Inguinal Hernia. Controversies
CONTROVERSIES
36. What are some of the anatomic issues related to inguinal hernias?
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At issue is the iliopubic tract, which is central to the Anson/McVay anatomic description of the inguinal area and featured in the McVay Cooper’s ligament repair. Although the McVay repair is used in England, the iliopubic tract is not referred to or described in English anatomic texts.
The term conjoined tendon, although commonly used, is considered by many to be anatomically inaccurate and misleading. The internal oblique and transversus abdominis muscles that make up the conjoined tendon are obvious and can be used surgically either alone or together. The tendinous edge of the transversus abdominis muscle and the tendinous edge of the internal oblique muscle start at their insertion on the pubic tubercle and course laterally and superiorly to the medial edge of the internal ring. At this point, the tendinous elements diminish, leaving only muscle tissues, and continue laterally and superiorly to their origins.
Whether the lacunar ligament or the iliopubic tract defines the medial border of the femoral canal is controversial. The compromise position is that the iliopubic tract is the border whereas in the normal unstretched state, the lacunar ligament (Gimbernat’s ligament) is the border in the presence of hernia (stretched state). At surgery it is enough to say that a palpable, visible curved ligament is present and used in some femoral repairs.
37. What are some surgical issues in the repair of inguinal hernias?
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The controversy over implanting mesh, as in the Lichtenstein repair, has been resolved in favor of mesh. Another controversy concerns the use of the laparoscope for hernia repair. A further issue is intra-abdominal or preperitoneal placement of mesh. At present, most surgeons accept laparoscopic repair as an alternative for preperitoneal hernia repair. The indications for a preperitoneal approach to hernia repair are still being defined, although the preperitoneal approach is acceptable for repair of recurrent hernia and unusually large or difficult hernias. The preperitoneal approach is used with increasing frequency for repair of femoral hernias. The repair should be appropriate to the circumstance of the hernia. Thus, hernia location and size as well as the patient’s age, general condition, and recurrence status should be factored into the strategy of repair.
References
BIBLIOGRAPHY
1. Avisse C, Delattre JF, Flament JB: The inguinal rings. Surg Clin North Am 80:49-69, 2000. Medline Similar articles
2. Avisse C, Delattre JF, Flament JB: The inguinofemoral area from a laparoscopic standpoint. History, anatomy, and surgical applications. Surg Clin North Am 80:35-48, 2000. Medline Similar articles
3. Bendavid R, Howarth D: Transversalis fascia rediscovered. Surg Clin North Am 80:25-33, 2000. Medline Similar articles
4. Collaboration EH: Laparoscopic compared with open methods of groin hernia repair: Systematic review of randomized controlled trials. Br J Surg 87:860-867, 2000. Medline Similar articles Full article
5. Collaboration EH: Mesh compared with non-mesh methods of open groin hernia repair. Systematic review of randomized controlled trials. Br J Surg 87:854-859, 2000. Medline Similar articles Full article
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
