ANNALS OF SURGERY

Vol. 148

October 1958

No. 4

Inguinal and Femoral Hernioplasty *

The Evaluation of a Basic Concept
C. B. MCVAY, M.D., PH.D.,** JoHN D. CHAPP, M.D., M.S.f

Introduction
THIs woRK began as a study of the normal anatomy of the inguino-femoral region
because of conflicting descriptions of the
transversalis fascia, the falx inguinalis and
other structures in this region. Originally
there was no thought of the hernia problem
but as the study continued over a four year
period and the examination of over 500
inguino-femoral regions, the implications
became obvious. This original work, between the years 1934 and 1938, was carried
out by the senior author under the direction of, and in association with, Doctor B.
J. Anson, Professor of Anatomy, Northwestern University Medical School.
The detailed results of these studies have
been recorded 1, 2, 25, 26 and only such features will be outlined here as are necessary
to orient the reader of this paper. The
transversalis fascia is simply the innermost
muscle fascia of the transversus abdominis
muscle. Where the layer is muscular, as at
the abdominal inguinal ring, it is easily'
* Presented before the American Surgical Association, New York, N. Y., April 16-18, 1958.
** Clinical Prof. of Surgery and Assoc. Prof.
of Anatomy, Univ. of South Dakota School of
Medical Sciences. Surgeon, The Yankton Clinic.
f Senior Resident in Surgery, University of
Kansas Medical Center. Formerly Resident in Surgery, Yankton Clinic and Univ. of South Dakota
School of Medical Sciences.

499

separable as a definite layer; but where it

is aponeurotic, the fascia becomes fused
with the aponeurotic fibers to form a single
layer. In the inguinal region and behind
the spermatic cord we refer to this layer as
the posterior inguinal wall (Fig. 1). It is
upon the variable strength and distribution
of this layer that direct ingunial and femoral hernias are dependent for their development. The patient in whom the aponeurotic fibers are sparse is the one likely to
develop a direct inguinal hernia because
the posterior inguinal wall is weak. The
patient with a narrow insertion of the posterior inguinal wall into Cooper's ligament
is the one likely to develop a femoral hernia
because this leaves a broadened femoral
ring.
Since the posterior inguinal wall inserts
into Cooper's ligament (ligamentum pubbicum superius) and has only a contiguous
relationship to the inguinal ligament, we
have always maintained that the repair of
the groin hernias that compromise the posterior inguinal wall (large indirect, direct
and femoral hernias) should use Cooper's
ligament in the hernia repair and not the
inguinal ligament. The details of our "Reconstruction of the Posterior Inguinal Wallr
are readily available 27-32 and wiU not be
repeated in this paper since this is a statistical evaluation of the method. However,

500

McVAY AND CHAPP

Annals of Surgery
October 1958

Apon.xni.transv. abd. MNobl.int.

|'

FIG. 1. The anatomy of the transversus abdominis muscle and aponeurosis in the
inguinal region. Note that the anterior femoral sheath is a continuation of the transversalis fascia; also, that the excised inguinal ligament is not part of the all important
posterior inguinal wall (transversus abdominis aponeurosis). (From McVay and
Anson: Anat. Rec., 76:213, 1940.25)

for ready reference, the completed "Reconstruction of the Posterior Inguinal Wall" is
shown in (Fig. 2).
The development of the small indirect
inguinal hernia, congenital in origin, is dependent upon the protrusion of a viscus
into a persistent processus vaginalis. The
crux of the small indirect inguinal hernia
problem is the size of the abdominal inguinal ring and not the length or size of
the peritoneal sac. Most of these hernias
need no more than high ligation and excision of the hernial sac with a closure of the
fascial abdominal inguinal ring to normal
size. The closure of the abdominal inguinal

ring may take one or several sutures, depending upon the size to which it has been
dilated by the hernia. The closure, our
"Abdominal Ring Repair," is accomplished
medial to the cord structures by suturing
the transversalis fascia above to the anterior
layer of the femoral sheath below (Fig. 3).
Again, the inguinal ligament is not utilized
because it is a more superficial structure
and not part of the normal continuity of
this layer. The lateral part of the inguinal
region, in which the abdominal inguinal
ring is located, lies over the external iliac
vessels; and distally where the muscular
fibers of the transversus abdominis termi-

Volume 148
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INGUINAL AND FEMORAL HERNIOPLASTY

raidlalis

501
M.

~~~~Aq\W~~~~~~V~~

FIG. 2. Reconstruction of the posterior inguinal wall. 1. Rectus sheath sutured to

Cooper's ligament. 2. Transition suture. 3. Transversalis fascia sutured to anterior
femoral sheath. (From Hernia, by C. B. McVay, Courtesy of Charles C Thomas,
Publisher, Springfield, Illinois.)

the transversalis fascia continues into

the thigh as the anterior layer of the femoral sheath (Fig. 1). It is the re-establishment of this fascial continuity to make a
snug abdominal inguinal ring that constitutes the repair of the small indirect innate,

guinal hernia and nothing more.31' 32

In this series of 580 hernioplasties, the

inguinal (Poupart's) ligament was not used
in a single instance. In all of them the
spermatic cord was replaced in its normal
position and the external oblique aponeurosis closed over the cord so that a snug subcutaneous inguinal ring was formed in the
normal position, just lateral to the pubic
tubercle. The inguinal ligament thus retains its sole purpose, that of a sling and
support for the contents of the inguinal
canal. Many years ago, Gallaudet 1 t stated,
"The inguinal ligament is a free margin"
and this simple anatomic fact can be demonstrated at the operating table by a moment of gentle dissection with the handle
of the knife. The medial end of the inguinal

ligament, known as the lacunar (Gimbernaut's) ligament, also attaches to Cooper's

ligament. The lateral one-fourth of the inguinal ligament is not free by virtue of
some of the fibers of the external oblique
aponeurosis passing caudally into the fascia
lata. However, in the region of hernia repair, the inguinal ligament is indeed a free
margin as stated by Gallaudet. The inguinal ligament has a slightly convex inferior margin and is held in this position by
the fascial layer in which it is imbeddedthe fascia lata. The fascial coverings of the
external oblique aponeurosis (innominate
fascia of Gallaudet) are continuous with
the fascia lata.
Finally, we consider the femoral hernia
to be simply a third variety of inguinal
hernia. Irrespective of the femoral location
of the hernial sac, the origin of this hernia
is as truly inguinal as the other two groin
hernias. No matter what one considers the
initial etiology of the femoral hernia to be,
the end result is a wide femoral ring and a

502

McVAY AND CHAPP

Annals of Surgery
October 1958

cutaneous inguinal ring in the normal position.

In previous publications we have acknowledged the many significant contributions to the subject of groin hernioplasty
and so this lengthy subject will be omitted
in this paper. However, we would be remiss not to again acknowledge the paper
of Lotheissen,23 who first used Cooper's
ligament in inguinal and femoral hernioplasty, and Dickson,7 who used Cooper's
ligament for femoral hernioplasty.
FIG. 3. Abdominal inguinal ring repair. (From
Hernia, by C. B. McVay, Courtesy of Charles C
Thomas, Publisher, Springfield, Illinois.)

narrowed insertion of the posterior inguinal

wall into Cooper's ligament. The proper
approach to the repair of this hernia is
through the inguinal region and consists
very simply (after disposing of the hernial
sac) of broadening the posterior wall attachment into Cooper's ligament so that
the femoral ring is obliterated.I1 32
For the purpose of emphasis it is worthwhile to restate the premises upon which
we base our repairs of the groin hernias.
For the small to medium size indirect inguinal hernias we do nothing more than
excise the hernial sac and tighten the abdominal inguinal ring to normal by suturing the transversalis fascia to the anterior
layer of the femoral sheath, medial to the
cord (Fig. 3). For large indirect inguinal,
direct inguinal, and femoral hernias we reconstruct a new posterior inguinal wall.
Briefly, this consists of excising all attenuated aponeurotico-fascial structures, the
relaxing incision, and a "slide" of the rectus
sheath into the position of a new posterior
inguinal wall. This new posterior wall is
sutured to Cooper's ligament as far laterally
as the femoral vein and after the transition
suture,31 ,32 the transversalis fascia is sutured to the anterior layer of the femoral
sheath far enough laterally to make a snug
abdominal inguinal ring (Fig. 2). In both
repairs the spermatic cord is replaced in its
normal position and the external oblique
aponeurosis closed to make a snug sub-

Hernia Recurrences
The repoited incidence of recurrence in
many series of hernia operations forms a
bulky contribution to the medical literature of the past half century. Although the
stated incidence of recurrence shows considerable variation through the years, most
authors are agreed that it is the direct inguinal and the large indirect inguinal hernias that form the bulk of the recurrences.
Some reports also show a high rate of recurrence following femoral hernioplasty.
Because many of the earlier series lumped
all inguinal hernias together, it was difficult
to arrive at the true picture of the recurrence rate. Since in all series, the small indirect inguinal hernia comprises roughly
60 per cent of the total and since success
attends almost any operation for this simplest of the groin hernias, a very favorable
recurrence rate in this group may conceal
an appalling recurrence rate for the direct
and the large indirect inguinal hernias.
This grouping of the indirect and direct inguinal hernias is not surprising since in
many series essentially the same operation
is used, irrespective of the type of hernia,
although more elaborate re-enforcement
methods may be used such as imbrication
of layers, or the use of fascial sutures and
grafts.
The many articles dealing with recurrence rates are difficult to compare. In general, most surgeons report very favorable
results in the small indirect inguinal hernia,
irrespective of the operation used; and
most agree that the direct inguinal hernia

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INGUINAL AND FEMORAL HERNIOPLASTY

carries the highest recurrence rate. In the

latter group the opinion varies from that of
Andrews and Bissel 3 to this present report.
Andrews and Bissel felt that the recurrence
rate was so high in the direct inguinal hernia that operation should not be attempted.
A fair average of the reported series would
be a figure of 20 per cent recurrence for
operations on direct inguinal hernia. Some
reports list recurrence after femoral hernioplasty to be just as high. A recent article
by Telle 40 divides the hernias into their
respective categories in considering the recurrence rates. Table 2 in this article by
Telle demonstrates the high recurrence rate
in the direct inguinal hernia using technics
that do not utilize Cooper's ligament. In
recent years it would appear that there has
been a general change to the use of Cooper's ligament in the repair of the difficult
groin hernias.
Koontz 22 analyzed a questionnaire sent
to 286 eminent surgeons and while most of
them reported that they still use an inguinal
ligament type of hernioplasty for the average inguinal hernia, there were a significant
number who used Cooper's ligament in the
difficult hernias. This is in sharp contrast to
the opinion prior to 1940. The reported results of Burton,4 Clark and Hashimoto,5
Farris,'" Ferguson,'2 Harkins,'6-19 Holloway,20 Matson,24 McVay,27-30 Rice and
Strickler,35 Sanderson and Rice,38 Telle,40
and others would appear to more than
justify the adoption of this very fundamental anatomic technic in all groin hernias
that compromise the posterior inguinal
wall.
Fallis,8 Telle,40 and Clear 6 emphasize
the importance of a long term follow up,
and in this we certainly concur. When the
TABLE 1. All Groin Hernias, 1946-1956

Type of Hernia
Indirect inguinal, all sizes,
including combined hernias
Direct inguinal
Femoral

Total

Number

Per cent

467
74
39

80
14
6

580

100

503

TABLE 2. Single, Recurrent and Combined Hernias

Primary single hernias

Recurrent hernias
Indirect-direct hernias
Indirect-femoral hernias
Indirect-direct-femoral hernias
Total hernias

498
45
21
9
7
580

direct inguinal hernia

following the repair of a small indirect inguinal hernia, it may not become apparent
for many years. On the other hand, when
the recurrence is due to a missed hernia,
the recurrence time is short (Table 5).
From the published reports, including the
material in this paper, it would appear that
a ten year follow up should be the standard. Any longer period would probably not
be practical since death and the gradual
decrease of follow up percentages would
offset the value of a longer period.
This paper is essentially the report of
two series since we have maintained, along
with Potts 34 and others,"1 37, 41 that in the
simple small indirect inguinal hernia, little
more need be done than to adequately remove the hernial sac. However, even in infants we suture the transversalis fascia to
the anterior layer of the femoral sheath,
medial to the cord, so as to snuggly close
the abdominal inguinal ring. In the indirect
inguinal hernia that has enlarged the abdominal inguinal ring medially beyond the
sagittal position of the medial margin of
the femoral ring, we change to the operation of "Reconstruction of a New Posterior
Inguinal Wall," in the same manner that
we repair a direct inguinal hernia. Therefore, in reporting this series of 580 hernioplasties, 344 are "Abdominal Ring Repair"
for small indirect inguinal hernias and 236
are "Reconstruction of the Posterior Inguinal Wall" for the larger indirect inginal, direct inguinal and femoral hernias
(Table 3).
This group of 580 hernias were operated
upon on the senior author's service during
the 11 year period from 1946 to 1956 inclusive. While the majority of these herniorecurrence is as a

Annals of Surgery
McVAY AND CHAPP
504
October 1958
TABLE
4.
Recurrences.
580
Hernioplasties
plasties were performed by two staff men,
all interns and residents rotating through
No. of RecurPer
the service did a good share of the hernia
Hernias rences
Cent
operations after careful supervision in their Total hernioplasties
580
13
2.24
(1946-1956)
earlier cases. It is interesting that all but
four of the recurrences were in cases oper- Abdominal ring repair
11
3.2
ated upon by the senior author. It is a Reconstruction posterior 344
inguinal wall
natural consequence of our long interest
(Cooper's ligament)
236
2
0.85
in this subject that we never let the intern
or new resident perform his first hernia opNo recurrences in 39 reconstructions of posterior
eration until he is thoroughly conversant inguinal wall for femoral hemia.
with the normal anatomy; and he is then
supervised as mentioned above. This is in shows the number of primary, recurrent
sharp contrast to the practice in years gone and combined hernias repaired. A weakby where a hernia operation was consid- ness or slight bulging of the posterior inered to be such a simple problem that it guinal wall discovered at the time of operawas the first operation that an intern per- tion for an indirect inguinal hernia was a
formed with very little instruction or super- fairly common occurrence and, although
vision. We have found that the proper the posterior inguinal wall was reconevaluation of the hernia problem at the op- structed, these have not been listed as comerating table takes considerable judgment bined or pantaloom hernias in this series.
and experience and, as will be seen shortly, The 21 hernias listed as indirect-direct in
it is the error in judgment that accounts for Table 2 were true double sac hernias. Likemost of our recurrences. Furthermore, not wise, direct inguinal hernias with an inall hernia operations are easy or technically cidentally discovered small indirect sac are
simple. Obesity usually makes a hernia op- listed only as direct hernias.
Table 3 shows the types of hernias, their
eration difficult; and most recurrent hernias
numbers
and the per cent of the total series
are difficult and time consuming operations
repaired
by
"Abdominal Ring Repair" and
because of the cicatricial fusion of all layers.
"Reconstruction
of the Posterior Inguinal
The follow up in this series is 91 per cent
with the examination period varying from Wall." Thus, in well over one-half of the
580 hernioplasties performed in this series,
one to eleven years after operation. Table 1 nothing
more was done than high ligation
shows the numbers and percentages of the of the indirect
sac and tightening of
three grion hernias repaired and Table 2 the abdominalhernial
inguinal ring. A special
point is made of this since the senior
TABLE 3. Operations for Groin Hernias
author has been quoted frequently as doing a "Cooper's Ligament" repair on all
No. of % of
Type of
Type of
Hernia
Cases Total
Operation
hernias. In spite of the fact that 11 of our
13 recurrences have been in this group of
Abdominal ring Small to medium 344
59.3
simple
repairs, we do not feel that the more
repair
indirect
inguinal hernia
lengthy and difficult Reconstruction Operation should be done on all hernias. AlReconstruction
123
Large indirect
though
one might infer from our results,
posterior
(including
combined
inguinal wall
Table 4, that this should be done, we have
(Cooper's ligahernias)
adhered to strict criteria for doing the "Rement)
construction" operation.28 30 Rather, we
Direct
74
Femoral
39
would emphasize the importance of the
judgment necessary to properly evaluate
236
40.7
the indications at the operating table.31

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INGUINAL AND FEMORAL HERNIOPLASTY

505

TABLE 5. Details of Recurrences. 91% Follow up. 1-11 Years

Case

Sex

1
2
3
4
5
6

M
M
M
M
M
M

Age,
Years

Hernia

Type of Recurred

Type

Repair

as

Time of
Recurrence

Cause of
Recurrence

19
76

I
I
I
I
D &I
I

A.R.
A.R.
A.R.
A.R.
R.P.W.
A.R.

I
I
I
I
D
D &I

6 years
3 years
3 years
32 months
4 years
6.5 years

Technic
Technic
Technic
Technic
Technic
Technic and

I
I
D
I
I
I
I

A.R.
A.R.
R.P.W.
A.R.
A.R.
A.R.
A.R.

D
D
D &I
F
F
F
F

7 years
6 years
9 months
6 months
9 months
16 months
3 weeks

32
60
54
57

7
8
9
10

M
M
M
F
11} MB
12J Bilateral
13
F

55
18
62
41
1.5

l
41

judgment
Judgment
Judgment
Infection
Missed
Missed
Missed
Missed

Repair

Years
Follow up
Without
Recurrence

A.R.
A.R.
A.R.
R.P.W.
R.P.W.
R.P.W.

3 years
2 years
2 years
8 years
2 years
4 years

Type of ]
Second

R.P.W.
2 years
Not yet operated upon
R.P.W.
9 years
R.P.W.
4 years
R.P.W.
6 years
R.P.W.
4 years
6 years
R.P.W.

Legend: I-Indirect. D-Direct. A.R.-Abdominal ring repair. R.P.W.-Reconstruction of the posterior

inguinal wall.

Table 5 is a statistical evaluation of our

recurrences and is largely self-explanatory
although some elaboration is pertinent.
When an identical hernia recurred this is
referred to as an error in technic, e.g.
cases 1-6 were essentially recurrences of
the original hernia. In four instances, cases
1, 2, 3 and 4, the small indirect inguinal
hernia recurred as a small indirect inguinal
hernia. In two instances, no exact cause
could be determined except that the abdominal inguinal ring must not have been
tightly enough closed. In the other two
cases, one right and the other left, bowel
must have been caught in the closure of
the hernial sac. The left-sided recurrence
had an epiploic appendage of the sigmoid
colon as the entering wedge of the hernial
sac. On the right, the small sac was principally a sliding hernia of the cecum and
we presume that the cecum must have been
caught and fixed in the closure of the abdominal ring.
Cases 6, 7 and 8 are listed as errors in
judgment since a small indirect inguinal
hernia recurred as a direct inguinal hernia.
In other words the posterior inguinal wall
gave out in time and this weakness should
possibly have been recognized at the time
of the first operation. It is significant that in

this group it took six years or more for the

recurrence to become manifest. In re-reading the operative notes on these three cases
there was no mention of suggestive weakness of the posterior inguinal wall. On the
other hand it is not uncommon to see a
translucent posterior wall in an elderly individual with an indirect inguinal hernia
who has not developed a direct inguinal
hernia. Therefore, it is probably inevitable
that there will always be some of these
cases in every series.
Case 9 represents a massive wound infection and the recurrence was evident in less
than a year. There was one other serious
wound infection in a reconstruction of the
posterior inguinal wall that has not developed a recurrence to-date but only one and
one-half years have elapsed. Minor subcutaneous wound infections have occurred
in two per cent of this series. While case
9 is listed as a second reconstruction of the
posterior inguinal wall this is not strictly
the case. There were two discrete apertures
1 cm. in diameter. The direct aperture was
just above and lateral to the pubic tubercle
in an otherwise intact and densely scarred
posterior wall and was closed transversely
with four 32 gauge stainless steel wire sutures. The other sac in this case was an in-

506

McVAY AkND CHAPP

direct one and after excision of the sac, the

scarred margins of the slightly dilated abdominal inguinal ring were approximated
medial to the cord with wire sutures. It is
now over nine years since the secondary
operation and there is no sign of recurrence.
Cases 10-13 are listed as missed hernias
since the femoral hernia appeared rather
promptly after the repair of a simple small
indirect inguinal hernia. One cannot escape
the fact that the femoral hernia must have
been present all the time and was simply
not recognized at the time of the original
operation. During the reconstruction of the
posterior inguinal wall for direct or large
indirect inguinal hernias, we have occasionally observed a protrusion of the preperitoneal fat through a slightly dilated
femoral ring and without any suggestion
of a peritoneal sac. It is likely that all femoral hernias begin with this entering wedge
of fat and this incipient phase should be
searched for carefully. It should be noted
that cases 11 and 12 represent bilateral indirect and femoral hernias in a male infant.
Of further interest, we have subsequently
repaired a femoral hernia in this child's
three year old sister and another sister now
age five has a femoral hernia. Had we been
astute enough to recognize the femoral hernias in this one case our recurrence record
would have been substantially better. While
some recurrences are inevitable, the missed
hernia is a blunder and it does not take
many such mistakes to be catastrophic in
any carefully guarded hernia series.
Case 5, mentioned above as a technical
failure, is an interesting recurrence. A reconstruction of the posterior inguinal wall
had been done for a direct-indirect inguinal hernia. The recurrence was a diverticular type of direct inguinal hernia with
a 12 mm. defect 1 cm. above and lateral to
the pubic tubercle. There was no peritoneal
sac but a protrusion of the urinary bladder,
with surrounding preperitoneal fat, that
protruded through the subcutaneous in-

Annals of Surgery

October 1958

guinal ring for a distance of 3 cm. Since the

remainder of the posterior wall was strong,
the defect was simply closed with interrupted silk sutures. The cause of this recurrence is, of course, speculative but probably represents injury to the posterior wall
at the time of the original operation. Another possibility is a missed defect. We
have occasionally found a tiny protrusion
of preperitoneal fat between the aponeurotic fibers of an otherwise intact and
strong posterior inguinal wall. Excision of
the fatty protrusion after ligation of its
pedicle and closure of the 1 or 2 mm. defect with a silk suture or two has sufficed.
At least to date there have been no recurrences in these cases.
Discussion
Since this presentation is the evaluation
of the author's methods, comparative tables
with other studied series of recurrences
using similar or other methods have not
been presented. These are readily available
in the medical literature and, furthermore,
it is difficult to compare the various series.
Time is an important element in the incidence of recurrence and unless two comparable series each had all their cases followed for the same length of time, they are
not comparable. We are aware that our
statistics will change from time to time and
that if all of our cases had been followed
for 11 years we would undoubtedly show
a higher recurrence rate in all categories.
If we had omitted our four cases of missed
femoral hernias, the recurrence rate in the
abdominal inguinal ring repair group would
have been 2 per cent instead of 3.2 per
cent. Some would argue that a direct inguinal hernia that appears years after the
repair of a simple indirect inguinal hernia
is a brand new hernia and not a recurrence.
While this may be theoretically true, we
feel that these should be listed as recurrent
hernias. In other words, a secondary or subsequent groin hernia must be listed as a re-

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INGUINAL AND FEMORAL HERNIOPLASTY

currence or any comparison of methods is

impossible.
Excellent results have been reported in
the small indirect hernia group with nothing more than high ligation of the peritoneal sac 34 but we feel that any dilatation
of the fascial abdominal inguinal ring
should be corrected, even in infants. The
protrusion of preperitoneal fat through the
dilated abdominal ring in the postoperative
period must surely be a basis for the development of a recurrent indirect inguinal
hernia. It only takes a moment to place a
suture or two medial to the cord, approximating the transversalis fascia to the anterior femoral sheath, and this restoration of
the abdominal inguinal ring would seem to
us to be a rational procedure. Koontz has
also expressed this opinion in a discussion

of the paper by Potts.34

Following our experience with a bilateral

recurrence as femoral hernias in an infant
(Table 5, cases 11 and 12) some seven
years ago we abandoned the very simple
approach to the repair of the small indirect
hernia in the infant and child as recommended by Potts and others. We have since
treated these more like adult hernias, although we do not disturb the cord beyond
the subcutaneous inguinal ring. In the infant it is not possible to insert a finger into
the peritoneal cavity for palpation of the
inguinal region, we therefore rely entirely
upon inspection. The speramtic cord or
round ligament with attached cremaster
muscle is carefully elevated from its bed
by incising the very delicate cremaster fascia where internal oblique and cremaster
muscle fibers join. This allows inspection
of the area of direct inguinal hernia and by
gently retracting the inguinal ligament distally, the base of the femoral canal can be
adequately evaluated for the presence of
a femoral hernia. If this is carefully done,
the posterior inguinal wall is not injured
and it only adds a few minutes to the operating time. We have not found another
femoral hernia in an infant whom we have

507
operated upon for indirect inguinal hernia
but we have found two cases of concomitant direct inguinal hernia. One might point
out that these are isolated instances, and
this is true, but it does not take many mistakes to drastically affect one's recurrence
rate. In this series of 580 hernioplasties,
sixty-two were in infants and all have been
followed. The two femoral hernias missed,
make a recurrence rate of 3.2 per cent for
the infants. Had we missed the two with
concomitant direct inguinal hernias the
number would be four and a recurrence
rate of over 6 per cent, which would hardly
be acceptable.
In the two years prior to our change in
policy for the evaluation of the infant hernia, we were occasionally exploring the opposite side as recommended by Mueller
and Rader.33 Since we started the more
time consuming exploration of the inguinal
canal in the infant we have abandoned the
simultaneous exploration of the opposite
side. While it is true that bilateral persistence of the processus vaginalis is common,
many of these sacs are small and never receive a viscus to become a detectable hernia. In a personal communication, Doctor
Anson informs me that in 100 consecutive
cadavers examined, 20 per cent had a remnant of the processus vaginalis but no hernia. In our entire series, 12 per cent had
bilateral hernias repaired. Additive to this
were 6 per cent who had had a previous hernia operation on the opposite side, or who
subsequently returned to have a hernia repair on the opposite side. This makes a total
over-all incidence of bilaterality of 18 per
cent. It is possible that many of the incipient sacs discovered by exploring the
opposite side in infants and children would
never develop into a true hernia.
Our results of reconstruction of the posterior inguinal wall in the difficult hernias
(large indirect, direct and femoral) speak
for themselves and need not be commented
upon further except to say that we consider
this operation a restoration of normal in-

Annals of Surgery
McVAY AND CHAPP
508
October 1958
guinal anatomy. With the exception of ten had a second recurrence, four had a
femoral hernioplasty, all reconstructions of third recurrence and one had had four rethe posterior inguinal wall must include the currences.
relaxing incision (Haisted 14) to permit the
In the entire group, one had been in"slide" (Tanner 39 ). The importance of a jected with paraffin years before and, in
relaxing incision and the use of the rectus addition to his hernia, had enormous parafsheath has also been recognized by Fallis,9 finomas. Twelve cases in the whole series
Rienhoff 36 and Farris.10 The relaxing inci- had previously had a sclerosing solution insion permits the shift of rectus sheath into jected. For the uninitiated it is worth menthe position of a new posterior inguinal tioning that the patient who has previously
wall and the suture of this wall to Cooper's had the injection treatment may present a
ligament without tension. We also believe most difficult problem. The dense fusion of
in replacing the cord in its normal position all layers, including the elements of the
so that the obliquity of the inguinal canal spermatic cord, makes for a time consumis restored. In all but three of our re- ing, bloody and difficult hernia repair.
current hernias, with the original hernia
The mortality in this series of 580 herniooperation performed elsewhere, we found plasties was 0.5 per cent. Two of the three
the cord in the subcutaneous or Halsted I cases were due to pulmonary embolism:
position.
one, age 70, in 1947 and the other, age 65,
We have not seen a hernia or even a in 1948. The third death w\vas in a moribund
weakness develop in the rectus sheath de- 87-year-old man, in 1952, with an incarcerfect left by the relaxing incision. The rectus ated femoral hernia. He survived the opand pyramidalis muscles with their invest- eration under local anesthesia nicely but
ing fascia, which is a medial continuation succumbed on the fourth postoperative day
of the transversalis fascia, plus the overly- from uremia and congestive heart failure.
ing external oblique aponeurosis, would
When indicated we have not refused a
appear to be a very adequate bulwark patient a hernia operation because of
against herniation.
chronologic age, and many of our patients
We have never used fascial sutures, fas- have been elderly and operated upon under
cial grafts or skin as a patch in the repair local anesthesia. A hernia operation can
of a groin hernia. On four occasions when be performed under local infiltration and
the relaxing incision and slide would not regional block anesthesia comfortably and
work because of anatomic anomalies, we with very minimal risk. This is certainly
have used stainless steel wire mesh as part preferable to procrastination when the herof the repair in a manner similar to that nia is incapacitating or there is a history of
described by Koontz.2' In all primary her- incarceration.
nias and most recurrent hernias, the rectus
Summary
sheath in the vicinity of the relaxing incision is virgin territory and the slide is ac(1) A one to 11-year-follow up on 580
complished with ease. It is for this reason hernioplasties utilizing the methods previthat we feel that prostheses are unnecesously described by the senior author has
sary in the great majority of inguinal hernia been presented. The recurrences have been
operations.
itemized and analyzed. The follow up is 91
We have been able to follow all of our
per cent.
cases in whom we have repaired a recur(2) The results in 236 reconstructions of
rent hernia and none of these has had a
the posterior inguinal wall for difficult hersubsequent recurrence. Of the 45 recurrent nias are significant. A recurrence rate of
hernias repaired, 30 were a first recurrence, 0.85 per cent.

Volume 148

Number

HERNIOPLASTY
450

INGUINAL AND FEMORAL

(3) The less dramatic results in 344 abdomianl inguinal ring repairs for the simple
indirect inguinal hernia (recurrence rate of
3.2%) point out the importance of high
ligation of the sac with tight closure of the
abdominal inguinal ring; the experience
and judgment necessary to properly evaluate the posterior inguinal wall; and the significance of the missed femoral hernia.
(4) The inguinal ligament was not used
in any of the hernioplasties in this series.
(5) The relaxing incision should always
be used in reconstruction of the posterior
inguinal wall, femoral hernioplasties usually excepted.
Bibliography
1. Anson, B. J. and C. B. McVay: The Anatomy
of the Inguinal and Hypogastric Regions
of the Abdominal Wall. Anat. Rec., 70:211,
1938.
2. Idem: The Anatomy of the Inguinal Region.
Surg., Gynec. & Obst., 66:186, 1938.
3. Andrews, E. and A. D. Bissel: Direct Hernia:
A Record of Surgical Failures. Surg., Gynec.
& Obst., 58:753, 1934.
4. Burton, C. C.: The Critical Point of Cooper's
Ligament Hernia Repair. Am. J. Surg., 91:
215, 1956.
5. Clark, J. H. and E. I. Hashimoto: Utilization
of Henle's Ligament, Iliopubic Tract, Aponeurosis Transversus Abdominis and Cooper's Ligament in Inguinal Herniorrhaphy.
Surg., Gynec. & Obst., 82:480, 1946.
6. Clear, J. J.: Ten Year Statistical Study of Inguinal Hernias. Arch. Surg., 62:70, 1951.
7. Dickson, A. R.: Femoral Hernia. Surg., Gynec.
& Obst., 63:665, 1936.
8. Fallis, L. S.: Inguinal Hernia: A Report of
1,600 Operations. Ann. Surg., 104:403, 1936.
9. Idem: Direct Inguinal Hernia. Ann. Surg.,
107:572, 1938.
10. Farris, J. M., J. Eittinger and J. A. Weinberg:
Hernia Problem with Reference to Modification of the McVay Technique. Surgery, 24:
293, 1948.
11. Ferguson, A. H.: Oblique Inguinal Hernia:
Typic Operation for Its Radical Cure. J. A.
M. A., 33:6, 1899.
12. Ferguson, D. J.: Recurrence Following Inguinal and Femoral Hernia Operations.
Minn. Med., 32:697, 1949.

509

13. Gallaudet, B. B.: A Description of the Planes

of Fascia of the Human Body. New York,
Columbia Univ. Press, 1931.
14. Halsted, W. S.: The Cure of the More Difficult
as Well as the Simpler Inguinal Ruptures.
Bull. Johns Hopkins Hosp., 14:208, 1903.
15. Harkins, H. N.: A Cooper's Ligament Herniotomy: Clinical Experience in 322 Consecutive
Cases. Surg. Clin. North Am., 23:1279, 1943.
16. Idem: The Repair of Groin Hernias: Progress
in the Past Decade. Surg. Clin. North Am.,
29:1457, 1949.
17. Idem: Recent Advances in the Treatment of
Hernia. Ann. West. Med. & Surg., 6:221,
1952.
18. Harkins, H. N., D. E. Szilagyi, B. E. Brush
and F. R. Williams: Clinical Experiences
with the McVay Herniotomy. Surgery, 12:
364, 1942.
19. Harkins, H. N. and R. H. Schug: Hernial Repair Using Cooper's Ligament: Follow-up
Studies on 367 Operations. Arch. Surg., 55:
689, 1947.
20. Holloway, J. K. and R. J. Johnson: Some Observations on the Causes and Methods of
Repair of Direct and Recurring Inguinal
Hernias. West. J. of Surg., Obst. & Gynec.,
56:473, 1948.
21. Koontz, A. R.: The Use of Tantalum Mesh in
Inguinal Hernia Repair. Surg., Gynec. &
Obst., 92:101, 1951.
22. Idem: Views on the Choice of Operation for
Inguinal Hernia Repair. Ann. Surg., 143:868,
1956.
23. Lotheissen, G.: Zur Radikaloperation der
Schenkelhernien. Centrabl. f. Chir., 25:548,
1898.
24. Mattson, H.: Use of Rectus Sheath and Superior Pubic Ligament in Direct and Recurrent
Hernia. Surgery, 19:498, 1946.
25. McVay, C. B. and B. J. Anson: Aponeurotic
and Fascial Continuities in the Abdomen,
Pelvis and Thigh. Anat. Rec., 76:213, 1940.
26. Idem: Composition of the Rectus Sheath.
Anat. Rec., 77:213, 1940.
27. Idem: A Fundamental Error in Current Methods of Inguinal Herniorrhaphy. Surg., Gynec.
& Obst., 74:746, 1942.
28. Idem: Inguinal and Femoral Hernioplasty.
Surg., Gynec. & Obst., 88:473, 1949.
29. McVay, C. B.: A Fundamental Error in the
Bassini Operation for Direct Inguinal Hernia.
Univ. Hosp. Bull., Ann Arbor, 5:14, 1939.
30. Idem: Inguinal and Femoral Hernioplasty:
Anatomic Repair. Arch. Surg., 57:524, 1948.

McVAY AND CHAPP

510

31. Idem: The Pathologic Anatomy of the More

Common Hernias and Their Anatomic Repair. Springfield, Charles C Thomas, 1954.
32. Idem, Chapter 19: Hernia. Davis-Christopher's
Textbook of Surgery, Sixth Edition. Philadelphia, W. B. Saunders Co., 1956.
33. Mueller, C. B. and G. Rader: Inguinal Hernia
in Children. Arch. Surg., 73:595, 1956.
34. Potts, W. J., W. L. Riker and J. E. Lewis:
The Treatment of Inguinal Hernia in Infants
and Children. Ann. Surg., 132:556, 1950.
35. Rice, C. 0. and J. H. Strickler: The Repair of
Hernia: With Special Application of the
Principles Evolved by Bassini, McArthur and
McVay. Surg., Gynec. & Obst., 86:169, 1948.
36. Rienhoff, W. F.: The Use of the Rectus Fascia
for Closure of the Lower or Critical Angle

37.
38.

39.

40.
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Annals of Surgery
October 1958

of the Wound in the Repair of Inguinal Hernia. Surgery, 8:326, 1940.

Russel, R. H.: Inguinal Hernia and Operative
Procedure. Surg., Gynec. & Obst., 41:605,
1925.
Sanderson, D. and C. 0. Rice: The More
Common Methods of Inguinal Hernia Repair. A Comparison of the Recurrence Rates.
Minn. Med., 31:485, 1948.
Tanner, N. A.: "Slide" Operation for Inguinal
and Femoral Hernia. Brit. J. Surg., 29:285,
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Telle, L. D.: Inguinal and Femoral Hernia: A
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133, 1912.

DISCUSSION
DR. HENRY HARKINS: Dr. Gilchrist, Members
and Guests: Eighteen years ago this month, I had
the privilege of hearing a young assistant resident
on Dr. Coller's service talk in Detroit on the subject of hernia-not an unnecessary operation even
then, in 1940. Like St. Paul on the road to
Damascus, I saw the light, and have used his
technic ever since. That young assistant resident
was Dr. Chester B. McVay. Dr. McVay deserves
credit for having taken his ideas to the laboratory,
but even more for not having left them there. His
practical contributions to the subject of hernia, in
my opinion, rank with the best of our members,
past and present-Andrews, Halsted, Koontz, etc.
In brief, my ideas relating to groin hernia are
very similar to those of Dr. McVay. He and I are
of the same religion, right or wrong, so to speak.
I will comment briefly on only four aspects of his
talk:
First, regarding the "missed" femoral hemia, I
will agree that it is much more common than generally realized. The femoral region should be explored from within through the open indirect sac.

In three successive recurrent femoral hernias, my

operation was the 4th, 7th and 3rd, respectively.
There was no evidence the femoral hernias themselves had ever been touched in the 11 previous
operation for these unfortunate 3 patients. The
"missed" femoral hernia syndrome is more common in women, in my experience.
Second, I formerly did not utilize "transition
sutures" as described by Dr. McVay, for the area
between the internal ring laterally and the Cooper's ligament sutures medially. Now I do.
Third, we agree with Dr. McVay as to the
great importance of narrowing the internal ring.
Fourth, we agree as to the need of classifying
hernias into degrees of difficulty, making 4 categories, as shown below.
Only in Grade IV (most direct hernias, femoral
hernias, recurrent hernias, large, indirect hernias)
do we use the Cooper's ligament repair, in agreement with Dr. McVay.
Finally, to indicate one new approach to the
subject, we are trying out the use of the CheatleHenry transabdominal preperitoneal approach for

Foutr Grades of Hernia Repair

Cheatle-Henry Repair
Number

Fascial

Grade

Sac
Ligation

Internal

Closure,

Cooper's

Ring

Hessel-

Liga-

Tightening

bach's
Triangle

ment
Sutures

I. Infant
II. Simple
III. Interme-

***

diate
IV. Radical

*
*

*
*

Type of Hernia

of Cases

Indirect inguinal
Direct inguinal

44
29

F emoral

36
2

Sliding
*
*

Total
*

111 hernias

(84 patients)