Inguinal hernias

You will see many indirect inguinal hernias in which a patient's abdominal viscera slide down his inguinal canal, from his deep to his superficial inguinal ring, and sometimes down to his scrotum. The hernial sac is closely related to his spermatic cord, and lies in the same fascial planes. You will also see a few direct inguinal hernias which bulge through a weakness in the posterior wall of his inguinal canal. They do not present through his internal ring, they lack any special relation to his cord, and they do not have the coverings from his cord that an indirect hernia has. Because of the way they arise, the spermatic cord lies behind an indirect hernia, and in front of a direct one. Occasionally, a patient has a hernia of both kinds.

Indirect inguinal hernias are common in males. Women less often have indirect hernias, and seldom have direct ones. If the sac of an indirect inguinal hernia and the tunica vaginalis are continuous with one another, it is complete. If they remain separate, it is incomplete. Treat complete and incomplete hernias in the same way.

A patient with an indirect hernia has a bulge in his groin, sometimes with a dragging feeling. He may say that he felt something ''give' in his groin during severe exertion, just before his hernia appeared. He is almost sure to need an operation, which will remove the risk of strangulation, and possibly death. Don't advise him to wear a truss. He will find it expensive and difficult to get; he is unlikely to understand that his hernia must be completely reduced before he applies it, and he is likely to find it very uncomfortable in a hot climate. Instead, treat him like this:

(1) If he has an indirect hernia, find the sac, isolate it, tie it as high as you can, and then excise it (herniotomy). Having done this, restore his anatomy exactly, without damaging it. Finding the sac may be the most difficult step. Remember to: (a) tie it high, so as to obliterate the sac completely, and, (b) to transfix the neck of the sac with a ligature, so that the tie does not slip off. In children under 10 this is all you need do. You can do it at the external ring of an infant, or at the internal ring of an adult or older child (14.5).

Having tied and excised the sac, you may need to repair his inguinal canal (herniorrhaphy), which you can do in several ways:

(2) If he has had an indirect hernia for some time, it may have enlarged his internal ring. If this is only moderately enlarged, you can narrow it with a few stitches, as in A, Fig. 14-5.

(3) If the posterior wall of his inguinal canal is weak, you can reinforce it by suturing his conjoint tendon (which is formed by the fibres of his internal oblique and transversus) to his inguinal ligament behind his cord. This is a modified Bassini repair. Having done this, you then suture his external oblique aponeurosis in front of his cord.

(4) If, when you are about to do a Bassini repair, you think that there is going to be unacceptable tension in the suture line, you can relieve it by first making a long incision in the fused aponeurosis of his internal oblique and transversus muscles superiorly, as in Fig. 14-7. This will allow part of the aponeurosis to slide down, and will relieve the tension on the suture line considerably. This is often known as a ''Tanner slide'.

(5) If he has a very large indirect inguinal hernia, or a recurrent direct one, and you cannot refer him, you can take a reef in the posterior wall of his inguinal canal and darn it, as in Fig. 14-14.

Direct inguinal hernias are of two kinds: (1) Ordinary direct hernias, which are rare in Africa and seldom strangulate (14-8). They may cause no symptoms, and remain the same size for long periods, so that they may not need surgery. (2) A special variety of direct hernia in which the patient has a narrow defect in his conjoint tendon, or in his transversalis fascia (14-9). In Europe this kind of direct hernia is called a Gill[nd]Ogilvie hernia, and is rare. But it is common in the Busoga area of Uganda, and in some other parts of Africa (including Ghana, where it is not uncommonly seen in women), so that it is sometimes known as the Busoga hernia. Gut readily strangulates through the Busoga type of direct hernia. The neck of the sac is small, so that when strangulation occurs, it often does so in only part of the circumference of the gut, to cause a Richter's hernia (14-1).

You can usually repair direct hernias by much the same methods as indirect ones, unless they are very large. But there are differences, and a direct hernia does have problems: (1) The sac may have no obvious neck (unless it is a Busoga hernia), so that you cannot excise it; instead, you have to tuck it in, as in Fig. 14-8. (2) The weak area in a direct hernia is ill-defined, and tends to involve all or most of the posterior wall of the inguinal canal. You can strengthen this by suturing the external oblique aponeurosis behind the cord [md]something you should never do with an indirect hernia. (3) A patient with a direct hernia is likely to be older with poor tissues, and perhaps prostatism, a stricture, dyspnoea, a cough, or constipation, all of which will stress his hernia repair. (4) His bladder may enter the hernia, and is easily injured. (5) A direct hernia is twice as likely to recur as an indirect one.

Recurrence is a problem with any inguinal hernia, especially if the patient is old and has weak muscles. Preventing recurrence needs care and skill, but curing a hernia that has recurred needs even more skill. Recurrence is less likely if you: (1) Repair a hernia early, before it has grown too large. Alas, many patients in the developing world do not present until their hernias are already huge. (2) Tie off the neck of the sac close to the inguinal ring. If you leave the neck, a hernia is much more likely to recur. (3) Narrow a patient's dilated internal ring by bringing the edges of his transversalis fascia together (A, 14-5). (4) Look to see if he has a coexisting direct hernia when he has an indirect one, or vice versa. (5) Put the sutures in a Bassini repair through the aponeurosis of his internal oblique, rather than through its muscle. (6) Do a Tanner slide when the sutures of a Bassini repair would otherwise be too tight. (7) Try to control any factors which might increase his intra-abdominal pressure for at least three months after the repair.

ANATOMY. The internal inguinal ring is a gap in the transversalis fascia, about a finger's breadth above the mid- inguinal point, midway between a patient's anterior superior iliac spine and his pubic tubercle. His external inguinal ring is an opening in his external oblique aponeurosis just above and lateral to his pubic spine. This aponeurosis forms the anterior wall of his inguinal canal: its posterior wall is formed by his transversalis fascia. As his cord passes down his inguinal canal, the muscle and tendon of his internal oblique and transversus arch over it, to form his conjoined tendon.

Divide the inguinal canal into thirds: in the lateral third, the internal oblique forms its lateral wall; in the middle third it forms its roof; in the medial third (as part of the conjoined tendon), it forms its floor. A hernia deforms this normal anatomy, but you can always see that this was its original state.

The inferior epigastric vessels leave the femoral artery and vein, and run vertically on the medial side of the internal inguinal ring. Direct hernias bulge medial to them, through the posterior wall of the inguinal canal, while indirect ones pass lateral to them through the internal ring.

The inguinal ligament is attached to the antero-superior iliac spine laterally, and to the pubic tubercle medially. At its medial end a small curved ligament, called the [f10]lacunar ligament, [f09]joins it to the pubic bone. The lacunar ligament forms the medial boundary of the femoral canal. A few of its fibres continue laterally along the upper border of the pubic bone to form the [f10]pectineal ligament [f09](Cooper's ligament). You can pass sutures through this when you repair a femoral hernia.

In the infant the two inguinal rings overlie one another; in the adult they separate. In many West African people the inguinal canal remains short into adult life, with the two rings widened and almost on top of one another. Inside the inguinal canal you will meet two very constant vessels, but you can easily control bleeding from them: they are the cremasteric artery, and the pubic branch of the inferior epigastric artery. Fig. 14-2 SOME INGUINAL ANATOMY. A, shows the coverings of a patient's spermatic cord, which also become the coverings of an inguinal hernia. B, his external oblique muscle. C, his internal oblique. D, his transversus abdominis. E, his conjoint tendon is formed from the aponeurosis of his internal oblique and transversus muscles as they arch over his spermatic cord.

1, his skin. 2, his fat. 3, his external oblique aponeurosis. 4, his internal oblique aponeurosis. 5, his transversus muscle. 6, his transversalis fascia. 7, his extraperitoneal fatty tissue. 8, his peritoneum. After ''Grant's Method of Anatomy', (9th edn 1975 edited by JV Basmajian), p.183 Figs. 217 and 219. Williams and Wilkins, with kind permission. TREAT INGUINAL HERNIAS WHILE THEY ARE STILL SMALL

UNSTRANGULATED INGUINAL HERNIAS [s8]IN ADULTS DIAGNOSIS. Examine the patient lying down. If he has no swelling, his hernia is reducible. Ask him to stand, cough or strain to make the bulge return. Insert your little finger into his external ring; direct it laterally, and ask him to cough. You will feel ''a cough impulse'.

CAUTION ! Sometimes in a muscular young man, when the neck of the sac is narrow, there is no cough impulse, even in an uncomplicated hernia.

Does the hernia extend into his scrotum? Are both his testes present? Testicular atrophy is one of the complications of herniorrhaphy, and if one testis is already atrophic, you will have to be particularly careful. In children, inguinal hernias are occasionally associated with cryptorchidism.

If a hernia is irreducible, can you reduce it by manipulation?

If he has a history of a lump that comes and goes, but he has no physical signs, ask him to stand, strain, and cough. This will often demonstrate it. If it does not appear, don't operate. See him again later, and wait until you have actually seen it.

THE DIFFERENTIAL DIAGNOSIS usually causes few problems.

Suggesting a hydrocele[md]a translucent swelling with no cough impulse. A hernia in a young child also transmits light, but not one in an adult. A hydrocele is the main differential diagnosis. If, with your finger and thumb, you can get above the swelling, no matter how large it is, it cannot be an inguinal hernia, because it cannot have come down through his external inguinal ring.

Suggesting a femoral hernia[md]the bulge is more globular, is below the inguinal ligament, and is just medial to the femoral vessels.

Suggesting inguinal lymphadenitis[md]the swelling is constant, and below the inguinal ligament. Distinguishing adenitis from a strangulated femoral hernia may be difficult.

Suggesting funiculitis[md]a thickened oedematous spermatic cord, with no cough impulse (31.6).

Suggesting torsion of the testis, epididymis, or both[md]there is no normal testis in addition to the hernial sac.

DIRECT OR INDIRECT? You can usually make a firm preoperative diagnosis; but if you cannot it is unimportant. In a direct hernia: (1) The patient is older, (2) the bulge is globular rather than elongated, (3) the sac does not extend into the scrotum, (4) your finger, when you put it into the external ring, feels as if it is going straight into the patient's peritoneal cavity, (5) irreducibility and strangulation are almost unknown (the Busoga type of direct hernia is an exception to some of these rules).

Lie the patient supine and reduce the hernia completely. Press your thumb firmly over his deep inguinal ring. Ask him to stand up and cough. If his hernia is controlled, it is indirect, otherwise it is direct.

Fig. 14-3 AN INDIRECT INGUINAL HERNIA, showing the patient's hernial sac passing through his internal and external rings, and lying anterosuperior to the vessels of his cord. The narrow part is the neck and the distal part is the fundus. The sac takes a covering from each layer of his abdominal wall. Adapted from a drawing by Frank Netter, with the kind permission of CIBA-GEIGY Ltd, Basle (Switzerland).

THE MANAGEMENT [s7]OF AN INGUINAL HERNIA Always operate on an indirect hernia, unless a patient is very old and frail. You can use local anaesthesia, so his poor general condition is not a bar to operation. If he has a simple hernia, you can treat him as an outpatient.

If he is an infant only a few days old, do nothing until he is at least 3 months old. Strangulation is unlikely in infancy, because the neck of the canal is fairly wide and the canal is so short. Then, dissect out the sac and transfix and divide its neck distally at his external ring. Excise the sac without opening up the canal. See Section 14.5.

If he is a child under 5, open up his canal, dissect out the sac, define its neck well, transfix it, tie it at his internal ring, and excise it.

CAUTION ! (1) In a child, in particular, dissect carefully to ensure that his cord, which lies posteriorly, but close to the sac, is not injured. (2) Simple herniotomy is all that he needs, if a hernial sac is his only abnormality. This is only so in infants and children. In all other patients you will have to narrow the internal ring. In some of them you will also have to do a Bassini repair, if necessary with a Tanner slide.

If he is a teenager, or young adult with a small indirect hernia and good tissues, excise the sac and narrow his internal ring.

If he is an older patient, do a Bassini repair, with a Tanner slide when necessary.

If he is an old man and has a difficult recurrent hernia, you can remove his testis (with his permission, which is seldom given) and close his inguinal canal completely, with a modified Bassini repair, and a Tanner slide if necessary.

If he has the standard type of direct hernia, which is a bulge in the posterior wall of his inguinal canal, do a Bassini repair, with a Tanner slide.

If he has a Busoga hernia, excise the sac and close the defect.

If the patient is a woman, excise her round ligament with the sac, and anchor them to her abdominal wall.

If he has a small recurrent indirect hernia, treat it as if it were a primary hernia.

If he has a very large primary hernia, or any but the smallest recurrent one, and you cannot refer him, you may have to operate as described in Section 14.4, but you will need skill. In a recurrent hernia the tissues may be tough and fibrotic, so that you will find monofilament or wire helpful in repairing them.

If his inguinal hernia is irreducible, but is not yet strangulated (he has no generalized abdominal pain or vomiting), you may be able to treat him conservatively by taxis (14.6).

If his hernia has strangulated, see Section 14.6.

A REDUCIBLE INGUINAL HERNIA [s7]IN AN ADULT PREPARATION. If a patient suffers from a chronic cough, treat him for a few days before the operation, in the hope of reducing the risk of recurrence. Use postural drainage, chest physiotherapy, and antibiotics as necessary. If he has a stricture, treat that first.

ANAESTHESIA. (1) Local infiltration anaesthesia (A 6.12) is excellent for ordinary small and medium hernias. It will show up the tissue planes beautifully. It is also useful if he is is old and feeble. It is less satisfactory if his hernia is strangulated. Don't use it in children, or if he is tense and anxious. (2) Epidural or subarachnoid (spinal) anaesthesia is excellent for all sizes of hernia, because relaxation is so good. (3) Intravenous ketamine with relaxants (A 8.1). (3) General anaesthesia, preferably with relaxants.

If you use local anaesthesia you can operate on all inguinal hernias as day cases, except for those which are complicated by an obstructive uropathy. If your surgical wards are overcrowded, this will relieve the pressure on them.

EQUIPMENT. A minor instrument set (14.2), plus McIndoe's dissecting scissors, sterile tape or a catheter to place round the cord, and curved needles and monofilament for the repair.

CAUTION ! Don't use silk; if it becomes infected, it will cause sinuses, and you will later have to pick out every piece.

Fig. 14-4 SIMPLE HERNIOTOMY. The text does not follow this figure exactly, and does some steps in a different order. A, the site of the incision. B, the patient's skin has been incised and the aponeurosis of his external oblique is exposed. C, his external oblique aponeurosis has been opened, from his external ring laterally, to expose his internal oblique with his ilio- hypogastric and ilio-inguinal nerves. D, his cord is being opened to search for the sac. E, his cord is being freed. F, the sac of his hernia is being opened. G, the sac is being twisted off. If a Bassini repair ]]is needed, it would be done at this point. H, his external oblique aponeurosis is being sutured. I, the operation complete. After Maingot R, ''Abdominal Operations', (4th edn 1961), pp. 874 and 876, Figs. 1 and 3. HK Lewis, with kind permission.

PREPARATION. On the side of the operation, prepare his skin from his umbilicus to a third of the way down his thigh and across to the midline. Drape his groin, and use towel clips to mark two critical anatomical landmarks: (1) His anterosuperior iliac spine, and (2) the midline over the superior border of his symphysis pubis. Between them lies his inguinal ligament. With towel clips on these markers, you are less likely to cut too high or too low.

INCISION. Find his mid-inguinal point by palpating his femoral artery, where it pases under his inguinal ligament, midway between his anterior superior iliac spine, and his pubic tubercle. Make the incision in a skin crease, or parallel to and 1 to 2 cm above his inguinal ligament, from just lateral to his mid-inguinal point to just medial to his pubic tubercle. For small hernias it can be a little shorter, and for large ones a little longer (A, Fig. 14-4). Find and tie securely his superficial epigastric and superficial external pudendal vessels. If they bleed later, he may get a postoperative haematoma.

Apply straight haemostats to all bleeding points, and tie them. Cut through the two layers of his superficial fascia down to the shining fibres of his external oblique aponeurosis (B).

Clear the upper skin flap from the underlying aponeurosis by swab dissection, to expose a wide area of aponeurosis above his internal ring.

Free the lower flap in a similar way to display his inguinal ligament, and its attachment to his pubic spine. Display his external ring, and insert a self-retaining retractor (not shown).

OPENING THE INGUINAL CANAL. Incise the aponeurosis of his external oblique in the length of its fibres over his inguinal canal, and about 1.5 cm above his inguinal ligament (C).

Open his inguinal canal right to its lateral end, starting at his external ring. Free the upper edge of his external oblique aponeurosis, including its extension as his cremaster muscle, from his underlying internal oblique, as far as the outer border of his rectus sheath.

Clip the upper border of his external oblique aponeurosis with straight haemostats. If you do this, you will not mistake them later for the curved haemostats you have used to control bleeding.

Use gauze or sharp dissection to free and clean the lower flap of his external oblique, as far as his inguinal ligament inferiorly, which is the lower border of this aponeurosis. You will now see his internal oblique muscle, leading medially to his conjoined tendon.

Look for his ilio-hypogastric nerve, and, a little below it, for his ilio-inguinal nerve on the surface of his cremaster, in front of and slightly below his spermatic cord. Mobilize his ilio-inguinal nerve, and retract it behind the haemostat on the lower flap. Try not to crush or overstretch either of these nerves, or include them in a stitch, because you may cause persistent pain.

Pick up his cremaster covering the sac and and cautiously split it with the points of scissors. You should see the white areolar tissue around the hernial sac and his spermatic cord. Free the cut edges of the cremaster, and separate them from structures of his cord.

Find his cord, dissect it out enough to put a sling or rubber catheter round it (kinder than the forceps shown in the figure), and retract it (F).

CAUTION ! Don't try blunt dissection high up where landmarks are hard to distinguish, especially if there is much extraperitoneal fat.

At this point you may be able to confirm which kind of hernia he has (direct or indirect), by observing the relationship of his inferior epigastric vessels to the neck of the sac. Examine the posterior wall of his inguinal canal for signs of a direct hernia. Examine also his conjoint tendon, where the Busoga type of direct hernia occurs.

If you have difficulty outlining a hernial sac, open it and insert the index finger of your left hand. Use this to help you define the rest of the sac for further dissection.

In a DIRECT HERNIA, the posterior wall of his inguinal canal is weak and flabby and provides little resistance to your fingers as you press. There usually an obvious bulge medial to his epigastric vessels. His cord almost always lies anterior to it. If its medial wall feels thick and fleshy, suspect that there is bladder in it (see below). If he has a direct hernia, go to near the end of this section.

In a BUSOGA HERNIA, the opening may be quite narrow, and is in the transversus or the conjoined tendon. Go to the end of this section.

In an INDIRECT HERNIA the neck of the sac is lateral to his epigastric vessels, and is intimately attached to his cord which is almost always posterior. You will see the white wall of the sac lying close to and in front of his spermatic cord, which contains his vas and his spermatic vessels. Continue as described immediately below.

CAUTION ! Make quite sure that he has not got the unusual combination of a direct and an indirect hernia (saddle hernia). A few minutes looking for an indirect sac is time well spent.

INDIRECT HERNIA FINDING AND FREEING THE SAC. If you are using local or subarachnoid (spinal) anaesthesia, ask him to cough. The sac will swell slightly. It may be easy to find, or difficult if fibrous tissue has formed round it. Catch an edge with forceps, and retract it upwards and outwards (F). Dissect the sac carefully, hold it with a haemostat, and keep close to its edge. Hold it at extra places as necessary. Usually, sharp dissection with a knife or scissors is better than using gauze, unless the tissues are very loose, because there will be less oozing. Free the sac from strands of his cremaster at their origin from his inferior oblique. If you don't do this, they may obscure his internal ring. Separate it from his cord with non-toothed forceps by working transversely to its long axis, using a mixture of sharp knife and gauze-on-finger dissection (E). If there is extraperitoneal fat round the sac, consider removing it.

CAUTION ! Be sure to find and define clearly: (1) his vas, (2) his spermatic artery, and (3) his spermatic veins (there is usually more than one). All these may separate during dissection. Avoid injuring them by keeping close to the sac.

If the sac descends into his scrotum, pull it into the wound, and dissect it free from the white tissue of his scrotal wall.

If, however, this is too difficult, divide the sac (but not his cord !) and drop the distal part back into his scrotum, while you continue to dissect out the proximal part.

Dissect the sac free from areolar tissue right down to its neck. You may see his inferior epigastric vessels running medial to its neck. Avoid them. If necessary, tie any small branches.

You will know that you have dissected it up as far as you should when you find: (1) His deep epigastric artery and veins on its medial side. (2) The constriction that forms its neck. (3) A collar of extraperitoneal fat around it. (4) Its wider junction with his peritoneal cavity. You can see this when you pull it.

OPENING THE SAC. Open its fundus (if you have not already done so) between haemostats, as if you were opening his peritoneal cavity. Pass a finger or forceps (F) through its neck into his peritoneal cavity to make sure it is empty, and no bowel or omentum remains inside. It has a moist shiny inside.

CAUTION ! (1) If his hernia is irreducible, you can very easily open his gut as you open the sac. (2) If one side of the neck is thick, there may be bladder or gut in its wall. This is more likely in a sliding hernia, either direct or indirect, see under ''Difficulties' below.

CLOSING THE SAC. Twist its neck until the turns reach his internal ring (G). If there is any gut or omentum in the sac, this will force it back into his peritoneal cavity. Transfix the neck as far proximally as you can. Tie it twice with monofilament or chromic catgut, leave the ends of the knot long, and hold them with haemostats.

If the neck of the sac is wide, place haemostats round it from outside, divide it distally, and close it with a continuous suture, as if you were closing the peritoneum of an abdominal wound.

Divide the stump 1 cm distal to the ligature. Examine it. When you are sure that the ligature is not going to slip, or ooze, cut its threads. If it is loose, apply another ligature or a continuous suture. When you release the stump, it will quickly disappear from view under the arched fibres of his internal oblique.

CAUTION ! (1) If you tie the sac distal to his deep ring it is more likely to recur. (2) Don't include his vas in your ligature. (3) If you divide the sac, don't tie it off and drop the distal part back into his scrotum. If you do, he may develop a hydrocele. Leave it open. (4) Try to avoid damaging small vessels; good haemostasis is important to prevent a haematoma forming.

Fig. 14-5 TWO METHODS FOR HERNIAS. A, narrowing the internal ring. In an adult a normal internal ring just admits the tip of your little finger. If it is larger than this, ''snug it up'. Start medially and work laterally. Tie the two ends of the suture together to prevent the inner end of the suture line from pouching forwards. B, the bladder occasionally bulges forwards extraperitoneally on the inner side of a direct hernia, and you can easily injure it. From Rob C and Smith R, ''Operative Surgery', (2nd edn 1969), Vol. 4, Part 1, p. 223 Fig. 8 and p. 229 Fig. 25. Butterworths, with kind permission.

NARROWING THE INTERNAL RING. Feel the size of the patient's internal ring. In an adult, a normal internal ring just admits the last joint of your little finger. If it is wider than this, it is dilated. If it is only a little dilated, narrowing it will be enough.

If his internal ring is only moderately dilated, stitch it with monofilament or catgut, starting medially, and stitching laterally, until the ring fits snugly around his cord. Tie the inner and outer ends of the suture together to prevent the inner end of the suture line pouching forwards.

CAUTION ! (1) If you don't narrow his internal ring when you should, his hernia will be more likely to recur. (2) Don't constrict his internal ring too much, or his testis may atrophy.

If necessary, proceed with a Bassini repair, as described below.

IN A WOMAN an inguinal hernia is probably caused by a congenital sac which is firmly stuck to her round ligament. This is narrower and less vascular than a man's spermatic cord. Her inguinal canal is smaller and you will hardly see anything to represent cremaster. Her hernial sac can extend only to her labia majora. Proceed as above until you come to reflect her cremaster from her round ligament. Pick up the sac, her round ligament, and the nearby vessels. Use sharp dissection to free them from her labium, or blunt dissection if her tissues are very loose.

Clamp, tie, and divide her round ligament close to its insertion. Then clean it and the sac as far as her internal ring. Open the sac, inspect its inside, and then probe it to make sure it is empty.

Grasp the sac, her round ligament and their vessels. Crush, transfix, and tie them, leaving the ends of the ligature long. Then divide these tissues 1 cm beyond the ligature. Use the long ends of the ligature to anchor the stump to the aponeurosis of her external ring above and lateral to her internal ring.

Obliterate her now empty inguinal canal with a few sutures joining her conjoined tendon and her transversalis fascia to her inguinal ligament. You will probably be able to make a Bassini repair without any tension on the suture line, so that she is unlikely to need a Tanner slide. Close her internal inguinal ring completely. There is nothing to strangulate.

If her muscles are weak, draw the edges of her external oblique aponeurosis together with interrupted monofilament sutures.

Fig. 14-6 A BASSINI REPAIR. Interrupted sutures are being used to join the arching fibres of a patient's internal oblique and conjoined tendon to his inguinal ligament. The first suture goes through the periosteum of his pubic tubercle. After Maingot R ''Abdominal Operations', (4th edn 1961) p.879 Fig. 4 drawing 1. HK Lewis, with kind permission.

MODIFIED BASSINI REPAIR [s7]FOR INGUINAL HERNIAS INDICATIONS. A weak internal ring, or a weak posterior wall to the patient's inguinal canal.

If a Bassini repair looks as if it is going to be unacceptably tight, you can do a Tanner slide before or afterwards.

REPAIR. Release the curved haemostats that you originally inserted on the lower flap of the patient's external oblique, and replace them in front of his cord while you repair the posterior wall of his inguinal canal. This will keep his cord out of the way while you proceed with the repair. Alternatively, hold his cord with gentle traction using the slings you have placed round it, as in Fig. 14-6.

Clean away all the areolar tissue from the upper shelving surface of his inguinal ligament. Retract his fleshy arching internal oblique muscle upwards, to expose the aponeurotic part of his transversus muscle, and his conjoined tendon. Use this layer for reconstruction, not the overlying muscle layer. You may have to use muscle if the aponeurosis is poorly developed.

Use 1/0 or 2/0 monofilament, or steel, on a round-bodied half- circle needle, to apply interrupted simple or mattress sutures 8 mm apart, from the arching fibres of his conjoined tendon above, to the inner shelving margin of his inguinal ligament below. Put a narrow retractor at the medial end of the wound, and take the first bite through the periosteum over his pubic tubercle. Proceed from the medial side laterally taking substantial (6[nd]8 mm) bites of the aponeurosis. To avoid splitting his inguinal ligament, take bites which are alternately large and small. Space the sutures evenly, and don't go too deep, or you may puncture his underlying femoral vessels. Hold the interrupted sutures in haemostats, until you have inserted them all, and then tie them all together. Proceed from medial to lateral.

CAUTION ! (1) Beware of his femoral artery, which lies just behind his inguinal ligament under his mid-inguinal point. Injuring the femoral vessels is the most serious potential complication of hernia surgery (see below). (2) Don't strangulate his cord with your last suture. Make sure you can still insert the tip of your forceps through his internal ring, alongside his emerging cord. (3) If you have had to use tension to bring the structures together, do a Tanner slide. (4) Use non- absorbable sutures only.

If you are not going to do a Tanner slide, close the wound as described below.

Fig 14-7 THE TANNER SLIDE for larger inguinal hernias. A, retract the patient's external oblique aponeurosis and excise the sac. B, incise the fused aponeurosis of his internal oblique and transversus, slide it downwards, and suture his conjoined tendon to his inguinal ligament (Bassini repair). C, the slide complete. The lateral cut edge of his aponeurosis has been sutured to his rectus muscle. This is an optional step. After Tanner.

THE TANNER SLIDE [s7]FOR INGUINAL HERNIAS INDICATIONS. (1) A Bassini repair that requires unacceptably tight sutures. (2) Large direct inguinal hernias. (3) Old indirect inguinal hernias, where the internal ring is so large, and the inferior egigastric vessels displaced so far medially, that they resemble a direct hernia. (2) Recurrent and strangulated hernias, provided there is no infected or gangrenous gut.

CONTRAINDICATIONS. (1) A patient in whom it is unnecessary: (a) an indirect inguinal hernia, where the inguinal ring is not dilated. Or, (b) where you can narrow it with a few sutures. Or, (c) a Busoga hernia. (2) A hernia containing infected or gangrenous gut. If you find a hernia like this, postpone repair to a second operation, or do a Bassini repair if this requires little extra dissection. (3) Damage to the lower rectus sheath and muscle, by a previous operation, for example prostatectomy.

Extreme age, feebleness, or a very large hernia are not contraindications to a Tanner slide.

METHOD. In doing a Bassini repair as described above, you found that you needed unacceptably tight sutures to complete it. If so, gently retract the superomedial leaf of the patient's external oblique aponeurosis. You may have to use sharp and blunt dissection to undermine his skin and superficial fascia a bit more first. Separate his external oblique from his underlying internal oblique, and burrow under it until you have exposed his rectus sheath, as in A, Fig. 14-7.

Continue to dissect medially using blunt dissection, and a few careful strokes of the scalpel. Dissection is easy, because at this point his external oblique is only loosely attached to the fused aponeurosis of the two muscles under it.

CAUTION ! Try not to damage his ilio-hypogastric nerve, which either: (1) leaves his internal oblique muscle lateral to his rectus sheath and runs medially to perforate his external oblique. Or, (2) runs straight forwards through his anterior rectus sheath.

Continue to separate the two layers medially to the junction of the inner one-third with the lateral two-thirds of his rectus muscle. Extend your separation to below his pubic crest inferiorly, and a hand's breadth above it superiorly.

Incise the fused aponeurosis of his internal oblique and transversus (B). Make a curved incision starting at or below his pubic crest as far medially as you can. Carry the incision upwards and then laterally to end a hand's breadth above his pubis, and 2 cm medial to the lateral edge of his rectus muscle. Again, try not to damage his ilio-hypogastric nerve.

As soon as you have made this incision, its lateral edge will start to slide downwards, especially if he strains. Help this sliding movement by catching the lateral part of his rectus sheath with Allis forceps, or a retractor, and gently pull it downwards and laterally.

The insertion of pyramidalis to the sheath will prevent you completing the slide. Free this from his rectus sheath by sharp dissection.

Continue the slide until his pyramidalis and his rectus muscles are widely exposed. Provided you have not cut too near to the lateral edge of his rectus muscle, its edge will not be exposed by the incision, even when he strains. Even if it is exposed, this is not important.

An optional step is to use fine sutures of continuous monofilament to join the lateral cut edge of the aponeurosis to his adjacent rectus and pyramidalis muscles, taking wide, deep bites of these muscles (C). This will prevent overslide. This can happen if you have taken the incision too close to the lateral edge of his rectus muscle.

Fig. 14-8 REPAIRING A LARGE DIRECT HERNIA of the ordinary kind.

A, a large direct hernia protrudes through most of the posterior wall of the patient's inguinal canal.

B, having reduced the large direct hernia in A, close the orifice in his transversalis fascia with interrupted sutures. Insert the first suture in his conjoint tendon.

C, close his internal ring snugly round his cord, taking care not to compress it. To do this place interrupted sutures in his internal oblique and transversalis.

D, insert more sutures. Put the three medial ones through his conjoined tendon, his pectineal ligament, and his inguinal ligament. Put those that go lateral to his femoral vessels through his conjoined tendon and his inguinal ligament only. This is the Estes rather than the Bassini procedure, and shows the sutures going through the pectineal ligament, which is rather more difficult than putting them through the inguinal ligament only, and is optional. After Estes, as reproduced in Maingot R, ''Abdominal Operations', (4th edn 1961), p.890 Figs. 17 to 20. HK Lewis, with kind permission.

ORDINARY DIRECT HERNIAS Don't try to open, tie, or excise the sac of a direct hernia, unless it is very obvious. Push it inwards with a sponge dissector, and while you keep it pushed in, bring its edges together with interrupted monofilament sutures. Apply 2 or 3 layers of sutures to close the defect. If these sutures are tight, do a Tanner slide.

It may help to bring the layers of the patient's external oblique aponeurosis together behind his cord (an anterior transposition of the cord), to strengthen his inguinal region. If it is convenient, overlap the flaps, suture the upper one to his inguinal ligament, and bring the lower one on top of it so as to overlap it about 2 cm.

If his hernia is very large, see sections 14.3 and 14.4.

Fig. 14-9 A BUSOGA (Gill[nd]Ogilvie) HERNIA[md]ONE. A, releasing a strangulated Busoga hernia. As soon as the sac is opened, grasp a loop of trapped gut gently with Babcock forceps. As you do so, gently but firmly stretch the neck of the sac with the tip of your little finger. B, sometimes you have to make a small nick in the fibrous edge of the ring. You can release a femoral hernia in much the same way.Kindly contributed by Brian Hancock.

BUSOGA DIRECT HERNIAS [s7](Gill[nd]Ogilvie hernias) You will see a tight bulge of gut coming through a patient's conjoint tendon medially.

Hold the bulging gut lightly with Babcock forceps to prevent it slipping back (A, Fig. 14-9). Cut the edge of the tight ring in the conjoint tendon with a scalpel cautiously (B). Dilate it with ]]your finger alongside the sac. Open the sac. Withdraw his gut and assess it by the criteria in Section 9.3 and Fig. 9-8.

If it is viable, return it to his abdomen.

If it is dubiously viable, leave it for 10 minutes covered with a warm, wet swab.

If it is not viable, you will have to decide whether to invaginate or resect it:

Invaginate the necrotic area of gut if it is: (1) A typical Richter-type strangulation which has produced a ''coin like' area of necrosis with a sharp margin, as in E, and F, Fig. 14-1. (2) The necrotic area has not yet perforated, so that it has been able to prevent the contents of the gut spilling into the peritoneal cavity. (3) It does not extend over more than 50% of the circumference of the gut. (4) It does not extend on to the mesenteric border of the gut, because invaginating it may interfere with its blood supply. (5) The gut at the edge of the necrotic area is healthy and pliable. If any of these criteria are not fulfilled, resect the necrotic segment of gut and do an end-to-end anastomosis (9-9).

To invaginate the necrotic area, use two layers of 2/0 or 3/0 catgut to bring its healthy borders together in their transverse axis, so as to invaginate the ischaemic segment into the lumen, where it can safely necrose (14-1).

If you need to enlarge the defect to get better access, extend the incision in his skin a little more laterally, and then split his internal oblique and transversus abdominis about 5 cm above his internal ring, level with his iliac spine, exactly as in the standard approach for appendicectomy. Open his peritoneal cavity, and withdraw his gut for inspection, invagination, or resection.

Alternatively, do a formal laparotomy through a low paramedian incision.

Finally, excise the sac, and close his transversalis fascia with a few monofilament sutures.

Fig. 14-10 A BUSOGA HERNIA[md]TWO. A, the patient's inguinal canal has been opened to show a small defect in his conjoined tendon and a hernia bulging through it; the sac has been opened. B, if his gut slips back while you are operating, extend the incision in his external oblique laterally, then split his internal oblique and transversus, as if you were doing an appendicectomy. Withdraw his gut. In this way you avoid enlarging the neck of the sac and weakening his conjoined tendon. Kindly contributed by Brian Hancock.

SLIDING HERNIAS [s7](not uncommon) If you find a boggy thickening in the wall of a hernial sac, suspect that some viscus has slid into it partly behind his peritoneum as in C, and D, Fig. 14-1. On the right his caecum and appendix can slide into an inguinal hernia. On the left his pelvic colon can do the same (unusual). His bladder can do so on either side, more commonly in a direct hernia. You may feel something irreducible in the sac which you cannot return to his abdomen. When you open it you find that the internal margins of the sac are impossible to identify along one side, because there is some viscus in the way. Dealing with a hernia like this can be difficult.

CAUTION ! If you cut through a thick part of the wall of the sac, you may enter the viscus.

Dissect the sac free from his cord and the surrounding tissues, without damaging the viscus which forms part of the wall

of the sac. Continue dissection until you have defined the sac clearly. Then pinch a fold of its wall where there is no viscus (usually anteriorly in an indirect hernia), and open it there. Remove redundant sac wall from around the viscus, leaving a margin of 1 or 2 cm all round. Free the viscus from the extraperitoneal tissue next to it by a combination of sharp and blunt disection. If the defect in the wall of the sac is small, close it with a transfixion suture. If it is larger, close it with continuous 2/0 chromic catgut sutures. Push the viscus with the stump of the sac into his abdominal cavity. Proceed with the herniorrhaphy.

Narrow his internal ring as usual (14-5). This may be sufficient; if not proceed to do a Bassini repair (14-6), with a Tanner slide (14-7) if necessary.

CLOSING THE WOUND [s7]AFTER ANY INGUINAL HERNIA Now that you have narrowed his internal ring, and done a Bassini repair, with perhaps a Tanner slide, you can replace his cord. Put it back in his inguinal canal, and tuck its distal end down into his scrotum. Close the gap in his cremaster (if you can identify it) with fine catgut.

Use continuous monofilament, or chromic catgut, to repair his external oblique in front of his cord (unless he has a direct hernia), starting from the lateral side and working medially. When you reach his external ring, reduce it to a size that will transmit his cord comfortably.

Repair the well-defined layer of superficial fascia with 4/0 continuous monofilament, or catgut, and his skin with 2/0 interrupted or continuous monofilament.

CAUTION ! Postoperative bleeding is particularly likely to occur in the inguinoscrotal region. So control all bleeding vessels carefuly. Any hernia repair can be spoilt by a haematoma, especially if it becomes infected.

POSTOPERATIVELY, get him up and walking on the next day. Give him a laxative to prevent him straining at stool. If he is bronchitic, give him an antibiotic and breathing exercises.

If he smokes, persuade him to stop. If he is a manual worker, he should avoid lifting or straining for 3 months, and if possible, give up heavy work.

Fig. 14-11 ADENOLYMPHOCELES or ''hanging groins' can occur in severe onchocerciasis. Don't confuse them with inguinal hernias. A, bilateral adenolymphoceles of unequal size. B, two very large symmetrical ones in a Ugandan patient. Dr KT Cherry's patient. Tropical Doctor 1959;36:229.