Poupart's Ligament Research Articles

Modified Lichtenstein Procedure for Repair of Direct or Indirect Inguinal Hernia by Triangulation of the Inguinal Canal

A modified Lichtenstein hernioplasty procedure was performed, by triangulating the inguinal canal, for indirect or direct inguinal hernia. A series of 276 patients is reported, who underwent a modified Lichtenstein procedure for surgical repair of the indirect or direct inguinal hernia, 32 of which were recurrent hernias. Because of the presence of bilateral hernia in 28 of the cases, the total number of modified Lichtenstein procedures performed was 304. The Lichtenstein hernioplasty procedure was modified by placement of the polypropylene mesh between the Poupart's ligament and the intersection line of the aponeuroses of the external oblique and internal oblique abdominal muscles. The main aim of this modification is to provide stabilization of the inguinal canal. Postoperative pain, and hematoma or seroma formation were very rare in the postoperative period. No recurrence was observed. Based on these results, a modified Lichtenstein hernioplasty procedure with inguinal canal triangulation should be considered for surgical stabilization of the inguinal canal, especially in the case of recurrent hernia.

Spermatic cord injury associated with blunt trauma

Spermatic cord injury due to blunt trauma is an entity rarely encountered in clinical practice, and it may be mainly characterized by the onset of severe pain, swelling, or hematoma in the groin area. We present a case of a fresh spermatic cord injury caused by blunt trauma, which was correctly diagnosed after a surgical exploration. A 53-year-old healthy man had a strong blow from a handlebar on the right groin region in a motorcycle accident. He was transferred to our hospital from a rural hospital 3 hours after the accident because a hematoma was suddenly expanding in the right groin. On presentation, a 12 cm diameter painful subcutaneous hematoma of the right groin extending into the right hemiscrotum was found (Fig. 1). There was no medical history of blood dyscrasias, anticoagulant therapy, inguinal hernia, or urinary symptoms. His vital signs were normal. Contrast-enhanced computed tomographic (CT) images showed a large subcutaneous hematoma with contrast medium extravasation at the groin level and the edematous spermatic cord at the pudendal level (Fig. 2). There was no evidence of either any external iliac or femoral artery injuries. The preoperative diagnosis was a large subcutaneous hematoma bleeding from disrupted subcutaneous vessels. He was taken to the operating room for the removal of the hematoma and hemostasis 5 hours after the accident. Under satisfactory spiral anesthesia, an 8-cm diagonal incision was made over the hematoma of the right groin. A large subcutaneous hematoma as well as the contused spermatic cord was found. The cord was severely damaged at a level approximately 4 cm distal from the internal inguinal ring, and it was bleeding modestly from the internal or external cremasteric vessels. A large hematoma was contained along the distal length of spermatic cord. The vas deferens was intact. A rupture of external oblique aponeurosis and transverse fascia was found after removing the 300-g subcutaneous hematoma. A search for these layers resulted in the discovery of preperitoneal fat without any active bleeding. Based on these findings, a right orchiectomy was performed, and then, the floor of the inguinal canal was repaired by joining the edge of the internal muscle and aponeurosis of the transverse oblique muscle to the Poupart ligament. The external oblique aponeurosis was

Modified Rives technic in the treatment of recurrent inguinal hernia

After the introduction of prosthetic material in hernia surgery the fundamental changes in operative strategy occurred. This is because the coverage of myopectineal orifitium with non-absorbable prosthesis decreases the incidence of recurrences. Because of the appearance of lateral re-recurrences after the classical Rives procedure, we modified the operative technique. The modified Rives technique consists of the following: always polypropilen mesh 15x10 cm; creation of the new internal inguinal ring between Poupart's ligament and mesh; no lateral notching the mesh and anchoring mesh 2-3 cm from the medial, inferior, lateral and superior edge. During the period January 2001-December 2003, 34 cases of recurrent hernias were operated on 7th dept. of I Surgical Clinic of CCS. The recurrences were managed by classical (10/34) or modified Rives technique through direct inguinal approach (22/34), less frequently Lichtenstein procedure (1/34) and McVay (1/34) technique. Among 10 patients with recurrent inguinal hernias managed by classical Rives technique 2 re-recurrences appeared (indirect and interstitial) and 2 cases of infection (immediately after the operation or 7 months after the operation), and in the group of 22 cases with recurrent inguinal hernias managed by modified Rives technique the aim complications didn't appear. Using the modified Rives technique we managed the primary hernias in 56 cases without recurrences and infections. The modified Rives technique, because of the way of mesh fixation (all around), no lateral notching of mesh and remaining hem in all directions secures abdominal wall protection 2-3 cm from the line of fixation and prevents any movement of the mesh. This procedure enables management of all inguinal hernias regardless to their size and full protection of the medial, femoral and lateral inguinal triangle. The modified Rives technique is the technique of choice for big multiple defects (giant inguino-scrotal and re-recurrences), especially among patients with increased intra-abdominal pressure when other techniques may be insufficient because of mesh protrusion.

The Lichtenstein open "tension-free" mesh repair of inguinal hernias.

All standard methods of hernia repair involve suturing together tissues which are not normally in apposition. This violates the basic surgical principle that tissue must never be approximated under tension and thus accounts for an unacceptable number of failures. A total reinforcement of the inguinal floor with a sheet of suitable biomaterial and the employment of a "tension-free" technique is a more effective approach. Since June 1984, 4,000 primary inguinal hernias have been repaired on an outpatient basis and under local anesthesia at the Lichtenstein Hernia Institute by the open "tension-free" technique using Marlex mesh. The patients were followed from 1 to 11 years by physician examination. The follow-up rate was 87%. There were four recurrences. The causes of recurrence and how to avoid them are herein discussed. Three of the recurrences occurred at the pubic tubercle and were caused by placing the mesh in juxtaposition to the tubercle. This error has since been corrected by overlapping the mesh at the pubic bone. One recurrence was caused by a disruption of the lower edge of the mesh from the shelving margin of Poupart's ligament. The error here was the utilization of a patch that was too narrow and therefore under tension. It became apparent that a wider patch, fixed in place with an appropriate degree of laxity, was required.

Critical scrutiny of the open “tension-free” hernioplasty

Tension-free hernioplasty is rapidly gaining worldwide acceptance. Since June 1984, 3,125 consecutive adult male primary inguinal hernias have been repaired by employment of an open tension-free prosthetic repair without approximation of the margins of the defect. Since the original publication of our technique in the 1989 February issue of The American Journal of Surgery, we have encountered four recurrences. These recurrences were caused by technical errors early in our experience and have since been corrected. The purpose of this paper is to bring those errors to the attention of surgeons, as well as to suggest certain modifications to further simplify the operation. Three of the recurrences occurred at the pubic tubercle and were caused by placing the mesh in juxtaposition to the tubercle. This error has since been corrected by overlapping the mesh at the pubic bone. One recurrence was caused by disruption of the lower edge of the mesh from the shelving margin of Poupart's ligament. The error here was utilization of a patch that was too narrow and therefore under tension. It became apparent that a wider patch, fixed in place with an appropriate degree of laxity, was required.

Meralgia Paresthetica and Tight Trousers

To the Editor.— Pressure on any sensory nerve can cause pain and paresthesia in its area of distribution. The carpal tunnel syndrome is the most common, but nerves other than the median can be involved. The lateral femoral cutaneous nerve can be compressed particularly as it passes under Poupart's ligament, leading to pain and paresthesia in the lateral aspect of the thigh. 1 I have seen this problem in a number of truck drivers, most of whom were obese and wore tight-fitting denim jeans. It was apparent during consultations that the tight inguinal crease of their jeans was exerting considerable pressure, possibly aggravating a compressed lateral femoral cutaneous nerve. A number of truck drivers who consented to wearing loose-fitting trousers, albeit less fashionable, had notable improvement of their symptoms. The long hours behind the wheel, with the hips flexed (particularly the right as it controls the accelerator pedal) in conjunction

Technique for repairing inguinal hernias with Marlex mesh

A technique using Marlex mesh for the repair of inguinal hernias is described. In this procedure the transversalis fascia is incised and a 1 inch strip of Marlex mesh is sutured as a cuff over the free edge of the conjoined tendon. The mesh-reinforced conjoined tendon is then sutured to Poupart's ligament. Continuous sutures of polypropylene monofilament are used both to affix the mesh cuff to the conjoined tendon and to suture the reinforced conjoined tendon to Poupart's ligament. Use of the mesh cuff results in a significant mechanical advantage and an exceptionally strong repair. This technique has been used in 72 patients since January 1979, with good results.

Femoral hernia in infancy and childhood

Ten years of experience with femoral hernia in children is reviewed. The following principles emerge from examples noted. Although femoral hernia is rare in childhood, it should be considered, especially in recurrent inguinal hernias or where the operative findings do not match the preoperative diagnosis. Nothing substitutes for a careful preoperative examination. A bulge inferior to the inguinal canal and Poupart's ligament suggests a femoral hernia. Repair of both direct and femoral hernias is best accomplished using Cooper's ligament. Poupart's ligament repair should never be used, as this weakens the femoral canal and may lead to an iatrogenic femoral hernia.

Femoral Neuropathy in Hemophilia

Six new cases of femoral neuropathy in hemophilic patients are described. The syndrome begins with severe pain in the groin, in the inferior aspect of the thigh, and deep in the hip region. This is followed by a pronounced contracture of the hip in flexion and external rotation. A tender swelling appears in the iliac fossa and groin with a depression in the center corresponding to the inguinal ligament. Finally, a flaccid paralysis of the quadriceps femoris and diminution or absence of sensation in the anteromedial aspect of the thigh and proximal portion of the leg, with a depressed or absent patellar reflex,is discovered. I propose that this syndrome is the result of hemorrhage in the iliopsoas muscle at the musculotendinous junction beneath the iliacus fascia and that the femoral nerve becomes compressed beneath the unyielding inguinal ligament superiorly and the iliopectineal ligament medially. Treatment consists in bed rest, analgesics, and fresh-frozen plasma during the acute phase. .During the convalescent phase, a Hessing long brace is used to protect the knee from hemarthrosis until functional return of the quadriceps femoris has occurred. To date, the validity of the theory that the femoral-nerve palsy is the result of iliopsoas hemorrhage at the musculotendinous junction and compression of the femoral nerve beneath the inguinal ligament has not been verified. I anticipate someday seeing a non-hemophilic patient with a traumatic iliacus hemorrhage and femoral neuropathy. Should such an opportunity present itself, exploration beneath Poupart's ligament may show the femoral nerve to be compressed and thus confirm the proposed cause of the clinical picture.

Treatment of inoperable cancer by intra-arterial administration of mechlorethamine.

This report describes results obtained from the fractionated, regional intra-arterial administration of mechlorethamine hydrochloride (methyl-bis[β-chlorethyl]amine hydrochloride; HN 2 ) in a series of 60 patients with inoperable cancer. In each instance, oxytetracycline (Terramycin) was given concomitantly with the mechlorethamine. The effects of oxytetracycline were investigated in view of the observations of Barberio, who noted that the simultaneous administration of chlortetracycline (Aureomycin) and mechlorethamine seemed to have a greater adverse influence upon the cancer than mechlorethamine alone. Methods and Procedure The femoral artery is cannulated under direct vision, an incision being made inferior to Poupart's ligament, parallel to the course of the artery. After the artery has been mobilized, a small polyethylene catheter is inserted through it into the aorta. If the treatment is for cancer of the pelvis, the polyethylene tube is inserted a few inches above the bifurcation of the aorta. If efforts are being made to alleviate hepatic or

Inguinal herniorrhaphy: Methods of repair in use at the present time

A survey of the methods of repair of inguinal hernia in use at the present time has been carried out. The basic types of repair and the important contributions to inguinal herniorrhaphy are briefly described. The most prevalent type of operation for inguinal hernia is the Bassini principle. The Lotheissen principle of utilization of Cooper's ligament instead of Poupart's ligament has recently increased in popularity.

HERNIAL REPAIR USING COOPER'S LIGAMENT

DURING the past seven years we have studied a method of herniorrhaphy which utilizes Cooper's ligament in situations in which one would customarily use Poupart's ligament. This method was first advocated by Lotheissen 1 for use in femoral hernia and was extended to direct and some indirect hernias on the basis of the anatomic studies of McVay and Anson 2 (1940). The conventional operations for the repair of hernia in the groin generally involve two principles: 1. Indirect inguinal, direct inguinal and femoral hernias are repaired by different methods. 2. When an inguinal approach is used, some structure is sutured to Poupart's ligament. The present method disregards both of these tenets and consists, in brief, of two essential features: 1. Those structures usually sutured to Poupart's ligament are fastened instead to Cooper's ligament (the ligamentum pubicum superius B N A). 2. Essentially the same technic can be used for all

Classical herniorrhaphies of Bassini, Halsted and Ferguson

Eduard Bassini's paper describing his new operation for inguinal hernia was dated July 30, 1889 but did not appear until 1890. He had operated, upon 251 patients over a four and one-half year period with six recurrences. The main features of his operation are: suture of the threefold layer to Poupart's ligament to form the posterior wall of the new inguinal canal; suture of the aponeurosis of the external oblique muscle over the cord, forming the anterior wall of the new inguinal canal. Wm. S. Halsted's new operation for inguinal hernia was described December, 1889. He presented five patients, representing work over a six-month period. The main features of this operation are: excision of most of the veins of the spermatic cord; transplantation of the vas deferens under the skin; closure of the structures of the abdominal wall (excluding the peritoneum and the skin) in one layer with interrupted mattress sutures. Alexander Hugh Ferguson's inguinal herniorrhaphy, having been performed by him sixty-four times, was described July 1, 1899. In his book in 1907, he still recommended the same operation. The main features of the Ferguson herniorrhaphy are: leaving the cord undisturbed; utilizing the cremaster muscle and the transversalis fascia in the repair, and suturing the internal oblique muscle and the conjoined tendon over the spermatic cord to Poupart's ligament, it being recommended that the spermatic cord not be lifted from its natural bed. Wm. S. Halsted published his new method of hernia repair August, 1903. The main features of this operation, as contrasted with the Halsted of 1893, are: transplantation of the neck of the sac, careful excision of any enlarged veins of the spermatic cord, utilization of the cremaster muscle and the transversalis fascia in the repair, and placing three rows of interrupted silk sutures and one of catgut in an overlapping type of repair of the layers of the region. Concerning this operation, Ferguson 6 6 Fergc'/son, Alexander Hugh. Modern Operations for Hernia. Chicago, 1907. CIeveIand Press. wrote in his book: “This modification, which is very similar to my operation, was not published until three years after I produced my method.”

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.

Effect of Venous Pressure on Volume Pulsation

In a previous study it was noted that, with ligation of the main venous outlet from the lower extremity of the dog, a marked reduction in peripheral pulse volume occurred.1 The present observations were made to throw some light on the mechanism of these changes.In 14 dogs the volume of pulsations in the hind foot was determined by adapting a specially constructed cellulose-acetate cup to the sensitive plethysmograph of Turner.2 All observations were conducted under ether anesthesia and the operative procedure, consisting of isolation and ligation with silk of the femoral vein at the level of Poupart's ligament, was performed aseptically. Direct venous pressure determinations3 were made in the saphenous vein at heart level before and after the ligation during the continuous determination of pulse volume. All observations were conducted under controlled atmospheric conditions, temperature 75 °F and humidity 50%.Observations were made on 2 groups of dogs: (1) 6 animals with intact sympathetic innervation, an...

Effect of Chemical Irritation of a Venous Segment on Peripheral Pulse Volume

In view of clinical observations suggesting the possibility of ipsolateral arterial and arteriolar vasoconstriction in femoro-iliac thrombophlebitis, the present investigations were undertaken to study some of the factors which may be concerned with such a phenomenon. The influence of local chemical femoral thrombophlebitis upon the volume of pulsations was studied in the hind feet of 12 dogs. The volume of pulsations was determined plethysmographically and recorded continuously by Turner's method, sensitive to volume changes of 0.1 cu mm. By means of a specially constructed cellulose-acetate plethysmographic cup the apparatus was adapted to the hind foot of the dog. Ether anesthesia was used on all dogs during the period of observation and aseptic precautions were observed in the operative procedures. In all observations comparable venous segments were isolated and ligated with silk. The perivascular tissues were not disturbed except for a distance of a few mm at the sites of the proximal and distal ligatures. This venous segment included the femoral vein from just proximal to the saphenous entrance below to Poupart's ligament above. Venous pressures were determined directly in the saphenous vein at heart level before and after the venous ligations in most of the dogs. All observations were conducted under controlled atmospheric conditions, temperature 75° and humidity 50%. The studies were divided into 5 groups of experiments as follows: (1) in 6 dogs (Nos. 1 to 6 inclusive) the venous segment in the left leg was exposed and ligated. Five minutes later 1 cc of blood was aspirated from the ligated segment and replaced by an equal quantity of 40% aqueous solution of sodium salicylate. Following another 5 minute interval the perivascular tissues of the entire venous segment were carefully infiltrated with 5 to 7 cc (depending upon the size of the dog) of 1% procaine hydrochloride.

Some practical experiences in the construction of abdominal supports

Abdominal supports are indicated for the pendulous abdomen, abdominal hernias, and low back pain. The construction varies with the difference in indication. Most of the ready-made corsets show certain standard forms which aim primarily at the cosmetic affect. The tailored abdominal support on the other hand is constructed accurately to fulfill the therapeutic requirements of the case. Among the rules for the construction of such supports may be mentioned the oblique course of the fibres of the lower part of the bandage but the horizontal course of the upper portion, the convex shape of the lower border following Poupart's ligament, and the hour-glass shape of the support. For abdominal hernias, the author described in 1929 a support with a pneumatic pad, using football or soccer-ball bladders. By inflating these bladders or opening the air-valve, the pressure of the support can be regulated.

THE USE OF LIVING FASCIA TRANSPLANT TO REPAIR A HERNIA OF THE TIBIALIS ANTICUS MUSCLE

It was over thirty years ago that McArthur 1 first brought out the use of fascia as a suture in the repair of hernia. After incising the external oblique aponeurosis he cut a small strip off the free border of the medial and lateral flaps. He left these attached at their inferior ends. After ligating the sac he used the strip from the medial border to suture the internal oblique muscle to Poupart's ligament under the cord. He then used the strip from the lateral border to suture together over the cord the flaps of the aponeurosis of the external oblique. Three years later he reported ninety-three consecutive cases in which fascia had been used as a suture without recurrence of the hernia. One of his patients died a year after the operation had been performed and he secured the scar. Microscopic sections showed the graft passing through

Puerperal infection: With special reference to the importance of anatomical pathways in the spreading of pyogenic infection

In this brief article, I have tried to lay stress on the fact that the problem of puerperal infection is almost entirely anatomical, depending on anatomical pathways for its spread, on physical and mechanical phenomena of stasis, drainage, etc., on cellular reactions called forth for defense, etc., and has very little to do with fancy theories of immunity, selective affinity of certain strains of bacteria for certain tissues, etc. In addition, the condition of septicemia, which denotes only the ability to recognize bacteria in the circulating blood, is in many of these cases intermittent, and, at times, does not exist. I have endeavored to enumerate the anatomical reasons for this assumption. In other words, bacteria do not multiply and grow in the blood but are discharged into it from either primary, secondary or tertiary depots in the various organs, in usually an intermittent fashion. When thrown into the circulating blood, nature makes every effort to quickly rid the blood of their presence through its organs of elimination and filtration. The application of chemotherapy in the intravenous injections of mercurochrome, gentian-violet, and other like substances, is only excusable on the premise of attempting to kill those organisms circulating in the blood at the time of the injections, and to thus prevent the establishment of secondary foci in other parts of the body. As one is unable to know when the blood is being showered, the hopelessness of such procedures seems convincing. Medication is, then, of no avail; vaccines and sera are equally useless. Only supportive blood transfusions seem to be of any benefit. I am not competent to discuss the value of artificial fever or heat produced by physical means. Williams 2 states, “In such cases prayer is the best treatment, and the better prayer a doctor is, the better his infected patients do.” The more radical the treatment the higher the mortality. The best results are obtained by those who do the least. While the anatomical view of the subject leads one immediately to the possibility of radical surgery in its irradication, the obvious difficulty in knowing how far the process has extended greatly restricts surgery to the incision and drainage of localized collections of pus (for instance, an abscess pointing above Poupart's ligament), and in rare, selected cases where either the immediate ligation of thrombosed veins or a quick hysterectomy for a uterus containing multiple abscesses, might be seriously considered. According to Williams the latter two surgical procedures were in his experience indicated only once in every few years. Finally, although this paper has been somewhat limited to the infections of the female pelvis, the general anatomical considerations, in the main, are applicable to other pyogenic infections, more especially to those of the middle ear and accessory sinuses of the head and to infected wounds of the extremities and trunk; the difference lying only in the type of tissues affected.

THE INTRA-ABDOMINAL METHOD OF REMOVING INGUINAL AND FEMORAL HERNIA

Whatever else may be necessary as a part of the operative procedure for the cure of hernia, complete removal of the sac followed by high ligation or suture of the peritoneum is essential. All surgeons recognize this as the most important part of the procedure and many believe that in small-sized indirect hernias in children and young persons success is apt to follow regardless of the method employed for closing the canal. For hernias of large size, for direct hernia with imperfect development or absence of the conjoined tendon and for postoperative rupture, it is necessary to suture together certain fascial structures, such as the conjoined tendon and the shelf of Poupart's ligament. In many cases the use of fascial strips as recommended by Gallie is extremely important. The numerous modifications of the original operations of Bassini and of Halsted have been directed largely, if not solely, to methods of