Radical Cure of Hernia.

—From the earliest times rude and crude methods of endeavoring to effect a radical cure of hernia have been in vogue. While sometimes effective they have always been dangerous and always clumsy. Not until the antiseptic method was introduced could they be regarded as in any way safe or reliable. With the introduction of Listerism it became practicable to do this work, upon principles simple in character and ordinarily easy of performance, which may be summed up in the formula: Isolation and obliteration of the hernial sac, with permanent closure of the hernial outlet. Easy as such description may sound it has been found more or less difficult in practice, and numerous methods, apparently both simple and ingenious, have proved defective and have called for the most pronounced modification. Considerable space could be devoted to operations for radical cure, but the intent here shall be to simplify the subject as well as the method, and consequently but two or three will be described. Suffice it to say that while all are based on the same principle they vary somewhat in detail, and that some of these details have to be adapted to the special requirements of individual cases.

With increase in experience has come enlarged confidence in the operation, and it is now regarded as justifiable in nearly every instance among individuals otherwise in good condition. It has a double purpose—namely, the avoidance of the danger of sudden strangulation and the riddance of necessity for wearing trusses, or suffering the discomforts of hernia without any mechanical control. Some modern methods include the utilization of some portion or all of the sac, while in others it is entirely cut away. Consequently some operators have endeavored to utilize such portion of the sac as could be made available for either purpose, either as plug or suture material.

The method of Bassini for relief of inguinal hernia, more or less modified to meet individual demands, seems to have become of late years the most popular and widely adopted. The incision is made over the most prominent part of the tumor, extending as far downward upon the scrotum as necessary, and upward to near the anterior superior spine. Through it the external ring, with its pillars, is exposed, and then the sac, by a dissection long and sufficiently wide to fully reveal it. The exposure is made more complete by dissection of the aponeurosis of the external oblique from the level of the external ring upward and outward for an inch or so above the external ring. By seizing the edges of the aponeurosis on each side with forceps and retracting there is now afforded an excellent view of the hernia proper. (See Fig. 611.)

By careful dissection the sac and cord are identified and isolated, while the sac is opened and its edges held apart by forceps, after which it is carefully separated from the other structures of the cord. After thus isolating the sac, and with the least possible disturbance of the cord and of the testicle, it is ligated as high as the internal ring, or, if possible, higher yet. This leaves the cord uninjured; its size should next be reduced by cutting away all superfluous tissue. Some operators remove all the veins, but this seems unpromising and dangerous.

By all this dissection and reduction the inguinal canal has been temporarily, cleared, and the sac having been elevated, ligated, and cut away it becomes now a question of what to do with the cord. The lower surfaces of the external oblique and of Poupart’s ligament are next freed, the edge of the internal oblique, of the transversalis with its fascia, the outer border of the rectus and the conjoined tendon being all exposed to view by whatever dissection may be required, all fat and areolar tissue being removed. The cord is finally disposed of by holding it out of the way, usually by a loop of gauze, while the deep layer of the external oblique and the external portion of Poupart’s ligament are sewed to the muscle edges of the internal oblique and transversalis, as appears in Fig. 612, by a line of sutures which include the conjoined tendon, at the lower angle of the wound, which should be affixed to the outer border of the rectus. In the deeper portion of every such wound there is danger of injury to the external iliac vessels as well as to the epigastric. For the escape of the cord, and to avoid its undue constriction, an opening should be left for it, i. e., a new internal ring, adapted for the purpose and not too small. This is made by not suturing the upper part of the wound. The cord being afforded this exit is now dropped, and the edges of the external oblique are brought together over it, the sutures extending well downward, but being omitted at the lower portion, where a new external ring is thus left, only not of its original size, but sufficiently large to accommodate the cord.

Such are the essentials of the Bassini method, which has been modified by Halsted in such a way that the cord, reduced as much as possible, usually by removal of most of its veins, is now not left within the inguinal canal, but transplanted entirely outside of the external oblique, escaping at the upper part of the incision and requiring no further accommodation in its course toward the testicle. In children, or even in adults with very small veins, he does not so reduce the cord. After isolation, opening and transfixion of the upper end of the sac, and its secure ligation, he drops the stump back into the abdomen. The muscular and tendinous layers of the ring and abdomen are united also, by layers, with quilted sutures.

In these as in many other methods, much, practically everything, depends upon the certainty and durability of the sutures used for disposal of the inguinal canal. For some years surgeons used silver wire, which has now been abandoned. The choice now seems to depend on silk, thoroughly and freshly boiled, or animal sutures, such as kangaroo or reindeer tendon. McArthur suggested to dissect off a strip from the margin of the opening in the external oblique, or from the aponeurosis, and to use this strip of the patient’s own tissue for suture material. I have modified this method, as will be described later. Kocher devised a method of isolation of the sac, without such complete emptying of the inguinal canal, the sac being drawn up through the canal, then through the internal ring, and finally through an opening in the external oblique, over the internal ring, where it was twisted and fastened, after which the external portion was removed.

My own preference in operations for radical cure has been, until recently, an exposure similar to that of Bassini’s, with complete isolation of the sac, which is separated up to the level of the internal ring or even higher. At this point it is drawn out through an incision made in the external aponeurosis, twisted and fastened. The inguinal canal is then closed, its deeper layers by a shoelace suture of tendon, threaded into two stout curved needles, by which the deeper margins of the canal are brought accurately together. Sometimes I have transplanted the cord and again have dropped it back, the layer of shoelace sutures closing the external aponeurosis over it. It has not seemed to me to make any difference which method was adopted, and I have practically never seen any atrophy or permanent disturbance of the testicle.

More recently it has occurred to me to utilize the sac itself for suture material, and this is the method which I now adopt in those cases that permit of it.

Figs. 613 to 616 show the method of thus utilizing the sac. A long thin sac may be twisted into a cord and used as an over-and-over suture, by which the margins of the canal are brought together. If found thick and unwieldy it may be trimmed down into a single suture, or it may be split, with more or less trimming, into two portions, by which the canal is then braided together or closed with a shoelace suture, the ends being tied or fastened at the lower portion. Fig. 616 shows how a short sac not otherwise available can be lengthened and made sufficient for the purpose.

This again is utilization of the patient’s own tissue, he himself furnishing his own animal ligature, which, being fresh and sterile, may be regarded as reliable. The method, furthermore, has this advantage, that there is reason to believe that tissue so utilized becomes organized, in time, and that the union becomes more reliable rather than otherwise. At all events in a considerable number of cases it has yielded satisfactory results, and in no case has it caused any disappointment.

Recurrence after these operations occurs less and less frequently as operators gain in experience and technique is improved. At all events the procedure has now become standard and disappointments are relatively rare. It is useless to quote statistics of individuals, for they necessarily differ. In general, however, it is probable that from 90 to 96 per cent. of cases properly operated suffer no recurrence.

In the female inguinal hernia is treated in practically the same way, conditions being simplified by the absence of necessity for making any provision for the blood supply of the testicle or cord. The canal and rings may, therefore, in the female be absolutely closed.

Femoral hernia is radically treated on the same general principles, but with greater difficulty, as anatomical conditions are less favorable. A flap is raised below Poupart’s ligament, with its centre over the tumor, and the sac exposed and completely dissected, then opened, as in inguinal hernia. Its contents being reduced obliteration of the sac and its utilization, if possible, are in order. It is rarely difficult to separate it from its surroundings well up in the femoral canal. It may be twisted and its neck ligated, or it may be possible in some cases to either infold or reduce a sufficient portion of it to thus form a plug, which, being pushed upward, serves as a means of closing the femoral opening from above. Whatever use may be made of it it should be obliterated as a pouch, and its descent prevented by closure of the canal around it. This is difficult because of the proximity of the femoral vein and the somewhat unyielding character of the falciform and crural fasciæ. By some form of purse-string suture, or by a little dissection and sliding of aponeurotic flaps, it is usually possible to bring the surrounding structures snugly together. Even here I have been able to apply my principle enunciated above, and, by cutting away a strip of the sac, utilize it for the purpose of closing the femoral canal; but it is not often that a femoral pouch will be sufficiently large to afford tissues for this purpose. Figs. 617, 618, 619 and 620 will save the necessity for further description.

In many inguinal and umbilical and in a few femoral hernias the operator will be hampered by adhesions between the omentum or between the bowel and the sac wall. These may be infrequent and slight or extensive and dense. They are relatively unimportant so long as they involve only the omentum, which may at any time be cut away, the stump being dropped back into the abdomen, after being suitably secured; but when bowel, especially large intestine, is thus adherent, great care should be exercised, avoiding all possibility of shutting off the blood supply while securing every divided vessel.

Particularly is this true in treatment of umbilical hernias, either radical or under conditions of strangulation. In stout individuals, usually women, umbilical sacs sometimes contain several feet of bowel, and adhesions may be met at many points, difficulties arising not only in their separation, but in the final disposition and accommodation of all this bowel within the abdominal cavity, from which it has been so long absent. Radical cure will in these cases leave intra-abdominal viscera in a rather overcrowded condition.

The essential details of radical treatment of umbilical hernia are the same, modified by the extent of sac which has to be removed, and by the wisdom in many instances of a large elliptical excision of the overlying skin and removal of much superfluous tissue. After freeing the contents and reducing them, the sac wall being completely separated, there is the choice of two or three methods of closing the umbilical opening, either by overlapping of flaps, which may be cut from the thickest portion of the sac, which will be close to the outlet, or by dissecting them from the aponeurosis, as suggested by Mayo, and turning the upper down over the lower, or by any other expedient which individual peculiarities may suggest (Figs. 621 to 624). I have been able to employ, to apparent advantage, my method of securing suture material for this deep closure from the sac wall itself, this not preventing the employment of any other method or improvement.

Ventral and postoperative hernias are operated on in essentially the same manner as the forms above described. Adhesions may be found in these cases, and plastic methods should be devised for bringing together irregularly shaped openings and holding them in the firmest possible manner. In any extensive abdominal hernia, umbilical or ventral, it is advisable to use buried sutures, closing the abdominal walls, layer by layer, and finally to insert at some distance a sufficient number of through-and-through retention sutures, guarded by plates or small rolls of gauze, these taking off tension from the wound and affording protection against any special strain, such as vomiting.