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Robb H. Rutledge, MD
A strong posterior inguinal wall is the best protection against a groin hernia in an adult. Normally this is provided by the insertion of the transversus abdominis and the underlying transversalis fascia from the pubic tubercle to the medial margin of the femoral ring. There is a weak area in this posterior wall that is protected only by the transversalis fascia. Fruchaud named this the myopectineal orifice. It is bounded by the internal oblique and transversus abdominis superiorly, the rectus muscle medially, the iliopsoas muscle laterally, and the Cooper's ligament and pubis inferiorly. It is spanned and divided by the inguinal ligament, traversed by the spermatic cord and femoral vessels, and bridged on its inner surface by the transversalis fascia (see Fig 1). 1 All groin hernias begin as a weak area in this myopectineal orifice. With a decrease in this area's aponeurotic fibers and a gradual attenuation from increased intraabdominal pressure, the transversalis fascia deteriorates and a hernia results. Depending on the length of the insertion of the transversus abdominis on the Cooper's ligament, the presence of a patent processus vaginalis, and the width of the femoral ring, the hernia could be direct, indirect, femoral, or any combination of the three. Groin hernias are treated by repairing or covering all or part of this myopectineal orifice. By suturing the transversus abdominis arch superiorly to the Cooper's ligament and femoral sheath inferiorly, the McVay method repairs the complete myopectineal orifice and is anatomically correct.
doctorate at Northwestern University, Chicago, IL. He pointed out that the normal insertion of the transversus abdominis and the transversalis fascia was on the Cooper's ligament, not the inguinal ligament. From his dissections McVay developed his technique of groin hernia repairs and, in 1942, reported this technique from Ann Arbor, MI, while he was a surgical resident. 3 He was unaware of Lotheissen's work at that time. McVay emphasized that the Cooper's ligament was the anatomically correct anchor for a posterior wall reconstruction, and recommended his repair for direct, large indirect, and femoral hernias. He used a relaxing incision to avoid tension. McVay's work provided a sound anatomical basis for this method and popularized its use in America. His method is known equally well as a McVay or a Cooper's ligament repair. 4 A relaxing incision is an essential part of a McVay repair. Although Anton Wolfler did not use the Cooper's ligament in his hernia surgery, he is given credit for making the first relaxing incision. In 1892 in the Festschrift for Theodor Billroth, Wolfler described making an incision in the anterior rectus sheath whenever he noted tension approximating the conjoined tendon to the inguinal ligament. He did this to relieve tension and also to gain access to the rectus muscle to transplant it to reinforce his repair. 5
Indications for a McVay Repair
A McVay repair should be considered whenever a posterior inguinal wall reconstruction is performed. Many surgeons, including McVay, would use this method for direct, large indirect, and femoral hernias. They would not use this repair for small or m e d i u m indirect hernias because they believe that a posterior inguinal wall reconstruction is unnecessary in these cases. Most recurrences are because of missed hernias, inadequate dissection, or subsequent further deterioration of the transversalis fascia. The indirect, direct, and femoral hernias are within inches of each other. Recurrences should be less if all possible defects are repaired and the myopectineal orifice is completely closed at the original operation. The McVay repair is a more extensive operation than other hernia repairs, but can be performed safely without increased complications. Since 1959, I have performed a McVay repair on all groin hernias in adults, primary or recurrent, regardless of the presenting type.
Historical Development of McVay Repair
In 1897, Georg Lotheissen was the first to suture the conjoined tendon to the Cooper's ligament. He was operating in Innsbruck on a 45-year-old woman with a twice-recurrent inguinal hernia after previous Bassini repairs. The patient's inguinal ligament was destroyed, therefore Lotheissen anchored the conjoined tendon to the Cooper's ligament. He subsequently reported success with this technique with both inguinal and femoral hernias, but did not use a relaxing incision. 2 In 1939, Chester McVay submitted his thesis on the anatomy of the inguinal and femoral areas for his Addresscorrespondenceto RobbH. Rutledge,MD, 5300 EI DoradoDr, Fort Worth,TX76107.Noreprintsavailable. Copyright9 1999byW.B.SaundersCompany 1524-153X/99/0102-0002510.00/0
Operative Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 116-131
1 Anterior view of the myopectineal orifice of Fruchaud. See text for boundaries. (Reprinted with permission from Lippincott Williams and Wilkins. 1)
There are three technical aspects of the McVay repair that are important to emphasize in order to avoid complications and obtain good results. 1. Relaxing incision. A generous relaxing incision is essential to prevent excessive tension on the repair. This incision begins just above the pubis and extends 4 to 5 inches superiorly in the plane of fusion of the external oblique aponeurosis and the anterior rectus sheath. If there is tension while the posterior wall reconstruction sutures are being tied, the relaxing incision is lengthened superiorly. This nearly always gives enough relaxation. On the rare occasion that relaxation is still inadequate, I look for aberrant aponeurotic fibers lateral to the pyramidalis and divide these to get adequate relaxation. 6 Although a relaxing incision does not make the posterior wall reconstruction "tension free," it reduces tension enough to allow good healing. 2. Vascular injuries. Many groin hernia series include injuries to the femoral vessels as a complication. 7 Careful technique should prevent these. I have found it easier to initially develop the femoral sheath (anterior femoral fascia) lateral to the femoral vessels. Then working
medially, the femoral sheath and the anterior surface of the femoral artery and vein are cleaned off. With the femoral vein clearly identified, the fat and lymph nodes are cleaned out of the femoral canal. This gives excellent exposure to any tributaries to the obturator circulation. These are then divided and ligated so they will not be torn during the repair. Because the femoral artery and vein are displayed and protected, the chances of injury are minimal. In my series of 1,682 McVay repairs, there has been no vascular injury. 3. Thromboembolic problems. Thromboembolism has been reported as a complication of the McVay repair. 8 This is because of compression of the femoral vein by transition sutures placed too far laterally in the Cooper's ligament. McVay's transition suture included the transversus abdominis, Cooper's ligament, and femoral sheath with one suture. Instead, I use three sutures that include only the Cooper's ligament and femoral sheath to separately close the femoral canal. The most lateral of these sutures should be placed just medial to the femoral vein so as not to compress it. Two patients in my series had pulmonary emboli requiring anticoagulants, but phlebograms did not show the operative leg to be the source.
Robb H. Rutledge
Interior oblique muscle.
Exterior obliqL aponeu rosis
Sac of indirect herni~
. i . . . . . . ..
Poupart's ligament / Cooper's ligament
2 General anesthesia has been used routinely, but local or regional anesthesia would be satisfactoW. Perioperative antibiotics are given, and the bladder is drained immediately preoperatively. An identical repair is performed whether the hernia is primary or recurrent, direct, indirect, or femoral. A low, almost transverse, incision is made, and the external oblique aponeurosis is opened through the external ring. The ilioinguinal nerve is usually preserved, but I clip and divide it laterally if I feel it has been injured during the surgery. The spermatic cord is mobilized in the canal but is not disturbed medial to the pubic tubercle in order to preserve testicular collateral circulation. The posterior wall of the inguinal canal is incised completely, destroying the internal ring. The iliopubic veins are controlled, and the Cooper's ligament is dissected free. (Reprinted with permission. 9)
3 The spermatic cord is retracted superiorly with a broad Deaver retractor, and the deeper portion of the Cooper's ligament is cleared. Then, starting lateral to the femoral vessels, the femoral sheath (anterior femoral fascia) is identified and dissected free. Working medially, the anterior surface of the femoral artery and vein are seen and cleared off as the femoral sheath is developed. The dissection continues medially, and the fat and lymph nodes are removed from the femoral canal medial to the femoral vein. Any femoral sac is reduced. Finally, any vascular connections to the obturator circulation are divided and ligated so they will not be torn during the repair. (Reprinted with permission. 9)
Robb H. Rutledge
Exterior oblique aponeurosis
Anterior rectus sheath
After the inferior dissection is completed, the transversus abdominis arch is mobilized superiorly from the underlying preperitoneal tissues and any attenuated transversalis fascia and internal oblique muscle are excised. A relaxing incision is made at the point of fusion of the external oblique aponeurosis and the anterior rectus sheath. This starts at the pubic tubercle and extends superiorly about 4 to 5 inches. If relaxation is inadequate, the incision is lengthened. If relaxation is still inadequate, fibers lateral to the pyramidalis can be divided. (Reprinted with permission. 9)
The patient is placed in the Trendelenburg position to decrease the likelihood of intestinal injury. The spermatic cord is opened and the cremaster fibers are divided at the internal ring. Any fat or lipoma is removed from the cord. (Reprinted with permission?)
Robb H. Rutledge
~astomotic to turator artery
6 The external spermatic artery is divided as it comes off the inferior epigastric artery so the cord can be moved laterally during the repair. (Reprinted with permission. 9)
Imbricated preperitoneal tissues
7 Indirect sacs are opened and explored to evaluate any intra-abdominal pathology. Small indirect sacs are removed. Large indirect sacs are transected just distal to the internal ring. The proximal sac is freed from the cord b y sharp dissection and is closed. To decrease the chances of developing an ischemic orchitis, the distal sac is left in place and filleted on its anterior surface to prevent hydrocoele formation. Most direct sacs are inverted but large ones are occasionally excised. Sliding hernias are reduced by freeing the sac from the cord by sharp dissection and then reducing the whole sac into the abdomen. The repair is begun by inverting the preperitoneal tissues with a continuous 1-0 chromic catgut suture to reduce them away from the main repair. (Reprinted with permission. 9)
Robb H. Rutledge
8 Beginning at the pubic tubercle, a layer of about 10 interrupted sutures is placed between the transversus abdominis arch and the Cooper's ligament, going as far laterally as the medial edge of the femoral vein. A short, thick tonsillectomy needle is used for this layer. Rather than using a "harpoon stitch," I have preferred to put the sutures in the Cooper's ligament right handed on right-sided hernias and left handed on left-sided hernias. (Reprinted with permission. 9)
Transversus abdominis arch
9 During the repair of the posterior wall, an Allis clamp is used to grasp the transversus abdominis arch to be certain that good bites are placed in it, not merely in the overlying internal oblique muscle. (Reprinted with permission. 9)
Robb H. Rufledge
10 The femoral canal is closed by three transition sutures between the Cooper's ligament and the femoral sheath. The lateral one is placed just lateral to the last suture previously placed in the Cooper's ligament. The medial two are then placed medial to this between the Cooper's ligament sutures. (Reprinted with permission. 9)
11 Using a larger needle, the repair is continued by placing sutures between the transversus abdominis arch and the femoral sheath, continuing laterally beyond any indirect sac so that the spermatic cord comes out obliquely laterally at the new internal ring. No sutures are placed lateral to the cord in this layer. This entire layer is done with 1-0 silk sutures (siliconized; Davis and Geck United States Surgical, Norwalk, CT). They are tied from medial to lateral, and the patient is brought out of the Trendelenburg position. Many surgeons would prefer to use Prolene (Ethicon, Inc, Somerville, NJ), but the silk is easier to tie and has given no problems. (Reprinted with permission. 9)
Robb H. Rutledge
12 The new internal ring is snug and admits only a Kelly clamp. The relaxing incision can be secured in place with a few interrupted sutures. (Reprinted with permission. 9)
Marlex mesh over relaxing incision Exterior oblique aponeurosis
13 If the relaxing incision is held in place as shown in 12, there will occasionally be a slight bulge of muscle that is apparent. To prevent this, I routinely fill the relaxing incision defect with a Marlex mesh patch (Bard-Davol Inc., Cranston, RI) that is held in place with continuous 1-0 Prolene (Ethicon, Inc). (Reprinted with permission. 9)
14 If I am concerned about the integrity of the repair, I occasionally will suture a sheet of Marlex mesh (Bard-Davol Inc., Cranston, RI) on top of the basic repair as an onlay reinforcement. (Reprinted with permission. 9)
15 The spermatic cord is returned to its natural position, and the external oblique aponeurosis is closed over the cord with continuous 2-0 Vicryl (Ethicon, Somerville, NJ). The new external ring is loose, easily admitting a finger. The soft tissues are closed, and the skin is closed with subcuticular 4-0 Dexon (Ethicon, Somerville, NJ) sutures and Steri-strips (3M Healthcare, St. Paul, MN). (Reprinted with permission?)
Robb H. Rutledge
RESULTS OF A PERSONAL SERIES
My total experience from 1959 through 1994 is shown in Table 1. This includes 1,682 repairs. My last complete report was in 1988 on 1,142 Cooper's ligament repairs in 942 patients performed between 1959 and 1984, with a 97% follow-up. 9 The only operative death was a 65-yearold man with a proven myocardial infarction on the fourth postoperative day; 167 patients (202 hernia repairs) had died by the time of the follow-up. They were followed an average of 7.2 years before death with 1 suspected recurrence. None in this group had an operation for a recurrence. The late death patients were not included in the statistics. Twenty eight patients (34 hernia repairs) were lost to follow-up. The remaining 747 living patients (906 hernia repairs) were followed an average of 9 years. I personally examined 80% and talked to the remaining 20% on the telephone. There were 18 recurrences, for a 2% overall recurrence rate. Seventeen of these were indirect along the cord in a subgroup of 147 repairs performed with a subcutaneously transplanted cord. This method was discarded in 1972. There was one recurrence in 572 repairs with the cord in the natural position; there was no recurrence in 154 repairs in women; and there was no recurrence in 33 repairs in men with an orchiectomy. Excluding the group with the subcutaneously transplanted cord, the recurrence rate is 0.13% for 759 repairs followed for an average of 7.4 years. The only 3 recurrences in the 127 recurrent repairs were indirect along the cord in the subcutaneously transplanted group. There has been no recurrence after repair of a recurrent hernia using the present technique, in use since 1972. Although a complete follow-up has not been performed since my 1988 report, I followed my patients closely through 1994 and believe the recurrence rates are essentially unchanged. 1~
Fifteen percent to 20% of hernia operations are performed for recurrent hernias. It is cost effective to keep recurrence rates as low as possible. Acceptably low recurrence rates can be achieved by several different types of hernia repair. Consequently, the recurrence rate
should be only one of the factors that is used to judge hernia repairs. Other factors include technical difficulty, complications, early and late postoperative pain and disability, medical costs, and societal costs. 11 Comparing series of hernia repairs from different centers is difficult. Definitions of recurrence differ and methods of follow-up vary. The techniques for doing a McVay repair differ even though the name is the same. Some reports mention that the posterior wall reconstruction is performed with four or five absorbable sutures, and a relaxing incision was made only about 50% of the time. n This is not the same McVay operation I have described. Physicians who are conducting these trials should realize that the operative technique is the main factor in preventing complications and obtaining good results. The operation must be performed properly and consistently. 13 The McVay repair is a more extensive operation than the open tension-free repairs. The surgical dissection must be handled carefully. Nevertheless, this method is not so demanding that it can't be performed safely by any well-trained surgeon. The McVay hernia repair patients have a slower early convalescence than other hernia patients. Although they can be managed as outpatients, they require more pain medication and have a slower return to work. After the initial 4 to 6 weeks, patients with a McVay repair do not have any more pain than other hernia repair patients. Long-term results show no differences in comfort or function. 14 Currently the vast majority of groin hernia surgery in adults is performed by one of the open tension-free repairs. These operations are easier, recovery is quicker, and recurrence rates should be low. 15 Whether or not these repairs will allow recurrences deep to the mesh, or will have increased inguinodynia 16 or fertility problems 17 is not yet clear. Mesh patches can become infected and plugs can migrate. Although most surgeons prefer a tension-flee mesh repair, not all patients will be suitable candidates or require thisl The surgeon should still be familiar with the anatomy of the groin so that he/she can do a good McVay repair when indicated.
Table 1. Cooper's Ligament Repair: 1959-1994 (1,682 repairs) Type of Hernia Direct Indirect Femoral Total Primary (1,437) No (%) 516 (36) 868 (60) 53 (4) 1,437 (10O) (85% of Total) Recurrent (245) No (%) 137 (56) 100 (41) 8 (3) 245 (100) (15% of Total)
1. Wantz GE: Atlas of Hernia Surgery. New York, NY, Raven Press, 1991, p 4 2. Lotheissen G: Zur radikaloperation der schenkelhernien. Centralb Chirg 25:548-550, 1898 3. McVayCB, Anson BJ: A fundamental error in current methods of inguinal herniorrhaphy. Surg Gynecol Obstet 74:746-750, 1942 4. McVayCB: The anatomic basis for inguinal and femoral hernioplasty. Surg Gynecol Obstet 139:931-945, 1974 5. Wolfler A: Zur radikaloperation des freien leistenbruches, in Billroth T (ed): Festschrift Beitrage Zur Chirurgie. Stuttgart, Verlag Von Ferdinand Enke, 1892, pp 552-603
McVay Herniorrhaphy 6. McVay CB: Anson and McVay Surgical Anatomy (ed 6). Philadelphia, PA, Saunders, 1984, p 556 7. Shamberger RC, Ottinger LW, Malt RA: Arterial injuries during inguinal herniorrhaphy. Ann Surg 200:83-85, 1984 8. Nissen HM: Constriction of the femoral vein following inguinal hernia repair. Acta Chirurg Scan 141:279-281, 1975 9. Rutledge RH: Cooper's ligament repair: A 25 year experience with a single technique for all groin hernias in adults. Surgery 103:1-10, 1988 10. Rutledge RH: The Cooper ligament repair. Surg Clin North Am 73:471-485, i993 11. Rutkow IM: The recurrence rate in surgery. Arch Surg 130:575~ 577, 1995 12. Barbier J, Carretier MD, Richer JP: Cooper ligament repair: An update. WorldJ Surg I3:499-505, 1989 13. Pettigrew RA, Burns HTG, Carter DC: Evaluating surgical risk:
The importance of technical factors in determining outcome. Br J Surg 74:791-794, 1987 Cunningham J, Temple WJ, Mitchell P, et al: Cooperative hernia study: Pain in the post-repair patient. Ann Surg 224:598-602, 1996 Kark AE, Kurzer MN, Belsham PA: Three thousand one hundred seventy five primary hernia repairs: Advantages of ambulatory open mesh repair using local anesthesia. J Am Coll Surg 186:447455, 1998 Heise CP, Starling JR: Mesh ingumodynia: A new clinical syndrome after inguinal herniorrhaphy? J Am Coll Surg 187:514518, 1998 Litwin D: Risks to fertility with laparoscopic mesh repair, in Arregui ME, Nagan RF (eds): Inguinal Hernia, Advances or Controversies. Oxford, NY, Radcliffe Medical Press, 1994, pp 223-225
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