My Department’s Debates

Department of Surgery Ospital ng Maynila Medical Center
Department Debate

Jose Pingul, MD

Derrick Chua, MD

Rick Mujer, MD

Jeffy Guerra, MD

Benjie Deveza, MD

Premise

In adult patients

With an internal inguinal ring less than or equal to 3 cm

Do we repair the floor or not?


History of on/off bulging mass in the inguinal area, associated with contraction of the abdominal muscles
PE: palpated external ring with less than 4 cm
Gilbert’s Classification
Type Description
Type I Indirect, tight ring, sac any size, reducible
Type II Indirect, ring <= 4 cm
Type III Ring > 4 cm, sliding component, displaces inferior epigastric vessels
Type IV Defective canal floor, ring is sound
Type V Direct diverticular defect 1-2 cm suprapubic, but anywhere along floor
Type VI Pantaloon hernia
Type VII Femoral hernia

Not to repair the floor

Options: We can

Ligate the sac

Excise the sac

Invert the sac

Tighten the internal ring, annulorrhapy (Marcy repair)


To repair the floor

More sutures needed

More unnecessary expenses

More Injury to underlying structures

More pain due to the sutures placed

In short it is unnecessary, as proven by evidence




Run down of RCT’s that repaired the floor
Author Type of
repair Number
of patients Follow-up
period Complication
rate(%)
Hernia
recurrence
rate (%)
Panos, et al. McVay 136 Average of 3 years, NR 9
Shouldice 136 Average of 3 years, NR 7
Paul, et al. Bassini 125 3.3 years 28 10
Shouldice 119 3.4 years 29 2
Tran, et al. Bassini 63 2 years 18 14
Shouldice 65 2 years 18 11

No difference in terms of pain

Bay-Nielsen M, Nilsson E, Nordin P, Kehlet H. Chronic pain after open mesh and sutured repair of indirect inguinal hernia in young males. Br J Surg. 2004 Oct;91(10):1372-6.


Main Problem

Failure to close the internal ring in transversalis fascia is the primary cause of recurrent indirect inguinal hernia.


Griffith CA. The Marcy repair revisited.

Is ligating the sac adequate?
Repair the floor – unnecessary?
Options Benefit Risk Cost Availability
Repair the floor CR = 18 -29%
RR = 2 -14% Injury to underlying structures P 3500 yes
Ligate the sac CR = < 1
RR = 1.6 -18% less P 3000 yes

End analysis
•Is it important to repair the floor at all?
•Have we learned that the important factor is the sac and not the floor, as based from evidence by numerous studies?
•Are we just following what we have traditionally done?

•The Pathophysiology of an indirect inguinal hernia with less than 4 cm is
•Patent procesus vaginalis
•Not a weak floor
•To treat it: directly ligate the sac
•No need to repair the floor because it is not pathologic at all

References

Panos RG, Beck DE, Maresh JE, Harford FJ.Preliminary results of a prospective randomized study of Cooper's ligament versus Shouldice herniorrhaphy technique. Surg Gynecol Obstet. 1992 Oct;175(4):315-9.

Paul A, Troidl H, Williams JI, Rixen D, Langen R.Randomized trial of modified Bassini versus Shouldice inguinal hernia repair. The Cologne Hernia Study Group. Br J Surg. 1994 Oct;81(10):1531-4.

Sayad P, Hallak A, Ferzli G.Laparoscopic herniorrhaphy: review of complications and recurrence. J Laparoendosc Adv Surg Tech A. 1998 Feb;8(1):3-10.

Bay-Nielsen M, Nilsson E, Nordin P, Kehlet H. Chronic pain after open mesh and sutured repair of indirect inguinal hernia in young males. Br J Surg. 2004 Oct;91(10):1372-6.

Shafik A .Invagination of the hernial sac stump. Technique for repair of inguinal hernia. Am J Surg. 1980 Sep;140(3):431-6.

Jess P, Hauge C, Hansen CR. Long-term results of repair of the internal ring for primary inguinal hernia. Eur J Surg. 1999 Aug;165(8):748-50.