Non-Mesh Repair of Femoral Hernia

Lloyd M. Nyhus, MD,* and Jose E Patifio, MD?

The evolution of operative approaches for the repair of groin hernias has been rapid during the past several decades. Undoubtedly, many of these proposed changes have been salutary, but not necessarily all. The tendency today is to espouse the use of prosthetic mesh, whether onlay, inlay, or plug, indiscriminately, for all groin hernia repairs; this is known as the "knee jerk" phenomenon.

The development of a hernia classification, when properly applied to the patient population under discus- sion, allows for a sensible choice of operative technical approaches. The "haberdashery mentality," of one suit fits all, can be discarded.

THE CLASSIFICATION OF GROIN HERNIA

The classification of groin hernia includes primary ingui- nal and femoral hernias (types 1, 2, and 3), as well as recurrent groin hernias (type 4). Primary inguinal her- nias are classified according to the severity of damage to the underlying internal abdominal ring or the defect in the Hesselbach triangle. Small to massive (eg, scrotal or sliding) indirect hernias may be viewed as a continuum of disease. Initially, they are confined to the internal abdominal ring (type 1), then they enlarge medially (type 2). In the final stages, they alter the posterior inguinal wall (type 3). All direct hernias (small and large without involvement of the internal abdominal ring) are in the transversalis fascia layer and are, therefore, consid- ered type 3.1

The classification of groin hernias is based on anatomi- cal criteria. The challenge in devising a classification of this nature lies in formulating descriptions that are clear and specific.

Type One Type 1 hernias are indirect inguinal hernias (usually in infants, children, or young adults) in which the internal

From the Living Institute for Surgical Studies, Department of Surgery, University of Illinois College of Medicine, Chicago, IL; and the Department of Surgery, Fundacion Santa Fe de Bogota, Bogota, Columbia.

*Professor of Surgery Emeritus, University of Illinois, Chicago, IL. "~Chairman Emeritus, Department of Surgery, Fundacion Santa Fe de Bogota,

Bogota, Columbia. Address reprint requests to Lloyd M. Nyhus, MD, Department of Surgery (mc

958), University of Illinois, College of Medicine, 840 South Wood St, Chicago, IL 60612.

Copyright �9 1999 byW.B. Saunders Company 1524-153X/99/0102-0003510.00/0

abdominal ring is of normal size, configuration, and structure. The boundaries are well delineated and the Hesselbach triangle is normal. The indirect hernial sac extends variably, from just distal to the internal abdomi- nal ring, to the midinguinal canal.

Type Two Type 2 hernias are indirect inguinal hernias in patients in whom the internal ring is enlarged and distorted without impinging on the floor of the inguinal canal. The Hesselbach triangle (floor of the canal) is normal as palpated through the opened peritoneal sac. The hernial sac is not scrotal but may occupy the entire inguinal canal.

Type Three Type 3 classifies defects in the posterior inguinal wall (floor) into three subtypes: direct, indirect, and femoral.

In direct inguinal hernias (type 3A), the protrusion does not herniate through the internal abdominal (ingui- nal) ring. The weakened transversalis fascia (posterior inguinal wall medial to the inferior epigastric vessels) bulges outward in front of the hernial mass. As previ- ously stated, all direct hernias, small or large, are type 3A.

Type 3B hernias are indirect inguinal hernias with a large dilated ring that has expanded medially and en- croaches on the posterior inguinal wall (floor) to a greater or lesser degree. Type 3B hernias frequently have a scrotal position. Occasionally, the cecum on the right or the sigmoid colon on the left makes up a portion of the sac wall. These sliding hernias always destroy a portion of the inguinal floor (type 3B). The internal abdominal ring may be dilated without displacement of the inferior epigastric vessels. Direct and indirect components of the hernial sac may straddle those vessels to form a panta- loon hernia (type 3B).

Type 3 C hernias are femoral hernias, a specialized form of posterior wall defect.

Type Four Type 4 hernias are recurrent hernias. They can be direct (type 4A), indirect (type 4B), femoral (type 4C), or a combination of these types (type 4D). They cause intri- cate management problems and carry a higher morbidity than do other hernias.

132 Operative Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 132-141

Non-Mesh Repair of Femoral Hernia 133

Following the precepts of our hernia classification, it seems clear that the type 1, 2, and 3C hernias may be handled successfully without the use of prosthetic mesh. 2,3 Parenthetically, one of us (J.ER) does use mesh to buttress a seemingly intact Hesselbach triangle in middle- aged or older men, as a prophylactic measure for type 2 hernias.

Femoral hernia repair from the open posterior preperi- toneal approach has proven ideal with a less than 1% recurrence rate? Why should a foreign body of any type other than two or three sutures of monofilament polypro- pylene be used in the repair of uncomplicated femoral hernias? Why should an intact posterior inguinal wall be

incised to approach the repair of a femoral hernia from the open anterior approach such as in the Bassini, McVay, Shouldice, and innumerable other publicized tech- niques? The open posterior approach bypasses the poste- rior inguinal wall, preserving its integrity. Further, this technique must be mastered so that in the presence of strangulated intestine within the femoral hernia sac, an adequate repair can be performed in a setting where the use of prosthetic mesh clearly is contraindicated.

The anatomical structures contained within the poste- rior inguinal wall (wherein lies the femoral hernia orifice) are given for orientation (see Fig 1).

Spe C

llic with po

Iliopubic tract

tbdominis arch

ubic tract

Intern~ iliac

ligament

1 The important anatomical structures of the posterior inguinal wall as seen from the preperitoneal approach. Areas susceptible to herniation: F, femoral; D, direct; I, indirect.

134 Nyhus and Pati~o

SURGICAL TECHNIQUE

General Approach to the Preperitoneal Space

Incision site

2 The preperitoneal space is entered through a transverse lower abdominal incision placed 3 cm above the inguinal ligament. The incision, then, is about 2 fingerbreadths above the symphysis pubis and slightly above the usual inguinal incision used in conventional anterior hernial repairs.

Non-Mesh Repair of Femoral Hernia 135

3 The left-sided dissection is carried successively through the skin, subcutaneous tissue, and anterior rectus sheath. Before incision of the rectus sheath, estimation of the external inguinal ring position as a basic landmark allows a more accurate "minds eye" visualization of the internal abdominal ring. The incision through the anterior abdominal wall must be placed so that it is above (cephalad to) the internal abdominal ring.

136 Nyhus and Patifio

4 The initial incision is placed over the rectus muscle.

Non-Mesh Repair of Femoral Hernia 137

Rectus abdominis

5 The rectus muscle is retracted slightly toward the midline, and the transverse incision is extended laterally a few centimeters through the full thickness of the musculoaponeurotic layers that are formed by the external oblique aponeurosis and the internal oblique and transversus abdominis muscles. The transversalis fascia is now exposed. It is opened transversely, with special care being taken not to enter the underlying peritoneum. The preperitoneal space is entered. Slight retraction of the lower margin of the incision exposes the posterior inguinal wall and the area of herniation. The general pelvic peritoneum and the preperitoneal fat are reflected by blunt dissection, and any peritoneal projections through the posterior inguinal wall are readily visualized.

138 Nyhus and Patifio

ates ~ction ial

A

nial mt

B

6 (A-B) The left femoral hernial sac is reduced by traction. If the hernia is incarcerated, one releases the sac by carefully incising the insertion of the iliopubic tract into the Cooper's ligament at the medial margin of the femoral ring.

Non-Mesh Repair of Femoral Hernia 139

7 The sac should then be opened for in- spection of its contents.

�9 : i �84 ~�9

i: i : i ; ?;) : ; ~ J

i, i~ !:

Excision !!' of hernial i sac

ii r

i i l i i ; :

Closure of peritoneum

8 The repair of the hernia is begun with high ligation of the sac. The anterior mar- gin of the hernial defect is formed by the fliopubic tract and the posterior margin by the Cooper's ligament.

140 Nyhus and Patifto

~i7 ~:~ ii i :i~i~ �84 :

5i!ii!~!

A

Iliopubic tract

Cooper's ligament

9 (A-B) The hernioplasty is completed by suturing these two structures together (0 or no. 1 monofilament polypropylene suture with a sweged-on Mayo needle), thereby obliterating the femoral canal medial to the femoral vein. In the preperitoneal approach, there is no problem in regard to visualization of the external iliofemoral vein; it is easily seen and protected, and the correct degree of closure of the canal medial to it without compressing it is more readily obtained. The aberrant obturator artery (corona mortis) crossing the Cooper's ligament is seen and protected when present.

Non-Mesh Repair of Femoral Hernia 141

ff defect I su tu re

B

9 (continued)

If the restraining fascia is distal at the femoral canal orifice (Gimbernat ligament), release can be attained from above. We can envision, however, the rare possibil- ity of performing a counterincision in the upper thigh over the femoral hernial mass for release of this restrict- ing fascia. We have, however, never found this necessary. Use of relaxing incisions or of polypropylene mesh has not been necessary for the iliopubic tract repair of femoral hernias.

Incarcerated or Strangulated Femoral Hernia

Incarceration or strangulation is managed with relative ease. Transperitoneal control of the unaffected intestine at the hernial ring allows full control of the necrotic intestine and its lethal contents. After proximal control of the intestine is achieved through the posterior approach (and, in this instance, preperitoneal and transperitoneal exposure), release of the constricting insertion of the posterior inguinal wall into the Cooper's ligament at the femoral ring, of the Gimbernat ligament at the distal femoral orifice, or of both, allows for easy intestinal resection and anastomosis. The classic iliopubic tract repair follows.

RESULTS

Our recurrence rate remains at 1% or less. We have never repaired a femoral hernia that has recurred after our recommended approach and repair. These exceptional results have been confirmed. 4 Thus, we continue to espouse the preperitoneal approach and iliopubic tract repair as the method of choice for the treatment of femoral hernia. The use of the foreign bodies (prosthetic mesh) currently promoted for the repair of femoral hernias is unnecessary in our opinion.

REFERENCES

1. Nyhus LM: Individualization of hemia repair: A new era. Surgery 114:1-2, 1993

2. Krahenbfihl L, Frei E: Laparoscopic inguinal hernia repair: An individualized approach? Dig Surg 14:82-87, 1997

3. Patifio JF, Garcia-Herreros LG, Zundel N: Inguinal hernia repair: The Nyhus posterior preperitoneal operation. Surg Clin North Am 78:1063-1074, 1998

4. Ljungdahl I: Inguinal and femoral hernia: Personal experience with 502 operations. Acta Chir Scand 439:7-81, 1973 (suppl)