Repair Of Indirect Inguinal Hernia Research Articles

Modified marcy repair of large indirect inguinal hernia in infants and children

Based on a review of operative notes of recurrent inguinal hernia cases from the authors' primary series, a surgical technique modified from the Marcy repair is described. With this technique, emphasis is placed on preservation of the intact internal spermatic fascia and reduction in the size of the internal inguinal ring. Through the inguinal approach, the sleeve-like extension of the internal spermatic fascia is incised longitudinally along the cord and up to the internal ring. The cord structures are dissected off the sac, and as much of the fascial tissue as possible is preserved intact. Both edges of the fascial defect are approximated with an unabsorbable suture; great care is taken to not penetrate the wall of the sac. The same suture is then used for high ligation, via a stay suture placed on the transversalis fascia on the other side of the neck, to reduce the size of the internal ring. The technique can be used in premature babies who have a flimsy, easily torn sac, and in some cases of giant hernia with a widely dilated internal inguinal ring, if the direct wall integrity remains adequate.

Optimal timing of elective indirect inguinal hernia repair in healthy children: Clinical considerations for improved outcome

Experience with several incarcerations that resulted in emergent surgery for children with known indirect inguinal hernias prompted this review to determine if there is an optimal time after hernia diagnosis during which elective repair should be undertaken to avoid incarceration. Over a 30 month period, 228 children less than 10 years of age underwent 303 indirect inguinal hernia repairs. They were analyzed for age, sex, interval between diagnosis and repair, predisposing conditions, major complications, and length of hospitalization. Excluded were 21 children who presented with incarceration of a previously undiagnosed indirect inguinal hernia that required operative reduction, 13 children with conditions predisposing to indirect inguinal hernia, and 53 children for whom the interval between diagnosis and repair was unknown, leaving a study group of 141 children who underwent 190 indirect inguinal hernia repairs. Nearly 13% (18 of 141) of the children developed incarcerated hernia prior to elective repair. Compared to children who underwent repair of a reducible indirect inguinal hernia, those with incarceration were more likely (p less than 0.05): 1) to have major complications (11% vs 0.6%), 2) to have a shorter interval between diagnosis and repair (26 vs 49 days), 3) to be younger (7.5 vs 25.6 mos), and 4) to require greater than 24 hours of hospitalization. Had children with reducible incarcerated indirect inguinal hernia been hospitalized and undergone repair 24 to 48 hours later, 83% of subsequent incarcerations would have been prevented. Furthermore, this experience supports the recommendation that for healthy children less than 10 years of age, indirect inguinal hernia repair should be performed on a semi-elective basis within 7 days of diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

A new technique for indirect inguinal hernia repair

This report concerns a preliminary study of a new technique for indirect herniorraphy, which was used in 242 patients from December 1988 through March 1991. Its main characteristics are the creation of a deep neo-inguinal ring in a more medial site, shortening of the inguinal canal by transposition of the superficial ring to the point where the inferior border of the internal oblique muscle is well represented, reinforcement of the inguinal canal by overlapping the external oblique aponeurosis in a double-breast fashion, and maintenance of the cremasteric muscle. Follow-up in our outpatient clinic was carried out at 1, 6, 12, and 24 months in 71% of our patients. There were no recurrences, except for one crural pseudo-recurrence, no mortality, and no testicular atrophy. Thirteen percent of patients had subcutaneous serous collection; 1% had hematomas; 2% temporary testicular edema; and 0.4% wound infection.

A technique for repair of recurrent indirect inguinal hernias

The repair of a recurrent inguinal hernia can be a technically demanding operation. Due to scar tissue from prior surgery, injury to the spermatic cord or compromise of the testicular blood supply is possible. A technique for repair of recurrent indirect inguinal hernia that allows minimal dissection of the spermatic cord structures is described.

Use of the foley catheter in the repair of adult indirect inguinal hernias

A widely opened internal ring and weakness of the transversalis fascia are the major defects in adult indirect inguinal hernia. Reducing the size of the ring and reinforcement of the transversalis fascia prevent hernial recurrence. During the repair, introduction of a Foley catheter into the internal ring and inflation of its balloon displaces the inferior epigastric vessels medially and the spermatic cord laterally. This position of the balloon enables a safe reconstruction of the internal ring without injury to the epigastric vessels and prevents tightening of the cord. This technique was successfully employed on 75 adult patients who underwent repair of an indirect inguinal hernia without complications.

Invagination of the hernial sac stump: Technique for repair of inguinal hernia

A technique for repair of indirect inguinal hernia is presented. The hernial sac stump is invaginated in an attempt to secure high ligation of the sac and obliterate any residual peritoneal diverticulum. Four hundred forty-two patients were operated on. The technique consists essentially of division of the internal spermatic fascial tube at the neck as well as embedding of the sac stump by purse-string sutures in a narrow neck or Lembert sutures in a wide neck. The defect in the fascia transversalis is closed over the stump. Three hundred eighty-one patients were followed up 2 to 15 years, with a recurrence rate of 1.6 percent. The concept that in indirect hernia the problem involves the sac rather than the defect is put forward. Recurrence results essentially from the existence of a handmade sac rather than an improperly repaired defect. The role of invagination of the sac in securing complete excision of the sac and proper closure of the defect is discussed. In initiating recurrence, the part played by the redundant peritoneum deep to the internal ring is emphasized. Changes in the dynamics of intraabdominal tension induced by stump embedding are explained.

Herniation of Rectus Muscle Through Relaxing Incision

To the Editor.— The McVay hernia repair 1 employing the ileopectineal (Cooper) ligament is frequently used to repair inguinal and femoral hernias. McVay 2 stresses the need for a simple linear incision in the anterior rectus sheath to prevent suture line tension, but admits that some surgeons might be hesitant to make a relaxing incision for fear of creating a defect that could later allow muscle herniation. The relaxing incision must be made as medially as possible, where the external oblique aponeurosis fuses with the rectus sheath. Report of a Case.— A 55-year-old man was operated on for repair of a large indirect inguinal hernia. A McVay repair was performed in which the aponeurosis of the transversalis muscle was sutured to the Cooper ligament, and a 5- to 7-cm relaxing incision was made in the anterior rectus sheath. The patient's recovery was uneventful. During his routine postoperative examination six weeks

The Marcy Repair of Indirect Inguinal Hernia

Surgical trainees often question the fact that different repairs are recommended for the single entity of indirect inguinal hernia, and ask which is the best repair and why. The purpose of this review is to answer these questions with fundamental anatomic, physiologic, and surgical concepts.

Clinical experiences with preperitoneal hernial repair for all types of hernia of the groin: With particular reference to the importance of transversalis fascia analogues

1. 1. The principle of preperitoneal laminar restoration of the anatomy and the importance of the transversalis fascia lamina in hernial repair of the groin are emphasized. 2. 2. The structures which are actually used for repair are a group of local ligaments within the transversalis fascia. We have designated these structures as transversalis fascia analogues. In direct hernial repair, for example, superomedial transversalis fascia is joined to inferolateral transversalis fascia analogues (Cooper's ligament and iliopubic tract). 3. 3. The surgical anatomy of the transversalis fascia and the transversalis fascia analogues is described. 4. 4. One hundred fifty patients with hernias of the groin have been operated upon by the preperitoneal approach; this represents an experience of 213 separate hernial repairs (forty-eight femoral, sixty direct, and 105 indirect inguinal hernias). 5. 5. A recurrent hernia rate of approximately 2 per cent was found. All but one recurrence followed repair of indirect inguinal hernias by a technic discarded by us over two years ago. There have been no recurrences following indirect hernial repair by the technic herein described.

The use of a quilting stitch for the repair of indirect inguinal hernia

The new repair is essentially a modification of the Halsted technic . A quilting type stitch (Fig. i) is placed in the medial edge of the internal ring and three additional stitches in the rest of the inguinal canal . This type of suturing approximates all the layers of the wall of the inguinal canal, including the peritoneum, thus providing a strong resistance against a recurrent indirect hernia, It is suitable in cases in which debility, senility, long-standing use of a truss or an extremely large hernia present a weak conjoined tendon and thinned out abdominal muscles in the wall of the inguinal canal . For such cases this repair has been used for a number of years in the Nankin Clinic with excellent results . Where the muscles of the abdominal wall are normal, however, the Halsted repair is used . The inguinal canals of ten cadavers, nine males and one female, ranging from forty to seventy years of age, were used in the experiment. The apparatus (Fig . 2) consisted of a single pulley and a strong malleable copper wire, one end of which was threaded through the inguinal canal and internal ring . A transverse incision was then made through the abdominal wall just inferior to the umbilicus . This permitted visualization of the internal ring and the end of the copper wire to which a stainless steel, bullet-shaped cone was attached . (Fig . 2.) At the other end of the copper wire weights were attached until the cone was puffed through the inguinal canal and the external inguinal ring . In this way an artificial indirect hernia resulted. Surprisingly enough, avulsion E VvER since the time of Halsted [3] and Bassini [r], numerous modifications of hernial repair have been devised. A new modification of the original Halsted repair has been devised which seals off the inguinal canal in those direct hernias where there is marked atrophy of the tissues ; it appears to he stronger than either the Bassini or Halsted repair . The method will be described and the technic applied for testing its strength . The recurrence rate is one of the clinical criteria used in evaluating repairs . According to Clear [a] a ten-year period of follow-up is required . This type of study is feasible when dealing with a select group of patients, such as veterans, since they usually return to a government institution more readily than do patients from the general population . As a result it becomes difficult to evaluate recurrence rates of follow-ups in non-government hospitals. Because of this difficulty it was decided to test the new type of repair in the laboratory using cadaver material . Although long clinical experience must be the ultimate test for any procedure, laboratory testing has the advantages that one can use as controls successive repairs on the same or opposite sides of the same cadaver . Furthermore, a cadaver is not subject to the extremely variable factors of activity, diet, emotional stress, disease, etc . Of course, such experiments arc designed to test only the strength of the repair and cannot be compared to the living individual in regards to intra-abdominal pressure, elasticity, or strength of tissues .

Purse-string suture repair of indirect inguinal hernia

A technic is presented which can contribute to a firm repair of the internal ring in patients with indirect inguinal hernia. Objections to the commonly used methods of repairing the dilated internal inguinal ring are mentioned. In my experience, the purse-string suture technic of repair has markedly reduced the recurrences of indirect inguinal hernia.

The internal spermatic fascia, with reference to repair of indirect inguinal hernia.

The internal spermatic fascia, with reference to repair of indirect inguinal hernia.

Eosinophilic Granuloma of Rib

EOSINOPHILIC granuloma of bone has been regarded as a disease that occurs in children and young adults and locally has a rapidly progressive course. A recently observed case has directed attention to the fact that the disease occurs in the older age groups and that its course can extend over a period of years.Case ReportA 46-year-old laborer entered the hospital on November 14, 1939, for the repair of a left indirect inguinal hernia. A routine roentgenogram of the chest revealed an area of decreased density posteriorly in the medullary portion of the left tenth rib. The area was . . .

Repair of Indirect Inguinal Hernia

Repair of Indirect Inguinal Hernia

Repair of Indirect Inguinal Hernia

Repair of Indirect Inguinal Hernia

Cremasteric Vessels and the Repair of Indirect Inguinal Hernia

Cremasteric Vessels and the Repair of Indirect Inguinal Hernia

Indirect inguinal hernia: Repair of the anatomically weak area

The logical procedure for repair of indirect inguinal hernia is to interpose a fascial layer anterior to the ligated sac neck. This is done by approximating the transversus abdominis aponeurosis at the arch of the internal ring, thus closing over the anatomically defective area.

Use of transversus abdominis in repair of indirect inguinal hernia

Four points in the anatomy of the inguinal region are brought out; first, the close relationship between the internal ring and the free edge of the transversus abdominis above and with Poupart's ligament below; second, the fact that the transversus abdominis is aponeurotic at this point; third, that the transversus abdominis aponeurosis and the transversalis fascia are almost on planes of identical depth in the makeup of the abdominal wall; fourth, the dangerous position of the deep epigastric vessels medial to the inner margin of the internal abdominal ring. Considering these anatomical facts, a technic has been devised in which the aponeurosis of the transversus abdominis is sewed down to the shelving margin of Poupart's ligament, the ring margins being included in the sutures for the closure of the dilated internal ring found in association with indirect inguinal hernias. The intimate reinforcement given by this technic, and the lack of “dead space” following its use is emphasized.

Mucocele of appendix

A case of mucocele of the appendix is reported. It was without subjective symptoms and was found during the repair of a right indirect inguinal hernia.