performing herniorrhaphy. In other specialties such as car- tify for a plaintiff; these include not testifying within a 500 mile
diac surgery, where outcome data have been collected for radius of their practice and not agreeing to testifY unless there is
individual surgeons and institutions, it has been found to be nec- real damage and/or unless there is at least one doctor in the same
essary to informed consent if there was any variation below the community who is outraged by what happened. Malpractice is real,
norm. Experience is recognized now as a factor in complications and when a patient has been hurt, the medical profession owes
from laparoscopy. If a surgeon is performing his first inguinal that patient whatever is fair to both parties in order to help com-
herniorrhaphy through a laparoscope and a more experienced pensate the patient for misfortune. A master surgeon who, after
surgeon is available in the same community, informed consent has reviewing the medical record carefully, comes to the conclusion
been found by at least one court to include such information.8 that a plaintiff is entitled to compensation can do more to get the
The courts generally do not require surgeons to include a history case settled rapidly and fairly than anyone else. A professional
of alcohol or drug abuse or any record of criminal convictions. If plaintiffs witness testifying loosely and inaccurately (usually for
a surgeon realizes that his vision or motor coordination are im- money) guarantees a protracted expensive pretrial ordeal and in-
paired by such experiences, however, informed consent would re- vites a runaway jury to make a bad decision based on less than ac-
quire that this information be divulged. Most courts have ruled curate understanding of where truth really lies.
that alcohol and drug abuse are the responsibility of the institu- A potential expert witness has three responsibilities. The first
tion and of licensing boards. Human immunodeficiency virus and responsibility is to remain detached from the case (refraining from
hepatitis infection have not been declared uniformly to be a part discussing it with any of the principals) while reviewing the med-
of informed consent, but position papers released recently by the ical record carefully and thoughtfully and then rendering an hon-
American Medical Association and the American Dental Associa- est opinion about negligence (standard of care), causation (what
tion place the burden of disclosure on each individual surgeon. 9 actually led to the damage), and the degree of damage. The sec-
118. Medicolegal Issues Relating to Herniorrhaphy 765
ond step, if the case progresses to trial after the expert has arrived rapidly. Once such a rhythm has been established, it is then easy
at an opinion, is to give a deposition. A deposition allows the op- to elicit a quick and possibly thoughtless response to a question
posing party to ask questions to determine how much and what that is not only extremely relevant but possibly even dispositive to
damage the expert witness can do to the client's case. The third the ultimate issue in a malpractice suit. Witnesses are well advised,
step is to testify in court, which means appearing credible while therefore, to develop some method of continually reminding
helping the jury to understand the case so that they can arrive at themselves to answer questions slowly and in a reasoned manner.
a just decision. A witness should always be on the lookout for clues from coun-
The first step, review of the record, is something a potential ex- sel objecting to the form of a question asked by the lawyer con-
pert witness usually does naturally. However to arrive at a decision ducting the deposition. On hearing the words "object to form; the
about standard of care, it is essential to use strict mental discipline witness may answer if he knows the answer," the witness should
and base that decision not on a personal standard and, particu- recognize a signal that a potentially dangerous question has been
larly, not on a standard the surgeon would like to impose or has asked. The proper response following such an objection is a pause
been trying to impose, but on knowledge of the prevailing stan- to think about the possible meanings of various answers and to
dard of care as he or she has experienced it. It then becomes rel- make certain that the question is clearly understood and, most im-
atively easy to judge and state whether the defendant surgeon portant, not to speculate.
deviated from that standard and whether such deviation directly A witness should never become tired. Giving a deposition is both
and predictably caused the damage that the plaintiff alleges. Hav- physically and mentally demanding and, if the surgeon is a de-
ing done so, the surgeon must then prepare to give the best defendant, emotionally exhausting as well. A witness should never
position possible. hesitate to call time out as frequently as necessary or to postpone
the completion of a deposition in order to stay mentally sharp and
physically rested.
Giving a Deposition A good expert witness never spars intellectually with opposing
counsel during a deposition. It is the other side's show, and they
A deposition is taken during what is called the discovery phase of have the right to ask questions they want answered. There is noth-
pretrial preparations so that theoretically and ideally there will be ing to be gained by giving answers designed to make the inter-
no surprises to either side at trial. Thus, a deposition gives both rogator appear stupid, even if he is. There is a proper time and a
sides 3 or 4 months to prepare a defense to whatever points the way to deal with improper questions and to bring out the bad side
witness is able to establish. A deposition, usually the most impor- of the opposition. Lawyers are trained to accomplish this; physi-
tant contribution a surgeon makes to a lawsuit, is somewhat dif- cians are not and can make irretrievable mistakes trying to play
ferent, depending on whether the surgeon is appearing as an on the lawyer's turf.
expert witness in support of another surgeon or a plaintiff or giv- When testifying in support of another surgeon, an expert wit-
ing a deposition as a defendant. A good lawyer, cognizant of these ness should banish the words "but I don't do it that way" or "I
differences, and also aware that most surgeons are unfamiliar with wouldn't have done it that way" from his vocabulary. The best that
giving depositions, will spend considerable time preparing the sur- can be done to help a colleague is to state clearly and unequivo-
geon to be an expert witness. Some lawyers shirk this responsibil- cally, that, in the expert's opinion, "the defendant did not deviate
ity, often with disastrous results. A few general principles apply to from the standard of care the patient had a right to expect." Once
all depositions and should be known to all surgeons. They include having done that simply, directly and unequivocally, the expert wit-
remembering that an expert witness, particularly a defendant's witness has done the best possible to support a colleague. To em-
ness, cannot help himself or his cause by giving a deposition. All bellish testimony is dangerous, and to state the expert's own
the expert witness can do in a discovery deposition is try to pre- practice or theory of practice if different from the defendant's can
serve professional credibility. be devastating. Deposition and trial are not times to make known
Particularly when a defendant surgeon is being deposed, there one's private philosophy on herniorrhaphy through a laparoscope.
is a tendency to try to overpower the other side with strong de- Whether Doctor Smith deviated from the standard of care the pa-
tailed testimony that will teach them a lesson for filing a frivolous tient had a right to expect in that community at that time by any
lawsuit and discourage the plaintiff from pursuing it further. Such technique is the issue, and expert testimony on that question alone
an outcome never happens, and all such an approach accom- is all that can really be of help to a colleague.
plishes is to give the other side everything they need to be pre- A good expert witness always takes time to read his deposition
pared in court to rebut or disarm whatever ammunition the witness and make any corrections required before signing it. If the case
is capable of delivering. It is very hard to do, but a defendant should go to trial, a careful expert witness will review his deposi-
should give only strict, narrow answers to the exact question asked tion as often as necessary to keep fresh recollection of what was
and should cautiously refrain from adding embellishments or de- said. A favorite method of impeaching an expert witness who came
tails that are not specifically requested. Above all, an expert wit- across favorably in front of a jury on direct examination is to ask
ness should never speculate; ideally, all answers should be a simple questions on cross examination in such a way or in such detail that
yes or no. a different answer or, at least an answer that can be interpreted to
A witness should always pause before answering. Answering im- a jury as different, is obtained. It is almost inevitable that this will
mediately denies the witness's own counsel an opportunity to ob- occur in the usual medical malpractice trial. A good expert wit-
ject if the question is an improper one. It is common practice when ness does not give the appearance of having been caught with a
taking a deposition to engage the witness in almost frivolous ques- hand in the cookie jar when it occurs. When differences between
tioning, usually on topics the witness enjoys talking about such as trial testimony and previous deposition are exposed, the mature
hobbies or professional accomplishments, for the sole purpose of witness does not show embarrassment but continues to answer
developing a rhythm in which the witness answers reflexively and questions calmly and assuredly, explaining the difference in an-
766 E.E. Peacock
swers, if allowed to do so. Even if that opportunity is denied by Finally, a surgeon must never lose sight of the disquieting but
opposing counsel, the defendant's counsel will provide it during practical realization that litigation in this age is a real and pre-
redirect examination, following the cross examination. Above all, dictable consequence of medical practice. Once a surgeon takes
an expert witness should never appear to be an advocate of one out a medical malpractice insurance policy, he or she is regarded
side over the other. A good expert witness strives to appear com- as a "deep pocket" and becomes an inviting target for both justi-
pletely neutral on all issues. fied and frivolous litigation. The surgeon must live with this char-
acteristic of our times, practice the best medicine and surgery
possible, keep accurate and complete records, and treat patients
as kindly and considerately as every surgeon would want to be
Risk Management treated if he or she were the patient. These are the basic tenets of
good risk management and will go a long way toward reducing
Most of the factors that have seemed important in reducing risk the number offrivolous lawsuits. Unfortunately, it is impossible to
of litigation following herniorrhaphy have been covered in previ- avoid greedy and unreasonable patients and the attorneys who sup-
ous sections of this chapter. The most important principle to report them for less than noble reasons. When this combination of
member is that the record provides the best evidence and is the bad luck occurs, the mature surgeon should cooperate gracefully
ultimate defense in a frivolous lawsuit. The most valuable defenses with the insurance carrier and defense attorney, secure personal
in the record are informed consent and the description of the op- counsel if the assigned attorney's defense is not adequate and ag-
erative procedure as performed. In addition, it is important never gressive, and maintain confidence that our judicial system, flawed
to change the record and never to guarantee the outcome. The as it may be, will ultimately expose the truth, and the truth will
most frequently asked question in herniorrhaphy risk manage- prevail.
ment is, "Should a videotape be made of a laparoscopy hernior- The courts have been very good to doctors over the years; ap-
rhaphy?" There is no universally correct answer to this question. proximately 70% of medical malpractice cases are decided in fa-
If the procedure went well and no deviations from the standard vor of defendant physicians. 12 As long as physicians are in relatively
occurred, the videotape can provide superb evidence and can give high income brackets, malpractice insurance is universally avail-
even an otherwise weak expert witness powerful evidence to tes- able, and the courts are readily available to virtually anyone who
tify from. If a deviation did occur, the surgeon will wish the video- seeks judicial redress, there probably will not be any reduction in
tape record had not been made but, of course, must never destroy lawsuits. Somewhere between lO and 20% of practicing physicians
or deny the existence of the tape. Negligence is only a tort, in- in the United States are sued every year.I 3 In this present state of
volving primarily monetary compensation for damages. Tamper- affairs, every surgeon will be involved in litigation sooner or later.
ing with evidence is a crime, punishable by imprisonment and fine. The answer is to be prepared, to accept the situation with grace
Most medical malpractice lawsuits are settled before trial. Most when it comes, settle quickly and fairly (if possible) when at fault,
medical malpractice insurance policies give an insurance company and use the judicial system intelligently and forcefully to defeat
the right to "settle expeditiously. "10 This practice is particularly im- unprincipled and unfair attack.
portant now that the settlement must be reported to the National
Physician's Data Bank. Because Data Bank information is being
used in managed care selection and de-selection of providers, it is References
probably worthwhile to insist on having a "no settlement without
permission of the insured" clause in medical malpractice insur- l. Schloendorffv. Society of New Yorlt Hosp., 105 N.E. 92 (N.V. 1914), over-
ance policies, even though an increased premium may be re- ruled by Bing v. Thunig, 163 N.Y.S. 2d 3, 143 N.E. 2d 3 (N.Y. 1957).
quired. Settlement can be structured under some conditions so 2. Merz]F. Infonned consent does not mean rational consent: cognitive
that reporting of the physician to the Data Bank is not required, limitations on decision making. j Legal Med. 1990;11:321-372.
for example, settlement with the surgeon's professional corpora- 3. Smith v. Weaver, 407 N.W. 2d 174 (Neb. 1987).
tion if the corporation has more than one surgeon. Even when 4. Canterbury v. spence, 464 F. 2d 772 (D.C. Cir. 1972).
settlement must be reported to the Data Bank, it should be re- 5. Furrow BR, Greaney TL, Johnson SH, et al. Physician obligations to
obtain a patient's infonned consent. In Furrow BR, Greaney TL,John-
membered that the wording of the report can be very important
son SH, et al. (eds): Health law, vol. 1. St. Paul: West Publishing Co.;
to the future of a surgeon. The surgeon should therefore partici-
1995:409--431.
pate actively in the composition of the report of the settlement 6. King N. Patient waiver ofinfonned consent. NCMj 1993;54:399-401.
and make it crystal clear that settlement was an act of expediency 7. DeVille K. Provider-specific outcomes data and the law of infonned
with no admission of guilt, if that was the case. Unfortunately, in- consent. CU1'T Surg. 1997;54:38-41.
surance policies state, often not clearly, that the duty of the in- 8. johnson v. Kohemoor, 525 N.W. 2d 71 (Wise. App. 1994).
surance company is to indemnify, not to defend, as most surgeons 9. Olson SM, Howard-Martin J. Controversy brews over guidelines for
believe. Moreover, the courts have uniformly ruled that the pri- AIDS-infected health care workers. Healthspan. 1991;8:13-15.
mary duty of an insurance company is "to investigate and settle 10. Thomas SS. An insurer's right to settle versus its duty to defend non-
expeditiously when possible."ll Defense lawyers are employed by meritorious medical malpractice claims. j Legal Med. 1995;16:545--583.
insurance companies, not defendants, and very frequently are nei- 11. Shuster v. South Broward Hospital District Physician s Professional Liability
Insurance Trust, 570 So. 2d 1362 (Fla. App. 1990), aff'd, 591 So. 2d 174
ther knowledgeable nor greatly concerned about the surgeon's
(Fla. 1992).
professional welfare if a settlement acceptable to the insurance 12. Weiler PC, Hiatt HH, Newhouse JP, et al. A measure of malpractice: med-
company is possible. It is often desirable, therefore, for a surgeon ical injury, malpractice litigation and patient compensation. Cambridge:
facing settlement of a frivolous lawsuit to have personal counsel Harvard University Press; 1993.
from an attorney experienced in Data Bank regulations and other 13. Daniels S. Tracing the shadow of the law: jury verdicts in medical mal-
settlement repercussions. practice cases. justice Syst J 1990; 14:4-39.
119
Ambulatory Hernia Surgery
Martin Kurzer, Philip A. Belsham, and Allan E. Kark
In 1969, when I was starting my surgical career as an intern at the The authors' experience at the British Hernia Centre is that well
Massachusetts Central Hospital, the routine patient with an inguinal over 95% of uncomplicated primary groin hernias, as well as many
hernia was admitted the night before the scheduled operation and uncomplicated primary umbilical, paraumbilical, and epigastric
was not discharged until the skin stitches were removed on the sev- hernias, can be surgically treated as day cases. 5
enth postoperative day. (Ryan)l
Key Features of Ambulatory Surgery

Introduction
The essential characteristic of ambulatory surgery is that the pa-
The management of patients with abdominal wall hernias has un- tient will be spending the first postoperative night at home with
dergone a dramatic change in recent times, with the increasingly no medical or nursing supervision. This requires the cooperation
widespread use of prostheses and the concept of the tension-free of the patient far more than for inpatient surgery. In essence one
repair with either an open or a laparoscopic approach. The inis asking the patient to manage himself postoperatively. For this
discriminate use of prostheses in groin hernia repair has, however, reason (and probably more so than in other areas of surgery), pa-
been criticized, and it has been pointed out that "tension-free re- tient selection is important and patient education is vital.
pairs have not demonstrated their superiority over pure tissue re- The reluctance on the part of some surgeons to adopt ambula-
pairs when both have been carried out by those who make tory hernia surgery may be because of the misperception of two
herniorrhaphies their speciality."2 Nevertheless, in the hands of potentially problematic areas. First, the management of postop-
nonspecialist surgeons both open and laparoscopic techniques erative pain and, second, the development of complications once
have to a large degree reduced the postoperative discomfort as- the patient is at home and "unobserved."
sociated with the traditional sutured methods of groin hernia re-
pair, with open mesh repair probably more straightforward for the
trainee surgeon to learn and perform. This has permitted easier Postoperative Pain
and quicker postoperative mobilization, making ambulatory her-
nia surgery appropriate for most patients. Tension-free mesh repair (either open or laparoscopic) has
markedly reduced postoperative pain. Pain that is experienced can
be adequately controlled by a nonsteroidal antiinflammatory anal-
Definition of Ambulatory gesic such as diclofenac, and there is now no need for parenteral
(Day-Case) Surgery opiate analgesia. The use of local anesthetic undoubtedly is a con-
tributory factor in the reduction in postoperative pain (seeming
The Royal College of Surgeons of England (RCS) has defined a to have an effect for over 24 hours) and reducing the require-
surgical day case as "a patient who is admitted for operation on a ments for postoperative analgesia. 6,7 Although a small percentage
planned non-resident basis ... who requires facilities for recov- of patients (less than lO%) may have severe early postoperative
ery."3 The definition excludes minor operative procedures un- pain following a repair under general anesthetic, the incidence
dertaken in outpatients or in emergency departments. The RCS and extent of this can be reduced by the infiltration of local anes-
goes on to comment that "the most suitable surgical operations thesia at the end of the procedure.
for day-case treatment are those which require a short general
anaesthetic," and the authors would add local or regional anaes-
thesia as well, "and do not carry the risk of postoperative compli-
The Development of Complications
cations that require management in hospital." Groin hernia repair Unobserved by a Trained Professional
fits these requirements ideally, although to date British surgeons
have been slow to adopt RCS guidelines regarding carrying out in- The fear that complications may develop "unobserved" may be
guinal hernia repair on a day-case basis using local anesthetic. 4 overcome by educating the patient (with appropriate counseling
767
768 M. Kurzer, P.A. Belsham, and A.E. Kark
and fact sheets) so that he or she becomes the observer. Keeping Medical Fitness of the Patient
the patient in hospital will neither prevent nor reduce the inci-
dence of complications, but the patient must have easy and rapid Patients of ASA grade I or II are particularly suitable for day-case
telephone access to the surgeon or deputy if there are any con- hernia repair. The decision whether ASA grade III patients should
cerns. Complications will be reduced by careful patient selection remain as inpatients for overnight observation will depend partly
and use of the most appropriate anesthetic and operative tech- on the predicted complexity or difficulty of the procedure, partly
nique. on the underlying medical condition, and partly on the level of
home support.
ASA grade IV patients with frank cardiorespiratory problems, as
Suitability of Patients for well as the very elderly in whom many of the well-recognized ad-
verse sequelae of general anesthesia may be enhanced, should be
Ambulatory Hernia Repair admitted for overnight observation, whichever anesthetic tech-
nique is used. It is important that even though they remain in hos-
Almost all reducible primary inguinal hernias, and primary um-
pital overnight, early mobilization is vigorously encouraged in
bilical or epigastric hernias less than 4 cm in diameter, can be
these patients.
repaired as day cases, the majority under local anesthetic. The as-
A full and detailed medical history and list of medication usage
sessment regarding suitability is made at the preoperative consul-
and allergies is important at the initial consultation stage so that
tation by an experienced surgeon, ideally the one who is going to
the appropriate steps can be taken in advance of the planned day
carry out the operation. The factors to be taken into account
of surgery. The most commonly encountered situation is the reg-
should be considered under three headings: technical, medical,
ular use of low-dose aspirin for its antiplatelet activity, and this
and social.
should be stopped 10 days preoperatively. There is no need for a
"routine" blood test or "routine" chest x-ray if the surgery is to be
done using local anesthesia, but they should be ordered if there
Technical Factors are specific indications.
The likelihood of an extensive or difficult dissection will militate

against day-case surgery, and the following categories of patient
are usually not suitable.
Social Circumstances
1. Patients with very large inguinal hernias, particularly if they de- There must be adequate support at home, specifically the pres-
scend into the scrotum, and umbilical and epigastric hernias ence of a responsible adult, whatever the age of the patient. Very
greater than 5 cm diameter. elderly or frail patients, even with apparently adequate home sup-
2. Patients with long-standing hernias. This often relates to the port and with no overt medical problems, should remain in hos-
size of the hernia, but sometimes even apparently moderate- pital overnight. Patients with a home journey time of more than
sized groin hernias may have been present for decades; the sur- 1 hour should at least remain in the vicinity of the clinic and sur-
geon will need to estimate the likelihood of a difficult geon for the first postoperative night. In such cases it would be
dissection. appropriate for a young, fit, accompanied patient to stay at a lo-
3. Patients with irreducible hernias. An incarcerated hernia, or cal hotel.
one that is not fully reducible, is certainly a contraindication to
local anesthetic repair (if it does not reduce in the consulting
room, it will be even less likely to reduce with an awake patient Anesthesia for Ambulatory
intraoperatively), although not necessarily to ambulatory
surgery. Nevertheless, because of the unpredictability of the
Hernia Surgery
findings and the likelihood of an extensive dissection, the pa-
The three categories of anesthesia available are general anes-
tient should be warned that an overnight stay may be needed.
thetic, spinal or epidural (sometimes known as regional), and lo-
4. Overweight patients with a body mass index (weight in kg/
cal anesthetic.
height m 2) greater than 30 require more dissection and are at
greater risk of developing a hematoma. The operation can be
technically demanding even if the hernia is small, and the her-
nia is frequently at a more advanced stage at presentation. For General Anesthesia
all of these reasons, a vacuum drain and overnight observation
may be advisable. It is difficult to predict this, however, and the Theoretically, general anesthesia is ideal for the operator, provid-
authors have operated on many overweight patients as day ing patient immobility and muscular relaxation if required. Large,
cases. complex or incarcerated hernias can be repaired in the confident
knowledge that any unforeseen intraoperative difficulty can be
The accuracy of predicting the technical difficulties likely to be dealt with.
encountered is dependent on the surgeon's experience. However, There are, however, a number of disadvantages when general
when making the decision regarding suitability for ambulatory anesthesia is used routinely for ambulatory surgery. Recovery from
surgery, the assessing surgeon must bear in mind that the actual the systemic and sedative effects of the anesthetic can be pro-
operation may well be carried out by someone less experienced longed so that an unplanned overnight stay may be needed. Nau-
than he. sea and vomiting may also delay recovery, and urinary retention
119. Ambulatory Hernia Surgery 769
may occur in elderly predisposed patients. This latter group, how- tions and a higher degree of satisfaction in patients over the age
ever, as mentioned above, may not be suitable for day-case surgery of 65 years. 9
in any case. The economic arguments for its use in ambulatory surgery are
As the hazards and risks of general anesthesia are the same compelling and have been extensively discussed elsewhere. 7•l7
whether the patient is a day case or an inpatient, the anesthetic
facilities provided must be comparable, and there are additional
costs when comparing general with local anesthesia. These include Patient Information and Education
the capital cost of equipment, disposables, additional drugs, the
cost of an anesthesiologist, extra operating room and recovery The development of rapport with the patient is important in all
staff, and more sophisticated postanesthesia recovery facilities. 7 aspects of medicine and surgery, nowhere more so than in am-
bulatory surgery, a situation where patient understanding and co-
operation are integral to recovery. Patients therefore need
Spinal or Epidural (Regional) Anesthesia preoperative counseling and explanation supplemented by writ-
ten information sheets, comprehensive postoperative instructions
When correctly carried out, regional anesthesia provides excellent written in language understandable by a layperson, and a 24-hour
intraoperative analgesia and relaxation. Sympathetic block results contact number for their surgeon or a responsible deputy.
in a lower limb vasodilation that often results in a compensatory
vasoconstriction in the inguinal and pelvic regions, giving a dry
operative field and excellent operating conditions.
Preoperative Counseling
When used in ambulatory surgery, problems will arise if recov-
Preoperative counseling is required to inform the patient about
ery from the motor block is prolonged, although new short act-
what to expect and to allay anxiety. The technique of the opera-
ing agents (available in the United States but not yet in the United
tion, the type of anesthetic, and the possibility of postoperative
Kingdom) have overcome this difficulty. This type of anesthetic is
problems should be discussed. This is supplemented by written in-
used routinely at a number of dedicated hernia centers with great
formation sheets that include specific details regarding preopera-
success.s However, postoperative urinary problems tend to be
tive preparation and what is required on the day of the operation.
more common (in predisposed patients) than after general or lo-
The arrangements for leaving the day-case center, such as the need
cal anesthesia. 9
to be accompanied home after the operation, must also be ex-
plained to the patient at this preoperative assessment. At this stage,
patients should also understand the likely postoperative course
Local Anesthesia and recovery time so that they can plan their return to work and
leisure activities.
Local anesthesia involves direct local infiltration of the tissues ei-
ther with or without a field block of the ilioinguinal and iliohy-
pogastric nerves, and the technique has been well described.I°. ll Postoperative Instructions
This is usually supplemented by a small amount of intravenous
sedation. In many cases this will be the patient's first experience of any op-
When skillfully used, local anesthesia gives excellent intraoper- eration, and he or she will be apprehensive in case things "go
ative analgesia, and it is undoubtedly the method of choice for re- wrong." On leaving the day unit, patients require comprehensive
pairing uncomplicated primary inguinal hernias in nonobese postoperative instructions written in language understandable to
patients. There are many reports of large numbers of hernias be- a layperson. This should explain in more detail what to expect if
ing repaired using only local anesthesia, with minimal morbidity recovery is uneventful. Patients need to understand that there will
and mortality.12-14 Because there is no motor block and no sys- inevitably be some bruising, swelling, and pain. Sufficient appro-
temic effect (provided sedation has not been given in excess), mo- priate analgesics must be given with instructions on how and when
bilization is rapid, and the technique is thus ideally suited to to take them.
ambulatory surgery. Instructions should also explain how to recognize and deal with
It is certainly not suitable for large or incarcerated hernias, for complications. For example, orthostatic hypotension occurring in
excessively obese patients, or for other cases that are likely to be the first 24 hours is a relatively rare but frightening occurrence that
technically challenging, such as complex recurrent hernias. Al- the patient and the person who accompanies him or her on leaving
though elderly or medically unfit patients may be ideal candidates the day unit must be warned about. Although urinary difficulties are
for local anesthesia, they may be far from ideal for ambulatory extremely rare when local anesthetic is used, all patients should be
surgery. asked to void before leaving the day unit. The features of wound in-
Local anesthesia is admittedly more demanding of the surgeon, fection should be listed in the fact sheet, as well as a note about tes-
requiring accurate sharp dissection and gentle handling of tissues, ticular swelling. Finally, it must be made clear that the surgeon or
and teaching hernia repair to the trainee with an awake patient deputy should be contacted if there is any doubt or con~rn.
presents its own challenges. It has been clearly shown, however,
that the use of local or regional anesthesia virtually eliminates the
incidence of urinary retention, allows rapid mobilization, limits Twenty-Four-Hour Contact Telephone Number
the need for hospitalization, reduces postoperative analgesic re-
quirements, and shortens the time in the recovery room. 7 Local Patients will often telephone seeking reassurance, and the exact
anesthesia has also been shown to result in fewer total com plica- nature of the problem can often be assessed at this time. If there
770 M. Kurzer, P.A. Belsham, and A.E. Kark
are doubts, patients can be asked to return to see their surgeon discomfort (lower analgesic requirements) and a more rapid re-
or be directed to their primary care physician. turn to work. 26 ,27 The counterargument, in favor of open mesh re-
Close liaison is important in the early postoperative period and pair, is that postoperative discomfort and the time for return to
creates goodwill. Surgeons tend to forget that what may appear work is not significantly different from that with laparoscopic re-
routine, normal, or uneventful to them is often a unique and ter- pair, with the direct medical costs of the latter being so much
rifying experience for a patient. The authors make extensive use higher that they simply do not outweigh these other factors. 28 How-
of telephone follow-up, and all patients are called the day after ever, a detailed discussion of the relative merits of open versus lap-
operation by a nonmedical member of staff. The surgeon is in- aroscopic hernia repair is beyond the scope of this chapter.
formed if there are any problems or concerns, in which case he Although feasibility, low postoperative morbidity, a reduction in
speaks to the patient personally. This is, in effect, a telephone ward costs, and high patient satisfaction were the conclusion of a recent
round. In the event of postoperative problems, the authors believe study of 400 consecutive ambulatory inguinal hernia repairs in
it is preferable that patients contact and speak to the operating Denmark,29 not all reports have been equally favorable. Patients
surgeon or a member of his team in the first instance rather than (and possibly surgeons) in several reported studies have been re-
the primary care physician or local emergency room. Over 90% luctant to wholeheartedly embrace ambulatory hernia surgery. A
of the telephone calls that the authors receive in the first postop- lack of patient information and education may have been the rea-
erative week are for reassurance only. son for patients' dissatisfaction with ambulatory hernia surgery in
three other studies (one from Switzerland, one from France, and
one from the United Kingdom). Patients either expressed, in a
British Hernia Centre Practice preoperative questionnaire, a reluctance to undergo ambulatory
surgery, so maintained that they had been discharged too early,S1
Patients are asked to arrive at the ambulatory center 45 minutes or simply refused to go home at the end of the day!S2
before the scheduled operation time. They are allowed to eat and In contrast, Gunnarsson'sS3 favorable experience of ambulatory
drink in moderation up to 2 hours preoperatively. Patients change, hernia surgery, without a separate preoperative consultation but
and routine observations are recorded. Consent is obtained by with detailed written information sent to patients beforehand,
their surgeon, who marks the side of the operation, and they then demonstrated the feasibility, efficiency, and economic advantages
walk into the operating room. Antibiotics are not used routinely of this approach, as well as highlighting the close relationship be-
but are given to the elderly, diabetics, and patients with prosthetic tween patient satisfaction and pre- and postoperative information.
heart valves, valvular prolapse, or orthopedic prostheses. An in-
travenous cannula is inserted for the administration of a small
amount of sedative (midazolam) and a pulse oxymeter, automatic Conclusion
blood pressure recorder, and cardiac monitor are attached. An
anesthetist is present to monitor and administer sedation where Accurate diagnosis, careful preoperative assessment, meticulous
specifically indicated. Patients are shaved on the table, and the surgical technique, and the minimum of postoperative complica-
line of the incision is infiltrated with local anesthetic. The details tions are of course the goal of all surgery. Nowhere is this more
of the technique have been given elsewhere,u,16 At the end of the important than in ambulatory surgery, where the margin for er-
procedure patients walk to the recovery area, where they are given ror is very much reduced. There is no doubt that the move toward
light refreshments. They remain at the Hernia Centre for ap- more widespread ambulatory hernia repair is gaining momentum,
proximately 2 hours before leaving. and, while it is true to say that economic factors were the initial
driving force behind it, the early mobilization has medical bene-
fits, such as the reduction of chest or thrombotic complications.
Economics, Feasibility, Wantz34 has pointed out that, in his experience, fully informed pa-
tients actually prefer not to be admitted as inpatients, and not be-
and Patient Satisfaction ing admitted softens the emotional impact of the operation and
reduces disability by encouraging the patient rapidly to return to
The important factors affecting the cost of the procedure are hos- normal activities. The economic effects are thus more far-reach-
pital stay, type of anesthetic, and the type of repair, particularly ing than simply the cost of the procedure. Although the arguments
whether an open or a laparoscopic technique is used. Admitting for ambulatory hernia repair are self-evident, patient safety and
patients to hospital for a hernia repair and keeping them in for 1 long-term results are paramount, and evidence today suggests that
or 2 nights will increase the total cost of the procedure markedly. these criteria can be met in day-case surgery. "If done correctly
Specific figures will obviously vary between countries and institu- and carefully, patients will be grateful and appreciative, and soci-
tions. 17- 21 There is also a dramatic reduction in intraoperative, re- ety will benefit by freeing up limited hospital resources for the crit-
covery area, and drug costs for ambulatory inguinal hernia repair ically ill. "34
when comparing regional block with general anesthesia. 7
Several studies of laparoscopic repair have shown how costs are
increased by the need for general anesthesia, the additional costs
of equipment, disposables, and increased staffing. 22- 24 Rutkow25
References
has carried out a detailed cost comparison of open tension-free 1. Ryan JA. Outpatient inguinal herniorrhaphy-Special comment. In
mesh repair and laparoscopic repair and argues convincingly for Nyhus LM, Condon RE (eds): Hernia. Philadelphia: J.B. Lippincott;
the greater cost efficiency of the open repair. 1989:516.
The direct medical costs of laparoscopic repair may be greater, 2. Bendavid R The merits of the Shouldice repair. Probl Gen Surg. 1995;
but its proponents maintain that this is offset by less postoperative 12:105-109.
119. Ambulatory Hernia Surgery 771
3. Clinical guidelines for day case surgery. London: Royal College of Sur- 19. van den Oever R, Debbaut B. Cost analysis of inguinal hernia surgery
geons of England; 1992. in ambulatory and inpatient management [in German]. Z Chir. 1996;
4. O'Riordan DC, Kingsnorth AN. Audit of patient outcomes after 121:836-840.
herniorrhaphy. Surg Clin North Am. 1998;78:1129-1139. 20. Saviano MS, Gelmini R, Piccoli M, et al. Evaluation of costs in surgery
5. Kark AE, Kurzer M, Belsham PA. Three thousand one hundred and of inguinal hernia. Day surgery and one day surgery versus ordinary
seventy-five primary inguinal hernia repair: advantages of ambulatory admission [in Italian]. Ann ltal Chir. 1996;67:615-619.
open mesh repair using local anesthesia. ] Am Coll Surg. 1998;186: 21. RyanJA, Adye BA,Jolly PC, et al. Out-patient inguinal herniorrhaphy
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120
Telemedicine and Robotics in Surgery
Peter M.N.YH. Go
The world around us seems to shrink due to new telecommuni- nized to a broad band for data transfer varying from 128 kB per
cations possibilities. The development of advanced computer sys- second to 2 MB per second. This might seem a lot, but for real-
tems and miniaturization stimulates the application of complex time video a data transfer of 184.3 MB per second is necessary.
auxiliary instruments such as robots. It is obvious that traditional Data compression is therefore necessary to reduce the bandwidth,
surgery also will be influenced by these emerging technologies. but usually results in reduction of the image quality, depending
The introduction of laparoscopic surgery has focused surgeons on the amount of compression. In our experience, ISDN-6 tele-
on the technological aspects in their profession. In this chapter, conferencing at a rate of 384 kB per second seems to be the min-
the possible impacts of the implementation of telemedicine and imallevel for application in surgery (Fig. 120.1).
robotics in surgery are discussed. On-site proctoring is time consuming and can be expensive, in
regard to travel expenses for example. Teleproctoring can be use-
ful for the introduction of hernia repair techniques, such as the
Telemedicine new laparoscopic methods, for which the learning period requires
approximately 20 operations. 3 Because this type of proctoring in-
Telemedicine is not new. Einthoven used a telecommunications volves instruction from surgeon to surgeon, verbal communication
line in 1902 to transfer electroencephalographic signals from a pa- and video images are sufficient. In a laparoscopic operation, the
tient, generated at the university hospital in Leiden, in the Nether- images are already generated in electronic form by the video en-
lands. The signals were visualized on a sensitive galvanometer on doscope. Thus, it is not difficult to transmit these images through
the other side of the city. Telemedicine can be defined as the use a teleconferencing system to almost any place in the world that can
of telecommunications technology to send data, graphics, and au- be reached by telephone. Proctoring time is reduced to the dura-
dio and video signals between participants who are physically at a tion of the operation or of the difficult parts of the operation. The
distance from one another as a means to achieve clinical care. l proctoring surgeon can teach the operation from his office or any
In surgery, three levels of telemedicine can be defined. The first other place where the teleconferencing system is set up.
level is the exchange of video images. This can be for either edu- In open surgery also, tele-instruction is possible, with a separate
cation or consulting purposes. A surgeon can demonstrate an op- imaging system to show the operative field. In our own experi-
eration to colleagues or students using a teleconferencing system. ment, we chose two minicameras mounted on a brace (Fig. 120.2).
On the other hand, a surgeon can seek assistance during an op- The attachment of the camera to the surgeon's body rather than
eration. In 1994, a surgeon in Hawaii was able to proctor a sur- his head gives a steadier image. 4
geon in the Netherlands during a laparoscopic procedure. 2 The Another application in surgery is the possibility for triage in trau-
novelty of this experiment was not only the distance between the matology using live video images. For example, in battlefield con-
surgeons involved in the same operation but also the type of ditions, images and vital signs of a wounded soldier can be
telecommunication system that was used: regular telephone lines! forwarded to a surgical unit. The surgeon on duty can assess the
injuries and triage for further care.
Voice and Image Interaction

Telemanipulation
Real-time video images for use in instructing operative procedure
must be of sufficiently high quality. Data for both images and voice The second level of telemedicine in surgery is the addition of tele-
can be transferred through a teleconferencing system via digital manipulation to teleconsulting and teleproctoring. A surgeon can
lines. The Integrated Digital Network System (ISDN) is easily ac- assist his colleague at a distance during an operation using com-
cessible because it uses the regular telephone lines and is readily plex auxiliary instruments such as robots. The AESOP robot arm
available throughout the world. It offers a variable digital band- controls the laparoscope for the visualization of the operative field
width. From 2 to 30 lines in ISDN-2 to ISDN-30 can be synchro- (Fig. 120.3). This robot arm can be controlled by a surgeon from
772
120. Telemedicine and Robotics in Surgery 773
FIGURE 120.1. A surgeon in Nieuwegein, the Netherlands, is demonstrat- FIGURE 120.3. The AESOP robot arm controls the laparoscope and the at-
ing a laparoscopic inguinal hernia repair at a meeting in Orlando, Florida, tached camera, allowing the surgeon to visualize the desired laparoscopic
using a teleconferencing system. Data transfer is through ISDN-6. image by manual or voice control.
a distance using ajoystick-like controller or even by voice control. sible when complications occur during or after teleproctering?
These control signals can be transmitted though teleconferencing What if the telecommunications system fails? How is licensing reg-
systems. This allows, for example, a proctoring surgeon to visual- ulated for a surgeon who operates in one country on a patient in
ize the operative field of his choice for instruction with more another? Different countries have different laws. Before tele-
emphasis. surgery can become a reality, reliable telecommunication systems
must become available, and international regulations should be
made. Ethical issues must be addressed as well. What will be the
Telesurgery relationship of the patient with the remote surgeon? The bond
between patient and physician, as well as the patient's trust, are
The third level is the concept of telesurgery. The surgeon is not part of surgical care. This is as important as the technological as-
physically present near the patient during the operation, and yet pect of telesurgery.
the surgeon performs the operation. It is called a concept because
the devices for distant instrumentation and reliable telecommu-
nication systems are not yet available. Telesurgery would have ap- Robotics
plications in remote areas, in space, or in high risk environments,
such as areas with life-threatening endemic infections or nuclear Endoscopic technology guides surgical technology in the operat-
radiation. ing room. The instruments used in endoscopic surgery are rela-
With new opportunities, new problems also arise. How are lia- tively primitive. They are extensions of current instruments, such
bility issues to be regulated? Which surgeon can be held respon- as scissors and graspers. The complexity of the surgeon's hand,
with its multiaxial movements and tactile sense, cannot yet be ap-
proximated, let alone matched. The development of complex de-
vices called robots may overcome these limitations.
Currently, two robotic systems are available in endoscopic
surgery. These systems are, in fact, servo- or master-slave systems.
The Automated Endoscopic System for Optimal Positioning, or
AESOP (Computer Motion, Inc., Santa Barbara, CA), is one of the
first commercially available robot systems for endoscopic surgery.
It consists of a metal cylinder fixed to the operating table. A me-
chanical arm with three joints holds the endoscope and allows
movements in six directions (Fig. 120.3). The arm can be con-
trolled either manually or by voice, allowing the surgeon to con-
trol the visualization of the operative field, eliminating the camera
operator. The robot arm can also be controlled from a remote
site, in teleproctoring, for instance. Mechanical arms to control
graspers and dissection instruments are becoming available. In the
ZEUS system from the same company, other endoscopic instru-
FIGURE 120.2. Two lipstick cameras are mounted on a brace. These cam- ments are controlled by the surgeon from a console. Instead of
eras allow the remote surgeon to see the same operative view as the proc- standing next to the patient, the surgeon can sit at a well-designed
tored surgeon. One camera shows an overview, the other a part of the ergonomic control panel to perform the operation.
operative field in detail. Another system that resembles the ZEUS system is the da Vinci
774 P.M.N.YH. Go
FIGURE 120.4. Three mechanical arms are prepared for surgery. One holds FiGURE 120.6. The surgeon sits behind a console, looking at a three-
the visualization device; the other two can act as the right and left arms of dimensional image of an endoscopic operation. The movements of his
the surgeon. hands in special holders are imitated by the endoscopic instruments in the
operative field within the body cavity.
Surgical System (Intuitive Surgical, Inc., Mountain View, CA).

Three mechanical arms are available (Fig. 120.4), one to hold an In orthopedics, the Robodoc 8 can prepare a space in the femur
endoscope that projects a three-dimensional image and two oth- for precise placement of a hip replacement, using computed to-
ers with a wrist-like joint at the end of the shaft, the EndoWrist,TM mography images. The Probot can perform a transurethral prosta-
to allow additional movement of endoscopic instruments (Fig. tectomy based on ultrasound images. 9
120.5). The surgeon controls the movements of the EndoWrist in Robots can replace human actions to a certain extent. They can
a practically intuitive way by moving hand and fingers within spe- facilitate complex manipulations in small body cavities and create
cial holders (Fig. 120.6) while sitting comfortably behind his con- a better ergonomic situation for the surgeon. Their use allows sur-
sole looking at a three-dimensional image. The EndoWrist has geons to gain access to the operative site with more precision and
seven directions of movement. It allows accurate performance of less trauma than by traditional surgery. One can imagine surgery
complex movements in confined areas such as the abdominal or on a beating heart made possible by compensatory movements of
thoracic cavity. The software of the system allows scaling of the sur- the instruments: The instruments moving at the same rate as the
gical action. A 1 in 10 scale-down will reduce a 1 cm hand move- heartbeat permit the surgeon to see a "pseudo-stationary" image
ment by the surgeon to a 1 mm displacement of the instrument during the suturing of a vascular anastomosis. Extracorporeal cir-
at the operative site, allowing great precision in dissection and su- culation might become unnecessary, culminating in a CABG in
turing. This robot arm is promising in the field of endoscopic ambulatory surgery.
CABG (Coronary Aortic Bypass Graft) and heart valve replace- The fear that robots will replace human surgeons is misplaced.
ment. 5,6 In Brussels the da Vinci Surgical System is used for lapa- Humans will always be needed to make important decisions and
roscopic operations such as gallbladder removal and Nissen judge how to proceed in unforeseen circumstances. The robot will
fundoplication. 7 remain a sophisticated instrument to aid surgeons, allowing them
to perform surgery in the way least harmful to patients. Respon-
sibility for surgical care remains firmly in the surgeon's hands.
Conclusion
The ultimate goal of telesurgery is the performance of surgery at
a location remote from the surgeon. Operations will be performed
on patients who are inaccessible because of distance, hazardous
environments, or other physical barriers. More and more sophis-
ticated robotics will assist in the enhancement of the quality and
accessibility of surgical care.
References
FiGURE 120.5. The tips of the endoscopic instruments in a body cavity can 1. Brecht RM, BarrettJE. Telemedicine in the United States. In Viegas SF,
bend like the human wrist, allowing natural hand movements in a limited Dunn K (eds): Telemedicine: practicing in the injrmnation age. Philadelphia:
surgical field. Lippincott-Raven; 1998:25-30.
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2. Go PMNYH, Payne JH, Satava RM, et al. Teleconferencing bridges two 6. Loumat D, Carpentier A, d'Attellis N, et al. Endoscopic coronary artery
oceans and shrinks the surgical world. Endose Surg. 1996;10:105-106. bypass grafting with the aid of robotic assisted instruments. ] Thome Car-
3. Liem MSL, van Steensel CJ, Boelhouwer RU, et al. The learning curve diovase Surg. 1999;118:4-10.
for totally extraperitoneallaparoscopic inguinal hernia repair. Am] Surg. 7. Cadiere GB, HimpensJ, Vertruyen M, et al. Fundoplicature selon Nis-
1996;171:281-285. sen realisee a distance du patient par robotique. Ann Surg. 1999;53:
4. Hin AJS, Daanen HAM, Lotens WA. Telemedicine-online teleeonsultancy 137-14l.
and telesurgery. Report TD 97-0484. Soesterberg: TNO Human Factors 8. Bagar WL, Bauer A, Bomer M. Primary and revision total hip replace-
Research Institute; 1997. ment using the Robodoc system. Clin Orthop. 1998;354:82-9l.
5. Shenhib H, Bastawysy A, McLoughlinJ, et al. Robotic computer assisted 9. Harris SJ, Arambula-Cosio F, Mei Q, et al. The Probot-an active robot
telemanipulation enhances coronary artery bypass. ] Thome Cardiovase for prostate resection. Proe [nst Meeh Eng. 1997;211:317-325.
Surg. 1999;117:310--312.
Epilogue
George E. Wantz
Readers who have read this far will know the current state of the that goes into these chapters. Besides the writing of the text, of-
art for the management of all kinds of hernias of the abdominal ten the easiest task, there is the preliminary research, the gather-
wall, as set forth by the acknowledged world experts on this sub- ing of illustrations, the review of illustrations created by the
ject. Untold numbers of articles, monographs, and books have medical artists they have engaged, the checking of references, and
been written on this subject during past millennia, however, and the procurement of permissions, all of which are tedious tasks at
my opening sentence would have been applicable at the end of best. Labors of love, however, have long been a tradition of physi-
each of them. Had the authors and editor believed otherwise, an cian authors. A notable example was Sir Astley Paston Cooper, the
apology such as Pierre Franco wrote in his great 1561 book, Traiti hero of many hernia surgeons. All copies of his 1804 magnificent
des Hernies, would have been in order. "Gentle reader," Franco illustrated folio on hernias were sold, yet he was out of pocket
wrote in his opening statement, "I am certain you will judge my £lOOO for his investment in the project!
book superfluous and me foolhardy for having written it when so Implicit in my phrase, "current state of the art of hernia repair"
many others have sufficiently dealt with this subject." This would at the opening of the Epilogue is the awareness that imperfect
be truly pertinent today but in his day must surely have been a hernioplasties still occur and that technological progress is in-
convention, for his treatise on hernias was one of the first ever to evitable. That is why so much has been written on this subject. This
be devoted to this subject. book is important because its comprehensive coverage of the sub-
The chapters in this book are labors of love on the part of the ject will provide the foundation on which the future of hernia
authors. Self-satisfaction, the pleasure of imparting their knowl- surgery will be built. There will be new experts and new biological
edge to others, and a complimentary copy of the book are their technologies as the quest continues for perfect hernioplasties. I join
sole rewards. Readers rarely appreciate the sheer amount of work other students of the subject in looking forward to future editions.
776
Index
A fascial and myofascial tissues, general, 768-769

Aachen classification, for inguinal hernia, 299-300 local,769
129 free vascularized myocutaneous flaps, spinal or epidural, 769
Abdominal muscles, 39-44, 488 300 defined, 767
flat muscles, 39-41 synthetic substitutes, 300-302 economics of, 770
linea alba, 43 See also specific hernia type feasibility, 770
rectus abdominis, 39, 40 Abdominal wall hernia. See Incisional her- groin hernia repair and, 5-6
rectus sheath, 41-43 nia; Spigelian hernia; Umbilical key features of, 767
semilunar line, 43-44 hernia patient satisfaction, 770
Abdominal wall Abdominal wall reconstruction, 547-554 patient education
anatomy of, 39-63, 487-489 prosthetic material and, 552 postoperative instructions, 769
anterior, 64-71, 487-488, 489. 498 techniques for, 548-549, 551-552 preoperative counseling, 769
anterolateral, 39-46 conventional, 548 twenty-four hour contact phone num-
blood supply, 488 dermal graft, 548,549 ber, 769-770
muscles, 488. See also Abdominal fascia, 549 patient suitability
muscles free tissue transfer, 550-552 medical fitness of, 768
nerves, 488 greater omentum, 549 social circumstances, 768
posterior, 57-60 muscle flaps, 549, 550, 551 technical factors, 768
loss of substance. See Loss of abdominal skin graft, 548, 549 postoperative pain, 767
wall substance (LAWS) transposed thigh muscle use, 553-554 tension free repair and, 767
Abdominal wall defects Abdominal wall tension, intraoperative unobserved complications, 767-768
chronic evaluation, 169-170 Anastomosis, gastrointestinal, loss of ab-
components separation technique Acupuncture, for chronic pain, 728 dominal wall substance, 538, 540
for, 487-496 Adhesion formation, 294-297, 304 Anatomy
evaluation of, 487, 488 patterns of ingrowth, 294-295 abdominal wall, 39-63, 487-489
contaminated, absorbable mesh use, prevention, 295-297 aponeurotic sheets, 64-71
306-313 antihistamines, 296 inguinal canal, 52-57
emergency repair, 302 calcium channel antagonists, 296 inguinofemoral area, 46-52
etiology, 547-548 carboxymethylcellulose (CMC), 296 innervation of, 44-45
irradiation injury, 548 heparin, 296 muscles, 39-44
postinflammatory defect, 547-548 hydroflotation bath, 295, 304 pelvic wall, 60-63
posttraumatic defect, 547 iloprost, 296 posterior, 57-60
primary hernia, 547 mechanical barriers, 295-296, 304 sciatic region, 61-62
secondary hernia, 547 nonsteroidal anti-inflammatory skin and vessels, 45-46
tumor surgery, 548 agents, 296 vascularization of, 44
sites of sodium tolmetin, 296 Cooper's ligament, 92-95
epigastric region, 547, 548 tissue plasminogen activator (t-PA), for herniography, 337
suprapubic and pubic region, 548 296 iliopubic bandelette of Thomson, 95
umbilical region, 547, 548 Age distribution, for inguinal hernia, inguinal region
techniques 110-111 fascial, 86-95
acquired primary closure, 299 Aging. See Geriatric hernia patient laparoscopic perspective, 72-84
artificial substitutes, 300 Ambulatory hernia repair, 767-774 space of Bogros, 101-106
epidermal graft, 299 anesthesia transversalis fascia, 97-100
777
778 Index
Anesthesia umbilical hernia, 662-664 See also Prosthetic material

ambulatory hernia repair, 768-769 anatomical considerations, 662 Bioreactivity, 222-225, 230-231
general, 6, 768-769 concomitant peritoneovenous shunt, biomaterials, 230-231
complications of, 700 664 infection, 224
for strangulated hernia repair, 565 postoperative care, 663-664 inflammation, 223, 224
geriatric hernia patient, 644, 650 rupture, 664 neoplasia, 224-225
as hernia repair complication, 693 strangulated, 664 thrombosis, 223-224
local, 6, 317-323, 769 surgical indications, 663 Bladder
absorption of, 318 uncomplicated, 664 genitourinary tract pathology and her-
actions of, 318 Atrium, comparative analysis, 286-291 nia repair, 653
advantages of, 319 early complications, 289 hernia repair complications of, 695
allergic reactions, 319-320 long-term complaints, 289 reaction to prosthetic material, 718-719
bupivacaine, 318 recurrences, 289 Bleeding, hernia repair complication
choice of, 317-318 textile analysis, 288 artery, 694
complications, 693 tissue reaction, 289-290 vein, 694
EMLA, 318-319 Autografts, loss of abdominal wall sub- Bochdalek hernia, in pediatric patients,
epigastric, umbilical, small incisional stance treatment, 535 599-603
hernias, 322, 323 Autologous implants, collagen-based pros- Bogros's space. See Space of Bogros
femoral hernia, 322-323 thetic material, 250-252 Bone, hernia repair complications of, 696
history of, 317 Bowel, hernia repair complications of,
indications, 319 B 695-696
for inguinal hernia, 320-321 Balloon dissector, 464, 465 Bowel obstruction, in incisional hernia re-
injection points, 371-372 Bard mesh pair, 585
lidocaine, 318 surgical treatment of obesity, 676 Breast reconstruction, rectus-sharing
ph of, 318-319 tissue response to, 204-205 modification for, 491-492, 493
preoperative medication, 320 use in giant hernia, 678 Bupivacaine, local anesthesia, 318
recommended dosage, 319 Bassini-Kirschner operation, femoral her- Burst abdomen
recurrent inguinal hernia, 321-322 nia repair, 441 clinical aspects, 530
in Shouldice repair, 371-372 Bassini operation, 353, 354-360 contributing factors, 530
topical, 318-319 history of, 12-13, 354,456 closure technique, 530
toxic reactions, 319 modified, 360 incision, 530
pregnant hernia patients, 622-624 technique infection, 530
spinal or epidural, 6, 769 closing, 359 suture thread, 530
Aneurysm, metabolic aspects of hernias cutaneous incision, 354, 356 secondary to fistula, 534
and, 140-141 incision of aponeurosis, 354, 356 treatment, 533-534
Anterior approach, groin hernia repair, isolating spermatic cord, 356, 357 See also Wound dehiscence
12-13 management of indirect sac, Buttonhole incisional hernia, suture selec-
Antibiotics 357-358, 359 tion and, 243
in hernia surgery, 324-333 resection of cremaster muscle,
pros and cons, 331 356-357, 358
recommendations for, 331-332 splitting the transversalis fascia, 357, C
studies of, 330-331 358 Carbon fiber. See Polymeric carbon fiber
principles of, 328-330 suture of deep plane, 358-359 Carcinogenesis, foreign body
drug concentrations, 330 Benchmarking, in quality control, risk of, 235-236
evidence-based approach, 328-329 123-124 in rodent models, 235
regimen, 330 Bendavid classification, for inguinal her- Cefazolin, recommendations for use, 332
target expected pathogens, 329 nia,129 Cheatle-Henry operation, history, 13
therapeutic, in hernia operations, 332 Bendavid's umbrella, femoral hernia re- Chest wall, reaction to prosthetic mater-
Aponeurotic hernias, 64-71 pair, 442, 444 ial, 719
Aponeurotic sheaths Biomaterials Children. See Pediatric hernia patient
epigastric zone, 65-67, 68 bioreactivity, 222-225, 230-231 Chronic pain, 726-729
hypogastric zone, 68 infection, 224 frequency of, 726-727, 728
midline zone, 64-65, 66, 67 inflammation, 223, 224 prevention, 729
umbilical orifice, 70-71 neoplasia, 224-225 role of surgery, 729
umbilical zone, 66, 67-68 thrombosis, 223-224 treatment, 727-729
Arteries carcinogenicity of, 235-236 acupuncture, 728
hernia repair complications, 694 materials principles, 221-222 drug therapy, 728
in space of Bogros, 104-105 bulk, 222 injection therapy, 728
vascular injury and, 745-747 surface, 221-222 See also Neuralgia
Ascites and hernia repair, 662-665 pathology of, 221-232 Chronic pelvic pain (CPP), female hernia
groin hernia, 664-665 tumorigenesis of, 235 patient, 630, 632-638
Index 779
Cirrhotic patients, umbilical hernia and, infection, 708, 709, 721-725 vascular injury and, 747-748
662-664 intestinal adhesions, 709-710 See also McVay operation
Clostridial myonecrosis polypropylene, 714, 715, 716 Corona mortis, defined, 743
LAWS clinical presentation, 192 seroma, 709 Cost, as quality control measure, 123
pathogenesis of, 194 tissue reactions, 714-720 Cross-linked dermal sheep collagen
Collagen as quality control measure, 123 (GDSC),252-255
metabolic aspects of hernias, 139-141 recurrences, 697 cytotoxicity and biocompatibility, 252
as prosthetic material, 250-255 sepsis, 580 tissue engineering of, 252-255
autologous implants, 250-252 seroma, 753-756 Cryptorchidism
cross-linked dermal sheep collagen, sexual dysfunction, 740-742 diagnosis, 175-176
252-255 dysejaculation, 757-758 effects of, 175
dermal grafts, 252 of the skin, 696 prognosis, 176
dermal implants, 250 strangulated hernia, 566-567 treatment, 176
fascial implants, 251 of the testicle, 693 undescended testis
heterologous implants, 252-255 of the urinary bladder, 695 acquired, 174-175
homologous implants, 250-252 of the vas deferens, 693-694 congenital, 174
human dura mater, 251-252 vascular injury, 743-751
Collagen lattice, of transversalis fascia, of the veins, 694 D
147-148 wound dehiscence, 569-574 Dacron mesh, 21-22, 266-271
Colon, reaction to prosthetic material, See also Recurrence; Strangulation; spe- adhesion formation of, 295
719 cific hernia repair clinical aspects, 266-267
Compartment syndrome Components separation technique, complications, 714
defined, 540 497-499 delayed, 270
loss of abdominal wall substance and, for abdominal wall defect, 487-496 hematomas, 267
540-541 alternative techniques infection, 268-269
positive end expiratory pressure distant tissue transfer, 494-495 intestinal occlusions, 269
(PEEP),541 endoscopic components separation, intravisceral migration of mesh, 269
Complications of hernia repair, 693-698 495 mesh breakage, 269
anesthesia, 693 primary repair, 492 neurological, 269
of the arteries, 694 prosthetic material, 493-494 tissue reaction, 715-716
of the bone, 696 tissue expansion, 494 wound dehiscence, 269
of the bowel, 695-696 anatomy, 487-489 experimental studies of
chronic pain, 726-729, 730-732, clinical application of, 489-491 extraperitoneal placement, 266
734-736, 737-739 complications, enterocutaneous fistulas, intraperitoneal placement, 266
epidemiological aspects of, 112-113 495 morbidity and morality, 269-271
ilioinguinal/iliohypogastric neuropathy, disadvantages of, 497 Dam repair, 361-364
737-739 history of, 487 anesthesia, 361
infections, 696 modified, 497-499 background, 361
laparoscopic considerations, 697-698, operative technique, 497, 498 dissection, 362
700-705 results, 497, 499 incision, 362
extraperitoneal repair, 702, 703 TRAM breast reconstruction, 491-492, preoperative assessment, 361
intraperitoneal onlay mesh, 702, 703 493 repair, 362
plug and patch repair, 70l, 703 for use with enterostomies, 497-499 the darn, 362-363
pneumoperitoneum, 700-701 Computed tomography (CT) skin preparation, 361
recurrence, 704, 705 imaging, 335-336 Deafferentation pain, 695
simple closure, 701, 703 for occult hernia, 120 Deposition, giving a, 765"':766
by technique, 703 Connective tissue disorders, associated Dermal grafts
transabdominal preperitoneal proce- with inguinal hernia, 114 abdominal wall reconstruction, 548,
dure, 701-702, 703 Consent 549
laparoscopic vs. open, 704, 705 general, 763 collagen-based prosthetic material, 252
lymphatics, 694 implied, 763 Dermal implants, collagen-based pros-
nerves, 694-695 informed, 763-764 thetic material, 250
neuralgia, 730-732, 734-736, 737-739 outcome data, 764 Dexon mesh
prosthetic material, 696-697, 707-712, physician standard, 763 in animal studies, 307-308
714-720 reasonable person standard, 763 in clinical studies, 308
contraction of prosthesis, 711, 712 surgeon experience, 764 histology of, 231
Dacron, 714, 715-716 verbal, 763 tissue response to, 205-206
expanded polytetrafluoroethylene Cooper's ligament, 78-79, 92 Diaphragm
(ePTFE), 714, 716, 717 in hernia surgery, 93 embryology of, 600
fistula formation, 71 0-711 surgical anatomy, 94-95 pelvic, 62
hollow viscus erosion, 710-711 Cooper's ligament repair relation to epigastric zone, 66-67, 68
780 Index
Diaphragmatic hernia wound dehiscence, 569-574 preperitoneal fascia, 88-89

congenital, in pediatric patients, EMLA, topical anesthesia, 318-319 transversalis fascia, 90-91
599-603 Endoscopic technology, 772-774 Fascial implants, collagen-based prosthetic
of the foramen of Morgagni, in pedi- Enterocutaneous fistulas, 495 material, 251
atric patients, 603 Enterostomy, components separation Female hernia patient
Direct hernia technique and, 497-499 chronic pelvic pain (CPP), 630,
defined,391 Envelope of the hernia, 513 632-638
mesh plug repair, 3$4 Epidermal growth factor, wound healing, epidemiology, 613-618
tissue pathology in/! 48 204 age distribution, 613-614
Distal external artery, vascular injury and, Epididymis, mass of, 655 anatomical considerations, 613
745-747 Epididymitis, 592 epigastric hernia, 618
Dorsal root ganglionectomy, for ilioin- Epigastric hernia, 685-687 femoral hernia, 616, 639-640
guinal neuropathy, 738 anatomy, 685-686 elective, 639
Drain usage, hernia formation and, 136 complications, 687 emergency, 639
Drains in hernia surgery, 347-350 diagnosis, 686 incisional hernia, 617
deep drains, 349 embryology, 685 inguinal hernia, 614-616
for groin hernia, 348-349 in females, 618 bilateral, 615
history, 347 history, 685 complex, 615
for incisional hernia, 349 local anesthesia for, 323 direct, 614
indications for, 349-350 in pediatric patients, 595 indirect, 614
position of, 348 postoperative care, 687 occult, 615-616
purpose of, 347 surgical technique, 68fHi87 pregnancy and, 616
risk of infection, 328 symptoms, 686 risk factor for, 615
subcutaneous, 349 Epigastric region obturator hernia, 618, 633-635
types of, 348 abdominal wall defect of, 547, 548 anatomy, 633
Dynamic Self-Regulating prostheses, aponeurotic sheets, 65-66,67 signs and symptoms, 633-634
412-415 relation to diaphragm, 6fHi7, 68 treatment, 634-635
complications Erectile dysfunction, hernia repair com- occult hernia, 625-629
long term, 415 plication, 740-742 diagnosis, 627
short term, 414 Esophagus, reaction to prosthetic mater- differential diagnosis, 627-628
methods, 412 ial, 719 mechanism of, 625-626
technique, 412-413 Expanded polytetrafluoroethylene symptoms, 625, 626
tension free repair, 413-414 (ePTFE) mesh, 262, 279-284 perineal hernia, 635-636
Dysejaculation, 757-758 abdominal wall defect repair, 283-284 pregnancy and, 620-624
defined, 757 adhesion formation of, 294-295 recurrent groin hernia, 61fHi17
hernia repair complication, 394, clinical uses of, 282 risks and complications, 617
740-741 complications of use, 714 sciatic hernia, 632-633
history, 757 tissue reaction, 716, 717 spigelian hernia, 618
mechanism, 757-758 infection, 280-282 sports hernia, 636
treatment, 758 intraperitoneal placement of, 262, 301 supravesical hernia, 636, 637
laparoscopic incisional hernia repair, umbilical hernia, 617-618
E 519-524 Femoral artery, vascular injury and,
Eagle-Barrett syndrome, in pediatric pa- mechanical characteristics of, 279, 280 745-747
tients, 604-606 onlay repair for inguinal hernia, 282 Femoral canal, 55-56, 439
Edema, loss of abdominal wall substance peritoneal healing, 280, 281 laparoscopic perspective of, 81
and,540 tissue incorporation, 279-280 Femoral hernia
Elderly. See Geriatric hernia patient tissue response to, 205 in females, 616, 639-640
Elective repair, abdominal wall defects Expert witness, being an, 764-765 herniography and, 338
acquired primary closure, 299 for plaintiff, 764 in pediatric patients, 593-594
artificial substitutes, 300 responsibilities of, 764-765 presentation
epidermal graft, 299 Extraperitoneal repair, laparoscopic tech- unusual, 439-440
fascial and myofascial tissues, 299-300 nique, 702 usual,439
free vascularized myocutaneous flaps, See also Totally extraperitoneal proce- Femoral hernia repair
300 dure (TEP) inguinal approach, 442, 443, 444-445
synthetic substitutes, 300-302 Bendavid's umbrella, 444
Emergency hernia repair, 560-567 F McVay operation, 366-367,444
femoral, in females, 639 Fascia, abdominal wall reconstruction, Moschowitz repair, 444
incisional hernia repair, 580, 581, 549 plug repair, 445
585-589 Fascia anatomy Rives technique, 444
prosthetic material use in, 557-559 of inguinal region, 86-95 local anesthesia for, 322-323
strangulated hernia repair, 577-579 peritoneum, 86-87, 88 low approach
Index 781
Bassini-Kirschner operation, 441 hemolytic streptococcus, 193 Welti-Eudel procedure, 509

Bendavid's umbrella, 442 idiopathic scrotal, 193-194 complications, 511
Lichtenstein's plug repair, 441 pathogenesis of, 196 patient preparation, 508
Lytle's operation, 441 loss of abdominal wall substance prosthetic repair, 509-510
Trabucco's plug repair, 441-442 (LAWS),527-528 material use, 515
unilateral giant prosthetic rein- progressive synergistic, 193 positioning, 510
forcement of the visceral sac pathogenesis of, 195-196 respiratory disturbances, 513-514
(GPRVS),442 spontaneous, 527-528 respiratory evaluation, 167-171
mesh plug repair, 385 traumatic, 527 abdominal wall tension, 169-170
open techniques, 439-448, 440 Gas gangrene, 527 acute respiratory failure syndrome,
posterior approach, 445-446 clostridial myonecrosis and, 194 168-169
iliopublic tract repair, 445-446 Gastroschisis, in pediatric patients, results, 511
plug repair, 446 598-599 long-term, 511
primary, uncomplicated, 446-447 Genitofemoral nerve, 737 Rive's procedure, 510-511
recurrent, 447 Genitourinary tract pathology, 653-656 Gibson's operation, major incisional her-
strangulated, 447 bladder, 653 nia repair, 509
incidence of, 561-562 lesions of scrotal contents, 654-656 Gilbert classification, for inguinal hernia,
technique choice, 446-447 epididymis, 655 128, 129
Femoral ring, 81, 439 testicle, 655-656 Gilbert's repair, 377-381
Femoral sheath, 55-56, 439 postoperative, urinary retention, 656 functional considerations, 378-379
laparoscopic perspective of, 81 spermatic cord, 653-654 history of, 377
Femoral vein, vascular injury and, tumors of, 654 prolene hernia system, 379
747-749 Geriatric hernia patient, 643-645, results, 380-381
Femoral vessels, reaction to prosthetic 646-652 technique, 380
material, 718 aging demographics, 646, 647 tension-free repair, 377-378
Fibrin glue aging process, 646 Gilmore's Groin. See Groin disruption
composition of, 246-247 associated pathologies, 643, 644, 648, Gore-Tex ePTFE Soft Tissue Patch
purpose, 248 652 histology of, 231
quality criteria, 247-248 complications, 649 pathology of, 228
study results, 248-249 groin hernia repair, 5 See also Expanded polytetrafluoroethyl-
use in incisional hernia repair, 246-249 hernia statistics, 643 ene (ePTFE) mesh
wound healing and, 246 influence of age, 643, 644 GPRVS. See Unilateral giant prosthetic re-
Fibroblast growth factor, wound healing, preoperative status of, 648 inforcement of the visceral sac
203 surgery, 648-649 (GPRVS)
Fibrovascular adhesions, 294-297 anesthesia, 644, 650 Gracilis muscle, loss of abdominal wall
Fistula femoral hernia, 645 substance treatment, 535
burst abdomen secondary to, 534 preperitoneal prosthesis, 645 Gram negative synergistic necrotizing cel-
drainage, 724 pure tissue repair, 644 lulitis, 193
enteric, 724-725 strangulated hernia repair, 566-567 Granuloma
enterocutaneous, 495 tension free repair, 645 spermatic, 394
reoperation, 725 technique choice, 646-647 suture, 243
Fistula formation, hernia repair complica- Giant hernia repair, 675-679 Granulomatous lesions, in inguinal hernia
tion, 71 0-711 emergency operations, 678-679 surgery, 186
Flat muscles pneumoperitoneum use, 676-678 Gridiron hernioplasty, 407-411
external oblique, 39, 40 prostheses, 678 operative technique
internal oblique, 39-40 surgical treatment of obesity, 675-676 cleavage of preperitoneal space, 408
transversalis fascia, 41, 42, 43 Giant incisional hernia Gridiron incision, 407-408
transversus abdominis muscles, 40-41 effects of, 166 instruments, 407
Fluorosoft mesh, 279 muscle alterations, 166-167 mesh replacement, 408-410
Foreign body, in inguinal hernia surgery, on respiratory mechanics, 166 prostheses choice, 407
185-186 herniographyoptions, 167 skin incision, 407, 408
Fournier's syndrome, loss of abdominal Giant incisional hernia repair, 166-172, postoperative management, 410
wall substance (LAWS), 528 508-515 preoperative management, 407
Free tissue transfer, abdominal wall recon- anatomy for, 513 results, 410
struction, 550-552 envelope of the hernia, 513 Groin area
muscles, 513 anatomy of, 46-52, 454-456
orifice in the abdominal wall, 513 landmarks, 454-455
G anesthesia, 508-509 musculature, 455
Ganglionectomy, dorsal root, for ilioin- classic surgery, 509 nerves, 455-456, 457, 458
guinal neuropathy, 738 Gibson's operation, 509 vascular structures, 455, 457
Gangrene Judd's technique, 509 See also Inguinofemoral area
782 Index
Groin disruption Growth factor technique, 336-337

etiology, 659 epidermal, 204 Hesselbach's ligament, 49-51, 79-80
pathology, 659 fibroblast, 203 Heterologous implants, collagen-based
physical signs, 660 insulin-like, 203-204 prosthetic material, 252-255
rehabilitation, 660, 661 platelet derived, 203 Hollow viscus erosion, hernia repair com-
results, 661 plication, 71 0-711
symptoms, 659 H Homologous implants, collagen-based
treatment, 660 Henle's ligament, 46, 49 prosthetic material, 250-252
Groin hernia Hepatomegaly, in pediatric patients, Human dura mater, collagen-based pros-
classification of, 5, 394 603-604 thetic material, 251-252
diagnosis, 5 Hereditary factors, of inguinal hernia, Hydroceles, 592
formation of. See Hernia formation 113 genitourinary tract pathology, 654
Groin hernia repair Hernia. See specific type hernia repair complication, 694
ascites, 664-665 Hernia disease, metabolic aspects of, Hypogastric zone
history of, 3, 4-8, 11-12 139-141 aponeurotic sheets, 68
anterior preperitoneal approach, Hernia formation tendinous intersections, 68-69, 70
12-13 early hernias, 136-137
posterior preperitoneal approach, drainage tubes, 136 I
13-14 layered closures, 136 IDF classification, for inguinal hernia, 130
indications for, 5 obesity, 136-137 Ileum, reaction to prosthetic material,
laparoscopic techniques postoperative complications, 137 719
intraperitoneal onlay mesh (lPOM) , sepsis, 136 Iliac artery, vascular injury and, 745-747
451-453 surgical incisions, 136 Iliac vein, vascular injury and, 747-749
totally extraperitoneal procedure suture material and technique, 136 Iliac vessels, reaction to prosthetic mater-
(TEP),464-471,472-480 evolution, 133-134 ial, 718
transabdominal preperitoneal proce- integrity of transversalis fascia, 135 Iliohypogastric nerve, 737
dure (TAPP), 454-462 late hernias, 137 Iliohypogastric neuropathy, 737-739
open techniques lipomas of the cord, 134 Ilioinguinal clinical triad, 737
Bassini operation, 354-360 mechanisms of, 133-137 Ilioinguinal nerve, 737
dam repair, 361-364 patent processus vaginalis, 134 Ilioinguinal neuropathy, 737-739
Dynamic Self-Regulating prosthesis, pathological tissue changes, 143-149 Iliopectineal arch, 79
412-415 physical activity, 136 Iliopsoas muscles, 58
Gilbert's repair, 377-381 raised intra-abdominal pressure, Iliopubic bandelette of Thomson, 92-93
Gridiron hernioplasty, 407-411 134-135 in hernia surgery, 93
Kugel patch, 416-418 shutter mechanism, 134 surgical anatomy, 95
Kugel repair, 504-507 surgical incisions, 135-136 Iliopubic tract, 78
Lichtenstein Tension-Free Hernio- Hernia repair Iliopublic tract repair, femoral hernia re-
plasty, 423-426 ambulatory, 767-774 pair, 445-446
McVay operation, 365-369 surgical technique, choices for, 466 Imaging, 335-340
mesh plug repair, 382-387 suture selection, 237-243 computed tomography (CT), 335-336
Moran's preperitoneal mesh repair, absorbable vs. nonabsorbable, occult hernia, 120
388-390 237-239 herniography, 336-339
Nyhus preperitoneal repair, 391-395 buttonhole incisional hernia, 243 occult hernia, 118-119
preperitoneal bilateral mesh prosthe- continuous vs. interrupted, 239-240 laparoscopy, occult hernia, 120
sis, 428-435 polypropylene, 240-241 magnetic resonance imaging (MRI), oc-
Rives technique, 401-406 suture granulomas, 243 cult hernia, 120
Shouldice repair, 370-376 wound infections, 241-243 nuclear scintigraphy, 336
Stoppa's operation, 437-438 See also specific repair peritoneography, positive contrast, 335
techniques for femoral hernia, Hernia repair complications. See Compli- pneumoperitoneography, 335
439-448 cations of hernia repair ultrasonography, occult hernia, 119-
unilateral giant prosthetic reinforce- Hernia sac, assessment of contents, 120
ment of the visceral sac (GPRVS), 565-566, 578 ultrasonography (US), 336
396-400 Hernial tuberculosis, in inguinal hernia Incarceration
icryl pads, 419-422 surgery, 185 hernia repair complication, 560
use of drains in, 348-349 Herniography, 336-339 in incisional hernia repair, 585
Groin pain anatomy for, 337 See also Strangulation
differential diagnosis, 117 complications of, 339 Incisional flank hernia, acquired, 688,
mechanism of, 626-627 hernia presentation in, 337-339 689
in occult hernia, 116 indications for, 336 Incisional hernia
as quality control measure, 123 for occult hernia, 118-119 in females, 617
sports injuries and, 657-661 results of, 339 herniography and, 338-339
Index 783
presentation, 586 classification of, 192 McVay operation, 365-369

wound dehiscence vs., 569 clinical presentation, 192-194 mesh plug repair, 382-387
Incisional hernia repair, 585-589 pathogenesis, 194-196 Moran's preperitoneal mesh repair,
bowel obstruction, 585 treatment, 196-197 388-390
buttonhole, suture selection and, 243 prosthetic material and, 708, 709, Nyhus preperitoneal repair, 391-395
complications from, 581 721-725 Shouldice repair, 370-376
mortality, 585 antibiotics for, 723, 724 totally extraperitoneal procedure
fibrin glue use, 246-249 bacteriology, 722 (TEP),472-480
giant. See Giant incisional hernia biology of, 721-722 Vicryl pads, 419-422
incarcerated, 585 delayed infection, 722 unexpected findings, 184-190
complicated, 587-589 diagnosis, 722 benign tumor of the contents of the
uncomplicated, 587 fistula, 724-725 sac, 189
irreducible exteriorized, 513 inguinal hernia, 723 foreign body, 185-186
laparoscopic techniques, 519-524 obesity, 722 granulomatous lesions, 186
equipment, 519, 520 pathogens, 722 hernial tuberculosis, 185
patient selection, 519-520 prevention, 724 inflamed hernia, 184-185
results, 522-524 treatment, 723--725 malignant inguinal hernia sac neo-
technique, 520-522, 523 ventral hernia, 723--725 plasm, 189-190
lateral, onlay mesh repair, 502 risk for, 324 omental and mesenteric cysts, 189
major. See Major incisional hernia re- Inflamed hernia, in inguinal hernia peritoneal free bodies, 186
pair surgery, 184-185 torsion of the omentum, 186-187
major but reducible and free-moving, Inguinal canal trauma, 187-188
513 anatomy of, 52-57 Inguinal hernia trauma
midline, onlay mesh repair, 500-502 femoral canal and femoral sheath, complete, 187
open techniques 55-56 incomplete, 187-188
components separation technique, limits of, 52-53 Inguinal ligament, 49, 50
487-496, 497-499 lymphatics, 56 Inguinal nodes
major incisional hernia repair, scrotum and labia majora, 54-55 aberrant, 57
508-515 spermatic cord, 53--54 deep, 57
onlay mesh repair, 500-503 superficial fascia, 55 superficial, 56, 57
shoelace repair, 483-486 laparoscopic perspective of, 80-81 Inguinal region
preparation for operation, 586-587 Inguinal hernia anatomy of, 72-84
prosthetic material use, 580, 581 classification of, 128-129 fascial anatomy of, 86-95
contraindication for, 581 direct, herniography and, 338 Inguinodynia. See Neuralgia
risk factors, 585 epidemiological aspects, 109-113 Inguinofemoral area
small, local anesthesia for, 323 age distribution, 110-111 anatomy of, 46-52
use of drains in, 349 bilateral, III myopectineal orifice, 46-49
visceral surgeries associated with, 581 complex, 111-112 Inguinofemoral hernia, 447
Incision (s) recurrent, 112 Innervation
relaxing. See Relaxing incisions risk of complications, 112-113 parietal muscle, 45
wound dehiscence and, 570-571 sex distribution, 11 0 posterior abdominal wall, laparoscopic
Indirect hernia etiologic aspects, 113--114 perspective of, 81-83
defined,391 hereditary factors, 113 of posterior abdominal wall, 59
mesh plug repair, 383--384 metabolic factors, 113-114 skin of anterolateral abdominal wall,
tissue pathology in, 148 risk factors, 113 44, 45
Infection, 696 indirect, herniography and, 337-338 See also Nerve(s)
determinants Inguinal hernia repair Insulin-like growth factor, wound healing,
bacterial contaminants, 324 female hernia patients, 614-616 203-204
operating room environment, 324 incidence of strangulation, 560-561 Interfoveolar ligament, 49-51
operative procedure, 325 local anesthesia for, 320-321 Interparietoperitoneal spaces, space of
preoperative patient status, 324 recurrent, 321-322 Bogros and, 103
following surgery muscle transpositions in, 554 Intestinal adhesion, hernia repair compli-
incidence, 325-326 pediatric patients, 592, 593 cation, 709-710
microbial etiology, 325 techniques Intestinal obstruction, inguinal hernia
type of hernia, 326 Bassini operation, 354-360 and, risk factors for, 112
laparoscopic vs. open repair, 326-328 darn repair, 361-364 Intra-abdominal pressure, raised, hernia
adverse effects of site infection, 328 Dynamic Self-Regulating prosthesis, formation and, 134-135
prosthetic material, 327-328 412-415 Intraperitoneal onlay mesh (IPOM),
use of drains, 328 Gilbert's repair, 377-381 451-453
loss of abdominal wall substance and, Lichtenstein Tension-Free Hernio- complications, 453, 477
192-196 plasty, 423--426 contraindications, 451
784 Index
Intraperitoneal onlay mesh (IPOM) (con- results, 34-35 pathological, 527-529

tinued) extraperitoneal repair, 702. See also To- classification of, 192
development, 451 tally extraperitoneal procedure clinical presentation, 192-194
indications, 451 (TEP) clostridial myonecrosis, 192
laparoscopic technique, 702 incisional hernia repair, 519-524 idiopathic scrotal gangrene, 193-194
results, 452-453 equipment, 519, 520 necrotizing fasciitis, 192-193
technique, 451-452 patient selection, 519-520 progressive synergistic gangrene, 193
technique comparison, 472-473 results, 522-524 compartment syndrome, 540-541
Intraperitoneal prostheses, 299-304 technique, 520-522, 523 complications, 539
acute abdominal wall defects, 302 intraperitoneal onlay mesh (lPOM) , infection, 539
techniques, 299-302 451-453, 702 mortality, 539
acquired primary closure, 299 complications, 702, 703 management
artificial substitutes, 300 open VS., 6-8, 454 initial, 541-542
epidermal graft, 299 infection, 326-328 intermediate, 542-543
fascial and myofascial tissues, plug and patch repair, 701 late, 543
299-300 complications, 701, 703 principles for, 538-540
free vascularized myocutaneous flaps, pneumoperitoneum, 700-701 pathogenesis
300 complications, 700-701 clostridial myonecrosis, 194
synthetic substitutes, 300-302 rationale for, 456-458 idiopathic scrotal gangrene, 196
IPOM. See Intraperitoneal onlay mesh simple closure, 701 necrotizing fasciitis, 194-195
(IPOM) complications, 701, 703 progressive synergistic gangrene,
Irradiation injury, abdominal wall defects surgical anatomy, inguinal region, 72- 195-196
and,548 84 prosthetic material use, comparison of,
Irreducibility totally extraperitoneal procedure 540,541
hernia repair complication, 560 (TEP), 464-471, 472-480 transient visceral swelling and, 540
See also Strangulation complications, 702, 703 treatment, 196-197
Ischemic orchitis, hernia repair complica- transabdominal preperitoneal proce- autografts, 535
tion, 741 dure (TAPP), 454-462, 701-702 burst abdomen, 533-534
complications, 701-702, 703 following septic therapeutic proce-
See also specific technique dures, 531-533
J Laparoscopy myoplasty, 535-536
Judd's technique, major incisional hernia
repair, 509 for occult hernia, 120 primary, 530-531
in pediatric patients, 594 prosthetic material, 535
LAWS. See Loss of abdominal wall sub- secondary, 531
K stance (LAWS) simple myoaponeurotic closure,
Kugel patch, 504-507 Lichtenstein Tension-Free Hernioplasty, 534-535
patch,504 423-426 use of anterior rectus sheath, 535
postoperative care, 507 complications, 426 Lotheissen-McVay repair. See McVay opera-
procedure, 504-507 history of, 456-457 tion
preparation, 504 outcome measures, 425-426 Lotheissen repair. See McVay operation
technique, 504-507 postoperative pain, 425 Lumbar hernia
results, 507 recurrence, 426 acquired, 688, 689
ventral hernia repair, 416-418 return to work, 425-426 diagnosis, 688
operative technique, 416, 417 recurrent repairs, 426 treatment, 688
patch,416 technique, 224-225, 423-425 in pediatric patients, 596-597
postoperative care, 416-417 Lichtenstein's plug repair, femoral hernia Lung, reaction to prosthetic material, 719
preparation, 416 repair, 441 Lymphatic drainage
results, 417 Lidocaine, local anesthesia, 318 of anterolateral abdominal wall, 44
Linea alba, 43 of cutaneous layers, 46
L aponeurotic sheets, 64-65,66,67 Lymphatic network
Labia majora, 54-55 Lipomas of the cord, hernia formation of inguinal area, 56
Langer's lines, 45 and, 134 of posterior abdominal wall, 59
Laparoscopic techniques Littre's hernia, strangulated hernia, 563 in space of Bogros, 105-106
benefits of, 457-458 Liver, reaction to prosthetic material, 719 Lymphatics, hernia repair complication,
choosing appropriate, 464-465, 466 Loss of abdominal wall substance 694
complications, 697-698, 700-705 (LAWS),527-536,538-543 LytIe's operation, femoral hernia repair,
recurrence, 704, 705 absorbable and nonabsorbable repair, 441
by technique, 703 292-293
evolution of, 33-35 absorbable mesh use, 310 M
development, 33-34 causes, 539 Magnetic resonance imaging (MRI), for
first use, 33 iatrogenic, burst abdomen, 529-530 occult hernia, 120
Index 785
Major incisional hernia, 166-172 Medicolegal issues, 761-766 method, 388, 389
effects of, 166 being an expert witness, 764-765 results, 388-389
muscle alterations, 166-167 giving a deposition, 765-766 Morgagni hernia, in pediatric patients, 603
on respiratory mechanics, 166 informed consent, 763-764 Moschowitz repair, femoral hernia repair,
herniography options, 167 malpractice, 761-763 444
respiratory evaluation, 167-171 risk management, 766 Muscle flaps, abdominal wall reconstruc-
abdominal wall tension, 169-170 Meralgia paresthetica, 734 tion,549,550, 551
acute respiratory failure syndrome, Mersilene mesh Muscle transpositions, in inguinal hernia
168-169 histology of, 231 repair, 553-554
Major incisional hernia repair, 508-515 mechanical aspects, 208-219, 218-219 Myopectineal orifice, 46-49
anatomy for, 513 animal implantation experiments, closure of, 48-49
envelope of the hernia, 513 209-210 inferior margin of, 47, 48
muscles, 513 biaxial tensile properties, 209, inguinal ligament, 49, 50
orifice in the abdominal wall, 513 212-213 lateral margin of, 48, 49
anesthesia, 508-509 compared to polymeric carbon fiber, medial margin of, 47-48
classic surgery, 509 213-214 peritoneum, 51, 52
Gibson's operation, 509 uniaxial tensile properties, 209, 212 superior margin of, 48
Judd's technique, 509 pathology of, 228-229 transversalis fascia, 49, 51
Welti-Eudel procedure, 509 Rives technique, 401-406
complications, 511 tissue response to, 205 N
patient preparation, 508 See also Polyester mesh Necrotizing fasciitis, 192-193
prosthetic repair, 509-510 Mesenteric cysts, in inguinal hernia gram negative synergistic necrotizing
material use, 515 surgery, 189 cellulitis, 193
positioning, 510 Mesh hemolytic streptococcus gangrene, 193
respiratory disturbances, 513-514 absorbable, 25-26, 306-313 pathogenesis of, 194-195
results, 511 adhesion formation of, 295 polymicrobial, 193
long-term, 511 in animal studies, 307-308 streptococcal, 193
Rive's procedure, 510-511 in clinical studies, 308-310 zygomycetic and noncholera vibrio, 193
Malpractice, 761-763 history of use, 306-307 Neoplasm, malignant, of inguinal hernia
burden of proof, 761 indications for use, 310-312 sac, 189-190
expert witness, 761-762 new approaches, 312 Nerve repair and grafting, for ilioinguinal
medical record, 762 recommendations, 312-313 neuropathy, 739
operative notes, 762 ideal, 26-27 Nerve(s)
res ipsa loquitur, 762-763 metal, 16-18 femoral,83
Marlex mesh, 262 synthetic, 18-26 genitofemoral, 82, 737
adhesion formation of, 294 See also Mesh, absorbable; Prosthetic of groin area, 455-456, 457, 458
in clinical studies, 308-309 material; specific biomaterial hernia repair complications, 694-695
comparative analysis, 286-291 Mesh plug repair, 382-387 iliohypogastric, 81, 737
early complications, 289 operative technique ilioinguinal, 81, 737
long-term complaints, 289 direct hernia, 384 lateral femoral cutaneous, 82-83
recurrences, 289 femoral hernia, 385 in space of Bogros, 106
textile analysis, 288 indirect hernia, 383-384 Neuralgia, 694-695, 730-732, 734-736,
tissue reaction, 289-290 pantaloon hernia, 384-385 737-739
histology of, 231 recurrent hernia, 385 causes, 730, 734
history of use, 306-307 perfix plug, 382 diagnosis, 730-731
pathology of, 225-227 postoperative routine, 385 ilioinguinal/iliogastric, 737-739
Marlex to Bard mesh, characteristics of, preoperative routine, 382-383 diagnosis, 737-738
272-277 results, 385-386 drug therapy, 739
Maydl's hernia, strangulated hernia, 563 Metabolic aspects etiology, 738
Mayo technique, umbilical hernia, 682 of hernia disease, 139-141 prevention, 738-739
McVay operation, 365-369 of inguinal hernia, 113-114 surgical treatment, 738, 739
assumptions, 366 Metal mesh pain
development of, 365-366 intraperitoneal prostheses use, 300 deafferentation, 695
drawbacks of, 368 See also Stainless steel mesh neuroma, 695
femoral hernia repair, 366-367, 444 Midline zone projected, 695
history, 365 aponeurotic sheets, 64-65,66,67 referred, 695
technique, 366-367 relation of skin to, 69-70 prevention, 731-732
direct inguinal hernia, 366 Monocytes and macrophages, wound treatment, 731, 734-735
femoral hernia, 366-367 healing,202-203 surgical, 735-736
indirect inguinal hernia, 366 Moran's preperitoneal mesh repair, Neurectomy
vascular injury and, 748 388-390 chronic pain treatment, 735-736
786 Index
Neurectomy (continuell) in females, 625-629 Orchitis, ischemic, 653

for ilioinguinal neuropathy, 738 femoral, 116-117 hernia repair complication, 693
Neurolysis, for ilioinguinal neuropathy, indirect, 116 testicular atrophy and, 181
739 physical examination, 118 Orifice in the abdominal wall, 513
Neuroma pain, 695 radiological examinations hernia with loss of parietal tissue, 513
Neuropathy, ilioinguinal/iliohypogastric, computed tomography (CT), 120 hernia without loss of parietal tissue,
737-739 herniography, 118-119 513
Neuropraxia, following intraperitoneal laparoscopy, 120 Osteitis pubis, 657
onlay mesh, 453 magnetic resonance imaging (MRI) , Outcome measures, for Lichtenstein Ten-
Nonhernia sites, tissue pathology in, 120 sion-Free Hernioplasty, 425-426
148-149 ultrasonography, 119-120
Nonpalpable hernia. See Occult hernia Omental cysts, in inguinal hernia surgery,
Nuclear scintigraphy, imaging, 336 189 p
Nyhus classification, for inguinal hernia, Omentum, greater, abdominal wall recon- Pain
128-129, 129 struction, 549 ambulatory hernia repair and, 767
Nyhus preperitoneal repair, 391-395 Omphalocele, in pediatric patients, 597- characteristics of, 730-731
background, 391-392 598 chronic, 726-729. See also Neuralgia
technique, 392-394 Onlay mesh repair, 500-503 frequency of, 726-727, 728
patient preparation, 500 prevention, 729
o results, 502-503 role of surgery, 729
Obesity technique treatment, 727-729
hernia formation and, 136-137 difficult cases, 502 chronic pelvic pain in females, 630,
surgical treatment of, 672, 675-676 lateral incisional hernia, 502 632-638
vertical banded gastroplasty (VBG), midline incisional hernia, 500-502 conditions that cause, 627
675-676 Open techniques diseases causing, 629
Obesity and hernia repair, 672-674 groin hernia repair, 419-422 groin
increased risks, 672 Bassini operation, 354-360 differential diagnosis, 117
infection, 673 dam repair, 361-364 mechanism of, 626-627
laparoscopic technique, 673-674 dynamic self-regulating prosthesis, in occult hernia, 116
pneumoperitoneum use in repair, 675- 412-415 as quality control measure, 123
679 Gilbert's repair, 377-381 sports injuries and, 657-661
prosthetic material gridiron hernioplasty, 407-411 as hernia repair complication, 694-695
choice of, 672 Kugel Patch, 416-418 types
infection and, 722 Lichtenstein tension-free hernio- deafferentation, 695
Oblique muscles plasty, 423-426 neuroma, 695
internal, 455 McVay operation, 365-369 neuropathic, 726
shutter down, 455 mesh plug repair, 382-387 nociceptive, 726
shutter up, 455 Moran's preperitoneal mesh repair, projected, 695
laparoscopic perspective of 388-390 referred, 658, 695
external,80 Nyhus preperitoneal repair, 391-395 testicular, 726
internal,80 preperitoneal bilateral mesh prosthe- Pantaloon hernia, mesh plug repair,
Obstruction sis, 428-435 384-385
bowel, in incisional hernia repair, 585 Rive's technique, 401-406 Paraostomy hernia, 666-670
defined,560 Shouldice repair, 370-376 definition of, 666
hernia repair complication, 560 Stoppa's giant prosthetic reinforce- mechanism of, 666
intestinal, inguinal hernia and, 112 ment of the visceral sac, 437-438 prevention, 666-668
Obturator area, 60-61, 60, 61 unilateral giant prosthetic reinforce- surgery technique, 666-667, 668
Obturator hernia, in females, 618, 633- ment of the visceral sac (GPRVS), prosthetic mesh repair, 668-670
635 396-400 surgical technique, 669-670
Occult hernia, 116-120 Vicryl pads, 419-422 Pararenal space, posterior, space of
asymptomatic, 116 incisional hernia repair Bogros and, 103
differential diagnosis, 117-120, 564 components separation technique, Parietal tissue
duration, 118 487-496,497-499 hernia with loss of, 513
evolution, 117 Kugel repair, 504-507 hernia without loss of, 513
history, 117 major incisional hernia repair, Parietalization of the elements of the
intensity, 117-118 508-515 spermatic cord, 396-397
localization, 117 onlay mesh repair, 500-503 Pathological tissue changes, in hernia for-
radiation, 117 shoelace repair, 483-486 mation, 143-148
reproducibility, 118 laparoscopic vs., 6-8, 454 direct, 148
direct, 116 infection, 326-328 indirect, 148
epidemiology, 116-120 Orchidopexy, for cryptorchidism, 176 nonhernia sites, 148-149
Index 787
Pathology of prosthetic materials Peritoneum Polyglycolic acid, tissue response to,

absorbable meshes, 229-230 fascia anatomy of, 86-87, 88 205-206
Dexon, 230 laparoscopic perspective of, 72-73, 74, Polymeric carbon fiber, mechanical as-
polyglycolide, 229-230 75 pects, 208-219, 216-219
Vicryl,230 myopectineal orifice and, 51, 52 compared to Mersilene mesh, 213-214
permanent meshes, 225-229 Pinprick hyperalgesia, 627, 628 hernia reinforcement, 216-217
Gore-Tex ePTFE Soft Tissue Patch, Plastic surgery, of abdominal wall, uniaxial testing, 210-211
228 547-554 Polymorphonuclear leukocytes, wound
Marlex, 225-227 Plastic surgery of abdominal wall recon- healing, 202
Mersilene, 228-229 struction, 547-554 Polypropylene, as suture selection,
polyethylene terephthalate, 228-229 prosthetic material and, 552 240-241
polypropylene, 225 techniques for, 548-549, 551-552 Polypropylene mesh, 22-23, 24, 262,
polytetrafluoroethylene, 227-228 conventional, 548 272-277, 286-291
prolene, 227 dermal graft, 548, 549 characteristics of, 272-277
Patient expectations, 3 fascia, 549 inertness, 272
Patient satisfaction free tissue transfer, 550-552 rapid fibrinous fixation, 273-274
ambulatory hernia repair and, 770 greater omentum, 549 resistance to infection, 272-273
as quality control measure, 123 muscle flaps, 549, 550, 551 complications of use, 714
Pectineal ligament of Cooper. See skin graft, 548, 549 tissue reaction, 715, 716
Cooper's ligament transposed thigh muscle use, 553-554 intraperitoneal prostheses use, 300-301
Pediatric hernia patient, 591-606 Platelet adhesion, wound healing, 202 pathology of, 225
congenital diaphragmatic hernia, Platelet derived growth factor, wound tissue response to, 204-205
599-603 healing, 203 Vypro, 286-291
diagnosis, 600 Plug and patch repair, laparoscopic tech- See also specific trade name mesh
goals of surgery, 600 nique, 701 Polytetrafluoroethylene (PTFE) mesh
prosthetic material choice, 602 Plug repair, femoral hernia repair, 445, intraperitoneal placement of, 263-264,
epigastric hernia, 595 446 301
femoral hernia, 593-594 Pneumoperitoneography, imaging, 335 pathology of, 227-228
inguinal hernia, 591-594 Pneumoperitoneum See also Expanded polytetrafluoroethyl-
diagnosis, 591-592 complications, 341 ene (ePTFE)
differential diagnosis, 592 defined, 675 Posterior approach, groin hernia repair, 3
embryology of, 591, 592 laparoscopic technique, 700-701 Postinflammatory defect, of abdominal
treatment, 592-594 recommendations, 341 wall,547-548
laparoscopy use, 594 techniques Pregnancy and female hernia patient,
lumbar hernia, 596-597 continuous drip, 341, 342 620-624
prosthetic material use, 597-606 fractionated injection, 341 anesthesia and, 622-624
congenital hernia of the foramen of pump, 341, 342 physiological changes
Morgagni, 603 in treatment of giant hernia, 675-679 cardiovascular, 620
gastrochisis, 598-599 Polyester mesh, 266-271 gastrointestinal, 621
hepatomegaly, 603-604 adhesion formation of, 295 hematological, 621
omphalocele, 597-598 clinical aspects, 266-267 respiratory, 620-621
prune-belly syndrome, 604-606 complications, 714 placental transfer of drugs, 622
spigelian hernia, 595-596 delayed, 270 risk classification of pain medication,
umbilical hernia, 594-595 hematomas, 267 623
Pedicle TRAM breast reconstruction, rec- infection, 268-269 uterine blood flow, 621-622
tus-sharing modification for, intestinal occlusions, 269 Preperitoneal approach, to groin
491-492, 493 intravisceral migration of mesh, 269 anterior, 12-13
Pelvic diaphragm, 62 mesh breakage, 269 posterior, 13-14
Pelvic wall morbidity and morality, 269-271 Preperitoneal bilateral mesh prosthesis
anatomy of, 60-63 neurological, 269 indications, 429
obturator area, 60-61 tissue reaction, 715-716 intraoperative pitfalls, 433-434
perineal area, 62-63 wound dehiscence, 269 long-term results, 434, 435
sciatic region, 61-62 experimental studies of postoperative complications
Penis, thrombophlebitis, 694 extraperitoneal placement, 266 hydroceles of the tunica vaginalis,
Perineal area, 62-63 intraperitoneal placement, 266 434
Perineal hernia intraperitoneal prosthesis use, 301 recurrences, 434-435
in females, 635-636 See also Mersilene mesh serohematomas, 434
sites of, 63 Polyethylene terephthalate suppuration, 434
Peritoneal free bodies, in inguinal hernia pathology of, 228-229 principles for, 428-429
surgery, 186 tissue response to, 205 partial wrapping of peritoneum, 428
Peritoneography, imaging, 335 Polyglactin, tissue response to, 206 preperitoneal approach, 428-429
788 Index
Preperitoneal bilateral mesh prosthesis history of, 707 endpoints for hernia surgery, 122-124
( continued) host tissue incorporation, 274-276 complications, 123
reinforcement of visceral sac, 428-435 key principles of application, 711-712 cost, 123
reoperation, 435 loss of abdominal wall substance patient satisfaction, 123
technique, 429-432 (LAWS),535 postrepair pain, 123
direct hernial sacs, 430 comparison of, 540, 541 recurrence, 122-123
indirect hernial sacs, 430-431 mechanical aspects, 208-219 future of, 126
variations, 432-433 metal mesh, 16-18 Swedish Hernia Register, 124-126
corrupt, 433 intraperitoneal prostheses use, 300 audit of audit, 125
Preperitoneal fascia, anatomy of, 88-89 silver filigrees, 16-17 cost-utility, 125-126
Preperitoneal space, 52 stainless steel, 18, 258-260 prerequisites and aims, 124
anatomy of tantalum gauze, 17-18 results, 124-125
nerves and vessels, 475 pathology of, 225-229. See also Pathol-
transverse view, 474 ogy of prosthetic materials R
laparoscopic perspective of, 73-76 precautions regarding use, 712 Radiological examinations. See Imaging
reaction to prosthetic material, 718 pure tissue repair vs., 3, 5 Reconstructive surgery, of abdominal wall,
use of, history, 12-13 reasons for use, 721 547-554
vessels of retroperitoneal and, laparo- risk of infection and, 327-328 Rectus sheath
scopic perspective, 76-77 synthetic, 18-26 anterior
Primary hernia, defined, 547 absorbable mesh, 25-26 biomechanical characteristics of, 143-
Processus vaginalis, testicular descent and, ampoxen,26 145
173-174 carbon fiber, 20-21 immunohistological characteristics of,
Projected pain, 695 expanded polytetrafluoroethylene 145-148
Prolene, 262 (ePTFE), 22-23, 24, 26 loss of abdominal wall substance
pathology of, 227 fluoropassiv mesh, 26-27 treatment, 535
Prophylactic agents fortisan fabric, 18 anterior lamina of, 42
principles of, 328-330 nylon, 19 arcuate line (Semicircular Line of Dou-
drug concentrations, 330 polyester dacron mesh, 21-22 glas),42-43
evidence-based approach, 328-329 polypropylene mesh, 22-23, 24 posterior lamina of, 42, 43
regimen, 330 polyvinyl sponge, 18-19 Recurrence
target expected pathogens, 329 silastic, 19 contributing factors
use in hernia operations, 330-332 soft hernia mesh, 27 anatomical issues, 697
Prostheses Teflon, 19-20 corruption, 697
autologous, 16 tissue response. See Tissue response mesh use, 697
evolution of, 16-27 use in pathology, 697
ideal, criteria for, 26-27 abdominal wall reconstruction, 552 surgeon experience, 697
metal, 16-18 emergency hernia repair, 557-559 laparoscopic considerations, 704, 705
synthetic, 18-26 incisional hernia repair, 500-503, as quality control measure, 122-123
See also Prosthetic material 508-515 See also specific surgery technique
Prosthetic material strangulated hernia repair, 558, Recurrent hernia
adhesion formation, 294-297 577-579 in females, 616-617
classification of, 707 vascular injury and, 750 mesh plug repair, 385
collagen-based See also Biomaterials; specific biomater- See also specific hernia
cross-linked dermal sheep collagen, ial; specific repair technique Reduction en masse, strangulated hernia,
252-255 Protease-antiprotease imbalance, role in 562, 563-564
dermal grafts, 252 groin hernias, 423 Referred pain, 695
dermal implants, 250 Protesi Autoregolantesi Dinamica (PAD), Relaxing incisions, 343-345
fascial implants, 251 412-415 components separation, 344
human dura mater, 251-252 Proximal loop strangulation, strangulated Gibson incision, 343, 345
combined absorbable and nonab- hernia, 562, 563 Halsted incision, 343, 344
sorbable repair, 292-293 Prune-belly syndrome, in pediatric pa- history of, 343, 344
complications with, 696-697, 707-712, tients, 604-606 pie-crusting, 343, 345
714-720 Pubic region, abdominal wall defect of, 548 in Shouldice repair, 371
contraction of prostheSis, 711, 712 Pure tissue repair, 353 technique, 344-345
fistula formation, 71 0-711 prosthetic material vs., 3, 5 Respiratory failure syndrome, acute, intra-
hollow viscus erosion, 71 0-711 operative evaluation, 168-169
infection, 708, 709, 721-725 Respiratory pathophysiology, giant inci-
intestinal adhesions, 709-710 Q sional hernia and, 166-172,
neuralgia, 734-736 Quality control, 3, 122-126 513-514
seroma, 709 challenges in, 123-124 Retroperitoneal, vessels of, laparoscopic
double layer principle, 301-302 benchmarking, 123-124 perspective of, 76-77
Index 789
Retropubic space, space of Bogros and, serum testosterone level, 741 veins, 105
104 sexual history, 741 concept of, 102-103
Richter's hernia, strangulated hernia, testosterone treatment, 741-742 history, 12
562-563 testicular atrophy, 741 interparietoperitoneal spaces and, 103
Risk management, 766 Shoelace repair, 483-486 laparoscopic perspective of, 73-76
insurance companies, 766 anatomy, 483 posterior pararenal space and, 103
National Physician Data Bank, 766 results, 485 retropubic space and, 104
"settle expeditiously," 766 technique, 483-485 Spermatic cord
video tape, 766 anesthesia, 483 anatomy
Rives technique, 401-406 incision, 483 arteries of, 53, 54
femoral hernia repair, 444 new linea alba, 483-484 fasciae of, 54
inguinal incision, 404 shoelace, 484-485 nerves of, 54
major incisional hernia repair, 510-511 Shouldice repair, 353, 370-376 round ligament, 54
recurrence, 403, 404-405 complications, 373 veins of, 53-54
results, 402-403 general principles genitourinary tract pathology and her-
risk of infection, 404 hernial sac, 371 nia repair, 653-654
technique, 401-402, 403 incision of cribriform fascia, 371 laparoscopic perspective of, 80-81
Robotics in surgery, 772-774 incision of transversalis fascia, 370- vascular injury and, 744
Automated Endoscopic System for Op- 371 Spermatic granuloma, hernia repair com-
timal Positioning (AESOP), 773 relaxing incisions, 371 plication, 394
da Vinci Surgical System, 773-774 resection of cremaster muscle, 371 Spiegelian Line, 43-44
Robodoc, 774 stainless steel wire suture, 371 Spigelian hernia
ZEUS system, 773 weight control, 370 in females, 618
history, 370 herniography and, 338-339
technical aspects in pediatric patients, 595-596
S dissection, 372, 373 Spinal axis, median, 57-58
Sciatic hernia, 61-62 local anesthesia, 371-372 Spinal muscles, lateral, 58-59
in females, 632-633 postoperative care, 373 iliopsoas, 58
Sciatic region, anatomy of, 61-62 reconstruction of inguinal wall, 373, quadratus lumborum muscle, 58-59
Scientific rigor, quality control and, 374, 375 Spleen, reaction to prosthetic material,
122-126 sedation, 371 719
Scrotum, 54-55 Shutter mechanism, hernia formation Sports hernia, in females, 636
Secondary hernia, defined, 547 and, 134 Sports injuries and groin pain, 657-661
Semicircular Line of Douglas, 42-43 Silastic sheets, intraperitoneal prostheses bursitis, 658
Semilunar line, 43-44 use, 301 direct trauma, 657
Sepsis Simple closure, laparoscopic technique, fractures
hernia formation and, 136 701 avulsion, 658
in strangulated hernia repair, 578 complications of, 703 stress, 657
Serohematomas, preperitoneal bilateral Simple myoaponeurotic closure, loss of groin disruption, 658-661
mesh prosthesis and, 434 abdominal wall substance treat- groin strains, 658
Seroma, 753-756 ment, 534-535 hernia, 658
as complication Skin hip problems, 658
of hernia repair, 694 graft of, abdominal wall reconstruction, muscle injuries
of prosthesis use, 709 548, 549 adductor, 657
defined, 753 hernia repair complications of, 696 iliopsoas, 657
incidence, 753 relation to aponeurotic sheath, midline rectus femoris, 657
groin repair, 754 zone, 69-70 osteitis pubis, 657
incisional hernia, 754 Smoking, metabolic aspects of hernias, referred pain, 658
mechanism, 753-754 140-141 Stainless steel mesh, 258-260
signs and symptoms, 754 Soft hernia mesh (SHM), 27 history of, 258
treatment Soft tissue infection (s), and loss of ab- result of use, 259-260
aspiration of, 754, 756 dominal wall substance, 192-196 techniques for
spontaneous resolution of, 754, 755 classification of, 192 incisional hernia repair, 258-259
surgical removal, 756 clinical presentation, 192-194 inguinal hernia, 258-259
Sex distribution, of inguinal hernia, 110 pathogenesis, 194-196 Stomach, reaction to prosthetic material,
Sexual dysfunction, 740-742 treatment, 196-197 719
dysejaculation, 740-741, 757-758 Space of Bogros, 52 Stoppa's operation, reinforcement of vis-
ischemic orchitis, 741 components of, 101-102 ceral sac, combined abdominoin-
nonorganic,740 arteries, 104-105 guinal approach, 437-438
preoperative assessment, 741 lymphatic network, 105-106 Strangulated hernia repair, 566-567
reassurance, 741 nerves, 106 anesthesia, 565
790 Index
Strangulated hernia repair (continued) in hernia repair, 237-243 Testicular descent

approach, 565 polypropylene, 240-241 embryology of, 591, 592
assessment of contents, 565-566 suture granulomas, 243 normal, 173, 174
complications, 567 wound infections, 241-243 Testicular torsion, 592
postoperative care, 566 Sutures, wound dehiscence and, 571-.~73 Testosterone treatment, for sexual dys-
preoperative care, 565 Swedish Hernia Register, 124-126 function, 741-742
prosthetic material use, 577-579 audit of audit, 125 Thomson's ligament. See Iliopubic ban-
combined series, 578 cost-utility, 125-126 delette of Thomson
complications, 577-578 prerequisites and aims, 124 Tissue engineering
risk of infection, 578 results, 124-125 of cross-linked dermal sheep collagen
risk of sepsis, 578 Symptomatic hernia. See Occult hernia (GDSC),252-255
surgical approach, 578-579 Synthetic material. See Prosthetic material of prosthetic material, 215-216
repair, 566 Tissue incorporation
results T anatomical location, 274-275, 276
complications, 567 TAPP. See Transabdominal preperitoneal pore size, 274, 275
mortality, 566 procedure (TAPP) surface texture, 274, 275
See also Strangulation Taxis, defined, 564-565 Tissue response
Strangulation Teflon, 265 mechanisms
anatomy of, 562-564 intraperitoneal placement of, 263-264 bioactive mediators of wound heal-
clinical features, 564 Telemanipulation, 772-773 ing, 203
defined,560 Telemedidne monocytes and macrophages, 202-
differential diagnosis, 564 defined, 772 203
incidence of, 560-562 levels of, 772 platelet adhesion, 202
femoral hernia, 561-562 telemanipulation, 772-773 polymorphonuclear leukocytes, 202
inguinal hernia, 560-561 telesurgery, 773 of organs to prosthetic material, 714-
management of, 564-566 voice and image interaction, 772, 773 720
manual reduction or taxis, 564-565 Integrated Digital Network System bladder, 718-719
operative procedures, 565-566 (ISDN), 772, 773 chest wall, 719
preoperative preparation, 565 tele-instruction, 772 colon, 719
pathophysiology, 564 Telesurgery, 773 esophagus, 719
types of Tension femoral vessels, 718
Littre's hernia, 563 abdominal wall, intraoperative evalua- ileum, 719
MaydI's hernia, 563 tion, 169-170 iliac vessels, 718
proximal loop strangulation, 562, loss of abdominal wall substance, 538 liver, 719
563 relaxing incisions and, 343-345 lung, 719
reduction en masse, 562, 563-564 Tension free repair, 376 preaponeurotic median submuscular
Richter's hernia, 562-563 ambulatory hernia repair and, 767-774 space, 717
See also Strangulated hernia repair Dynamic Self-Regulating prosthesis, premuscular subaponeurotic space,
Streptococcal subcutaneous cellulitis, loss 413-414 717
of abdominal wall substance for geriatric hernia patient, 645 preperitoneal space, 718
(LAWS),528 history of, 377-378, 456-457 spleen, 719
Subaponeurotic space, premuscular, reac- Kugel patch, 416-418 stomach, 719
tion to prosthetic material, 717 Lichtenstein Tension-Free Hernioplasty, subcutaneous space, 716
Subcutaneous space, reaction to pros- 423-426 ureter, 718
thetic material, 716 preperitoneal bilateral mesh prosthesis, to specific material, 201-204
Submuscular space, preaponeurotic me- 428-435 expanded polytetrafluoroethylene,
dian, reaction to prosthetic mater- Tensor fasciae latae, loss of abdominal 205
ial, 717 wall substance treatment, 535-536 polyethylene terephthalate, 205
Suppuration TEP. See Totally extraperitoneal procedure polyglactin, 206
delayed (fistulas), 434 (TEP) polyglycolic acid, 205-206
preperitoneal bilateral mesh prosthesis Testicle polypropylene mesh, 204-205
and,434 blood supply of, 179, 180, 653 Torsion of the appendix testis, 592
Suprapubic region, abdominal wall defect cryptorchid. See Cryptorchidism Torsion of the omentum, in inguinal her-
of,548 genitourinary tract pathology, 655-656 nia surgery, 186-187
Supravesical hernia, in females, 636, 637 hernia repair complication of, 693 Totally extraperitoneal procedure (TEP) ,
Suture granuloma, suture selection and, undescended, 173-176, 655 464-471, 472-480
243 Testicular atrophy, 179-183 anatomy for, 474
Suture selection, 237-243 clinical conclusions, 181-182 benefits of, 472
absorbable vs. nonabsorbable, 237-239 clinical course, 181 complications, 470-471, 477-478
buttonhole indsional hernia, 243 hernia repair complication, 693, 741 contraindications, 474-475
continuous vs. interrupted, 239-240 incidence, 179-181 cost considerations, 479-480
Index 791
development of, 464, 472-473 Transversus abdominis muscle, 455 transverse abdominal incision, 396-
indications, 474-475 laparoscopic perspective of, 79-88 398
inguinal hernia repair, 472-480 shutter down, 455 Ureter, reaction to prosthetic material, 718
modification of, 478 shutter up, 455
operative technique, 466-470, 475-477 Trauma, abdominal wall defects and, 547 V
rationale for, 473-474 Trelex, 262 Vaginalis, patent processus, hernia forma-
recurrence, 478-479 Trocar sites, 459 tion and, 134
results, 471 Tumor Varicoceles, 592
surgical preparation, 466 benign genitourinary tract pathology, 655
technical problems, 470 of the contents of the sac, 189 Vas deferens
technique comparison, 464-465, of the inguinal sac, 188-189 genitourinary tract pathology, 654
472-473 loss of abdominal wall substance hernia repair complications of, 693-
Trabucco's plug repair, femoral hernia re- (LAWS),528 694
pair, 441-442 malignant, loss of abdominal wall sub- Vascular injury, 743-751
TRAM breast reconstruction, rectus- stance (LAWS), 528-529 anatomy, 743, 744, 745
sharing modification for, 491-492, septic, 531-532 arterial, 745-747
493 Tumor surgery, abdominal wall defects prevention, 747
Transabdominal preperitoneal procedure and,548 treatment, 747
(TAPP), 454-462 Tumorigenesis, of biomaterials, 235 corona mortis and lesser vessels,
anatomy for, 454-456 743-744
landmarks, 454-455 prostheses and, 750
musculature, 455 U types of, 743
nerves, 455-456, 457, 458 Ultrasonography (US) venous, 747-749
vascular structures, 455, 457 imaging, 336 compression, 748-749
complications, 45-461, 477 for occult hernia, 119-120 Cooper's ligament repair, 747-
gas embolization, 460 Umbilical hernia, 680-684 748
hemorrhage, 460 anatomy, 680 direct, 747
nerve injuries, 461 ascites and, 662-664 indirect, 747-748
port site hernia, 460 demographics, 680 McVay repair, 748
recurrence, 461 diagnosis, 681 Vascular structures, of groin area, 455,
seromas, 461 embryology, 680 457
skin infection, 460 in females, 617-618 Vascular surgery, hernia complications in,
visceral perforation, 460 herniography and, 338-339 750-751
indications, 458 local anesthesia for, 322, 323 Vascularization, arterial
laparoscopic technique, 701-702 in pediatric patients, 594-595 of anterolateral abdominal wall, 44
occult hernia and, 116 postoperative care, 683 cutaneous layers of abdomen, 46
results, 461-462 results, 683 of posterior abdominal wall, 59
technique, 458-460 surgical technique, 682-683 Vein(s)
technique comparison, 464-465, 472- complications, 683 hernia repair complications, 694
473 Mayo technique, 682 iliopubic, 76
Transcutaneous nerve stimulation, for technical considerations, 682-683 rectusial, 76
chronic pain, 728 symptomatology, 681 retropubic, 76-77
Transforming growth factor beta, wound Umbilical orifice, aponeurotic sheets, in space of Bogros, 105
healing, 203 70-71 vascular injury and, 747-749
Transient visceral swelling, loss of abdomi- Umbilical region, abdominal wall defect Venous drainage
nal wall substance and, 540 of, 547, 548 of anterolateral abdominal wall, 44
Transversalis fascia, 455 Umbilical zone, aponeurotic sheets, 66, of cutaneous layers, 46
biomechanical characteristics, 143-145 67-68 Ventral hernia repair, 416-418
immunohistological characteristics Undescended testis Kugel patch, 416
collagen lattice, 147-148 acquired,174-175 postoperative care, 416-417
elastic fibers, 146-147 congenital, 174 procedure
fascia, 145-146 Unilateral giant prosthetic reinforcement preparation, 416
integrity of, hernia formation and, of the visceral sac (GPRVS), 396- technique, 416, 417
135 400 results, 417
laparoscopic perspective of, 77-78 femoral hernia repair, 442 Vertical banded gastroplasty (VBG) ,
myopectineal orifice and, 49, 51 permanent prostheses for, 396 675-676
new observations, 97-100 recurrence, 400 Vicryl pads, 419-422
posterior lamina of, 90-91 results, 400 in animal studies, 307-308
reinforcement of, 49-51 techniques histology of, 231
Transversalis fascia replacement, Rives subinguinal reinforcement, 399-400 results, 420
technique, 401-406 transinguinal reinforcement, 398-399 technique
792 Index
Vicryl pads (continued) long-term complaints, 289 suture technique, 572-573

for direct and indirect, 419 recurrences, 289 sutures, 571-572
efficacy of pad, 420 textile analysis, 288 systemic factors, 569
for recurrent, 419-420 tissue reaction, 289-290 treatment, 573-574
tissue response to, 206 See also Burst abdomen
Visceral sac W Wound healing
reinforcement of Welti-Eudel procedure, major incisional bioactive mediators of, 203
preperitoneal bilateral mesh prosthe- hernia repair, 509 epidermal growth factor, 204
sis, 428-435 Wound dehiscence, 569-574 fibroblast growth factor, 203
Stoppa's operation, 437-438 clinical features, 573 insulin-like growth factor, 203-204
unilateral giant prosthetic reinforce- defined,569 platelet derived growth factor, 203
ment of the visceral sac, 396-400 etiology, 569-570 transforming growth factor beta,
Visceral surgery, associated with incisional incisional hernia vs., 569 203
hernia repair, 581 local factors, 569-570 cellular aspects, 201-204
Vypro mesh, 286-291 surgical factors, 570-573 nature of, 204
comparative analysis, 286-291 incision, 570-571 Wound infections, suture selection and,
early complications, 289 knots, 572 241-243

Abdominal Wall Hernias - Principles and Management.

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Abdominal Wall Hernias - Principles and Management.

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Springer Science+Business Media, LLC

With 738 Figures, 46 in Full Color

Jean Bernard Flament, MD

Library of Congress Cataloging-in-Publication Data

Printed on acid-free paper.

© 2001 Springer Science+Business Media New York

ISBN 978-1-4612-6440-8 SPIN 10750916

Who shall decide, when doctors disagree?

We are usually convinced more easily by reasons we have found ourselves

The certainties of one age are the problems of the next.

Foreword by Raymond C. Read ................................... ix

1 Evolution and Present State of Groin Hernia Repair . . . . . . . . . . . . . . . . 3

2 Use of the Preperitoneal Space in Inguinofemoral Herniorrhaphy:

3 Prostheses in Hernia Surgery: A Century of Evolution .............. 16

4 Evolution of Laparoscopic Hernia Repair ....................... 33

5 Anatomy of the Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

6 Aponeurotic Hernias: Epigastric, Umbilical, Paraumbilical, Hypogastric . . . 64

7 Surgical Anatomy of the Inguinal Region

9 The Ligaments of Cooper and Thomson ....................... 92

10 The Transversalis Fascia: New Observations ..................... 97

11 The Space of Bogros and the Interparietoperitoneal Spaces ........ 101

Part III Epidemiology

13 Occult Hernias in the Male Patient ........................... 116

14 Quality Control and Scientific Rigor .......................... 122

15 Classification of Inguinal Hernias ............................ 128

17 Metabolic Aspects of Hernia Disease . . . . . . . . . . . . . . . . . . . . . . . . .. 139

18 Pathological Tissue Changes and Hernia Formation .............. 143

19 The Role of Collagen in Hernia Genesis ....................... 150

20 Recurrent Herniation: Etiology and Mechanisms 156

21 Respiratory Pathophysiology and Giant Incisional Hernias ......... 166

22 Undescended and Cryptorchid Testes ......................... 173

23 Testicular Atrophy ............................. :......... 179

24 Unexpected Findings in Inguinal Hernia Surgery 184

26 Biochemistry, Immunology, and Tissue Response to

27 Biomaterials: Structural and Mechanical Aspects

29 Carcinogenicity of Implantable Biomaterials .................... 235

30 Suture Selection for Hernia Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

31 Use of Fibrin Glues in the Surgical Treatment

32 Collagen-Based Prostheses for Hernia Repair ................... 250

33 Clinical Applications of Stainless Steel Mesh .................... 258

34 Repair of Abdominal Wall Defects by Intraperitoneal Implantation

35 Polyester (Dacron®) Mesh ................................. 266

36 Polypropylene Prostheses 272

37 Expanded Polytetrafluoroethylene ........................... 279

38 Vypro®: A New Generation of Polypropylene Mesh ............... 286

39 Combined Absorbable and Nonabsorbable Prostheses in the

40 Prosthetic Materials and Adhesion Formation ................... 294

41 Intraperitoneal Prostheses ................................. 299

42 Use of Absorbable Mesh in the Staged Repair of Contaminated

Part VI Adjuncts to Surgery

43 Local Anesthesia ........................................ 317

44 Antibiotics in Hernia Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324

45 Imaging Hernias of the Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . 335

46 Techniques of Pneumoperitoneum . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

47 Relaxing Incisions ....................................... 343

48 Drains in Hernia Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

Part VII Techniques of Open Groin Hernia Repair

49 The Bassini Operation .................................... 354

50 The Dam Repair ........................................ 361

51 The McVay Operation .................................... 365

52 The Shouldice Repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370

Introduction to Tension-Free Repairs 376