Surgical physiology of inguinal hernia repair--a study of 200 cases

Abstract

Background: Current inguinal hernia operations are generally based on anatomical considerations. Failures of such operations are due to lack of consideration of physiological aspects. Many patients with inguinal hernia are cured as a result of current techniques of operation, though factors that are said to prevent hernia formation are not restored. Therefore, the surgical physiology of inguinal canal needs to be reconsidered.

Methods: A retrospective study is describer of 200 patients operated on for inguinal hernia under local anaesthesia by the author's technique of inguinal hernia repair.

Results: The posterior wall of the inguinal canal was weak and without dynamic movement in all patients. Strong aponeurotic extensions were absent in the posterior wall. The muscle arch movement was lost or diminished in all patients. The movement of the muscle arch improved after it was sutured to the upper border of a strip of the external oblique aponeurosis (EOA). The newly formed posterior wall was kept physiologically dynamic by the additional muscle strength provided by external oblique muscle to the weakened muscles of the muscle arch.

Conclusions: A physiologically dynamic and strong posterior inguinal wall, and the shielding and compression action of the muscles and aponeuroses around the inguinal canal are important factors that prevent hernia formation or hernia recurrence after repair. In addition, the squeezing and plugging action of the cremasteric muscle and binding effect of the strong cremasteric fascia, also play an important role in the prevention of hernia.

Figure 1

The medial leaf of the external oblique aponeurosis is sutured to the Inguinal ligament. 1) Medial leaf; 2) Interrupted sutures taken to suture the medial leaf to the inguinal ligament; 3) Pubic tubercle; 4) Abdominal ring; 5) Spermatic cord; and 6) Lateral leaf.

Figure 2

Undetached strip of external oblique aponeurosis forming the posterior wall of inguinal canal. 1) Reflected medial leaf after a strip has been separated; 2) Internal oblique muscle seen through the splitting incision made in the medial leaf; 3) Interrupted sutures between the upper border of the strip and conjoined muscle and internal oblique muscle; 4) Interrupted sutures between the lower border of the strip and the inguinal ligament; 5) Pubic tubercle; 6) Abdominal ring; 7) Spermatic cord; and 8) Lateral leaf.

Figure 3

Section of inguinal canal at rest. 1) External oblique aponeurosis, 2) Internal oblique muscle, 3) Transversus abdominis muscle, 4) Endo abdominal fascia, 5) Internal inguinal ring, 6) Iliopubic tract, 7) Inguinal ligament, 8) Pubic symphisis, 9) Spermatic cord, 10) Interparietal connective tissue (cremasteric fascia), 11) cremasteric muscle, 12) Aponeurotic layer of posterior inguinal wall, 13) Fascial layer of posterior inguinal wall

Figure 4

Changes during raised intra abdominal pressure. A) Contraction of transversus abdominis muscle pulls the posterior inguinal wall above and laterally creating tension in it (Dynamic shielding action), B) External oblique aponeurosis and posterior inguinal wall come closer (anterior-posterior compression action), C) Squeezing action and pulling effect of cremasteric muscle, D) Dense and strong cremasteric fascia exerts binding effect on structures in the inguinal canal for their optimal dynamic movements.

Figure 5

Flow chart.