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16 The Most Important Clinical Trial intheLast 10 Years inInguinal andIncisional Hernia Surgery
155
for continuous midline abdominal closure into
two allocation arms: standard long stitch closure
with a half-circle needle with a 41mm diameter
and a 1-0 PDS suture versus short stitch closure
with a 20mm diameter and a 2-0 PDS suture. The
study was patient- and assessor-blinded with follow-up at 1 and 12months [11].
The study outcomes were more benecial in
the short stitch group, as both SSI (10.2% vs.
5.2%) and incisional hernia at 1year (18.0% vs.
5.6%) were signicantly higher in the long stitch
group. The authors suggested that closure with
the large stitch promotes ischemia and SSI, as
the suture embraces more remote tissue than just
the aponeurosis. There are several reasons to
explain the preventive effect of the small stitch
closure on the rate of incisional hernia. SSI and
early slackening of the suture due to a cutting
effect on soft tissues are prevented, when the
stitches are placed close to the edge of the aponeurosis. Moreover, a higher number of applied
stitches causes less tension on each suture and
hence a reduced tendency toward tearing of the
aponeurosis. Due to the large study, other risk
factors for SSI (contamination and diabetes) and
incisional hernia formation (male sex, BMI,
operative time, SSI and suture-wound ratio<4)
could be identied in multivariable models.
Interestingly, these benecial effects were not
offset by a longer operative time in the short
stitch allocation arm.
The study by Israelsson and coworkers has
several merits. It is a prominent example of
extremely relevant clinical research for a large
group of patients introducing a relatively simple
and inexpensive surgical technique. The study
group was able to monitor the study closely, as it
exclusively took place in their own department
through years of dedicated inclusion of patients to
obtain sufcient study power. Opponents of the
small stitch– small bites technique have claimed
that the results had not proven reproducible in a
general surgical setting. However, a recent large
randomized Dutch multicentre study (the STITCH
trial) came to a similar conclusionas reported in
the Swedish study 6years earlier asconcerns the
preventive effect on the development of incisional
hernia. The Dutch study elegantly demonstrated
the external validity of Israelsson and coworkers’
main nding [12].
Development of incisional hernia is associated
with morbidity, prolonged hospitalization,
repeated surgery, and increased costs. The simple
and inexpensive abdominal closure technique for
midline laparotomies as originally proposed by
Dr. Israelsson should now be considered gold
standard with enormous signicance for the
operating results of the surgical patients in
general.
The studies from the groups of Löfgren and
Israelsson pose a unique potential to inspire the
surgical community to work together and conduct multicentre evaluation of relevant research
questions in a randomized manner. Sadly, the
abundance of such questions is presently not
answered by high-level evidence.
References
1. Sanders DL, Kingsnorth AN, Stephenson
BM. Mosquito net mesh for abdominal wall hernioplasty: a comparison of material characteristics with commercial prosthetics. World J Surg.
2013;37:737–45.
2. Stephenson BM, Kingsnorth AN. Inguinal hernio-
plasty using mosquito net mesh in low income countries: an alternative and cost effective prosthesis.
BMJ. 2011;343:d7448.
3. Löfgren J, Nordin P, Ibingira C, Matovu A, Galiwango
E, Wladis A.A randomized trial of low-cost mesh in
groin hernia repair. N Engl J Med. 2016;374:146–53.
4. Fink C, Baumann P, Wente MN, etal. Incisional her-
nia rate 3 years after midline laparotomy. Br J Surg.
2014;101:51–4.
5. Bucknall TE, Cox PJ, Ellis H.Burst abdomen and inci-
sional hernia: a prospective study of 1129 major laparotomies. Br Med J (Clin Res Ed). 1982;284:931–3.
6. Meyhoff CS, Wetterslev J, Jorgensen LN, etal. Effect
of high perioperative oxygen fraction on surgical site
infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial.
JAMA. 2009;302:1543–50.
7. Sauerland S, Walgenbach M, Habermalz B, Seiler
CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair.
Cochrane Database Syst Rev. 2011:CD007781.
8. Gillion JF, Sanders D, Miserez M, Muysoms F. The
economic burden of incisional ventral hernia repair: a
multicentric cost analysis. Hernia. 2016;20:819–30.
9. Timmermans L, de Goede B, Eker HH, van Kempen
BJ, Jeekel J, Lange JF.Meta-analysis of primary mesh
156
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
L. N. Jorgensen and T. Bisgaard
augmentation as prophylactic measure to prevent incisional hernia. Dig Surg. 2013;30:401–9.
10. Muysoms FE, Antoniou SA, Bury K, etal. European
Hernia Society guidelines on the closure of abdominal
wall incisions. Hernia. 2015;19:1–24.
11. Millbourn D, Cengiz Y, Israelsson LA. Effect of
stitch length on wound complications after closure of
midline incisions: a randomized controlled trial. Arch
Surg. 2009;144:1056–9.
12. Deerenberg EB, Harlaar JJ, Steyerberg EW, et al.
Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind,
multicentre, randomised controlled trial. Lancet.
2015;386:1254–60.
Part II
Inguinal
Anatomy of the Inguinal Region
Cooper's ligament
ligament
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
J. Loriau
17
As Fruchaud proposed in 1956 [1] (cf. anatomy
of the femoral region), we should consider both
femoral and inguinal regions as a unique entity:
the Myopectineal orifice.
In his conception, widely shared since his
description, there are in the area between: the pelvic
bone and its surrounding ligaments, the superficial
and the deep layer of the abdominal wall muscles
Fig. 17.1 Myopectineal
orifice with femoral
vessels
Internal oblique
Ilioposas muscle
Fascia iliaca
Iliopectineal tract
Pubic tubercle
forming the conjoint tendon, the psoas muscle and
the rectus muscle two zones of potential weakness.
The lower one is the femoral region. The upper one
is the inguinal region. Those two zones are separated
by the inguinal ligament. This approach by Fruchaud
is based on the fact that physiopathology of hernia
formation in those areas is commonly based on the
weakness of the fascia transversalis (Fig. 17.1).
Rectus
muscle
Femoral
vein
Inguinal
Femoral
canal
J. Loriau, MD
Department of Digestive Surgery, Groupe Hospitalier Paris St Joseph,
Paris, France
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_17
159
160
Books of anatomy looks sometimes diffi-
cult to appropriate as they display many
informations, historical names or nick-
names. Their drawings can be beloved for
their artistic appearance or hated because
of looking old-fashioned.
Nevertheless it is totally impossible
to forget anatomic considerations in a
textbook about abdominal wall surgery.
If we should give only one reason for
that I would say that knowing anatomy
is one of the best ways to avoid dramatic
complications!
Therefore, our purpose will be to highlight the “surgical anatomy” of the inguinal
region and give cartography of the points of
wreck!
J. Loriau
17.1 The Myopectineal Orifice
of Fruchaud and the Inguinal
Region: Three Muscular
Layers Concurring
to Weakness (Fig. 17.2)
Although present in the inguinal region, the large
muscles of the abdominal wall fail in building a
strength rampart to hernia formation.
The external oblique is the most superficial
and present just under the skin, fat tissues and
superficial fascia.
Indeed the superficial fascia is the first layer
the surgeon will cross approaching the inguinal
region. This superficial fascia has been described
as comporting itself two layers. One more areolar
is called Scamper’s fascia and one more fibrous
and deep called Scarpa’s fascia. Both are continued down into the genital organs (penis or labia
major). Superficial fascia is easily identified during surgery but it’s more uncommon to distinguish its two layers.
Transverse abdominis
Located under the obliques,
it is the deepest of the
abdominal muscles and
wraps around your spine for
protection and stability.
Internal abdominal oblique
Located under the external
obliques, running in the
opposite direction.
Fig. 17.2 Muscles of the core
External abdominal oblique
Located on the side and
front of the abdomen
Rectus abdominis
Located along the front of
the abdomen, this is the
most well-known
abdominal. Often referred
to as the “six pack”.
Skin and superficial
us
17 Anatomy of the Inguinal Region
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161
The external oblique of the abdomen consists
only in an aponeurosis at that level. Its fibers,
directed downward and medially towards the
midline constitute a strong membrane. Despite
this strength, it cannot contribute to avoid hernia
formation. First because it is too superficial and
contains a whole as a result of its fibers split from
each other: the superficial inguinal ring; the exit
of the inguinal canal. In case of oblique hernias
the superficial inguinal ring, as a whole, cannot
play any role in stopping the hernia sac during its
outward movement. Second because in case of
direct hernias it is also too superficial and can
only overhang the hernia. Third because the
external oblique fascia ends caudally constituting
the inguinal ligament which is the “ground” of
the inguinal canal. Inguinal ligament divides in
two parts (inguinal and femoral) the myopectineal orifice of Fruchaud but doesn’t confer any
additional opposition to inguinal hernia formation (Fig. 17.3).
The internal oblique is the second layer. Its
fibers run opposite to the one from the external
oblique upward and medially. It is a muscle of
importance because its fibers joined with the
ones from the transverse will constitute the
“conjoint tendon”. The “tendon conjoint” is the
ceiling of the inguinal canal. The role of the
“conjoint tendon” in hernia occurrence is discussed under but the internal oblique cannot be
considered as an efficient rampart to hernia formation (Fig. 17.4).
The internal oblique also contains fibers that
will downward with ones from the transverse
muscle constitute the lateral cremaster muscle
(see under). When present the medial fibers from
the cremaster muscle come from the inguinal
ligament.
Deeper lays the transverse muscle. In its
lower part , its fibers runs horizontally from the
iliac fascia, anterior-superior iliac spine and the
lateral third or the inguinal ligament almost parallel to the ones from the internal oblique and
contributes to the formation of the conjoint tendon. Some fibers also distribute fibers to the cremaster (Fig. 17.5).
Fig. 17.3 Superficial layers of the inguinal region
Ant. sup.
iliac spine
Superficial iliac
circumflex vein
fascia reflected
Inguinal ligament
Superficial
epigastric vein
Spermatic cord
Scrotum
Superficial fascia
Aponeurosis of
obliquus extern
Intercrural fibres
Subcutaneous
inguinal ring
Superior crus
162
Tr
Great saphenous
m
Lumbodorsal
Rectus abdominis
J. Loriau
Obliquus
externus
ansversus
Inguinal
ligament
Iliacus
Femoral
nerve
Femoral
artery
Sartorius
Fascia lata
Fig. 17.4 Deep layers of the inguinal region
Sternum
Obliquus
internus
Transversalis
fascia
Femoral vein
Femoral canal
Fossa ovalis
Inferior layer of
femoral sheath
vein
5th
6th
Fig. 17.5 Oblique and
rectus muscle insertions
Tendinous
inscriptions
Sheath of rectus
(its posterior
lamella)
Linea alba
Pyramidalis
Pubis
7th
8th
9th
10th
11th
12th
fascia
Crest of iliu
Inguinal ligament
Falx inguinalis
17 Anatomy of the Inguinal Region
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Role of the conjoint tendon in hernia constitution
Born from the horizontal running fibers of both internal oblique and transverse muscle, the conjoint tendon runs horizontally and then vertically to the crest of the pubis and pectineal line.
Therefore it was also called inguinal aponeurotic falx. The medial insertion of the conjoint tendon
is variable and the variations have been described as possibly playing a role in hernia formation.
Since the tendon is the lowest musculo aponevrotic structure of the myopectineal orifice, all
the space between itself and the pectineal ligament represents a weakness space only closed by
the transversalis fascia. The more this space (including medially the “inguinal triangle” also
called Hesselbach’s triangle and laterally the deep inguinal ring) is large due to high lying conjoint tendon, the more the surface receiving abdominal pressure without musculoaponevrotic
reinforcement is large and subject to hernia formation.
Physiologic shutter mechanisms exist to deal with this anatomic weakness. In standing position the conjoint tendon is pulled up with the abdominal wall muscles and the potential orifice
is open.
During coughing or straining, contraction of the fibers of the conjoint tendon pulls it downward
in order to “close” the orifice and contain increased abdominal pressure. The same movement is
also observed during squatting where the tendon covers the weak area. The Hesselbach’s ligament
has also been described to play a role in the movement of closing the inguinal diaphragm.
But in case of an excessive surface due to a high or too external insertion of the conjoint tendon all these movements can be too limited to provide an efficient coverage of the area. Therefore
these anatomical predispositions (among others) can play a role in hernia formation (Fig. 17.6)
163
Deep inguinal
orifice
Inguinal ligament
External oblique
aponeurosis
During coughing
or straining
High Lying Internal
Oblique : Large Orifice
Small Lying Internal
Oblique : Small Orifice
Fig. 17.6 Different modalities of insertions of the components of the ring
Conjoint Tendon
Epigastric vessels
Rectus muscle
Pubicspine
164
14%
15%
68%
75%
17%
11%
Fig. 17.6 (Continued)
In summary the three different musculo aponevrotic layers doesn’t confer any solidity to the
inguinal region of the Myopectineal orifice due to their respective positions. A high position of
the conjoint tendon could enlarge the myopectineal orifice and facilitate hernia occurrence.
J. Loriau
17.2 The Inguinal Canal (Fig. 17.7)
As it has to be understood as a 3D structure, the
inguinal canal and its anatomy might be difficult to
understand and/or teach to residents. We used to
say that one thinks he understands its anatomy as
medical students, he (she) believes at last he (she)
understands as resident but nobody has really
caught the reality before being a certified surgeon!
The easier approach is to consider it as a rect-
angular block (parallelepiped) which is a geometric structure known to anybody.
Describing such a way the canal 6 sides have to be
defined: one on each extremity which are the entrance
and the exit of the channel, one ceiling and one bottom; one superficial and one deep face and the content represented by the spermatic cord (Fig. 17.8).
17.3 Entrance to the Channel:
the Deep Inguinal Ring
Deep anal ring is a whole inside the transversalis fascia allowing entrance to the spermatic cord
into the channel. If we describe it as a square,
its 4 for sides are anticlockwise from the top
(looking the right side in front of a patient): the
conjoint tendon on top and anterior sides constituted by fibers from the internal oblique and
transverse muscle, the inguinal ligament in the
inferior side, the epigastric vessels medially.
Along the epigastric vessels, the transversalis
fascia is reinforced and called Hesselbach’s ligament or interfoveolar ligament. Keeping in mind
that the internal limit of the internal ring is composed by the Hesselbach’s ligament but must of
all by epigastric vessels might be useful for safe
surgery… (Fig. 17.9)!
17.4 Exit to the Channel:
the Superficial Inguinal Ring
Located above the pubic tubercle, the superficial
ring is, as we described before, a near triangular
whole within the lower part of the external
oblique aponeurosis. It is made of its fibers split.
Medial crura is inserted on the public crest, lateral crura runs to the public tubercle. The inferior
side of the surficial ring triangle is made of the
lowest fibers of the external oblique aponeurosis
constituting the inguinal ligament (Fig. 17.10).
Inter
inguinal
Conjoint
ligament
17 Anatomy of the Inguinal Region
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165
a
nal oblique
Cremaster
muscle
muscle
Transversalis fascia
c
Epigastric vessels
Deep inguinal
Hesselbach
ligament
External oblique muscle
ring
b
Transverse
muscle
Deep
inguinal
ring
Femoral
canal
Cremaster
muscle
Spermatic
cord
Internal oblique
Transversalis
fascia
Lateral umbilical ligament
Peritoneum
External inguinal fossa
Median inguinal fossa
Internal inguinal fossa
muscle
Cremaster
muscle
Fig. 17.7 (a) Superficial layers of the inguinal canal. (b) deep layers of the inguinal canal. (c) internal “laparoscopic”
view of the inguinal region
Fig. 17.8 The inguinal
“3D Channel”
tendon
Transversalis
fascia
Deep
ring
External
oblique fascia
Superficial
Inguinal
inguinal ring
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