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Karl A. LeBlanc
Andrew Kingsnorth
David L. Sanders
Editors
Management of
Abdominal Hernias
Fifth Edition
123
Management of Abdominal Hernias
Karl A. LeBlanc
Andrew Kingsnorth • David L. Sanders
Editors
Management of Abdominal
Hernias
Fifth Edition
Editors
Karl A. LeBlanc Andrew Kingsnorth
Surgeons Group of Baton Rouge of Our Peninsula College of Medicine and
Lady of the Lake Physician Group Dentistry (Emeritus)
Baton Rouge Plymouth
Louisiana United Kingdom
USA
David L. Sanders
North Devon District Hospital
Barnstaple
United Kingdom
ISBN 978-3-319-63250-6 ISBN 978-3-319-63251-3 (eBook)

https://doi.org/10.1007/978-3-319-63251-3
Library of Congress Control Number: 2017964725
© Springer International Publishing AG, part of Springer Nature 2018

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Preface
Quantum leaps in mesh technology and minimally invasive surgery have seen the practice of
hernia surgery improve beyond recognition since the first edition of this book was written
30 years ago. The pace of progress continues with the introduction of robotics and advanced
techniques of abdominoplasty. Such progress results from the contributions of many individual
surgeons. We would like to acknowledge our good fortune in having the benefit of such a gal-
axy of internationally renowned experts who have shared their experiences to compile this text.
To update each chapter and introduce new topics, an extensive review of the literature has
been undertaken, in order to identify important advances which can be translated into general
surgical practice. What has emerged is an in-depth consideration of all aspects of hernia man-
agement and of each type of abdominal wall hernia. Our approach has not been uniform; we
have allowed the contributors to emphasise the facts that they deem important to their area of
specialisation in hernia surgery. The common varieties receive extra attention and discussion.
Topics covered in depth include the management of patients with co-morbidities, particularly
morbid obesity, ambulatory surgery and anaesthesia and choice of mesh. The avoidance of
wound dehiscence is of fundamental importance to the avoidance of abdominal incisional
hernias, and a chapter has been introduced on this topic.
Although much of the content of this book will not be relevant to low-income countries due
to cost considerations, because of increasing interest in globalisation and volunteerism, we
have commissioned a chapter on management of giant inguino-scrotal hernia, as it would be
carried out in a poorly resourced, but optimally managed, environment. For the surgeon start-
ing out on a career specialising in abdominal wall surgery, the description of rare intraoperative
and postoperative complications will reduce the risk of poor outcomes.
Finally, continued progress in the surgical treatment of hernias relies on fresh talent and an
early recognition of potentially revolutionary changes in clinical practice. With this in mind,
Andrew Kingsnorth and Karl LeBlanc have recruited David Sanders, a younger surgeon
already experienced and specialised in hernia surgery, to assist in editing this book. Although
the content is directed primarily at the specialist, individual chapters can be accessed to pro-
vide important insights for other surgical disciplines and the non-specialist.
Baton Rouge, LA, USA Karl A. LeBlanc

Plymouth, UK Andrew Kingsnorth
Barnstaple, UK David L. Sanders
v
Preface for First Edition (1988)
Another book on hernia? Well, not quite! My intention was to produce a neat practical book on
hernia, not an exhaustive text. But a book about hernias would be incomplete without mention
of the past; hence, the ‘practical book’ has become encrusted with history and anecdote, and
conceivably the book is more readable for this. Almost all the material included has already
been published elsewhere—the skeleton is the section on hernia in the current edition of Rob
and Smith’s Operative Surgery, also published by Butterworths, whereas other parts have
appeared in The Lancet, the British Journal of Surgery, the Annals of the Royal College of
Surgeons of England, Surgery, Surgical Review I and Recent Advances. The work on econom-
ics and administration has appeared in The Lancet, the Health and Social Service Journal, vari-
ous Department of Health publications and, most importantly, the Royal College of Surgeons
of England Guidelines for Day Case Surgery (1985).
I am grateful to the respective editors and authorities for permission to reproduce from
these articles and in some cases to expand them. Hernias, their complications and their man-
agement continue to use much surgical resources; repair of a groin hernia is the commonest
operation in males and the third commonest operation in British hospitals. Sadly, the results
of hernia surgery are still far from ideal. Long hospitalisation spells, perioperative complica-
tions and, above all, unacceptable recurrence rates disfigure our surgical audit. Practically
every book about hernias reiterates the cliché that too often the repair of a hernia is under-
taken by the inexperienced or infrequent operator—the statement has added cogency in an
era of healthcare cost containment and computerised medical records. It is now easy to
compare durations of stay and complication rates and then, using record linkage, to identify
the recurrence receiving treatment elsewhere some years later. You no longer need a surgical
training to undertake this accounting of results! The results of hernia repair are improved by
specialisation. The Shouldice Clinic in Toronto dictates the gold standard. The anatomical
variations and technical difficulties of hernia surgery are such that the advisability of spe-
cialist hernia units, similar to the regional cardiothoracic units in the National Health
Service, merits consideration. Whereas we can debate whether primary hernia repair should
remain in the province of the ‘general surgeon’, recurrent and incisional hernia repairs
demand extra skills and such cases should always be referred to experts. The prevention of
iatrogenic, incisional hernia should be a priority for abdominal surgeons and gynaecologists,
yet in all series of incisional hernioplasties, surgeon failure at the initial operation is often
well documented.
The use of inappropriate suture material, sloppy technique, haematoma and sepsis are the
all too frequent progenitors of the troublesome incisional hernia. In setting out my stall,
20 years’ experience of hernia surgery, I acknowledge the influence of teachers, particularly
the late Frederick Gill, PRCSI, who persuaded me to make myself a surgeon; Austin Marsden,
FRCS, who convinced me there is a hernia problem; and Sir Hugh (Lyn) Lockhart-Mummery
who taught me so much about surgical technique and its gentleness. To these gentlemen I owe
a major debt. Caroline Doig, Allan Kark, Nick Barwell, James Bourke and Frank Glassow
have all shared their experience and interest in hernia surgery with me. Percy Payne and
vii
viii Preface for First Edition (1988)
Maurice Down have explained all about trusses and demonstrated these appliances to me.
Above all, these two gentlemen told me much of the history of British hernia surgery which
has corrected my perspective of the recent past.
My colleagues in Stockton-on-Tees and in the North East have referred many of the more
complex hernias to me, hernias that have presented technical challenges but afforded me new
insights into the anatomy and pathology of hernia. Former junior colleagues have contributed
greatly; P. Tiwari, Ranu Singh, A. K. Sahay, Dirk Muller, Denis Quill, Peter Gillen and Bruce
Waxman deserve a mention. Permanent members of our department who have a major impact
on my perception of hernia surgery include Laurence Rosenberg and Greg Rubin. Mary Fell
has undertaken all our socio-economic interviewing and managed all our research into these
fields. Irene Anderson has checked references and done a myriad of secretarial tasks. Elizabeth
Clemo and her staff at North Tees Medical Library have undertaken all the library searches.
The libraries of the Royal Society of Medicine and the Royal College of Surgeons of England
have tracked down all the more difficult and obscure books I needed. Alexandra Maclean
kindly checked and indexed the references for me.
The photographic work has been done by Ken Watson. Peter Gill and Elizabeth Dillon
have undertaken numerous X-ray and ultrasound examinations of hernias for me over the
years, and both deserve my particular thanks. Angus McNay and Katherine Denham have
helped me with statistical problems. I thank Ron Lawler for the photomicrographs at the
Department of Medical Photography at North Tees. The artwork is by Gillian Lee, and it
has been a great pleasure to work with her. Surgery books are nothing without artwork;
Gillian has put as much into this venture as I have. John Lunn advised me about anaesthesia
and persuaded me about other aspects of hernia surgery and surgical audit. Former regis-
trars have assisted me very generously in preparing the various drafts of the text: Simon
Raimes, Nigel Fox, Stewart Nicholson, Tom Keane and Paul Stuart deserve my special
thanks for their patience and tolerance in that task. The main burden of turning all this into
a book has fallen to Julie Davies. She has painstakingly converted all my handwriting into
neat typescript, word processed this and finalised the ultimate manuscript. Books need
publishers and sub-editors; Butterworths have supported and encouraged me throughout
the enterprise. My particular thanks go to John Harrison and to Bob Pearson for all the
work they have undertaken. Lastly, and most importantly, my personal secretary, Anne
Lindsley, has kept our surgical service on the road despite my involvement in this project.
To all of these colleagues, and to many others, I must express my thanks for their help and
enthusiasm.
Note on Terminology. Hernia repair, herniotomy, herniorrhaphy and hernioplasty are terms
that are almost but not quite interchangeable. Herniotomy (Gk temnein, to cut), herniorrhaphy
(Gk rhaphe, a seam) and hernioplasty (Gk plassein, to mould) connote slightly different mean-
ings. Herniotomy is appropriate to the inguinal operation in children only and I have used it
solely in that context. Otherwise, sometimes herniorrhaphy or sometimes hernioplasty is cor-
rect, but to switch terms about within the book makes reading difficult. I have, therefore, set-
tled for hernioplasty throughout, perhaps realising that effective hernia surgery requires all the
skills of tissue handling and repair that plastic surgeons so rightly emphasise.
Stockton-on-Tees, UK H. Brendan Devlin

Preface for Second Edition (1998)
This second edition reflects the rapidly changing world of hernia surgery since 1988. A new,
younger author has participated fully in this new edition. Three events have precipitated the
need for a new edition: the concept of the ‘tension-free’ repair introduced by Irving Lichtenstein,
the revolution caused by the laparoscope and the increased role of economics in the contempo-
rary cost-constrained healthcare system. The realisation from the work of Raymond Read, that
underlying most, or all, abdominal wall hernias is a defect in the fascia transversalis and that
this layer needs replacing, is the seminal advance of replacement by prosthetic mesh intro-
duced by Lichtenstein. This has very important messages for hernia surgeons. Incorporation of
this concept into everyday practice is a powerful reason why a new book about hernias is
needed. The new biocompatible plastic meshes and the widespread adoption of mesh replace-
ment repairs in hernia surgery is an important, almost revolutionary, development of contem-
porary surgery. The laparoscope and its need for a role has captured patients’ and surgeons’
imaginations and required some overview of the use of this tool in hernia repair. Coupled with
this, added cogency has been given to questions of cost and outcomes in evaluation of laparo-
scopic surgery. The laparoscope makes this new edition inevitable.
There is now a consensus that money will always be limited for surgery and surgeons must
perforce adopt cost-efficient and cost-effective surgery. These important conclusions are spelt
out in the (Revised) Guidelines for Day Case Surgery issued by the Royal College of Surgeons
of England in 1992. Above all, this new edition has benefitted from the resurgence of interest
in the age-old problem of hernia surgery. The authors’ friendship and conversations with many
hernia surgeons worldwide are reflected in this new text. European surgeons Kark, Schumpelick,
Paul, Nilsson, Stoppa and Kux; transatlantic surgeons Wantz, Gilbert, Skandalakis, Bendavid,
Alexander and Rutkow; Indian surgeons Sahay, Doctor and Rajan; and many others worldwide
have all indirectly participated in this work.
In this second edition, the artwork is again drawn by Gillian Lee. It has been an enormous
pleasure for both of us to work with her. Elizabeth Clemo and the librarians at North Tees
General Hospital and Tina Craig and Michelle Gunning of the Library, Royal College of
Surgeons of England, have always very willingly helped find different texts for us. Our secre-
taries Valerie Peel and Jill Laurence have worked fabulously to put the manuscript into shape.
Our publishers, especially Nick Dunton, have been a great support throughout the whole ven-
ture. Doreen Ramage, our senior production editor, has patiently guided us throughout; we
thank her particularly. Finally, we have written the book together, so whatever its faults and
omissions they are our failings alone.
Stockton-on-Tees, UK H. Brendan Devlin

Plymouth, UK Andrew N. Kingsnorth
ix
Preface for Third Edition (2003)
The first edition of this book was a monograph written by the late H. Brendan Devlin and was
a landmark in the scientific analysis of surgery of the abdominal wall, which discarded many
of the older out-of-date concepts. We are heavily indebted to Brendan not only for providing
the basis for this text but also for the inspiration to follow along a line of inquiry for evidence-
based material to present to our readers. At the same time we have not neglected the impor-
tance of historical and economic aspects of hernia surgery and some of our own personal
views.
Andrew Kingsnorth assisted Brendan in writing the second edition of this book, and Karl
Le Blanc now adds an entirely new perspective from North America with particular emphasis
on the use of prosthetic materials and laparoscopic techniques. We have thoroughly revised
and added to all the chapters resulting in an increase in material of approximately 50% and the
addition of hundreds more up-to-date references. We have also provided the reader with clear
line drawings of operative techniques, photographs and several short video clips on CD. This
extra effort should allow the reader the ability to adopt and apply much of the information and
operative techniques that are presented. The technological revolution that began a decade ago,
and still continues to evolve, has therefore been fully recognised in this text which we believe
will appeal to surgeons in training and those already experienced in managing abdominal wall
hernias. It is hoped that this work will be an effective reference to all those that possess this
book.

xi
Preface for Fourth Edition (2013)
The literature in hernia surgery is vast, and keeping abreast of developments is a never-ending
task that one or two individuals may find difficult to fit into their daily routine. With this in
mind, for the fourth edition of this book, we have recruited selected experts to write each chap-
ter, so that a ray of discerning knowledge is beamed into each crevice of the hernia story to
create a comprehensive and authoritative text. A detailed description of the anatomy of the
abdominal wall is of utmost importance and a primary concern for planning all hernia opera-
tions. Recent technical developments will influence our decision making now and in the future.
More training is needed to increase awareness of a large number of prosthetic meshes, innova-
tive plastic procedures and the appropriate use of biologic meshes. Each requires a thorough
knowledge of the literature and outcomes research rather than the mere use of a technique or
product because it is new and ‘seems like a good idea’.
The long-term outcomes of our patients are now an area of important consideration and can
no longer be overlooked in the discussion of consent prior to surgery. This discussion includes
the issue of postoperative pain, quality of life, recurrence rates and cosmesis. Hernia science is
a relatively new specialty, and its future will be defined by the introduction of ‘physiologic’
repairs and the prosthetic meshes used. Biologic products may be used for tissue replacement,
for tissue reinforcement or simply as a ‘bridge’ to synthetic materials that will perform as good
as or better than the biologic materials.
This text strives to introduce these concepts and to educate readers about the current state
of the art in hernia surgery and to prepare them for future considerations of which we should
all be aware at this point.

xiii
Contents
Part I General Topics
1 General Introduction and History of Hernia Surgery�� 3

Andrew Kingsorth and David L. Sanders
2 Essential Anatomy of the Abdominal Wall�� 31
Vishy Mahadevan
3 Epidemiology and Etiology of Primary Groin Hernias�� 59
Brian M. Stephenson
4 Incisional and Parastomal Hernia Prevention�� 79
Sofiane El Djouzi and J. Scott Roth
5 The Application of Complex Systems Science to Healthcare
and Hernia Disease�� 89
Kyle L. Kleppe and Bruce Ramshaw
6 Anesthesia �� 95
Pär Nordin
7 Prostheses and Products for Hernioplasty�� 109
Karl A. LeBlanc
8 Progress in Synthetic Prosthetic Mesh for Ventral Hernia Repair �� 173
Sheila Grant and Bruce Ramshaw
9 Logistics and Specialised Hernia Units�� 179
Giampiero Campanelli, Piero Giovanni Bruni, Francesca Lombardo,
Andrea Morlacchi, and Marta Cavalli
10 Outcomes Assessment and Registries�� 185
Ferdinand Köckerling, Iris Kyle-Leinhase, and Filip E. Muysoms
Part II Groin Hernia
11 Diagnosis of a Lump in the Adult Groin�� 195

Andrew C. de Beaux and Dilip Patel
12 Anterior Open Repair of Inguinal Hernia in Adults�� 209
David L. Sanders, Kelly-Anne Ide, and Joachim Conze
13 Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement �� 235
Martin Kurzer
xv
xvi Contents
14 Tissue Repairs for Inguinal Hernia�� 247

Nicholas H. Carter and David C. Chen
15 Laparoscopic Inguinal Hernia Repair �� 253
Ty Kirkpatrick, Brent W. Allain Jr., and Karl A. LeBlanc
16 Robotic Transabdominal Preperitoneal Inguinal Hernia Repair�� 267
Stephanie Bollenbach, Filip E. Muysoms, and Conrad D. Ballecer
17 Single Incision Laparoscopic Inguinal Hernia Repair �� 275
Hanh Minh Tran, Mai Dieu Tran, and Wayne John Hawthorne
18 Massive Inguino-scrotal Hernia�� 287
Michael Ohene-Yeboah
19 Management of Abdominal Wall Hernias, Sports Hernias,
and Athletic Pubalgia�� 291
Wen Hui Tan and L. Michael Brunt
20 Femoral Hernia�� 305
Ursula Dahlstrand
21 Inguinal Hernias in Babies and Children�� 315
R. Miller and S. Clarke
22 Management of Adverse Events After Inguinal Hernia Repair�� 335
Gina L. Adrales and Sepehr Lalezari
23 Chronic Pain After Inguinal Repair�� 345
Nicholas H. Carter and David C. Chen
Part III Incisional and Ventral Hernia
24 The Open Abdomen: Indications and Management�� 357

Helen J. Thomson and Alastair Windsor
25 Open Repair �� 365
Flavio Malcher, Leandro Totti Cavazzola, and Andrew Kingsnorth
26 Component Separation of Abdominal Wall Muscles�� 381
Flavio Malcher and Leandro Totti Cavazzola
27 Minimally Invasive Sublay Mesh Repair of Abdominal Wall Hernias
with the MILOS Technique (Mini or Less Open Sublay Repair)�� 387
Wolfgang Reinpold
28 Laparoscopic Incisional and Ventral Hernia Repair�� 393
Karl A. LeBlanc
29 Laparoscopic Ventral and Incisional Hernia Repair
with Closure of the Fascial Defect�� 411
Adam S. Weltz, H. Reza Zahiri, Udai S. Sibia, and Igor Belyansky
30 Robotic Incisional Hernia Repair�� 417
Karl A. LeBlanc
31 Component Separation: Robotic Approach�� 423
L.R. Beffa and A. M. Carbonell
Contents xvii
32 Postpartum Divarication Navel-Sparing Treatment

by Multidisciplinary Approach�� 431
Fien Decuypere, Rudolf Vertriest, Iris Kyle-Leinhase, and Filip Muysoms
33 Umbilical, Epigastric, and Spigelian Hernias�� 437
David L. Webb, Benjamin S. Powell, Nathaniel F. Stoikes, and Guy R. Voeller
34 Parastomal Hernia �� 449
Leif A. Israelsson and Alfred Janson
35 Laparoscopic and Robotic Repair of Parastomal Hernias�� 461
Karl A. LeBlanc
36 Lumbar Hernia�� 471
Maciej Śmetański and Karl A. LeBlanc
37 Hernias of the Pelvic Wall �� 479
Michael S. Kavic, Suzanne M. Kavic, Mary K. Hanissee, and Stephen M. Kavic
38 Umbilical Hernia in Babies and Children�� 489
R. Miller, A. Khakar, and S. Clarke
39 Adverse Events After Ventral Hernia Repair�� 503
S. Ulyett and D. L. Sanders
40 Abdominal Wall Mesh Infections �� 511
K.M. Coakley, B.T. Heniford, and V.A. Augenstein
Biographical Notes �� 519
Index�� 529
Contributors
Gina L. Adrales John Hopkins Hospital, Baltimore, MD, USA

Brent W. Allain Jr Surgeons Group of Baton Rouge/Our Lady of the Lake Physician Group,
Baton Rouge, LA, USA
V.A. Augenstein Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical
Center, Charlotte, NC, USA
Conrad D. Ballecer Arrowhead Medical Center, Banner Thunderbird Medical Center, Peoria,
AZ, USA
Andrew C. de Beaux Department of General Surgery, Royal Infirmary of Edinburgh,
Edinburgh, UK
L.R. Beffa Department of Surgery, Greenville Health System, University of South Carolina
School of Medicine, Greenville, SC, USA
Igor Belyansky Anne Arundel Medical Center, Annapolis, MD, USA
Stephanie Bollenbach MIHS, Phoenix, AZ, USA
Piero Giovanni Bruni Istituto Clinico Sant’Ambrogio, Day & Week Surgery Unit, Milano
Hernia Center - MHec, University of Insubria, Center of Research on the Pathology and High
Specialization on the Abdominal Wall and Hernia Surgery, Milan, Italy
Giampiero Campanelli Istituto Clinico Sant’Ambrogio, Day & Week Surgery Unit, Milano
A.M. Carbonell Department of Surgery, Greenville Health System, University of South
Carolina School of Medicine, Greenville, SC, USA
Nicholas H. Carter Residency in General Surgery, Vanderbilt University Medical Center,
Nashville, TN, USA
Marta Cavalli Istituto Clinico Sant’Ambrogio, Day & Week Surgery Unit, Milano Hernia
Center - MHec, University of Insubria, Center of Research on the Pathology and High
Leandro Totti Cavazzola Universidade Federal do Rio Grande do Sul and Hospital de
Clínicas de Porto Alegre, Porto Alegre, Brazil
David C. Chen Lichtenstein Amid Hernia Clinic at UCLA, Santa Monica, CA, USA
Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
S. Clarke Department of Pediatric Surgery, Chelsea and Westminster Hospital, London, UK
K.M. Coakley Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical
xix
xx Contributors
Joachim Conze UM Hernia Centre, München, Germany

Ursula Dahlstrand Department of Clinical Science, Intervention and Technology, Karolinska
Institutet and Center for Digestive Diseases, Karolinska University Hospital, Solna, Sweden
Fien Decuypere Department of Surgery, Maria Middelares, Ghent, Belgium
Sofiane El Djouzi Division of GI/Minimally Invasive Surgery, Stritch School of Medicine,
Loyola University Medical Center, Maywood, IL, USA
Sheila Grant College of Engineering, University of Missouri, Columbia, MO, USA
Mary K. Hanissee Department of Surgery, University of Maryland Medical Center,
Baltimore, MD, USA
Wayne John Hawthorne Sydney Medical School, The University of Sydney, Sydney, NSW,
Australia
B.T. Heniford Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical
Kelly-Anne Ide North Devon District Hospital, Barnstaple, UK
Leif A. Israelsson Department of Surgery and Perioperative Sciences, Umeå University,
Umeå, Sweden
Department of Surgery, Sundsvall Hospital, Sundsvall, Sweden
Alfred Janson Department of Surgery, Sundsvall Hospital, Sundsvall, Sweden
Ferdinand Köckerling Vivantes Hospital Spandauv, Berlin, Germany
Michael S. Kavic Department of Surgery, St. Elizabeth Health Center, Youngstown,
OH, USA
Northeast Ohio Medical University, College of Medicine, Rootstown, OH, USA
Suzanne M. Kavic Loyola University Medical Center, Maywood, IL, USA
Stephen M. Kavic University of Maryland School of Medicine, Baltimore, MD, USA
A. Khakar University Hospital Southampton NHS Foundation Trust, Southampton, UK
Andrew Kingsnorth Peninsula College of Medicine and Dentistry (Emeritus), Plymouth,
UK
Ty Kirkpatrick Surgeons Group of Baton Rouge/Our Lady of the Lake Physician Group,
Kyle L. Kleppe Department of Surgery, University of Tennessee Graduate School of
Medicine, Knoxville, TN, USA
Martin Kurzer St John and St Elizabeth Hospital, London, UK
Iris Kyle-Leinhase Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
Sepehr Lalezari John Hopkins Hospital, Baltimore, MD, USA
Karl A. LeBlanc Department of Surgery, Louisiana State University Health Sciences Center,
Minimally Invasive Surgery Institute, Baton Rouge, LA, USA
Surgeons Group of Baton Rouge/Our Lady of the Lake Physician Group, Baton Rouge,
LA, USA
Our Lady of the Lake Physician Group, Department of Surgery Minimally Invasive Surgery
Institute, Louisiana State University School of Medicine, Baton Rouge, LA, USA
Contributors xxi
Francesca Lombardo Istituto Clinico Sant’Ambrogio, Day & Week Surgery Unit, Milano
Vishy Mahadevan The Royal College of Surgeons of England, London, UK
Flavio Malcher Celebration Center for Surgery, Celebration, FL, USA
L. Michael Brunt Section of Minimally Invasive Surgery, Washington University School of
Medicine, St. Louis, MO, USA
Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
St. Louis Blues Hockey Club, St. Louis, MO, USA
R. Miller Chelsea and Westminster Hospital, London, UK
Andrea Morlacchi Istituto Clinico Sant’Ambrogio, Day & Week Surgery Unit, Milano
Filip E. Muysoms Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
Pär Nordin Department of Surgery, Östersund Hospital, Östersund, Sweden
Michael Ohene-Yeboah Department of Surgery, School of Medicine and Dentistry, College
of Health Sciences, University of Ghana, Accra, Ghana
Dilip Patel Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
Benjamin S. Powell Department of Surgery, University of Tennessee Health Science Center,
Memphis, TN, USA
Bruce Ramshaw Department of Surgery, University of Tennessee Graduate School of
Medicine, Knoxville, TN, USA
University of Tennessee Medical Center, Knoxville, TN, USA
Wolfgang Reinpold Department of Surgery and Reference Hernia Center, Gross Sand
Hospital Hamburg Wilhelmsburg, Hamburg, Germany
H. Reza Zahiri Anne Arundel Medical Center, Annapolis, MD, USA
J. Scott Roth Center for Minimally Invasive Surgery, Gastrointestinal Surgery, University of
Kentucky, Lexington, KY, USA
David L. Sanders North Devon District Hospital, Barnstaple, UK
Udai S. Sibia Anne Arundel Medical Center, Annapolis, MD, USA
Maciej Śmetański 2nd Department of Radiology, Medical University of Gdańsk, Gdańsk,
Poland
Department of Surgery and Hernia Center, District Hospital in Puck, Puck, Poland
Brian M. Stephenson Department of General Surgery, Royal Gwent Hospital, Aneurin
Bevan University Health Board, Newport, UK
Nathaniel F. Stoikes Department of Surgery, University of Tennessee Health Science Center,
Memphis, TN, USA
Wen Hui Tan Section of Minimally Invasive Surgery, Washington University School of
Medicine, St. Louis, MO, USA
Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
Helen J. Thomson Pinderfields Hospital, Wakefield, UK
xxii Contributors
Hanh Minh Tran The Sydney Hernia Specialists Clinic, Sydney, NSW, Australia
Mai Dieu Tran The Sydney Hernia Specialists Clinic, Sydney, NSW, Australia
S. Ulyett North Devon District Hospital, Barnstaple, UK
Rudolf Vertriest Department of Plastic Surgery, Maria Middelares, Ghent, Belgium
Guy R. Voeller Department of Surgery, University of Tennessee Health Science Center,
Memphis, TN, USA
David L. Webb Department of Surgery, University of Tennessee Health Science Center,
Memphis, TN, USA
Adam S. Weltz Anne Arundel Medical Center, Annapolis, MD, USA
Alastair Windsor University College Hospital, London, UK
About the Editors
Karl A. LeBlanc MD, MBA, FACS, FASMBS,

General, bariatric and abdominal wall surgeon, Baton
Rouge, LA, USA, 1984-present. Attended the Louisiana
State School of Medicine in Shreveport, LA, and USA
from 1974–1978, followed by a General Surgical
Residency from 1978–1983. From 1983–1984, he
returned to his hometown of Breaux Bridge, LA, USA
but saw the need to pursue his career in a larger city.
He remains active in the private practice of general sur-
gery, specializing in herniology and bariatric surgery.
He is Professor of Surgery at the Louisiana State School
of Medicine Department of Surgery and Associate
Medical Director of Surgery of the Our Lady of the
Lake Physician Group.
Born in a rural area of southern Louisiana known for its “Cajun” heritage, he pursued
his undergraduate education in nearby Lafayette, LA at the University of Southwestern
Louisiana. Even at that early age, he was interested in the medical field. During his sur-
gical residency, the interest in hernia was sparked and this has been with him ever since.
During this residency, he was able to become familiar with laparoscopic surgery and
used it for diagnostic purposes. Once the laparoscopic era of general surgery began, he
rapidly engaged in the advancement of this wonderful tool. His research led to his per-
formance of the world’s first laparoscopic incisional hernia repair in 1991.
He is a founding member of the Americas Hernia Society and has served as its
President. He sits on the Editorial Board of the journals Hernia and the Journal of the
Society of Laparoendoscopic Surgery and a peer reviewer for numerous national and
international journals. He has lectured internationally on numerous topics. He has edited
or co-edited five surgical texts, some of which has been translated into Turkish and
Chinese. He has authored numerous articles and/or book chapter contributions. Research
continues to be an area of interest and he serves a principal investigator of several proj-
ects at this time.
xxiii
xxiv Contents
Andrew Kingsnorth JP, BSc (Hons), MB BS, MS,

FRCS, FACS (1948-) General, pancreatic and abdominal
wall surgeon, Derriford Hospital, Plymouth, UK and
Professor of Surgery Peninsula College of Medicine,
1996–2013. Qualified at the Royal Free Hospital School of
Medicine in London in 1973 and undertook postgraduate
training in Norwich, Oxford, Harvard, Edinburgh and
Cape Town. Appointed consultant surgeon, senior lecturer
and subsequently reader in surgery at the University of
Liverpool (1987–1996) before moving to Plymouth.
Born into the austerity of post-War Britain, Andrew
was brought up in rural Kent and educated at Sevenoaks
School where he acquired a lifelong interest in voluntary
service and internationalism. He has been Arris & Gale
Lecturer (1983) and Hunterian Professor (2007) at the Royal College of Surgeons of England.
He is Past-President of the Pancreatic Society of Great Britain and Ireland, Founding President
of the British Hernia Society, Past-President of the European Hernia Society and President of
the Section of Surgery of the Royal Society of Medicine.
In 1993 he chaired the Royal College of Surgeons of England working party that introduced
the first national Guidelines for the Management of Adult Inguinal Hernia. In 1998 he estab-
lished the Plymouth Hernia Service, the first specialist hernia unit in a public hospital, and
pioneered the Lichtenstein operation in the UK. In 2007, he was the first surgeon outside India
to use low-cost mosquito net mesh for hernia repair in low-resource countries. With Dr.
Ravindranath Tongaonkar (q.v.) and David Sanders (q.v.) he has carried out clinical and labora-
tory research to support the global use of mosquito net mesh hernioplasty. Andrew has champi-
oned the Chevrel (q.v.) prefascial, onlay incisional hernia repair with a series of over 500 cases.
Between 2001 and 2014, Andrew participated in over 30 humanitarian surgical missions to
Eastern and Central Europe, Central Asia, The Far East, SE Asia, Africa and South America.
In 2005 he established a Hernia charity which is now the largest and most active such organisa-
tion in the world (www.herniainternational.org.uk). In 2010, The Times of London in a survey
of top doctors, noted that Andrew was “regarded as the UK’s expert on hernias”.
Andrew retired from academic and clinical practice in 2013, but continues to lecture occa-
sionally and acts as Director of Hernia International.
David L. Sanders BSc(Hons), MBChB, FRCS, MD,

PGDipMedEd, received his undergraduate degree from
the University of Edinburgh in 2003. He received post-
graduate training in the South West of England and a
trauma fellowship in South Africa. His doctorate thesis
was on the influence of mesh and fixation techniques on
infection in abdominal wall hernia repair. In 2016 he was
appointed consultant upper GI surgeon and specialist in
abdominal wall reconstruction at North Devon Hospital,
Barnstaple, Devon, UK.
David specializes in surgery of the gallbladder, anti reflux,
hiatal surgery and hernia surgery. He is an internationally rec-
ognized expert in the field of abdominal wall reconstruction
with numerous publications in the field of hernia surgery and
several book chapters. He has given numerous invited lectures on the topic both nationally and
internationally. David is on the board of the British Hernia Society, Chaired the National Institute
for Clinical Excellence approved commissioning guidance for groin hernia, was involved in devel-
oping the RightCare patient decision aid for inguinal hernias and is on the European working group
that developed the Abdominal Wall Closure Guidelines and the International Hernia Guidelines.
David is the editor of the Bulletin of the Royal College of Surgeons of England.
Contents xxv
Hugh Brendan Devlin CBE, MA, MD, MCh (Dublin),

FRCS (England), FRCS (Ireland), FRCS (Edinburgh),
FACS (1932–1998) Consultant Surgeon, North Tees
General Hospital, Stockton-on-Tees. Director, Surgical
Epidemiology and Audit Unit, Royal College of Surgeons
of England. Research Associate, Department of Surgery,
University of Newcastle upon Tyne, Council Member,
Royal College of Surgeons of England.
Brendan pioneered the use of surgical audit. When he
was appointed to Stockton-on-Tees in 1970 the hospital
was run down and morale was low. Four years later, he
commissioned the new North Tees General Hospital and
worked hard to put it on the surgical map. This he did, by
his reputation as a teacher and by his publications, which
always dealt with common conditions. His first success
was to organise better postoperative care for patients with colostomies. He became Chairman
of the British Standards Institution Committee on Stoma Appliances and founded the British
Colostomy Society.
Brendan’s enduring interest however was in hernia and he was the most prominent exponent
of the Shouldice tissue repair in the UK during the 1970s. Realizing that too often hernias were
being repaired by partially trained juniors using techniques that had been proven to be inade-
quate, he set up a multi-centre audit of hernia surgery. This generated guidelines, innumerable
publications and this classic textbook (initially a monograph), the second edition of which was
written jointly with Andrew Kingsnorth (q.v.) and published shortly before his untimely death
in 1998.
In 1982 together with John Lunn, Brendan set up the Confidential Enquiry into Perioperative
Deaths (CEPOD). The study became a national one (NCEPOD), providing annual reports. The
report on the management of emergency hernia surgery revealed preventable causes of periop-
erative deaths, such as lack of intensive therapy beds and lack of staff and resources at night.
He was elected to the Council of the Royal College of Surgeons in 1986. There he set up and
chaired the clinical audit committee. As Chairman of the examination committee he reformed
FRCS examinations.
Brendan travelled widely to examine and to give lectures. He gave the Arris and Gale lec-
ture in 1970, the Bradshaw lecture and oration in 1996, and a Hunterian oration in 1997. He
was a member of many distinguished societies and on the editorial board of many prestigious
surgical journals. He was appointed Commander of the British Empire (CBE) in 1994.
After his retirement he continued to work for the King’s Fund on the commissioning of
medical services in London and the organisation of audit.
Part I
General Topics
General Introduction and History
of Hernia Surgery 1
Andrew Kingsorth and David L. Sanders
Ancient and Renaissance Hernia Surgery
The high prevalence of hernia, for which the lifetime risk is

27% for men and 3% for women [87], has resulted in this con-
dition inheriting one of the longest traditions of surgical man-
agement. Descriptive anatomy of the anterior abdominal wall
dates back over 6000 years, to the beginning of civilization, the
Valley of the Nile and the ancient Egyptian papyri. These texts,
often by unknown authors, were written in a time when medi-
cine was magico-religious and the first steps in inductive rea-
soning were being taken. The Egyptians (1500 BC), the
Phoenicians (900 BC) and the Ancient Greeks (Hippocrates,
400 BC) diagnosed hernia. During this period a number of
devices and operative techniques have been recorded.
Attempted repair was usually accompanied by castration, and
strangulation was usually a death sentence. The word ‘hernia’
is derived from the Greek (hernios), meaning a bud or shoot.
The Hippocratic school differentiated between hernia and
hydrocele—the former was reducible and the latter transillu-
minable [88]. The Egyptian tomb of Ankh-ma-Hor at Saqqara
dated to around 2500 BC includes an illustrated sculpture of an
operator apparently performing a circumcision and possibly a
reduction of an inguinal hernia [94] (Fig. 1.1). Egyptian pha-
raohs had a retinue of physicians whose duty was to preserve
the health of the ruler. These doctors had a detailed knowledge
of the anatomy of the body and had developed some advanced
surgical techniques for other conditions and also for the cure of
hernia. The mummy of the pharaoh Merneptah (1215 BC)
showed a complete absence of the scrotum, and the mummified Fig. 1.1 Egyptian tomb of Ankhmahor (Saqqara). The operator (bot-
body of Rameses 5th (1157 BC) suggested that he had had an tom right) rubs in something with an instrument and seems to perform
inguinal hernia during life with an associated faecal fistula in a reduction of an inguinal hernia
the scrotum and signs of attempts at surgical relief.
Greek and Phoenician terracottas (Figs. 1.2 and 1.3) illus-

A. Kingsorth (*)
Peninsula College of Medicine and Dentistry (Emeritus),
trate general awareness of hernias at this time (900–600 BC),
Plymouth, UK but the condition appeared to be a social stigma, and other
e-mail: kingsnorthandrewn@gmail.com than bandaging, treatments are not recorded. The Greek phy-
D.L. Sanders sician Galen (129–201 AD) was a prolific writer and one of
North Devon District Hospital, Barnstaple, UK his treatises was a detailed description of the musculature of
© Springer International Publishing AG, part of Springer Nature 2018 3

K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_1
4 A. Kingsorth and D.L. Sanders
Fig. 1.2 Terracotta ex voto shows femoral hernia (from Geschichte der
Medizin (1922))
Fig. 1.3 Phoenician terracotta figure (female) shows umbilical hernia

the lower abdominal wall in which he also describes the defi- (fifth–fourth century BC) (from Museo Arquelogico, Barcelona, Spain)
ciency of inguinal hernia. He described the peritoneal sac
and the concept of reducible contents of the sac. geons who wrote several books, which gave detailed descrip-
Celsus (AD 40) was a prolific writer, and although he had tions of operative procedures including inguinal hernia.
no medical training, he documented in encyclopaedic detail Aulus Cornelius Celsus (first century AD) who first
the Roman surgical practice: taxis was employed for stran- described the importance of surgical closure of the abdominal
gulation, trusses and bandages could control reducible her- wall [104]. The procedure was termed ‘gastrorrhaphy’ origi-
nia, and operation was only advised for pain and for small nating from the Greek ‘gastir’ meaning abdomen and ‘rhaphy’
hernias in the young. The sac could be dissected through a meaning suture. In fact, what Celsus was describing was a lay-
scrotal incision, the wound then being allowed to granulate. ered closure of the abdominal wall to prevent an incisional
Scar tissue was perceived as the optimum replacement for hernia. A century later, Aelius Galenus (Fig. 1.2), better known
the stretched abdominal wall. A common method of treating as Galen of Pergamon, a Roman of Greek origin and arguably
hernia at this time was to reduce the contents of the sac and the most prominent physician of the G reco-Roma period, pro-
then attempt to obliterate it by a process of inflammation and vided a detailed description of mass closure of the abdominal
gangrene by applying pressure to the walls of the sac through wall [105]:
clamping the hemiscrotum between two blocks of wood. The In stitching the needle should be thrust from without inwards
last of the Graeco-Roman medical encyclopaedists, Paul of through skin and rectus muscle, and then from within outwards
Aegina (625–900 AD), distinguished complete scrotal from through the muscle and skin, repeating this until the wound is
closed. Some operators include the peritoneum in the stitches,
incomplete inguinal herniation or bubonocele. For scrotal but this is not usual. The dressing should be soft wool dipped in
hernia, he recommended ligation of the sac and the cord with oil moderately warm and cover the space between the flanks and
sacrifice of the testicle. Paul was the last of the great sur- armpit.
1 General Introduction and History of Hernia Surgery 5
It seems that Galen was aware of the risk of incisional He described four surgical interventions, one of which was a
hernia following abdominal surgery, and he describes in herniotomy without castration, another consisting of cauter-
detail the paramedian incisions, in order to prevent a hernia ization of the hernia down to the os pubis and third consist-
from developing [105], an incision which was used coming of transfixion of the sac to a piece of wood by a strong
monly until the late twentieth century: ligature. His fourth method however was conservative treat-
A wound in this situation is less dangerous than in the mid-line, ment with bandaging and several weeks of bed rest accompa-
since the thin aponeuroses are lacking. In the mid-line stitching nied by enemas, bloodletting and special diet. At the time he
is accomplished with difficulty and the intestines are more likely was the authoritative expert on hernia.
to protrude and be hard to replace. Franco’s book Traites des Hernies [61] standardized the
practice of hernia surgery at the time and diminished the
The works of Galen were later translated into Latin and influence of the itinerant practitioners (Fig. 1.6). Franco pop-
helped to form the basis of modern surgery. ularized the punctum aurium and using this instrument made
a small incision in the upper scrotum, isolated the hernia sac
from the spermatic cord and then encircled it with a gold
The Middle Ages (AD500–AD1500) thread, thus sparing the testis. He chose gold thread because
this was considered to be the best nonreactive material. In
In the Middle Ages, the notable techniques of Greco-Roman spite of the known hazards and high mortality of operating
surgery were largely lost. This was an age of faith and scho- on a strangulated hernia, Franco advised early intervention
lasticism. During this period, different types of abdominal and rejected the conservative measures employed such as
wall hernia were rarely differentiated. However, Arnaud de bloodletting and tobacco enemas. As a result he saved
Villeneuve, a French physician and surgeon, described an numerous patients with life-saving operations. He wrote
epigastric hernia in 1285, and another Frenchman, Guy de many up as case reports illustrating his management and sur-
Chauliac (1300–1368), wrote De ruptura, which classified gical techniques. He recommended reducing the contents
different types of hernias and distinguished between umbili- and closing the defect with linen suture (Fig. 1.7). His beau-
cal and epigastric hernia; however in his classification, they tifully written manuscript was rediscovered and published
were not given these names [106, 107]. again in 1925 by Walter van Brunn. As shown in the illustra-
The drawing of the Vitruvian Man by Leonardo da Vinci tion, the unusual feature of the book was the patients posing
(circa 1487) is considered to be one of the world’s greatest in everyday attire as if they were going about their everyday
works of art. It is da Vinci’s representation of ideal human life.
proportions described by the ancient Roman architect In 1559 Stromayr, a German surgeon from Lindau, pub-
Vitruvius in Book III of his treatise De Architectura. The left lished a remarkable contribution to surgery. His book
inguinal region of the Vitruvian Man demonstrates a spheri- Practica Copiosa describes sixteenth-century hernia surgery
cal fullness above his groin, above and medial to the pubic in great detail and is comprehensively illustrated. Stromayr
tubercle. This corresponds to the classical manifestation of differentiated direct and indirect inguinal hernia and advised
an inguinal hernia. Leonardo da Vinci made the drawing in excision of the sac and of the cord and testicle in indirect
the coronal plane to illustrate the geometrical dimensions of hernia [96]. Having differentiated and classified the two
the human body through the observation of living subjects types of inguinal hernia, Stromayr recommended a testis
and cadaveric dissection [108] (Fig. 1.4). sparing procedure for the direct type. His operation for high
During the dark time of the Middle Ages, there was a ligation of an indirect sac at the internal ring is illustrated in
decline of medicine in the civilized world, and the use of the Fig. 1.8. Stomayr also advanced the technology of trusses,
knife was largely abandoned, and few contributions were which he designed to be adapted to the rigours of everyday
made to the art of surgery, which was now practised, by itin- life. The Renaissance brought burgeoning anatomic knowl-
erants and quacks. With the rise of the universities such as edge, now based on careful cadaver dissection. William
the appearance of the school of Salerno in the thirteenth cen- Cheselden successfully operated on a strangulated right
tury, there was some revival of surgical practice [94]. At this inguinal hernia on the Tuesday morning after Easter 1721.
time three important advances in herniology were made: The intestines were easily reduced and adherent omentum
Guy de Chauliac, in 1363, distinguished femoral from ingui- was ligated and divided. The patient survived and went back
nal hernia. He developed taxis for incarceration, recom- to work [54] (Fig. 1.9).
mending the head-down, Trendelenburg position [58]. Guy Without adequate interventional surgery, some patients
was French and studied in Toulouse and Montpelier and later survived hernia strangulation when spontaneous,
learned anatomy in Bologna from Nicole Bertuccio. Guy preternatural fistula occasionally followed infarction and
wrote extensively about hernia in his book Chirurgia princi- sloughing of a strangulated hernia. Cheselden’s Margaret
pally about diagnosis and methods of treatment (Fig. 1.5). White survived for many years ‘voiding the excrements
Fig. 1.4 Vitruvian Man (from

Ashrafian)
through the intestine at the navel’ after simple local sur- to send the faeces along the natural route to the anus [72]
gery for a strangulated umbilical hernia [54]. The closure (Fig. 1.10).
of such a fistula in the absence of distal bowel pathology
was described by Le Dran, who had noted that it was quite
common for poor people with incarcerated hernias to mis- The Anatomical Era
take the tender painful groin lump for an abscess and
incise it themselves. He found that these painful wounds The great contribution of the surgical anatomists was
with faecal fistulas required no more than cleaning and between the years 1750–1865 and was called the age of dis-
dressing. Often the wound would heal, nature preferring section [94]. The main contributors were Antonio Scarpa
Fig. 1.5 The visit of surgical

patients in Chirurgia. Guy de
Chauliac, fifteenth-century
manuscript (from the
Bibliothèque Nationale, Paris,
France)
and Sir Astley Cooper and few major advances in our knowl- dates lymph glands and cutaneous vessels of the groin.
edge of the anatomy of the groin have been made since this Below the external ring, Camper’s fascia becomes the dartos
time. The names of these great anatomists are Pieter, Camper, muscle of the scrotum, which like the platysma is a muscle
Adrian van der Spieghel, Antonio Scarpa (Fig. 1.11), of the superficial fascia. Camper was the author of the defini-
Percival Pott, Sir Astley Cooper, John Hunter, Thomas tive surgical text on hernia. Camper also contributed to ana-
Morton, Germaine Cloquet, Franz Hesselbach, Friedrich tomical descriptions of the foot, upper limb and axilla. His
Henle and Don Antonio Gimbernat. explanation of the aetiology of inguinal hernias significantly
The Dutchman Camper was a polymath who described a affected surgical practice at the time [109].
fascia, which is sandwiched in between the skin and deep Adrian van der Spieghel (1578–1625) was educated at the
fascia and can only be separated from this fascia below the University of Padua, and he occupied the chairs of anatomy
inguinal ligament where the space between them accommo- at the University of Modena and later Pavia. He was Flemish
Fig. 1.6 Frontispiece and

surgery instruments in Traités
des Hernies (by Pierre Franco,
Vincent, Lyon [61])
and another polymath. He was privileged to have two of the described Spiegel’s lobe (caudate lobe) of the liver and the
most accomplished anatomists of that period, Fabricius ab linea semilunaris (Spiegel’s line) on the lateral side of the
Aquapendente and Yulius Casserius, as his teachers. He first rectus abdominis muscle. Spigelian hernia (lateral ventral
Fig. 1.8 The dissection of the sac and cord in an indirect hernia, car-
ried to the level of the internal ring (in von Brunn (1925))
Fig. 1.7 Woman with femoral hernia. In Die Handschrift des Schmitt-
und Augenartztes. Caspar Stromayr (by Walter von Brunn (1925))
hernia) was named after him. He was a renowned physician

in his time and was the first to give a detailed description of
malaria. He made significant contributions as a botanist: the
genus Spigelia, which has six species, is named after him
[110].
Sir Percival Pott described the pathophysiology of stran-
gulation in 1757 and recommended surgical management
(Fig. 1.12): ‘I am perfectly satisfied that the cause of strangu-
lated hernia is most frequently a piece of intestine (in other
respects sound and free of disease) being so bound by the
said tendon, as to have its peristaltic motion and the circula-
tion through it impeded or stopped’ [86]. Pott was trained at
St Bartholomew’s Hospital and wrote the manuscript A
Treatise on Rupture. This publication brought him into con-
flict with the Hunters who accused him of plagiarism for his
description of congenital hernia, which they claimed to have
Fig. 1.9 Ligation of strangulated omentum in a strangulated right scro-
described 2 years previously. He emphasized that the hernia tal hernia. The wound then granulated. The patient survived and the
sac was peritoneum continuous with the general peritoneal hernia did not recur (operation by Cheselden in 1721 [7])
Fig. 1.11 Antonio Scarpa (1752–1832) professor of surgery and anat-

omy in Pavia, Italy
Fig. 1.10 Development of a preternatural colon fistula (colostomy)

after strangulation of an umbilical hernia. The wound was trimmed. The
patient survived many years ‘voiding’ the excrements at the umbilicus
(operation by Cheselden about 1721 [7])
cavity and had not been in any way ruptured or broken,

which until that time was the popular theory of causation of
hernia.
Fifty years later Astley Cooper (Fig. 1.13) implicated
venous obstruction as the first cascade in the circulatory fail-
ure of strangulation: ‘By a stop being put to the return of
blood through the veins which produces a great accumula-
tion of this fluid and a change of its colour from the arterial
to the venous hue.’ Nevertheless ligature, the insertion of
setons and castration remained the mainstays of treatment
prior to the publication of Astley Cooper’s monograph in
1804 [56] (Fig. 1.14). Sir Astley Cooper (1768–1841) trained
at St Thomas’ Hospital, London, and became a surgeon at
Guy’s Hospital and from 1813 to 1815 was Professor of
Comparative Anatomy of the Royal College of Surgeons.
Cooper published six magnificent books, two of which cov-
ered the subject of hernia, which were liberally illustrated by
Fig. 1.12 Intestine strangulated by the ‘tendon’ so that the venous cir-
his own hand from dissections he had performed personally. culation through it is stopped, leading to gangrene (described by Pott
Cooper was a charismatic lecturer and socialite and had an in 1757 [9])
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buttons here for his little boy at home, and gave them
to me to deliver, as he was about to die. Have them
sewed on to my pants for safe keeping.
July 14.—We have been too busy with the raiders
of late to manufacture any exchange news, and now
all hands are at work trying to see who can tell the
biggest yarns. The weak are feeling well to-night over
the story that we are all to be sent North this month,
before the 20th. Have not learned that the news
came from any reliable source. Rumors of
midsummer battles with Union troops victorious. It’s
“bite dog, bite bear,” with most of us prisoners; we
don’t care which licks, what we want is to get out of
this pen. Of course, we all care and want our side to
win, but it’s tough on patriotism. A court is now held
every day and offenders punished, principally by
buck and gagging, for misdemeanors. The hanging
has done worlds of good, still there is much stealing
going on yet, but in a sly way, not openly. Hold my
own as regards health. The dreaded month of July is
half gone, almost, and a good many over one
hundred and fifty die each day, but I do not know how
many. Hardly any one cares enough about it to help
me any in my inquiries. It is all self with the most of
them. A guard by accident shot himself. Have often
said they didn’t know enough to hold a gun. Bury a
rebel guard every few days within sight of the prison.
Saw some women in the distance. Quite a sight. Are
feeling quite jolly to-night since the sun went down.
Was visited by my new acquaintances of the 9th
Michigan Infantry, who are comparatively new
prisoners. Am learning them the way to live here.
They are very hopeful fellows and declare the war
will be over this coming fall, and tell their reasons
very well for thinking so. We gird up our loins and
decide that we will try to live it through. Rowe,
although often given to despondency, is feeling good
and cheerful. There are some noble fellows here. A
man shows exactly what he is in Andersonville. No
occasion to be any different from what you really are.
Very often see a great big fellow in size, in reality a
baby in action, actually sniveling and crying, and then
again you will see some little runt, “not bigger than a
pint of cider,” tell the big fellow to “brace up” and be a
man. Stature has nothing to do as regards nerve, still
there are noble big fellows as well as noble little
ones. A Sergt. Hill is judge and jury now, and
dispenses justice to evil doers with impartiality. A
farce is made of defending some of the arrested
ones. Hill inquires all of the particulars of each case,
and sometimes lets the offenders go as more sinned
against than sinning. Four receiving punishment.
July 15.—Blank cartridges were this morning fired
over the camp by the artillery, and immediately the
greatest commotion outside. It seems that the signal
in case a break is made, is cannon firing. And this
was to show us how quick they could rally and get
into shape. In less time than it takes for me to write it,
all were at their posts and in condition to open up
and kill nine-tenths of all here. Sweltering hot. Dying
off one hundred and fifty-five each day. There are
twenty-eight thousand confined here now.
July 16.—Well, who ever supposed that it could be
any hotter; but to-day is more so than yesterday, and
yesterday more than the day before. My coverlid has
been rained on so much and burned in the sun, first
one and then the other, that it is getting the worse for
wear. It was originally a very nice one, and home
made. Sun goes right through it now, and reaches
down for us. Just like a bake oven. The rabbit mules
that draw in the rations look as if they didn’t get much
more to eat than we do. Driven with one rope line,
and harness patched up with ropes, strings, &c. Fit
representation of the Confederacy. Not much like U.
S. Army teams. A joke on the rebel adjutant has
happened. Some one broke into the shanty and tied
the two or three sleeping there, and carried off all the
goods. Tennessee Bill, (a fellow captured with me)
had charge of the affair, and is in disgrace with the
adjutant on account of it. Every one is glad of the
robbery. Probably there was not ten dollars worth of
things in there, but they asked outrageous prices for
everything. Adjt. very mad, but no good. Is a small,
sputtering sort of fellow.
July 17.—Cords contracting in my legs and very
difficult for me to walk—after going a little ways have
to stop and rest and am faint. Am urged by some to
go to the hospital but don’t like to do it; mess say had
better stay where I am, and Battese says shall not
go, and that settles it. Jimmy Devers anxious to be
taken to the hospital but is pursuaded to give it up.
Tom McGill, another Irish friend, is past all recovery;
is in another part of the prison. Many old prisoners
are dropping off now this fearful hot weather; knew
that July and August would thin us out; cannot keep
track of them in my disabled condition. A fellow
named Hubbard with whom I have conversed a good
deal, is dead; a few days ago was in very good
health, and its only a question of a few days now with
any of us. Succeeded in getting four small onions
about as large as hickory nuts, tops and all for two
dollars Confederate money. Battese furnished the
money but won’t eat an onion; ask him if he is afraid
it will make his breath smell? It is said that two or
three onions or a sweet potato eaten raw daily will
cure the scurvy. What a shame that such things are
denied us, being so plenty the world over. Never
appreciated such things before but shall hereafter.
Am talking as if I expected to get home again. I do.
July 18.—Time slowly dragging itself along. Cut
some wretchs hair most every day. Have a sign out
“Hair Cutting,” as well as “Washing,” and by the way,
Battese has a new wash board made from a piece of
the scaffold lumber. About half the time do the work
for nothing, in fact not more than one in three or four
pays anything—expenses not much though, don’t
have to pay any rent. All the mess keeps their hair
cut short which is a very good advertisement. My
eyes getting weak with other troubles. Can just
hobble around. Death rate more than ever, reported
one hundred and sixty-five per day; said by some to
be more than that, but 165 is about the figure. Bad
enough without making any worse than it really is.
Jimmy Devers most dead and begs us to take him to
the hospital and guess will have to. Every morning
the sick are carried to the gate in blankets and on
stretchers, and the worst cases admitted to the
hospital. Probably out of five or six hundred half are
admitted. Do not think any lives after being taken
there; are past all human aid. Four out of every five
prefer to stay inside and die with their friends rather
than go to the hospital. Hard stories reach us of the
treatment of the sick out there and I am sorry to say
the cruelty emanates from our own men who act as
nurses. These dead beats and bummer nurses are
the same bounty jumpers the U. S. authorities have
had so much trouble with. Do not mean to say that all
the nurses are of that class but a great many of them
are.
July 19.—There is no such thing as delicacy here.
Nine out of ten would as soon eat with a corpse for a
table as any other way. In the middle of last night I
was awakened by being kicked by a dying man. He
was soon dead. In his struggles he had floundered
clear into our bed. Got up and moved the body off a
few feet, and again went to sleep to dream of the
hideous sights. I can never get used to it as some do.
Often wake most scared to death, and shuddering
from head to foot. Almost dread to go to sleep on this
account. I am getting worse and worse, and prison
ditto.
July 20.—Am troubled with poor sight together with
scurvy and dropsy. My teeth are all loose and it is
with difficulty I can eat. Jimmy Devers was taken out
to die to-day. I hear that McGill is also dead. John
McGuire died last night, both were Jackson men and
old acquaintances. Mike Hoare is still policeman and
is sorry for me. Does what he can. And so we have
seen the last of Jimmy. A prisoner of war one year
and eighteen days. Struggled hard to live through it,
if ever any one did. Ever since I can remember have
known him. John Maguire also, I have always known.
Everybody in Jackson, Mich., will remember him, as
living on the east side of the river near the
wintergreen patch, and his father before him. They
were one of the first families who settled that country.
His people are well to do, with much property.
Leaves a wife and one boy. Tom McGill is also a
Jackson boy and a member of my own company.
Thus you will see that three of my acquaintances
died the same day, for Jimmy cannot live until night I
don’t think. Not a person in the world but would have
thought either one of them would kill me a dozen
times enduring hardships. Pretty hard to tell about
such things. Small squad of poor deluded Yanks
turned inside with us, captured at Petersburg. It is
said they talk of winning recent battles. Battese has
traded for an old watch and Mike will try to procure
vegetables for it from the guard. That is what will
save us if anything.
July 21.—And rebels are still fortifying. Battese has
his hands full. Takes care of me like a father. Hear
that Kilpatrick is making a raid for this place. Troops
(rebel) are arriving here by every train to defend it.
Nothing but corn bread issued now and I cannot eat
it any more.
July 22.—A petition is gotten up signed by all the
sergeants in the prison, to be sent to Washington, D.
C., begging to be released. Capt. Wirtz has
consented to let three representatives go for that
purpose. Rough that it should be necessary for us to
beg to be protected by our government.
July 23.—Reports of an exchange in August. Can’t
stand it till that time. Will soon go up the spout.
July 24.—Have been trying to get into the hospital,
but Battese won’t let me go. Geo. W. Hutchins,
brother of Charlie Hutchins of Jackson, Mich., died
to-day—from our mess. Jimmy Devers is dead.
July 25.—Rowe getting very bad. Sanders ditto.
Am myself much worse, and cannot walk, and with
difficulty stand up. Legs drawn up like a triangle,
mouth in terrible shape, and dropsy worse than all. A
few more days. At my earnest solicitation was carried
to the gate this morning, to be admitted to the
hospital. Lay in the sun for some hours to be
examined, and finally my turn came and I tried to
stand up, but was so excited I fainted away. When I
came to myself I lay along with the row of dead on
the outside. Raised up and asked a rebel for a drink
of water, and he said: “Here, you Yank, if you ain’t
dead, get inside there!” And with his help was put
inside again. Told a man to go to our mess and tell
them to come to the gate, and pretty soon Battese
and Sanders came and carried me back to our
quarters; and here I am, completely played out.
Battese flying around to buy me something good to
eat. Can’t write much more. Exchange rumors.
July 26.—Ain’t dead yet. Actually laugh when I
think of the rebel who thought if I wasn’t dead I had
better get inside. Can’t walk a step now. Shall try for
the hospital no more. Had an onion.
July 27.—Sweltering hot. No worse than yesterday.
Said that two hundred die now each day. Rowe very
bad and Sanders getting so. Swan dead, Gordon
dead, Jack Withers dead, Scotty dead, a large
Irishman who has been near us a long time is dead.
These and scores of others died yesterday and day
before. Hub Dakin came to see me and brought an
onion. He is just able to crawl around himself.
July 28.—Taken a step forward toward the
trenches since yesterday, and am worse. Had a
wash all over this morning. Battese took me to the
creek; carries me without any trouble.
July 29.—Alive and kicking. Drank some soured
water made from meal and water.
July 30.—Hang on well, and no worse.
MOVED JUST IN TIME.
REMOVED FROM ANDERSONVILLE TO THE MARINE HOSPITAL,

SAVANNAH—GETTING THROUGH THE GATE—BATTESE HAS
SAVED US—VERY SICK BUT BY NO MEANS DEAD YET—
BETTER AND HUMANE TREATMENT.
Aug. 1.—Just about the same. My Indian friend

says: “We all get away.”
Aug. 2.—Two hundred and twenty die each day.
No more news of exchange.
Aug. 3.—Had some good soup, and feel better. All
is done for me that can be done by my friends. Rowe
and Sanders in almost as bad a condition as myself.
Just about where I was two or three weeks ago.
Seem to have come down all at once. August goes
for them.
Aug. 4.—Storm threatened. Will cool the
atmosphere. Hard work to write.
Aug. 5.—Severe storm. Could die in two hours if I
wanted to, but don’t.
Aug. 12.—Warm. Warm. Warm. If I only had some
shade to lay in, and a glass of lemonade.
Aug. 13.—A nice spring of cold water has broken
out in camp, enough to furnish nearly all here with
drinking water. God has not forgotten us. Battese
brings it to me to drink.
Aug. 14.—Battese very hopeful, as exchange
rumors are afloat. Talks more about it than ever
before.
Aug. 15.—The water is a God-send. Sanders
better and Rowe worse.
Aug. 16.—Still in the land of the living. Capt. Wirtz
is sick and a Lieut. Davis acting in his stead.
Aug. 17.—Hanging on yet. A good many more
than two hundred and twenty-five die now in twenty-
four hours. Messes that have stopped near us are all
dead.
Aug. 18.—Exchange rumors.
Aug. 19.—Am still hoping for relief. Water is
bracing some up, myself with others. Does not hurt
us.
Aug. 20.—Some say three hundred now die each
day. No more new men coming. Reported that Wirtz
is dead.
Aug. 21.—Sleep nearly all the time except when
too hot to do so.
Aug. 22—Exchange rumors.
Aug. 23.—Terribly hot.
Aug. 24.—Had some soup. Not particularly worse,
but Rowe is, and Sanders also.
Aug. 25.—In my exuberance of joy must write a
few lines. Received a letter from my brother, George
W. Ransom, from Hilton Head.[A] Contained only a
few words.
[A] My brother supposed me dead, as I
had been so reported; still, thinking it
might not be so, every week or so he
would write a letter and direct to me as a
prisoner of war. This letter, very strangely,
reached its destination.
Aug. 26.—Still am writing. The letter from my
brother has done good and cheered me up. Eye sight
very poor and writing tires me. Battese sticks by;
such disinterested friendship is rare. Prison at its
worst.
Aug. 27.—Have now written nearly through three
large books, and still at it. The diary am confident will
reach my people if I don’t. There are many here who
are interested and will see that it goes north.
Aug. 28.—No news and no worse; set up part of
the time. Dying off a third faster than ever before.
Aug. 29.—Exchange rumors afloat. Any kind of a
change would help me.
Aug. 30.—Am in no pain whatever, and no worse.
Aug. 31.—Still waiting for something to turn up. My
Indian friend says: “good news yet.” Night.—The
camp is full of exchange rumors.
Sept 1.—Sanders taken outside to butcher cattle.
Is sick but goes all the same. Mike sick and no longer
a policeman. Still rumors of exchange.
Sept. 2.—Just about the same; rumors afloat does
me good. Am the most hopeful chap on record.
Sept. 3.—Trade off my rations for some little luxury
and manage to get up quite a soup. Later.—
Sanders sent in to us a quite large piece of fresh
beef and a little salt; another God-send.
Sept. 4.—Anything good to eat lifts me right up,
and the beef soup has done it.
Sept. 4.—The beef critter is a noble animal. Very
decided exchange rumors.
Sept. 5.—The nice spring of cold water still flows
and furnishes drinking water for all; police guard it
night and day so to be taken away only in small
quantities. Three hundred said to be dying off each
day.
Sept. 6.—Hurrah! Hurrah!! Hurrah!!! Can’t holler
except on paper. Good news. Seven detachments
ordered to be ready to go at a moment’s notice.
Later.—All who cannot walk must stay behind. If left
behind shall die in twenty-four hours. Battese says I
shall go. Later.—Seven detachments are going out
of the gate; all the sick are left behind. Ours is the
tenth detachment and will go to-morrow so said. The
greatest excitement; men wild with joy. Am worried
fearful that I cannot go, but Battese says I shall.
Sept. 7.—Anxiously waiting the expected
summons. Rebels say as soon as transportation
comes, and so a car whistle is music to our ears.
Hope is a good medicine and am sitting up and have
been trying to stand up but can’t do it; legs too
crooked and with every attempt get faint. Men laugh
at the idea of my going, as the rebels are very
particular not to let any sick go, still Battese say I am
going. Most Dark.—Rebels say we go during the
night when transportation comes. Battese grinned
when this news come and can’t get his face
straightened out again.
Marine Hospital, Savannah, Ga., Sept. 15, 1864.
—A great change has taken place since I last wrote
in my diary. Am in heaven now compared with the
past. At about midnight, September 7th, our
detachment was ordered outside at Andersonville,
and Battese picked me up and carried me to the
gate. The men were being let outside in ranks of four,
and counted as they went out. They were very strict
about letting none go but the well ones, or those who
could walk. The rebel adjutant stood upon a box by
the gate, watching very close. Pitch pine knots were
burning in the near vicinity to give light. As it came
our turn to go Battese got me in the middle of the
rank, stood me up as well as I could stand, and with
himself on one side and Sergt. Rowe on the other
began pushing our way through the gate. Could not
help myself a particle, and was so faint that I hardly
knew what was going on. As we were going through
the gate the adjutant yells out: “Here, here! hold on
there, that man can’t go, hold on there!” and Battese
crowding right along outside. The adjutant struck
over the heads of the men and tried to stop us, but
my noble Indian friend kept straight ahead, hallooing:
“He all right, he well, he go!” And so I got outside,
and adjutant having too much to look after to follow
me. After we were outside, I was carried to the
railroad in the same coverlid which I fooled the rebel
out of when captured, and which I presume has
saved my life a dozen times. We were crowded very
thick into box cars. I was nearly dead, and hardly
knew where we were or what was going on. We were
two days in getting to Savannah. Arrived early in the
morning. The railroads here run in the middle of very
wide, handsome streets. We were unloaded, I should
judge, near the middle of the city. The men as they
were unloaded, fell into line and were marched away.
Battese got me out of the car, and laid me on the
pavement. They then obliged him to go with the rest,
leaving me; would not let him take me. I lay there
until noon with four or five others, without any guard.
Three or four times negro servants came to us from
houses near by, and gave us water, milk and food.
With much difficulty I could set up, but was
completely helpless. A little after noon a wagon came
and toted us to a temporary hospital in the outskirts
of the city, and near a prison pen they had just built
for the well ones. Where I was taken it was merely an
open piece of ground, having wall tents erected and
a line of guards around it. I was put into a tent and
lay on the coverlid. That night some gruel was given
to me, and a nurse whom I had seen in Andersonville
looked in, and my name was taken. The next
morning, September 10th, I woke up and went to
move my hands, and could not do it; could not move
either limb so much as an inch. Could move my head
with difficulty. Seemed to be paralyzed, but in no pain
whatever. After a few hours a physician came to my
tent, examined and gave me medicine, also left
medicine, and one of the nurses fed me some soup
or gruel. By night I could move my hands. Lay awake
considerable through the night thinking. Was happy
as a clam in high tide. Seemed so nice to be under a
nice clean tent, and there was such cool pure air.
The surroundings were so much better that I thought
now would be a good time to die, and I didn’t care
one way or the other. Next morning the doctor came,
and with him Sergt. Winn. Sergt. Winn I had had a
little acquaintance with at Andersonville. Doctor said I
was terribly reduced, but he thought I would improve.
Told them to wash me. A nurse came and washed
me, and Winn brought me a white cotton shirt, and
an old but clean pair of pants; my old clothing, which
was in rags, was taken away. Two or three times
during the day I had gruel of some kind, I don’t know
what. Medicine was given me by the nurses. By night
I could move my feet and legs a little. The cords in
my feet and legs were contracted so, of course, that I
couldn’t straighten myself out. Kept thinking to
myself, “am I really away from that place
Andersonville?” It seemed too good to be true. On
the morning of the 12th, ambulances moved all to the
Marine Hospital, or rather an orchard in same yard
with Marine Hospital, where thirty or forty nice new
tents have been put up, with bunks about two feet
from the ground, inside. Was put into a tent. By this
time could move my arms considerable. We were
given vinegar weakened with water, and also salt in
it. Had medicine. My legs began to get movable more
each day, also my arms, and to-day I am laying on
my stomach and writing in my diary. Mike Hoare is
also in this hospital. One of my tent mates is a man
named Land, who is a printer, same as myself. I hear
that Wm. B. Rowe is here also, but haven’t seen him.
Sept. 16.—How I do sleep; am tired out, and
seems to me I can just sleep till doomsday.
Sept. 17.—Four in each tent. A nurse raises me
up, sitting posture, and there I stay for hours, dozing
and talking away. Whiskey given us in very small
quantities, probably half a teaspoonful in half a glass
of something, I don’t know what. Actually makes me
drunk. I am in no pain whatever.
Sept. 18.—Surgeon examined me very thoroughly
to-day. Have some bad sores caused by laying down
so much; put something on them that makes them
ache. Sergt. Winn gave me a pair of socks.
Sept. 19.—A priest gave me some alum for my
sore mouth. Had a piece of sweet potato, but couldn’t
eat it. Fearfully weak. Soup is all I can eat, and don’t
always stay down.
Sept. 20.—Too cool for me. The priest said he
would come and see me often. Good man. My left
hand got bruised in some way and rebel done it up.
He is afraid gangrene will get in sore. Mike Hoare is
quite sick.
Sept. 21.—Don’t feel as well as I did some days
ago. Can’t eat; still can use my limbs and arms more.
Sept. 22.—Good many sick brought here.
Everybody is kind, rebels and all. Am now differently
sick than at any other time. Take lots of medicine, eat
nothing but gruel. Surgeons are very attentive. Man
died in my tent. Oh, if I was away by myself, I would
get well. Don’t want to see a sick man. That makes
me sick.
Sept. 23.—Shall write any way; have to watch
nurses and rebels or will lose my diary. Vinegar
reduced I drink and it is good; crave after acids and
salt. Mouth appears to be actually sorer than ever
before, but whether it is worse or not can’t say. Sergt.
Winn says the Doctor says that I must be very careful
if I want to get well. How in the old Harry can I be
careful? They are the ones that had better be careful
and give me the right medicine and food. Gruel made
out of a dish cloth to eat.

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Management of Abdominal Hernias Karl

Robotic Assisted Hernia Repair Current Practice Karl A.

Atlas of Abdominal Wall Reconstruction 2nd Edition

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Procurement and Transplantation of Abdominal Organs in

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ISBN 978-3-319-63250-6 ISBN 978-3-319-63251-3 (eBook)

Library of Congress Control Number: 2017964725

© Springer International Publishing AG, part of Springer Nature 2018

Printed on acid-free paper

Baton Rouge, LA, USA Karl A. LeBlanc

Stockton-on-Tees, UK H. Brendan Devlin

Stockton-on-Tees, UK H. Brendan Devlin

Plymouth, UK Andrew N. Kingsnorth

Plymouth, UK Andrew N. Kingsnorth

Part I General Topics

1 General Introduction and History of Hernia Surgery������������������������������������������������� 3

Part II Groin Hernia

11 Diagnosis of a Lump in the Adult Groin������������������������������������������������������������������� 195

14 Tissue Repairs for Inguinal Hernia��������������������������������������������������������������������������� 247

Part III Incisional and Ventral Hernia

24 The Open Abdomen: Indications and Management����������������������������������������������� 357

32 Postpartum Divarication Navel-Sparing Treatment

Gina L. Adrales John Hopkins Hospital, Baltimore, MD, USA

Joachim Conze UM Hernia Centre, München, Germany

Karl A. LeBlanc MD, MBA, FACS, FASMBS,

Andrew Kingsnorth JP, BSc (Hons), MB BS, MS,

David L. Sanders BSc(Hons), MBChB, FRCS, MD,

Hugh Brendan Devlin CBE, MA, MD, MCh (Dublin),

Ancient and Renaissance Hernia Surgery

The high prevalence of hernia, for which the lifetime risk is

Greek and Phoenician terracottas (Figs. 1.2 and 1.3) illus-

© Springer International Publishing AG, part of Springer Nature 2018 3

Fig. 1.3 Phoenician terracotta figure (female) shows umbilical hernia

Fig. 1.4 Vitruvian Man (from

Fig. 1.5 The visit of surgical

Fig. 1.6 Frontispiece and

hernia) was named after him. He was a renowned physician

Fig. 1.11 Antonio Scarpa (1752–1832) professor of surgery and anat-

Fig. 1.10 Development of a preternatural colon fistula (colostomy)

cavity and had not been in any way ruptured or broken,

REMOVED FROM ANDERSONVILLE TO THE MARINE HOSPITAL,

Aug. 1.—Just about the same. My Indian friend

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