Chapter 197: Cooper Ligament Repair of Groin Hernias
A hernia through the relaxing incision
is normally prevented by the medial
exten-sion of the transversalis fascia as
the rectus fascia, but, in some patients,
the rectus muscle may protrude through
the relaxing incision. To prevent this, I
routinely fill the relaxing incision defect
with a Marlex mesh patch.
Femoral Vessels
Careful technique around the femoral ves-
sels is required. Well-trained surgeons are
familiar with basic vascular techniques and
should have no trouble with this. I have
found it easier to dissect the anterior femo-
ral sheath lateral to the femoral vessels
first. Then, working medially, the anterior
femo-ral sheath is developed, and the front
sur-face 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
tributaries are then divided and ligated so
they are not torn during the repair.
Placement of sutures in the Cooper
liga-ment is stopped at the medial edge
of the femoral vein to prevent any
venous con-striction and decrease the
likelihood of thromboembolic problems.
Testicular Problems
To minimize risks to the testicle, several
maneuvers are important. No dissection is
performed medial to the pubic tubercle. The
external ring is left loose. An ipsilateral
hydrocele is not removed unless an orchiec-
tomy is performed. Only sharp dissection is
used around the cord. Large indirect sacs are
transected at the internal ring. The proximal
portion is ligated but the distal portion left in
place and filleted on its ante-rior surface to
prevent hydrocele formation. Although the
external spermatic artery is routinely divided
and the new internal ring made quite snug, no
sutures are placed lat-eral to the cord to avoid
any constriction.
Table 1 Cooper Ligament Repair, 1959 to 1994
1,437 Primary
No. % No.
Direct 516 36
Indirect 868 61
Femoral 53 4 8
Total 1,437 100
(85% of total)
e-93
These technical steps protect testicular
circulation and decrease the chances of
thrombophlebitis of the spermatic cord
and ischemic orchitis.
Orchiectomy is rarely necessary in her-
nia surgery and is performed only with
prior consent. Examples include a patient
with an undescended, painful, or atrophic
testi-cle or an elderly patient with a large
coex-isting ipsilateral hydrocele. Patients
with recurrent hernias only rarely require
an or-chiectomy. Nearly always, enough of
the spermatic cord can be preserved to
save a good testicle.
Results of a Personal Series
My total experience from 1959 through 1994
is given in Table 1. It includes 1,652 Cooper
ligament repairs. My last complete report
was in 1988 on 1,142 Cooper ligament
repairs in 942 patients performed between
1959 and 1984, with a 97% follow-up. The
only operative death was in a 65-year-old
man with a proven myocardial infarction on
the fourth postoperative day. One hundred
and sixty seven patients (202 hernia repairs)
had died by the time of the follow-up. They
were followed for an average of 7.2 years be-
fore death, with one suspected recurrence.
None of this group had an operation for a
recurrence. The late death patients were not
included in the statistics. Twenty-eight pa-
tients (34 hernia repairs) were lost to follow-
up. The remaining 747 live patients (906
hernia repairs) were followed for an av-erage
of 9 years. I personally examined 80% of the
patients and talked to the remaining 20% on
the telephone.
There were 18 recurrences, for a 2% over-
all 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 dis-
carded in 1972. There was one recurrence in
572 repairs with the cord in the natural po-
sition; there was no recurrence in 154 re-
pairs in female patients and there was no
1,682 Repairs
245 Recurrent
% to do heavy work were off from 4 to 6
137 56
100 39
3
245 100
(15% of total)
recurrence in 33 repairs in male patients
with an orchiectomy. Excluding the group
with the subcutaneously transplanted cord,
the recurrence rate is 0.13% for 759 repairs
followed an average of 7.4 years.
The only three recurrences in the 127
re-current repairs were indirect along the
cord in the subcutaneously transplanted
group. There has been no recurrence in a
recurrent repair using the technique that
was begun in 1972.
Although a complete follow-up has not
been performed since my 1988 report, I
fol-lowed my patients closely through
1994 and believe that the recurrence rates
are essen-tially unchanged.
ADVANTAGES OF A COOPER
LIGAMENT REPAIR
The Cooper ligament repair restores normal
anatomic planes and provides the best an-
chor for a strong posterior wall reconstruc-
tion. It closes the femoral canal and displays
the femoral vessels to protect them from in-
jury. It is the only anterior repair that closes
the complete myopectineal orifice. It can re-
pair all of the hernias that occur in the groin.
DISADVANTAGES OF A
COOPER LIGAMENT REPAIR
There are five disadvantages that are fre-
quently cited as problems with the
Cooper ligament repair. I agree with the
first two, but the remaining three can be
prevented by good surgical technique:
1. More extensive operation—The Cooper
ligament repair has a longer operating
time than open tension-free repairs and
requires more extensive dissection. It is
not as easily performed under local an-
esthesia.
2. Slower convalescence—Although most
patients with a Cooper ligament repair
are cared for as outpatients, they require
Surgery
more medication for pain relief and con-
valesce more slowly than do patients
with tension-free or laparoscopic re-
pairs. This is especially true for patients
Nongastrointestinal Transabdominal
with bilateral hernia repairs.
3. Eighty-nine percent of my patients with
desk jobs were back at work within 2
weeks. Fifty percent of patients who had
weeks. Often, this length of time was de-
termined by the employer. Thirty-three
percent of my patients had resumed
their usual activities by 2 weeks and 88%
by 4 weeks. Motivation is a strong factor.
All of my physician patients were back at
work within 1 week.