HOWIDOIT
Sutureless Repair of Inguinal Hernia Arthur I. Gilbert,
MD,
Sutureless repair is successful for all but the largest of indirect iqguinal hernias. After reduction of the peritoneal sac, the presenting indirect component of the hernia is immediately resolved by placement of a polypropylene mesh through the internal ring. The posterior wall is reinforced with a second swatch of Pmlene mesh to prevent hemiation, which often results from future degenerative changes. Both swatches of mesh are held in place in separate tissue planes by the body’s internal hydrostatic forces. Being sutureless, no tension is placed on any layer, there is no damage to tissues from an errant suturing technique. This procedure has been used in 412 of the 1,091 inguinal hernia repairs over the past 36 months.
FACS,SouthMiami,Florida
ifferent techniques of inguinal hernia repair have gained acceptance based on their statistical or theoD retic advantages. Common to each technique has been the undesirable result caused by errors of surgical commission [I]. Needle holes and tension created by suture material on tissues destroy the valuable sling and shutter mechanisms [2,3]. These tissues eventually weaken, and the repair fails. It has been possible to perform excellent repairs without sutures for all but the largest indirect inguinal hernias using two swatches of polypropylene mesh. The repair was performed by forming one swatch into an umbrella plug, placing it through and immediately deep to the internal ring. The position of the graft was confirmed radiographically in a number of patients early in the trial period of this technique. The other swatch that covered the canal’s posterior wall was an overlay graft. Suturing the grafts was unnecessary because each was held in place between flat tissue layers. Fibroblastic activity penetrates the interstices of the mesh and secures it permanently in place. The author has confirmed in lab ratory animals the assertion by Tyrell et al [4] that the inflammatory response to polypropylene mesh is no different than it is to polypropylene suture material (Figures 1 and 2). This technique, performed with local or epidural anesthesia on ambulatory patients, has been used to repair 412 inguinal hernias in the past 3 years. Patients reported only minimal discomfort and returned to full activity almost immediately. Only one recurrence has been seen in this closely followed group. This technique was used to repair small and medium-sized indirect hernias that had an internal ring that did not exceed one fingerbreadth (type 1 and type 2). This represents 75% of all indirect inguinal hernias seen [5]. The refinements of this concept represent an improved version of the previous technique in which, by the anterior approach, a prosthetic rolled plug passed through the internal ring is used to contain the peritoneal sac, followed by suture reinforcement of the posterior wall [6J. TECHNIQUE
Requcats for reprints should be addressed to Arthur I. Gilbert, MD, FACS, 6280 &met Drive, Suite 410, Swtb Miami, Florida 33143. Manuscript submitted November 9, 1990, and accepted in revised form February 13.1991.
THE AMERICAN
Forty to 60 mL of local anesthetic field block of chloroprocaine, bupivacaine hydrochloride with neutralizing sodium bicarbonate, or a single injection epidural is used, A low inguinal incision is made through the skin and subcutaneous tissues. The external oblique aponeurosis (EOA) is opened through the external ring. The cremasteric branch of the ilioinguinal nerve, when identifiable, is retracted with one of the flaps of the EOA. The cremasteric fascia is opened, and its medial flap excised. The lateral flap containing the external spermatic vessels and the genital branch of the genitofemoral nerve are preserved. The spermatic cord is secured with a soft drain. The integrity of the posterior wall is established. The
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OF SURGERY
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MARCH
1992
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to knotted rlalfroma
Ftgure 2 Tissue reaction pyknemeshfromarabbit
internal spermatic fascia surrounding the spermatic cord is opened. The entire peritoneal sac, sliding-type or otherwise, if not tightly adherent to the cord’s vascularity, is separated from all adhesions to the cord and from the investing fibers of the transversalis fascia at the internal ring. If removing the sac completely from the spermatic cord creates the potential for devascularization of the testicle, only the most proximal portion of the sac is dissected and divided [7j. If the internal ring does not exceed one fmgerbreadth in width, the sutureless repair is performed. The intact peritoneal sac or its proximal ligated stump is invaginated through the internal ring and 332
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
relocated within the abdominal cavity. A 2’S X 2’55 inch swatch of polypropylene is cut and shaped like an umbrella (Figore 3). The umbrella plug is inserted through the internal ring and positioned immediitely deep to the muscles and transversalis fascia of the posterior wall of the canal. When the carrier hemostats are released, the umbrella plug unfolds and quickly becomes attached to tissues surrounding the deep surface of the internal ring (Figure 4). In that position, except for the spermatic vessels and vas deferens, reduced lipomas and the peritoneal sac are completely blocked from hemiation. The awake patient is encouraged to try to push the 163
MARCH
1992
SUTURELESS
REPAIR OF INGUINAL HERNIA
3. Placement
2. Forming the umbrella plug I
Evatuatlon for a plug grat;
4. Umbrella plug in place
Flgwo 4. Radiopaque hemocltps placedonibfolr-oftheunbdrclplUg-ti~ snknlapfCmmmotlheqeftalta thecmylnghC#nomthesbwnrs moved.Thecird@kKlcatssthelocatlon of the internal ring.
sac out by coughing and straining; the more the patient coughs and strains, the more securely fmed the umbrella plug becomes. Instant cure of the indirect component is evident. No sutures are used in the sac, the graft, or the posterior wall at the internal ring, or elsewhere. The canal’s posterior wall is reinforced by placing a second swatch of Prolene mesh without sutures against its anterior surface. Through a slit in this swatch, the prosthetic graft is positioned inferior, medial, lateral, and superior to the internal ring @gore 5). The cord is replaced anterior to the overlay graft. Suturing the graft is unnecessary because placement of the spermatic cord over it and closure of the EOA with interrupted absorbable sutures secures the overlay graft to the underlying posterior wall. The subcutaneous and subcuticular closures are done with absorbable suture, and the skin closure is comple-
mented by Steristrips. Patients who underwent local anesthesia exercise immediately on the operating table, and those who had epidural anesthesia are observed in the recovery room for an hour after the procedure. All patients are discharged from the ambulatory facility within 2 hours of their procedure. RESULTS In the 36-month period between August 1987 and July 1990, the sutureless technique was used by the author in 378 patients, 25 (6.5%) females and 353 (93.5%) males. Four hundred twelve total repairs were performed, of which 383 (93%) were for primary hernias and 29 (7%) were for hernias that had recurred from 1 to 5 times. Patients’ ages ranged from 16 years to 85 years with a mean age of 48 years. Eleven patients were in the second
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5. (1) htemal ring with umbrella plug g-aft in place. (2) Paddk shapadgraftcutinqpwoneWf.(3) overlay gaft placed ovw the canal fhxwandundwthespermaticcord (suhreh9ss). (4) External oblique layer rwpproximatd with suture. Fipe
decade of life, 51 in the third decade of life, 63 in the fourth decade of life, 62 in the fifth decade of life, 70 in the sixth decade of life, 72 in the seventh decade of life, 40 in the eighth decade of life, and 9 in the ninth decade of life. The significant herniating component was indirect in 412 (100%) repairs. Complications include 10 hematomas, 8 seromas, and 2 wound infections. Testicular atrophy has not been encountered; however, one patient had significant testicular swelling. Only a minimal amount of postoperative analgesics was necessary. One failure oo curred in a patient whose original repair was performed elsewhere and a type 2 recurrent hernia was found. Because the floor of the canal was thick and appeared strong, only an umbrella plug was used to repair the recurrence. Eighteen months later, this patient presented with a new recurrence lateral to the internal ring. Compliance in the first 260 patients in this series has been 88% (229 patients), which was verified in 210 patients (81%) by personal examination and in 18 patients (7%) by telephone interview. As of July 1990,3 1 (12%) patients had not been reevaluated. COMMENTS Prior to the past 100 years, hernia repair was performed ineffectively by surgeons who operated onlysuperficial to the EOA, never violating the intact external inguinal ring [ 7j. Bassini, Hal&d, and Marcy framed for future surgeons the realization that the best chance for permanent cure of inguinal hernia rested on sound reconstruction or reinforcement of the canal’s posterior wall. Ill-fated techniques were reported in the early part of the 20th century. These warned of a “not to be disturbed” sphincteric mechanism of the canal musculature. Russell [8] in 1906 claimed that removal of the peritoneal sac was the only element necessary for total cure. For many surgeons of that era, it was preferable to leave unaltered a widened internal ring and not to reinforce the otherwise intact posterior inguinal wall. As a result of their errant thinking, a high incidence of direct hernia recurrences was noted [3]. Realization of the need to repair or rein-
force the posterior inguinal wall was unarguably reestab lished. Thii canon of hernia repair has been repeatedly ratified but not without cost [1,9-121. Needle holes created by approximation of the sutured “conjoined tendon” to the inguinal ligament in the classic Bassini operation have been responsible for initiating future direct herniation. My own observations about the cause of recurrent hernia are essentially the same as those described by others [I JO]. One cannot discount those iatrogenic errors of commission any more than one can deny the inevitability of the processes of aging and tissue degeneration, specifically, in the matter of collagen metabolism [131. Whether left unaltered or reinforced by suture approximation, the posterior wall in many patients will weaken, disrupt, and eventually herniate. Therefore, its reinforcement is advisable whenever hernia surgery is performed. The technique of hemiorrhaphy described here is new; it is performed without suturing either those tissues essential for the repair or the prosthetic plug used to effect the repair. In an earlier report, I described for the first time the technique using a sutured rolled plug through the internal ring [ 141. Although both are approached anteriorly and both are inserted through the internal ring, the umbrella plug represents two improvements in the sutured rolled plug technique. Prolene mesh that is less dense than Marlex conforms more easily to the posterior inguinal wall. Also, the opened umbrella configuration attaches itself to the deep side of the abdominal wall in a greater circumference than did the previous rolled plug. The value of a prosthetic support to the posterior wall of the canal and the internal ring has been appreciated by many authors who approached the internal ring posteriorly to do a preperitoneal repair [13,15,16]. This updated technique satisfies the need to support the posterior wall against future direct hemiation while immediately curing the indirect hernia. Both are accomplished without potentially damaging sutures. By not altering the valuable shutter or sling mechanisms and by avoiding needle and suture holes in the musculature, several identifiable
334
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OF SURGERY
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causes of recurrent hemiation are eliminated. Preservation of the lateral flap of the cremasteric fascia leaves intact the genital branch of the genitofemoral nerve and the external spermatic vessels. This results in fewer postoperative complaints of annoying neuralgia or numbness in the skin of the upper inner thigh or the lateral aspect of the scrotum. Concern regarding a relaxing incision is unnecessary because a completely tension-free repair has been performed. CONCLUSIONS A technique of sutureless and tensionless repair has been described. It avoids errors of commission while preserving the sling and shutter mechanisms of the canal. In 36 months, the author performed 1,09 1 hernia repairs, of which 412 were done with the sutureless technique. The repair can he used for primary and recurrent hernias. One recurrence has been noted in a patient who underwent repair for a recurrent hernia. Admittedly, the follow-up period has been short. This procedure has proved quite satisfactory and can be performed in about 40% of patients presenting with primary or recurrent hernias and in 75% of those patients with indirect hernias encountered in the usual surgical practice.
REFERENCES 1. Zimmerman L. Recurrent inguinal hernia. Surg Clin North Am 1971; 51: 317-24.
2. Lytle W. Internal inguinal ring. Br J Surg 1945; 32: 441-6. 3. Andrews E. A method of hemiotomy utilizing only white fascia. Ann Surg 1924; 880: 225-38. 4. Tyrell J, Silberman H, Chandrasoma P, Niland J, Shull J. Absorbable versus permanent mesh in abdominal operations. Surg Gynecol Obstet 1989; 168: 227-32. 5. Gilbert A. Prosthetic adjuncts to groin hernia repair: a classitication of inguinal hernias. Contemporary Surg 1988; 32: 128-35. 6. Gilbert A. An anatomic and functional classification for the diagnosis and treatment of inguinal hernia. Am J Surg 1989; 157: 331-3. 7. Read R. The development of inguinal hemiorrhaphy. Surg Clin North Am 1984; 64: 185-96. 8. Russell RH. The saccular theory of hernia and the radical operation. Lancet 1906; 2: 1197-203. 9. Donahue P. Surgical repair of groin and ventral hernia: the rationale and strategy of treatment. Adv Surg 1981; 15: 93-121. 10. McVay C. Inguinal hemioplasty-common mistakes and pitfalls. Surg Clin North Am 1966; 46: 1089-100. 11. McVay C. Inguinal and femoral hernioplasty. Arch Surg 1970; 101: 127-35. 12. Griffith C. Marcy repair of indirect inguinal hernia. Surg Clin North Am 1971; 51: 1309-16. 13.Peacock E. Internal reconstruction of the pelvic floor for recurrent groin hernia. Ann Surg 1984; 200: 321-7. 14. Gilbert A. Overnight hernia repair: updated considerations. South Med J 1987; 80: 191-5. 15. Stoppa R. The treatment of complicated groin and incisional hernias. World J Surg 1989; 13: 545-54. 16. Rignault D. Properitoneal prosthetic inguinal hemioplasty through a pfannenstiel approach. Surg Gynecol Obstet 1986; 163: 465-8.
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VOLUME 163 MARCH 1992
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Sutureless Repair of Inguinal Hernia Arthur I. Gilbert,
MD,
Sutureless repair is successful for all but the largest of indirect iqguinal hernias. After reduction of the peritoneal sac, the presenting indirect component of the hernia is immediately resolved by placement of a polypropylene mesh through the internal ring. The posterior wall is reinforced with a second swatch of Pmlene mesh to prevent hemiation, which often results from future degenerative changes. Both swatches of mesh are held in place in separate tissue planes by the body’s internal hydrostatic forces. Being sutureless, no tension is placed on any layer, there is no damage to tissues from an errant suturing technique. This procedure has been used in 412 of the 1,091 inguinal hernia repairs over the past 36 months.
FACS,SouthMiami,Florida
ifferent techniques of inguinal hernia repair have gained acceptance based on their statistical or theoD retic advantages. Common to each technique has been the undesirable result caused by errors of surgical commission [I]. Needle holes and tension created by suture material on tissues destroy the valuable sling and shutter mechanisms [2,3]. These tissues eventually weaken, and the repair fails. It has been possible to perform excellent repairs without sutures for all but the largest indirect inguinal hernias using two swatches of polypropylene mesh. The repair was performed by forming one swatch into an umbrella plug, placing it through and immediately deep to the internal ring. The position of the graft was confirmed radiographically in a number of patients early in the trial period of this technique. The other swatch that covered the canal’s posterior wall was an overlay graft. Suturing the grafts was unnecessary because each was held in place between flat tissue layers. Fibroblastic activity penetrates the interstices of the mesh and secures it permanently in place. The author has confirmed in lab ratory animals the assertion by Tyrell et al [4] that the inflammatory response to polypropylene mesh is no different than it is to polypropylene suture material (Figures 1 and 2). This technique, performed with local or epidural anesthesia on ambulatory patients, has been used to repair 412 inguinal hernias in the past 3 years. Patients reported only minimal discomfort and returned to full activity almost immediately. Only one recurrence has been seen in this closely followed group. This technique was used to repair small and medium-sized indirect hernias that had an internal ring that did not exceed one fingerbreadth (type 1 and type 2). This represents 75% of all indirect inguinal hernias seen [5]. The refinements of this concept represent an improved version of the previous technique in which, by the anterior approach, a prosthetic rolled plug passed through the internal ring is used to contain the peritoneal sac, followed by suture reinforcement of the posterior wall [6J. TECHNIQUE
Requcats for reprints should be addressed to Arthur I. Gilbert, MD, FACS, 6280 &met Drive, Suite 410, Swtb Miami, Florida 33143. Manuscript submitted November 9, 1990, and accepted in revised form February 13.1991.
THE AMERICAN
Forty to 60 mL of local anesthetic field block of chloroprocaine, bupivacaine hydrochloride with neutralizing sodium bicarbonate, or a single injection epidural is used, A low inguinal incision is made through the skin and subcutaneous tissues. The external oblique aponeurosis (EOA) is opened through the external ring. The cremasteric branch of the ilioinguinal nerve, when identifiable, is retracted with one of the flaps of the EOA. The cremasteric fascia is opened, and its medial flap excised. The lateral flap containing the external spermatic vessels and the genital branch of the genitofemoral nerve are preserved. The spermatic cord is secured with a soft drain. The integrity of the posterior wall is established. The
JOURNAL
OF SURGERY
VOLUME
163
MARCH
1992
331
to knotted rlalfroma
Ftgure 2 Tissue reaction pyknemeshfromarabbit
internal spermatic fascia surrounding the spermatic cord is opened. The entire peritoneal sac, sliding-type or otherwise, if not tightly adherent to the cord’s vascularity, is separated from all adhesions to the cord and from the investing fibers of the transversalis fascia at the internal ring. If removing the sac completely from the spermatic cord creates the potential for devascularization of the testicle, only the most proximal portion of the sac is dissected and divided [7j. If the internal ring does not exceed one fmgerbreadth in width, the sutureless repair is performed. The intact peritoneal sac or its proximal ligated stump is invaginated through the internal ring and 332
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
relocated within the abdominal cavity. A 2’S X 2’55 inch swatch of polypropylene is cut and shaped like an umbrella (Figore 3). The umbrella plug is inserted through the internal ring and positioned immediitely deep to the muscles and transversalis fascia of the posterior wall of the canal. When the carrier hemostats are released, the umbrella plug unfolds and quickly becomes attached to tissues surrounding the deep surface of the internal ring (Figure 4). In that position, except for the spermatic vessels and vas deferens, reduced lipomas and the peritoneal sac are completely blocked from hemiation. The awake patient is encouraged to try to push the 163
MARCH
1992
SUTURELESS
REPAIR OF INGUINAL HERNIA
3. Placement
2. Forming the umbrella plug I
Evatuatlon for a plug grat;
4. Umbrella plug in place
Flgwo 4. Radiopaque hemocltps placedonibfolr-oftheunbdrclplUg-ti~ snknlapfCmmmotlheqeftalta thecmylnghC#nomthesbwnrs moved.Thecird@kKlcatssthelocatlon of the internal ring.
sac out by coughing and straining; the more the patient coughs and strains, the more securely fmed the umbrella plug becomes. Instant cure of the indirect component is evident. No sutures are used in the sac, the graft, or the posterior wall at the internal ring, or elsewhere. The canal’s posterior wall is reinforced by placing a second swatch of Prolene mesh without sutures against its anterior surface. Through a slit in this swatch, the prosthetic graft is positioned inferior, medial, lateral, and superior to the internal ring @gore 5). The cord is replaced anterior to the overlay graft. Suturing the graft is unnecessary because placement of the spermatic cord over it and closure of the EOA with interrupted absorbable sutures secures the overlay graft to the underlying posterior wall. The subcutaneous and subcuticular closures are done with absorbable suture, and the skin closure is comple-
mented by Steristrips. Patients who underwent local anesthesia exercise immediately on the operating table, and those who had epidural anesthesia are observed in the recovery room for an hour after the procedure. All patients are discharged from the ambulatory facility within 2 hours of their procedure. RESULTS In the 36-month period between August 1987 and July 1990, the sutureless technique was used by the author in 378 patients, 25 (6.5%) females and 353 (93.5%) males. Four hundred twelve total repairs were performed, of which 383 (93%) were for primary hernias and 29 (7%) were for hernias that had recurred from 1 to 5 times. Patients’ ages ranged from 16 years to 85 years with a mean age of 48 years. Eleven patients were in the second
THE AMERICAN JOURNAL OF SURGERY
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5. (1) htemal ring with umbrella plug g-aft in place. (2) Paddk shapadgraftcutinqpwoneWf.(3) overlay gaft placed ovw the canal fhxwandundwthespermaticcord (suhreh9ss). (4) External oblique layer rwpproximatd with suture. Fipe
decade of life, 51 in the third decade of life, 63 in the fourth decade of life, 62 in the fifth decade of life, 70 in the sixth decade of life, 72 in the seventh decade of life, 40 in the eighth decade of life, and 9 in the ninth decade of life. The significant herniating component was indirect in 412 (100%) repairs. Complications include 10 hematomas, 8 seromas, and 2 wound infections. Testicular atrophy has not been encountered; however, one patient had significant testicular swelling. Only a minimal amount of postoperative analgesics was necessary. One failure oo curred in a patient whose original repair was performed elsewhere and a type 2 recurrent hernia was found. Because the floor of the canal was thick and appeared strong, only an umbrella plug was used to repair the recurrence. Eighteen months later, this patient presented with a new recurrence lateral to the internal ring. Compliance in the first 260 patients in this series has been 88% (229 patients), which was verified in 210 patients (81%) by personal examination and in 18 patients (7%) by telephone interview. As of July 1990,3 1 (12%) patients had not been reevaluated. COMMENTS Prior to the past 100 years, hernia repair was performed ineffectively by surgeons who operated onlysuperficial to the EOA, never violating the intact external inguinal ring [ 7j. Bassini, Hal&d, and Marcy framed for future surgeons the realization that the best chance for permanent cure of inguinal hernia rested on sound reconstruction or reinforcement of the canal’s posterior wall. Ill-fated techniques were reported in the early part of the 20th century. These warned of a “not to be disturbed” sphincteric mechanism of the canal musculature. Russell [8] in 1906 claimed that removal of the peritoneal sac was the only element necessary for total cure. For many surgeons of that era, it was preferable to leave unaltered a widened internal ring and not to reinforce the otherwise intact posterior inguinal wall. As a result of their errant thinking, a high incidence of direct hernia recurrences was noted [3]. Realization of the need to repair or rein-
force the posterior inguinal wall was unarguably reestab lished. Thii canon of hernia repair has been repeatedly ratified but not without cost [1,9-121. Needle holes created by approximation of the sutured “conjoined tendon” to the inguinal ligament in the classic Bassini operation have been responsible for initiating future direct herniation. My own observations about the cause of recurrent hernia are essentially the same as those described by others [I JO]. One cannot discount those iatrogenic errors of commission any more than one can deny the inevitability of the processes of aging and tissue degeneration, specifically, in the matter of collagen metabolism [131. Whether left unaltered or reinforced by suture approximation, the posterior wall in many patients will weaken, disrupt, and eventually herniate. Therefore, its reinforcement is advisable whenever hernia surgery is performed. The technique of hemiorrhaphy described here is new; it is performed without suturing either those tissues essential for the repair or the prosthetic plug used to effect the repair. In an earlier report, I described for the first time the technique using a sutured rolled plug through the internal ring [ 141. Although both are approached anteriorly and both are inserted through the internal ring, the umbrella plug represents two improvements in the sutured rolled plug technique. Prolene mesh that is less dense than Marlex conforms more easily to the posterior inguinal wall. Also, the opened umbrella configuration attaches itself to the deep side of the abdominal wall in a greater circumference than did the previous rolled plug. The value of a prosthetic support to the posterior wall of the canal and the internal ring has been appreciated by many authors who approached the internal ring posteriorly to do a preperitoneal repair [13,15,16]. This updated technique satisfies the need to support the posterior wall against future direct hemiation while immediately curing the indirect hernia. Both are accomplished without potentially damaging sutures. By not altering the valuable shutter or sling mechanisms and by avoiding needle and suture holes in the musculature, several identifiable
334
163
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
MARCH
1992
SUTURELESSREPAIROFINGUINALHERNIA
causes of recurrent hemiation are eliminated. Preservation of the lateral flap of the cremasteric fascia leaves intact the genital branch of the genitofemoral nerve and the external spermatic vessels. This results in fewer postoperative complaints of annoying neuralgia or numbness in the skin of the upper inner thigh or the lateral aspect of the scrotum. Concern regarding a relaxing incision is unnecessary because a completely tension-free repair has been performed. CONCLUSIONS A technique of sutureless and tensionless repair has been described. It avoids errors of commission while preserving the sling and shutter mechanisms of the canal. In 36 months, the author performed 1,09 1 hernia repairs, of which 412 were done with the sutureless technique. The repair can he used for primary and recurrent hernias. One recurrence has been noted in a patient who underwent repair for a recurrent hernia. Admittedly, the follow-up period has been short. This procedure has proved quite satisfactory and can be performed in about 40% of patients presenting with primary or recurrent hernias and in 75% of those patients with indirect hernias encountered in the usual surgical practice.
REFERENCES 1. Zimmerman L. Recurrent inguinal hernia. Surg Clin North Am 1971; 51: 317-24.
2. Lytle W. Internal inguinal ring. Br J Surg 1945; 32: 441-6. 3. Andrews E. A method of hemiotomy utilizing only white fascia. Ann Surg 1924; 880: 225-38. 4. Tyrell J, Silberman H, Chandrasoma P, Niland J, Shull J. Absorbable versus permanent mesh in abdominal operations. Surg Gynecol Obstet 1989; 168: 227-32. 5. Gilbert A. Prosthetic adjuncts to groin hernia repair: a classitication of inguinal hernias. Contemporary Surg 1988; 32: 128-35. 6. Gilbert A. An anatomic and functional classification for the diagnosis and treatment of inguinal hernia. Am J Surg 1989; 157: 331-3. 7. Read R. The development of inguinal hemiorrhaphy. Surg Clin North Am 1984; 64: 185-96. 8. Russell RH. The saccular theory of hernia and the radical operation. Lancet 1906; 2: 1197-203. 9. Donahue P. Surgical repair of groin and ventral hernia: the rationale and strategy of treatment. Adv Surg 1981; 15: 93-121. 10. McVay C. Inguinal hemioplasty-common mistakes and pitfalls. Surg Clin North Am 1966; 46: 1089-100. 11. McVay C. Inguinal and femoral hernioplasty. Arch Surg 1970; 101: 127-35. 12. Griffith C. Marcy repair of indirect inguinal hernia. Surg Clin North Am 1971; 51: 1309-16. 13.Peacock E. Internal reconstruction of the pelvic floor for recurrent groin hernia. Ann Surg 1984; 200: 321-7. 14. Gilbert A. Overnight hernia repair: updated considerations. South Med J 1987; 80: 191-5. 15. Stoppa R. The treatment of complicated groin and incisional hernias. World J Surg 1989; 13: 545-54. 16. Rignault D. Properitoneal prosthetic inguinal hemioplasty through a pfannenstiel approach. Surg Gynecol Obstet 1986; 163: 465-8.
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