Hernia (2002) 6: 137–140

DOI 10.1007/s10029-002-0065-1

A PP L IE D AN A T OM Y

R. Bendavid

Sliding hernias

Received: 1 April 2002 / Accepted: 25 April 2002 / Published online: 10 July 2002

Springer-Verlag 2002

the condition in 1631; Spiegel reported cases in 1645 and

Introduction
Nothing so tests the surgeon’s knowledge of the anat-
omy of the inguinal region as a chance encounter with
a sliding hernia. If Condon’s [4] dictum ‘‘The anatomy
of the inguinal region is misunderstood by some sur-
geons at all levels of seniority’’ is correct, it is safe to
say that sliding hernias are understood by few surgeons
at any level of seniority. Few surgical procedures have
had so many illustrations attempting to explain the
mechanism of the ‘‘slide’’ and its surgical treatment; yet
they have served only to complicate and confuse the
picture. What surgeon about to start a practice has not
worried about a strangulated sliding hernia presenting
in the middle of the night! ‘‘Sliders’’ are simple to treat
– we will see why.
Definition
A sliding hernia is a protrusion through an abdominal
wall opening of a retroperitoneal organ, with or without
its mesentery, with or without an adjacent peritoneal
sac. This organ may be the cecum, ascending colon, or
appendix on the right side, the sigmoid colon on the left
side, or the uterus, fallopian tubes, ovaries, ureters, and
bladder on either side.
1680, followed by Arnaud (1732), who managed an ‘‘old
scrotal hernia with great difficulty, removing, in the
process, the cecum and part of the colon and ileum in a
patient who eventually recovered!’’ [11]. Scarpa [20] in
1814 reported a cecum forming part of the wall of a
hernial sac. William Mitchell Banks [1] (1843–1904)
coined the term ‘‘landslide of the cecum’’; he was also
the first proponent in England of complete removal of
the hernial sac, declaring that ‘‘the great object of the
whole proceeding is to restore a uniform surface to the
peritoneal wall and hence the higher up the sac is tied,
the better the chance of this being permanent.’’ Ironi-
cally, this thoroughness in excising the sac may well have
contributed to the dangerous reputation of sliding her-
nias. Morris [16] (1895), Hotchkiss [10] (1909), Zim-
merman and Laufman [23] (1942), and Maingot [14]
(1961) emphasized the need to free the sliding hernia
from the spermatic cord and to return the sac and viscus
to the abdominal cavity.
The idea of reperitonealization of a viscus outlined by
Bevan [2] (1930) and many others can now be safely and
assuredly discarded. The Laroque [13] counterincision
(1932) is now considered unnecessary, since the con-
vincing reports of Ryan [18, 19] and Glassow [6] and
confirmation by Welsh [22].

Classification
History
The classification of sliding hernias in the past may have
Galen (130–200 AD) gave us the first description of a been partly responsible for some confusion. Since there
sliding hernia involving the cecum. Rousteus mentioned are three types of sliding hernias, it is probably simplest
to call them types I, II, and III in descending order of
frequency.
R. Bendavid • Type I: any hernia in which part of the peritoneal sac
Department of Surgery, is made up by the wall of a viscus. This is the com-
Laniado General Hospital, Netania Israel
E-mail: rbdavid@netvision.net.il monest type and accounts for nearly 95% of sliding
Tel.: +972-9-8604673 hernias. This type has also been referred to as intra-
Fax: +972-9-8609517 mural, parasaccular, and visceroparietal (Fig. 1).
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Fig. 1. Type I sliding inguinal hernia. The posterolateral aspect of
the sac is made up of the cecum and ascending colon
• Type II: any hernia containing a retroperitoneal viscus
and its mesentery, in which the mesentery forms part
of the wall of the peritoneal sac. About 5% of sliding
hernias are of this type, which has also been named
intrasaccular, extrasaccular (a misnomer), and vis-
ceromesenteric (Fig. 2).
• Type III: a protrusion of the viscus itself; the perito-
neal sac may be very small or even absent. This is the
rarest type and is found in only one of 8,000–10,000
hernia. This type is the most treacherous and its di-
agnosis requires a high index of suspicion. It has been
described as extraperitoneal, sacless, and extrasaccu-
lar sliding hernia (Fig. 3).
An additional type, although not truly a sliding hernia, is
the so-called ‘‘incipient slider.’’ When the sac is opened,
one can see the viscus, but it has not yet entered the
internal inguinal ring.
Pathophysiology
The mechanism whereby the viscus or viscera ‘‘slide’’
has not been fully explained. Before the slide can take
Fig. 2. Type II sliding inguinal hernia. In this case the mesentery
forms a part of the posterior wall of the sac. Note that part of the
anterior wall of the cecum is also forming part of the posterior wall
of the sac
Fig. 3. Type III sliding inguinal hernia: the sac is somewhat
miniscule and may easily be overlooked. This is the most dangerous
type, but fortunately the rarest (1/8–10,000)
place, however, there must be a widening of the internal
inguinal ring; this is the precondition of an indirect in-
guinal hernia.
Sir Arthur Keith (1866–1955) proposed that, devel-
opmentally, the cecum and ascending colon do not
complete their rotation to the right side, and thus the
cecum slides inferiorly toward not only the right but also
the left internal inguinal ring [11]. Moschowitz [17] in
1925 presented his ‘‘pulling-pushing’’ mechanism
whereby an inguinal sac enlarging through a widening
internal ring exerts a pull on the cecum or ascending
colon, whereas anterior structures such as the urinary
bladder would be pushed through the posterior inguinal
wall by intra-abdominal pressure. Graham [8] of To-
ronto suggested another possible mechanism: over long
periods the layers of the mesentery (especially of the
sigmoid) separate, allowing the bare posterior aspect of
the viscus to slide and protrude through an enlarged
internal ring. The common initial factor is always the
widened internal inguinal ring.
Clinical characteristics
As observed by Ryan [18, 19], Glassow [6], and Welsh
[22], sliding inguinal hernias account for 8% of groin
hernias, with a left to right ratio of 4.5 to 1. Maingot
[14], however, found a 1.5 to 1 preponderance of right-
sided sliders. In the series of Ryan et al. [18, 19] 8%
were bilateral, and women made up only 1% of the
3,000 patients analyzed; the average age of patients
was 59.3 years, compared to 51 years for nonsliding
hernias. After the age of 50 years the incidence of
sliding hernias is 3.5 times more frequent. In 9% of
patients there is a history of previous inguinal surgery,
and 94% of sliders are easily reducible preoperatively.
The size of these sliders is categorized as small (16%),
medium (44%), and large (40%). Delay before coming
to surgery is 11.8 years on average. The incidence of
sliding inguinal hernias increases with the age of the
patient, being nearly zero before the age of 30 years
and increasing to as much as 20% after the age of
70 years.

In the pediatric population boys are not subject to
sliding hernias, whereas in ‘‘female pediatric patients,
inguinal hernias are usually sliding hernias’’ with the
mesosalpinx adherent to one side of the sac (type II) [12].
Frequently the ovary and/or fallopian tube is involved.
The round ligament may be resected, but the sac itself
must not be ligated ‘‘high’’ lest the ovary/tube be dam-
aged. The incidence of sliders in girls was 21% in two
series by Goldstein and Potts [7] and Gaus [5].
Discussion and operative technique
As early as 1955 Ryan [18] stated that ‘‘too great an
emphasis had been placed on removal of the hernial
sac.’’ To the surgical section of the Toronto Academy of
Medicine the hallowed ground of Gallie and Graham,
this was heresy. Nevertheless, Ryan substantiated
his statement with a series of 313 cases: ‘‘In 47% of
the patients no sac was removed, in 43% only a part
of the sac was removed. In the remaining 10% of the
cases, the sliding hernia was small and most of the sac
was removed’’ [18].
Ryan also emphasized that the important step in the
operation is to reconstruct the posterior inguinal wall in
order to confine the sliding elements of the hernia to the
preperitoneal space. This was achieved with a recurrence
of less than 1%, at a time when one report from Phila-
delphia admitted to a recurrence rate of 55% [18]! Welsh
[22], as if to consecrate his colleague, validated Ryan’s
large series with a yet larger series of 3,000 cases. These
were culled from among 4,516 patients: incipient sliders
were excluded (25%) as well as direct sliding hernias
(1.5%) and ‘‘unconfirmed’’ sliding hernias (3%; by
‘‘unconfirmed’’ was meant that the sac was not opened
for confirmation of the sliding nature of the hernia). The
method of repair used was the Shouldice technique, but
the Bassini repair and tension-free repairs (except for the
plug) would have been appropriate. The plug, which has
a depth of 4 cm, would cause concern, as it would be in
contact with either sliding bowel or an iliac vessel. The
iliac artery on the supine patient is usually 1–2 cm deep
to the internal ring.
In brief, the cremaster muscle is divided longitudi-
nally for better access to the spermatic cord and internal
ring. The cord is then separated from the sliding hernia
sac, and the dissection stays close to the cord, its in-
vesting fascia and adipose tissue. The internal ring, al-
ready wide, allows separation of the transversalis fascia
about the neck of the sac. It is important to realize at
this stage that the posterior lamina of the transversalis
fascia may in itself form a constricting ring around the
hernia, separate from the anterior lamina of the trans-
versalis fascia. Constricting tissue, if scarred, can be
safely incised at the anterior or medial aspect of the
constricting ring. The viscus is invariably found on the
139
posterior and lateral aspect of the internal inguinal ring.
Gentle dissection in this area frees all adhesions
and allows sac and sliding viscus to return to the
preperitoneal space. If it can be done safely, the sac may
be opened for inspection and then closed; it need not be
resected. High ligation of the sac should never be at-
tempted, as it is not necessary. A counterincision has
never been needed. If in doubt as to the nature of a
thick-walled sac, do not open it! It could be the wall of
bowel, as seen in the sacless variety or type III slider.
The remainder of the operation is devoted to the re-
construction of the posterior inguinal wall by the chosen
technique of the operating surgeon.
Follow-up revealed 16 recurrences out of 3,000 op-
erations, an incidence of 0.5%. Six were femoral hernias,
five direct inguinal hernias, and four appeared to be
femoral hernias but were not operated on; only one was
a true recurrent sliding indirect inguinal hernia.
Complications
Two patients died following surgery; one from a coro-
nary thrombosis on the third postoperative day, the
other from a cerebral hemorrhage 2 weeks after surgery.
Not a single patient developed a bowel obstruction.
Wound infection remained constantly below 1%.
Special considerations
In acute de novo strangulation, or strangulation of a
chronic irreducible sliding inguinal hernia, the adhe-
sions, inflammation, and edema between the cord and
the viscus may blur the anatomical picture. The viscus
may not be safely separated from the cord without the
risk of perforation, which carries an associated mortality
between 6% and 60%, depending on the age of the
patient, the delay in diagnosis, and the degree of vas-
cular compromise [15, 21]. It would not be unreasonable
in these conditions to consider division of the cord, as
close to the internal inguinal ring as feasible. The col-
lateral circulation of the testicle is so abundant that loss
of the testicle occurs in 0–37% of the cases, at the very
worst [3, 9]. It would be, in any case, a small price to
pay, considering the far graver risk of perforation. The
medicolegal aspects of this situation should be explained
to the patient prior to surgery so that the consent forms
are signed with full understanding of possible perioper-
ative decision-making.
Sliding inguinal hernias are common, particularly in
the aging population. They need not any longer engen-
der the apprehension they once did, thanks to the con-
tributions of Ryan. The brevity and simplicity of this
review mirrors the present status of this once fearsome
hernia.
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