INDIRECT INGUINAL HERNIA: A CONTRAST BETWEEN THE SITES OF RECURRENCE AFTER THE SIMPLE AND AFTER THE PLASTIC OPERATION1

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Abstract
Summary: 1. Two series of cases of indirect inguinal hernia operated on by the method of R. Hamilton Russell are reported. The second of these series consisted of 154 operations personally conducted. There was a close personal follow‐up. The recurrence rate in this last series was 3‐2%. As 31 cases of large hernia were excluded from this series, it is thought that the recurrence rate was too high.2. An analysis of the 20 recurrences occurring after both series showed that 19 were indirect in type. Tn those operated on it was found that the new sac reproduced the original one exactly, as far as site was concerned. The one direct recurrence occurred live years after the previous operation and was of the Ogilvie “tubular” type. It is thought that this was a new hernia. The state of affairs described above is contrasted with what obtains after the plastic operations involving gross interference with the muscles surrounding the inguinal canal. After these operations not only are there indirect recurrences, but there are also direct recurrences.3. It is suggested that, in the great majority of cases, these direct recurrences are due not to the presence of an overlooked sac, but to the operative interference with the posterior Avail of the canal.4. Because of the reasons given above it is thought, firstly, that the simple operation should be strengthened and, secondly, that, except for certain types of advanced hernia, the plastic operations should be abandoned altogether. It is suggested that a new operation be devised which has as its main principle the establishment of a strong sheet of fascia between the exposed transversalis fascia and the origin of the cord. Part of the procedure would be reeducation of the muscles.5. Two additional methods are described, to be used either alone or as adjuncts to other methods, (a) The injection of sclerosing solutions during operation, (b) Inversion of the sac. Ten large sliding hernias treated by this method are described. The method used in ordinary cases is also described.