VENTRAL HERNIA

A NEW TECHNIQUE IN ITS REPAIR

VINCENT FARMER, M.D.

HACKENSACK, N. J.

M ASSON reports from the Mayo CIinic for the period IgIg-Igzo that 2 per cent of 28,970 abdomi-

rence, which is more IikeIy to deveIop in patients who are obese because of the poor quaIity of the tissues.

naI operations were for postoperative hernia and that 33.8 of a11 postoperative hernias occurred through Iow midIine incisions.

An anatomica examination of the ab- domina1 wal1 shows that the fibers of the main supporting structure, nameIy the aponeurotic bundIes of fibers, to a Iarge extent Iie transverseIy. This is especiaIIy true of the fibers of the transversaIis fascia in the Iower abdomen. A study of the dynamics of the abdomina1 waI1 shows that this is essentia1 as the IateraI tension is apparentIy greater than the vertica1. One frequentIy notes a considerabIe diastasis of the rectus muscIe without a hernia but onIy when there is no separation of the aponeurotic fibers. Therefore, in an ade- quate repair of the abdomina1 waI1, it is necessary to strengthen and repIace these transverse supporting fibers not aIong the axis of the hernia but for a considerabIe distance perpendicuIar to this line.

AIcohoI-preserved dead ox-fascia strips are used in such a manner in this technique as first to obviate a11 tension on the suture Iine by distributing the tension over a Iarge area of the muscIe and its overIying fascia and second to give the fascia strips as much contact as possibIe over a Iarge area of muscIe fibrous tissue. We thereby create strong transverse bands of revived tissue which Iend powerfu1 support not onIy to the area of incision but to the surrounding tissues as weI1, so that the entire structure is better abIe to withstand the increased intra-abdomina1 pressure which foIIows these procedures.

In many cases the greater part of the an- terior abdominal waI1, apart from the post- incisiona region, is weakened, stretched and atrophied and it is of great importance to take cognizance of this fact in the technique so as to prevent recurrence after repair of Iarge hernias.

To obtain the best resuIts it is essentia1 that the edges of the fascia Iayer, whether imbricated or not, be aIIowed to hea with- out tension. When there is puIIing on the Iine of suture considerabIe connective tissue forms between the edges or there is union onIy at points or union is foIIowed later by stretching of the scar; conse- quentIy, there is a predisposition to recur-

Koontz2 has shown that in the repair of inguina1 hernias the amount of fibrous union and scar-tissue formation was greater when raw muscIe surface was brought into contact with the Iigament; because the fibrous components of the muscIe were brought into more intimate contact and thus afforded wider contact for fascia-to- fascia union, on which the strength de- pends. The use of Iiving sutures by GaIIie and Lemessieurz affords a chance for an even more intimate union by furnishing a Iiving bridge of fibrous tissue extending from the Iigament into the very heart of the muscle. That this same Iiving bridge can be uItimateIy produced by using strips of aIcohoI-preserved fascia-Iata of the ox, Koontz4 showed in a paper pubiished in 1926. The coIIagen fibriIs of fascia are inert substances in the Iiving anima1, and are entireIy unaItered by their preservation in aIcoho1, so that when these strips of fascia are pIaced in another anima1, they act in no way as a foreign body, producing

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NEW SERIES VOL. XXI, No. I Farmer-VentraI Hernia American Journal of Surg~r-y 11,

phagocvtosis and a foreign body reaction, some distance beneath the skin and in but are”invaded by new ceIIs and fibrobIasts these cases care must be exercised not to from the host, thus in a short time becom- inject too cIose to what seems to be the

Frc. I. A. Incision for ventra1 hernia where sac is large and there is danger of injuring gut. IL Exposure of one- haIf of inside of sac. c. Approach to neck of sac.

ing revivified and acting in exactIy the same way as the “Iiving structures” of GaIIie and Lemessieur. The obvious ad- vantage of this materia1 over the “ Iiving structures” is that it can be kept ready for use in the operating room, it is uniform in width and strength and it is not neces- sary to perform an additiona operation in order to obtain it.

ANESTHESIA

Of a11 procedures in which IocaI anes- thesia is used those which concern the abdomina1 waII give the most satisfaction to the patient and to the operator. In ex- tensive repairs a considerabIe amount of soIution (0.5 to 1 per cent novocaine- adrenaIin soIution) may be required. We may greatIy reduce the amount by freeing the skin and fat, anesthetized by the subderma1 method, before injecting in the fascia. The hernia1 sac may extend

Iimit of the sac. If doubt exists it is best to inject the fascia1 and peritonea1 Iayers after they have been exposed. However many surgeons stiI1 prefer spina anesthesia.

TECHNIQUE

If the patient is extremeIy obese with considerabIe depth of fat in the abdomina1 waI1, it is advisable to make a Iarge trans- verse incision, remove the portion of skin and subcutaneous fat and then make the incision through the muscIe in the median Iine. In cases in which the sac is smaI1 it may be readiIy excised, and the peritoneum sutured, the edges of the muscle thoroughIy cIeansed and brought together and then an over-Iapping cIosure of the externa1 sheath of the rectus can be made. If the hernia is Iarge and the muscIes wideIy separated an imbrication of the peritoneum and fascia is necessary, a pIastic cIosure of the Mayo type -bringing the cIeansed

FIG. 2. A. Interrupted mattress sutures everting trans- versalis-peritoneum layer so that peritoneum comes in contact on each side. B. Bringing fascia layers together by overIapping with chromic catgut sutures.

FIG. 4. A. and B. Best method of anchoring with Iinen thread so that anchor is secure without weakening fascia strip. Compare with Figure 3 where fascia strip is split transversley by needle. Same suture may be utiIized in different pIaces along strip, covering surface with tissue.

FIG. 3. A. &at? needle, first suture. B. Depth of bite. c. Fascia drawn tight and deep through tissues.

FIG. 5. Strips extending Iaterally, where tissues are not so stretched or atrophied, placed between blood vesseIs supplying skin and fat, Iatter being retracted for ilIustration.

NEW SERIES VOL. XXL, No. I Farmer-VentraI Hernia

peritoneum over the scarified fascia or rectal sheath. In doing this too much time can not be taken in order to cleanse the tissues thoroughIy before they are approxi- mated by interrupted mattress sutures. In doing this much tension is required to cause the edges to overlap and it is here that the ox-fascia strips pIaced transversIy as shown in the iIIustration are: of the greatest benefit.

!l;here the sac contains omentum or bo\veI with numerous adhesions, often in a multiIocuIar fashion, it is we11 to enter the peritoneum above the sac, insert the index finger into the abdomina1 cavity and with the finger as a guide carefully dissect the rim of the sac on one side. The skin and subcutaneous tissue covering the sac may then be Iifted and the dissection completed without injury to the bower. It may be advantageous to Ieave parts of the parieta1

peritoneum attached to the bowel. In patients where the surgical risk is

very uncertain it is expedient to pIace ox- fascia strips, as illustrated, to strengthen the fascia and muscIe layers and partIy reduce the defect in the first operation. The second stage consists of dissection of the Iayersand an overIapping procedure as described.

COMMENTS

We have used fascia both Iiving and dead of varied sizes and shapes in varied wavs in herniopIasty; and have had opportuni- ties of viewing the results. Our conclusions are that large fascia strips of Iiving struc- tures do not become vivified. This is more obvious when the strip, whether living or dead, is not pIaced so that every centimeter is in cIose contact with Iiving tissue having ample circulation. We have aIso observed that the results are more favorabIe when the strip is inserted deeply with tension through the tissue rather than being sutured in place on the surface. The recur- rence is Iess frequent and the number of operabIe cases increased. In the postopera- tive care one need not be concerned about the tension on the suture line; abdominal binders are not needed and the patient is more comfortabIe. This method is founded on a true anatomica basis.

REFERENCES

I. MASON, J. C. Postoperative ventral hernia. Surg., Gynec. Obst., 37: 14, 1923.

2. KOONTZ, A. R. Healing in hernia repair. Internat. Surg. Dig., 4: 195-198, 1927.

3. GALLIE ~~~LEMESSIEUR. Living sutures in treatment of hernia. Canada MedicaI Assoc., July, 1923.

4. KOONTZ, A. R. Experimental results in the use of dead fascia grafts. Ann. Surg., 83: 523-536, rgz6.

5. GRATZ, C. M. New instruments for living sutures. AM. J. SURG., n.s. 13: 81, rg3 I (see illustrations).

REFERENCES OF DRS. SHAWAN AND LONG*

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I I. PORTER, L. Abt’s Pediatrics, PhiIa., Saunders, 1924, 3: 676.

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IX. SNYDEK, C. C. Cholecvstitis and cholelithiasis in young children. J. A: M. A., 85: 31, ,923.

14. STILL. ChoIecystitis in chiIdhood. Tr. Path. Sec. London, 4: 1515, r8gg.

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16. WALKER, D. Quoted by E. Freundlich. Jab&. f. Kinderb., 46: 72, rgzr.

17. WHARTON, H. R. A case of acute choIecystitis folIowing acute appendicitis. Tr. Am. Surg. Assn., 27: 540, 1909.

*Continued from p. 46.