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Hernia (2002) 6: 137­140 DOI 10.1007/s10029-002-0065-1

A PP L IE D AN A T OM Y

R. Bendavid

Sliding hernias

Received: 1 April 2002 / Accepted: 25 April 2002 / Published online: 10 July 2002 Ó Springer-Verlag 2002

Introduction

Nothing so tests the surgeon's knowledge of the anatomy of the inguinal region as a chance encounter with a sliding hernia. If Condon's [4] dictum ``The anatomy of the inguinal region is misunderstood by some surgeons at all levels of seniority'' is correct, it is safe to say that sliding hernias are understood by few surgeons at any level of seniority. Few surgical procedures have had so many illustrations attempting to explain the mechanism of the ``slide'' and its surgical treatment; yet they have served only to complicate and confuse the picture. What surgeon about to start a practice has not worried about a strangulated sliding hernia presenting in the middle of the night! ``Sliders'' are simple to treat ­ we will see why.

Definition

A sliding hernia is a protrusion through an abdominal wall opening of a retroperitoneal organ, with or without its mesentery, with or without an adjacent peritoneal sac. This organ may be the cecum, ascending colon, or appendix on the right side, the sigmoid colon on the left side, or the uterus, fallopian tubes, ovaries, ureters, and bladder on either side.

the condition in 1631; Spiegel reported cases in 1645 and 1680, followed by Arnaud (1732), who managed an ``old scrotal hernia with great difficulty, removing, in the process, the cecum and part of the colon and ileum in a patient who eventually recovered!'' [11]. Scarpa [20] in 1814 reported a cecum forming part of the wall of a hernial sac. William Mitchell Banks [1] (1843­1904) coined the term ``landslide of the cecum''; he was also the first proponent in England of complete removal of the hernial sac, declaring that ``the great object of the whole proceeding is to restore a uniform surface to the peritoneal wall and hence the higher up the sac is tied, the better the chance of this being permanent.'' Ironically, this thoroughness in excising the sac may well have contributed to the dangerous reputation of sliding hernias. Morris [16] (1895), Hotchkiss [10] (1909), Zimmerman and Laufman [23] (1942), and Maingot [14] (1961) emphasized the need to free the sliding hernia from the spermatic cord and to return the sac and viscus to the abdominal cavity. The idea of reperitonealization of a viscus outlined by Bevan [2] (1930) and many others can now be safely and assuredly discarded. The Laroque [13] counterincision (1932) is now considered unnecessary, since the convincing reports of Ryan [18, 19] and Glassow [6] and confirmation by Welsh [22].

Classification History

Galen (130­200 AD) gave us the first description of a sliding hernia involving the cecum. Rousteus mentioned The classification of sliding hernias in the past may have been partly responsible for some confusion. Since there are three types of sliding hernias, it is probably simplest to call them types I, II, and III in descending order of frequency. · Type I: any hernia in which part of the peritoneal sac is made up by the wall of a viscus. This is the commonest type and accounts for nearly 95% of sliding hernias. This type has also been referred to as intramural, parasaccular, and visceroparietal (Fig. 1).

R. Bendavid Department of Surgery, Laniado General Hospital, Netania Israel E-mail: [email protected] Tel.: +972-9-8604673 Fax: +972-9-8609517

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Fig. 1. Type I sliding inguinal hernia. The posterolateral aspect of the sac is made up of the cecum and ascending colon

Fig. 3. Type III sliding inguinal hernia: the sac is somewhat miniscule and may easily be overlooked. This is the most dangerous type, but fortunately the rarest (1/8­10,000)

· Type II: any hernia containing a retroperitoneal viscus and its mesentery, in which the mesentery forms part of the wall of the peritoneal sac. About 5% of sliding hernias are of this type, which has also been named intrasaccular, extrasaccular (a misnomer), and visceromesenteric (Fig. 2). · Type III: a protrusion of the viscus itself; the peritoneal sac may be very small or even absent. This is the rarest type and is found in only one of 8,000­10,000 hernia. This type is the most treacherous and its diagnosis requires a high index of suspicion. It has been described as extraperitoneal, sacless, and extrasaccular sliding hernia (Fig. 3). An additional type, although not truly a sliding hernia, is the so-called ``incipient slider.'' When the sac is opened, one can see the viscus, but it has not yet entered the internal inguinal ring. Pathophysiology The mechanism whereby the viscus or viscera ``slide'' has not been fully explained. Before the slide can take

place, however, there must be a widening of the internal inguinal ring; this is the precondition of an indirect inguinal hernia. Sir Arthur Keith (1866­1955) proposed that, developmentally, the cecum and ascending colon do not complete their rotation to the right side, and thus the cecum slides inferiorly toward not only the right but also the left internal inguinal ring [11]. Moschowitz [17] in 1925 presented his ``pulling-pushing'' mechanism whereby an inguinal sac enlarging through a widening internal ring exerts a pull on the cecum or ascending colon, whereas anterior structures such as the urinary bladder would be pushed through the posterior inguinal wall by intra-abdominal pressure. Graham [8] of Toronto suggested another possible mechanism: over long periods the layers of the mesentery (especially of the sigmoid) separate, allowing the bare posterior aspect of the viscus to slide and protrude through an enlarged internal ring. The common initial factor is always the widened internal inguinal ring.

Clinical characteristics

As observed by Ryan [18, 19], Glassow [6], and Welsh [22], sliding inguinal hernias account for 8% of groin hernias, with a left to right ratio of 4.5 to 1. Maingot [14], however, found a 1.5 to 1 preponderance of rightsided sliders. In the series of Ryan et al. [18, 19] 8% were bilateral, and women made up only 1% of the 3,000 patients analyzed; the average age of patients was 59.3 years, compared to 51 years for nonsliding hernias. After the age of 50 years the incidence of sliding hernias is 3.5 times more frequent. In 9% of patients there is a history of previous inguinal surgery, and 94% of sliders are easily reducible preoperatively. The size of these sliders is categorized as small (16%), medium (44%), and large (40%). Delay before coming to surgery is 11.8 years on average. The incidence of sliding inguinal hernias increases with the age of the patient, being nearly zero before the age of 30 years and increasing to as much as 20% after the age of 70 years.

Fig. 2. Type II sliding inguinal hernia. In this case the mesentery forms a part of the posterior wall of the sac. Note that part of the anterior wall of the cecum is also forming part of the posterior wall of the sac

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In the pediatric population boys are not subject to sliding hernias, whereas in ``female pediatric patients, inguinal hernias are usually sliding hernias'' with the mesosalpinx adherent to one side of the sac (type II) [12]. Frequently the ovary and/or fallopian tube is involved. The round ligament may be resected, but the sac itself must not be ligated ``high'' lest the ovary/tube be damaged. The incidence of sliders in girls was 21% in two series by Goldstein and Potts [7] and Gaus [5].

Discussion and operative technique

As early as 1955 Ryan [18] stated that ``too great an emphasis had been placed on removal of the hernial sac.'' To the surgical section of the Toronto Academy of Medicine the hallowed ground of Gallie and Graham, this was heresy. Nevertheless, Ryan substantiated his statement with a series of 313 cases: ``In 47% of the patients no sac was removed, in 43% only a part of the sac was removed. In the remaining 10% of the cases, the sliding hernia was small and most of the sac was removed'' [18]. Ryan also emphasized that the important step in the operation is to reconstruct the posterior inguinal wall in order to confine the sliding elements of the hernia to the preperitoneal space. This was achieved with a recurrence of less than 1%, at a time when one report from Philadelphia admitted to a recurrence rate of 55% [18]! Welsh [22], as if to consecrate his colleague, validated Ryan's large series with a yet larger series of 3,000 cases. These were culled from among 4,516 patients: incipient sliders were excluded (25%) as well as direct sliding hernias (1.5%) and ``unconfirmed'' sliding hernias (3%; by ``unconfirmed'' was meant that the sac was not opened for confirmation of the sliding nature of the hernia). The method of repair used was the Shouldice technique, but the Bassini repair and tension-free repairs (except for the plug) would have been appropriate. The plug, which has a depth of 4 cm, would cause concern, as it would be in contact with either sliding bowel or an iliac vessel. The iliac artery on the supine patient is usually 1­2 cm deep to the internal ring. In brief, the cremaster muscle is divided longitudinally for better access to the spermatic cord and internal ring. The cord is then separated from the sliding hernia sac, and the dissection stays close to the cord, its investing fascia and adipose tissue. The internal ring, already wide, allows separation of the transversalis fascia about the neck of the sac. It is important to realize at this stage that the posterior lamina of the transversalis fascia may in itself form a constricting ring around the hernia, separate from the anterior lamina of the transversalis fascia. Constricting tissue, if scarred, can be safely incised at the anterior or medial aspect of the constricting ring. The viscus is invariably found on the

posterior and lateral aspect of the internal inguinal ring. Gentle dissection in this area frees all adhesions and allows sac and sliding viscus to return to the preperitoneal space. If it can be done safely, the sac may be opened for inspection and then closed; it need not be resected. High ligation of the sac should never be attempted, as it is not necessary. A counterincision has never been needed. If in doubt as to the nature of a thick-walled sac, do not open it! It could be the wall of bowel, as seen in the sacless variety or type III slider. The remainder of the operation is devoted to the reconstruction of the posterior inguinal wall by the chosen technique of the operating surgeon. Follow-up revealed 16 recurrences out of 3,000 operations, an incidence of 0.5%. Six were femoral hernias, five direct inguinal hernias, and four appeared to be femoral hernias but were not operated on; only one was a true recurrent sliding indirect inguinal hernia.

Complications

Two patients died following surgery; one from a coronary thrombosis on the third postoperative day, the other from a cerebral hemorrhage 2 weeks after surgery. Not a single patient developed a bowel obstruction. Wound infection remained constantly below 1%.

Special considerations

In acute de novo strangulation, or strangulation of a chronic irreducible sliding inguinal hernia, the adhesions, inflammation, and edema between the cord and the viscus may blur the anatomical picture. The viscus may not be safely separated from the cord without the risk of perforation, which carries an associated mortality between 6% and 60%, depending on the age of the patient, the delay in diagnosis, and the degree of vascular compromise [15, 21]. It would not be unreasonable in these conditions to consider division of the cord, as close to the internal inguinal ring as feasible. The collateral circulation of the testicle is so abundant that loss of the testicle occurs in 0­37% of the cases, at the very worst [3, 9]. It would be, in any case, a small price to pay, considering the far graver risk of perforation. The medicolegal aspects of this situation should be explained to the patient prior to surgery so that the consent forms are signed with full understanding of possible perioperative decision-making. Sliding inguinal hernias are common, particularly in the aging population. They need not any longer engender the apprehension they once did, thanks to the contributions of Ryan. The brevity and simplicity of this review mirrors the present status of this once fearsome hernia.

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References

1. Banks WM (1887) Some statistics on operation for the radical cure of hernia. BMJ 1:1259 2. Bevan AD (1930) Sliding hernias of the ascending colon and caecum, the descending colon and sigmoid and of the bladder. Ann Surg 92:750­760 3. Bodhe YG (1959) Condition of the testicle after division of the cord in treatment of hernia. BMJ 6:1507­1510 4. Condon R (1995) The anatomy of the inguinal region and its relation to groin hernia. In: Nyhus LM, Condon RE (eds) Hernia, 4th edn. Lippincott, Philadelphia 5. Gans SL (1959) Sliding inguinal hernia in female infants. Arch Surg 79:109 6. Glassow F (1965) High ligation of the sac in indirect inguinal hernia. Am J Surg 109:460­463 7. Goldstein IR, Potts WJ (1958) Inguinal hernias in female infants and children. Ann Surg 148:819 8. Graham RR (1935) The operative repair of sliding inguinal hernia of the sigmoid. Ann Surg 102:784 9. Heifetz CJ (1971) Resection of the spermatic cord in selected inguinal hernias. Twenty years of experience. Arch Surg 102:36­39 10. Hotchkiss LW (1930) Large sliding hernias of the sigmoid. Ann Surg 92:750­760 11. Iason AH (1941) Hernia. Blakiston, Philadelphia

12. Koop CE (1957) Inguinal hernias in infants and children. Surg Clin North Am 1675­1682 13. Laroque GP (1932) Intra-abdominal method of removing inguinal and femoral hernia. Arch Surg 24:189 14. Maingot R (1961) Operations for sliding herniae and for large incisional herniae. Br J Clin Pract 15:993­1033 15. McNealy RW, Lichtenstein ME, Todd MA (1942) The diagnosis and management of incarcerated and strangulated hernias of the groin. Surg Gynecol Obstet 74:1005 16. Morris H (1895) Two cases of inguinal hernia presenting unusual characters. Lancet 7:979 17. Moschowitz AV (1925) The rational treatment of sliding hernia. Ann Surg 81:330 18. Ryan EA (1956) An analysis of 313 consecutive cases of indirect sliding inguinal hernias. Surg Gynecol Obstet 102:45­58 19. Ryan EA (1956) Indirect sliding inguinal hernias. Bulletin of the Academy of Medicine, February. Based on a talk to the Toronto Academy of Medicine Surgical Section on 13 October 1955 20. Scarpa A (1814) A treatise on hernia, transl Wishart JH. Longman, Hurst, Rees, et al., Edinburgh 21. Temple CO (1958) Incarcerated and strangulated femoral hernias. J Int Coll Surg 30:51 22. Welsh DRJ (1969) Repair of the indirect sliding inguinal hernias. J Abdom Surg 11:204­209 23. Zimmerman LM, Laufman H (1942) Sliding hernia. Surg Gynecol Obstet 75:76­78

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