Attenuation of the rectus sheath in inguinal herniation.
TL;DR: Results indicate that in inguinal herniation the rectus sheath unrelated to the defect is thinner than normal, and a patent processus vaginalis allows herniated with less atrophy than in direct defects.
Abstract: Summary During the preperitoneal approach to groin hernias in the adult, the abdominal aponeuroses but not the musculature appeared thinner than normal. This impression was investigated by weighing samples of constant area. A disk of rectus sheath just lateral to the linea alba, one fingerbreadth below the anterior superior iliac spine, was trephined in a series of hernias along with "controls." Mean wet weight (gm) in these fifty-four control patients operated on for abdominal disease, whose average age was 56.9 years, was 0.174 ± 0.34 (SD). This differed significantly (p value .01 and .001) from both that of 0.164 ± .036 obtained in 188 veterans (average age 54.9) with indirect herniation, and a mean of 0.138 ± .031 found in 134 men (average age 55.8) having direct hernias. Thirty-four patients with mixed hernias either unilateral (pantaloon) or bilateral had intermediate results. In each hernial type, patients with bilateral defects had "lighter" aponeuroses compared to those with unilateral defects. Water content (64 to 74 per cent) was comparable. Surprisingly, biopsy weight did not relate to age (nineteen to ninety-five years) or muscle mass. These results indicate that in inguinal herniation the rectus sheath unrelated to the defect is thinner than normal. A patent processus vaginalis allows herniation with less atrophy than in direct defects. Presenile aponeurotic atrophy, whose etiology is unknown, explains the development and recurrence rate of inguinal herniation in the adult. Biochemical studies are underway to characterize the nature of the fascial deficiency which may be a form of premature aging.
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TL;DR: The evidence in this study that spans a 22-year period questions much surgical technical dogma and raises the possibility that parastomal hernias may represent a failure in the transversalis fascia that might technically be avoidable.
Abstract: PURPOSE: This study was designed to evaluate the longterm complication rate of left iliac fossa end sigmoid colostomies and to determine etiologic factors. METH-ODS: A retrospective chart review and actuarial analysis were performed. RESULTS: The crude and actuarial risks of paracolostomy complications in 203 patients were 51.2 percent and 58.1 percent at 13 years, respectively. Paracolostomy hernia was the most common complication (36.7 percent at 10 years). Siting the stoma through the belly of the rectus abdominis muscle did not reduce the risk of hernia, but an extraperitoneal course had a significantly lower risk of herniation when compared with a transperitoneal course and intestinal obstruction was marginally less frequent. Paracolostomy hernias were otherwise more likely in the elderly, and in those with other abdominal wall hernias. Mesenteric fixation did not reduce the subsequent chance of prolapse. The reduction in the risk of intestinal obstruction when lateral space closure was employed was not statistically significant (4 percent
vs.
10 percent,P <
0.1), and all three patients with stomal retraction had had lateral space closure. CONCLUSION: The evidence in this study that spans a 22-year period questions much surgical technical dogma and raises the possibility that parastomal hernias may, like inguinal hernias, represent a failure in the transversalis fascia that might technically be avoidable.
359 citations
Book•
01 Jun 1988
TL;DR: General introduction and history of hernia surgery, essential anatomy of the abdominal wall, epidemiology and aetiology of primary groin hernias in adults, and logistics of hernian repair.
Abstract: General introduction and history of hernia surgery. Essential anatomy of the abdominal wall. Epidemiology and aetiology of primary groin hernias in adults. Logistics of hernia repair. Economics of hernia repair (with Karen Bloor). Principles in hernia surgery. Anaesthesia. Complications of hernia in general. Groin hernias in babies and children. Umbilical hernia: operation in babies and children. Diagnosis of a lump in the groin in the adult. Inguinal hernia in adults - I - The operation. Extraperitoneal or perperitoneal repair of groin hernias using prosthetic reinforcement. Laparoscopic groin hernia repair (with P J O'Dwyer). Inguinal hernia in adults II - the outcomes. Femoral hernia. Umbilical hernia in adults. Epigastric hernia and laparoscopic "port site" hernias. Lumbar hernia. Pelvic wall hernias - obturator hernia, sciatic hernia, perineal hernia, supravesical hernia. Spigelian hernia. Incisional hernia (excluding parastomal hernia) Parastomal hernia. Complications of hernia repair. Biographical notes.
182 citations
Cites background or methods from "Attenuation of the rectus sheath in..."
...As early as 1900, Goepel and Witzel used silver wire braided meshes [126, 127, 140]....
[...]
...Others, such as Witzel [126], Goepel [127] and Bartlett [128], described the repair of incisional hernia from continuous fascial sutures from the external oblique [126–128]....
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149 citations
TL;DR: The results indicate that an imbalance between blood proteases and antiproteases, resulting from chronic smoking can damage connective tissue in the groin as well as the lung.
Abstract: Since our previous work had indicated that veterans with inguinal herniation demonstrated qualitative and quantitative changes in connective tissue, we tested the hypothesis that a possible mechanism for the defect was chronic exposure to circulating proteases generated in the lung by cigarette smoke We investigated 59 men (average age: 60 years) with eigher primary direct of indirect hernias Most of the patients smoked Circulating serum elastolytic activity was significantly greater in patients with direct hernias who smoked when compared with controls (p less than 0001) In addition, the serum alpha-1-antitrypsin inhibitory capacity was significantly lower in this category than controls (p less than 0001) Patients with indirect defects who smoked also had significantly higher elastolytic values but to a lesser degree (p less than 001) Serum antiprotease and protein concentrations were within the normal range in all categories Our results indicate that an imbalance between blood protease and antiproteases, resulting from chronic smoking can damage connective tissue in the groin as well as the lung
129 citations
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TL;DR: It is concluded that satisfactory repair can be performed through this exposure which has definite advantages and compared to those of the conventional approach.
Abstract: During nearly a two year period all patients presenting with herniation of the groin at the Little Rock Veterans Administration Hospital have been operated upon through a preperitoneal approach. The technic developed, the results obtained, and the impressions gained from this experience are presented. The advantages and disadvantages of this approach are compared to those of the conventional approach. The development of various types of inguinal herniation in this previously healthy adult male population is documented. It is concluded that satisfactory repair can be performed through this exposure which has definite advantages.
33 citations
TL;DR: It was concluded that preperitoneal herniorrhaphy should be used in femoral hernia, recurrent herniation, bilateral hernias, cryptorchidism, slidingHernia, and cases of incarceration or strangulation.
Abstract: A technic of pre-extraperitoneal approach to inguinofemoral herniorrhaphy is described. The role of the rectus fascia is discussed. Pseudosac formation in direct inguinal hernia is emphasized. Transversalis fascia was found to be unsuitable for suturing. The advantages and disadvantages of the approach are outlined. A superior relaxing incision is described. It was concluded that preperitoneal herniorrhaphy should be used in femoral hernia, recurrent herniation, bilateral hernias, cryptorchidism, sliding hernia, and cases of incarceration or strangulation.
15 citations