Pre-peritoneal prosthetic herniorrhaphy.

Abstract

Summary Theusual operations foringuinal hernia suffer from anumberofundesirable features, whicharebriefly discussed. A newoperation isdescribed, inwhichthesites forpotential herniation areprotected witha synthetic prosthesis, asinUsher's methodof incisional herniorrhaphy (1962). MULTIPLICITY oftreatments foracondition implies that noneisentirely satisfactory. Thisistruesofar asoperations foringuinal hernia areconcerned and consequently thequest fortheideal operation continues. Operations foringuinal hernia, astheyaremost usually performed, haveinmy opinion several undesirable features which areasfollows: Theinguinal canal isopenedupanditscontents disturbed: inmobilizing thehernial sactheblood supply ofthetestes maybedamagedleading to testicular atrophy, ortheilio-inguinal nerve traumatized giving rise togroin neuralgia; arepair approximating theconjoint tendontoPoupart's ligament orGimbernat's ligament distorts tissues outoftheir normalanatomical alignment, attempts tounite muscle toligament possibly undertension and utilizes tissues whichhavedemonstrated their incompetence bytheverypresence ofthehernia. All these features ongeneral principles wouldbebest avoided ifacceptable alternative methods areavailable andIsubmit that theoperation herein described attains this object. Itconsists essentially ofapre-peritoneal approach tothedeepaspect oftheinguino-femoral areaand theinsertion ofasynthetic fabric prosthesis tocover thepotential sites ofinguinal andfemoral hernia. Ithasbeenevolved fromthefollowing reasoning. Thefirst layer oftheabdominal parietes whichis transgressed inthedevelopment ofahernia isthe transversalis fascia; itwouldseemlogical, therefore, toreinforce this layer inorder toprevent recurrence. Hernia repairs basedonreinforcing theposterior walloftheinguinal canal atthelevel oftheconjoint tendon savourof'closing thestable doorafter the horse hasbolted'. Inmy experience ofthehernia operation described byNyhus& Harkins (1964) whichentails a suture repair ofthetransversalis fascia viaapre-peritoneal approach, this layer has mostly appeared tome tobeinsubstantial andI