BAUMBER: GROIN HERNIA 667

cases the classic Kocher subcostal incision is used, which allows a slightly better access to the region of the renal pelvis and pedicle. In 2 instances nephrec- tomy was performed because the kidney was thought

Table VI.-TYPE OF OPERATION Operations No. of Kidneys

Nephrectomy 2 Y-V plasty 4

23 Hynes-Anderson

Total 29 -

Table VII.-RADIOLOGICAL RESULTS Radiological Result No. of Kidneys

Better No change Worse Too early Not known (Nephrectomy)

I1 9

6 -

I 2 -

Total 29

to be irrevocably damaged. These occurred relatively early on in the series and our policy since has been towards conservative surgery as far as possible. Only two types of plastic procedures were used: a Y-V-plasty as described by Foley (I937), and the Hynes-Anderson (1949) pyeloplasty. The types of operation are shown in Table VI. The choice between these types of surgical procedure depended essentially on the size of the renal pelvis.

RESULTS The results of surgery for pelvi-ureteric obstruc-

tion are difficult to assess. If the results are judged by pyelographic appearances they are usually dis- appointing. The radiological results are shown in

Table VZI, but it may well be that a long follow-up from 5 to 10 years after operation will show more encouraging results. However, rapid filling and visualization of the ureter after surgical relief of the obstruction denote success even if the cakes appear radiologically unchanged. On the other hand, the symptomatic results have been much more dramatic. All patients who presented with abdominal pain have had no further pain; neither have patients with haematuria had further attacks of haematuria. Of the 9 patients who presented initially with symptoms of urinary-tract infection, only I has had persistent or recurrent infection. This child developed a recurrent stricture (the only one in the series) as well as a stone in the renal pelvis, and has had to have a repeat pyelo- plasty and pyelolithotomy. His progress since the second pyeloplasty has been uneventful. We are most impressed by the ease with which a second pyeloplasty could be performed after having used an anterior transperitoneal approach on the first occasion. To date, none of the patients has developed hypertension, but this possibility must be borne in mind in a long-term follow-up.

REFERENCES ANDERSON, J. C., and HYNES, W. (1g49), Br. J. Urol.,

ECKSTEIN, H. B. (1968), in Paediatric Urology (ed.

FOLN, F. E. B. (1g37),J. Urol., 38, 643. JOHNSTON, J. H. (1969), Br. 3. Urol., 41, 724. MURNAGHAN, G. F. (I959), Ibid., 31, 370. NIXON, H. H. (1953), Ibid., 40, 601. PATHAK, I. G., and WILLIAMS, D. I. (1964), Ibid., 36,318. SCOTT, J. E. S . (1965)~ 2. Kinderchir. Grenzgeb., 2, 338. WILLIAMS, D. I., and KARLAFTIS, C. M. (1966), Br. J.

21, 209.

WILLIAMS, D. I.), p. 149. London: Butterworths.

Urol., 38, 138.

GROIN HERNIA BY C. D. BAUMBER

THE ROYAL INFIRMARY, SHEFFIELD

SUMMARY I. The recurrence rate for primary inguinal hernia

operated on in this series was 12-2 per cent. 2. The recurrence rate is higher for direct inguinal

hernia (16 per cent) than for indirect (11 per cent).

3. Those cases operated on by less experienced surgeons had recurrence more frequently (17 per cent) than those operated on by senior surgeons (9 per cent).

4. The incidence of hernia occurring in the opposite side is high: 44 per cent in the case of direct hernia and 21 per cent in the case of indirect hernia.

5. The prospects of a second or third successful operation are good. Only 2 patients (less than I per cent) in this series remain uncured; they are well controlled by a truss.

6. The recurrence rate for femoral hernia is low. 7. There was no difference in the time off work

between those cases that did or did not subsequently have a recurrence.

8. No relationship between recurrence rate and age was demonstrated.

THIS paper is concerned with 234 patients with groin hernia treated on routine operating lists between 1958 and 1964. They were all under the care of one consultant surgeon in a teaching hospital, which also has a service commitment for an area of Sheffield. The average time of follow-up was just under 9 years (range 6-11 years).

A simple pro forma was posted to each patient, a reminder being sent if there was no reply within 3 weeks. If their reply said that they had had no further trouble they were not examined. If they had had any symptoms at all they were seen and assessed per- sonally. Those who had been treated elsewhere for recunence were asked for details, and in all these cases their clinical notes were obtained for review.

The definition of recurrence was the same as that used by Marsden (195g), Le., a weakness at the

668 BRIT. J. SURG., 1971, Vol. 58, NO. 9, SEPTEMBER

HERNIA N O . OF PATIENTS Type I No.

operation site necessitating a further operation or the wearing of a truss.

Patients’ names were taken from the operating register. Approximately one-third were excluded from the series because either the original clinical records were missing or incomplete or the survey forms were returned by the Post Office as ‘undelivered’, the latter being caused by extensive redevelopment in the immediate vicinity of the Royal Infirmary. Patients who died during the period of follow-up (12 per cent) were also excluded, unless either they had been seen in the clinic shortly before death or the relatives

RECURRENCE

NO. I Percentage NO. OF

PATIENTS

zz 9

12 - Total 43

Table ZI.-DETAILS OF PATIENTS* WITH INDIRECT INGUINAL HERNIA

HERNIA RECURRENCE

Type +Lr. N O .

Right 7.2 Left 9 I Bilateral? I4 2

45 7 ---- -

NO. OF

Total 138 I - 1 144 1 16 17 * Only 13 female patients. Twenty-one per cent of patients had an

inguinal hernia on the opposite side at some stage. t Ten patients with bilateral hernia had a direct hernia on one side

and an indirect on the other.

HERNIA RECURRENCE

Type 1 No. 1 No. I Percentage -- ___-

specifically stated that there had been no further trouble from the hernia prior to death.

As much information as could be obtained from the original clinical notes was tabulated. Records of indirect inguinal hernia, direct inguinal hernia, and femoral hernia were kept separately. Pantaloon-type inguinal hernia was included with the direct inguinal hernia. Six patients with recurrent hernias (new to this series) were grouped together with the results of second operations on patients in the original series.

RESULTS The age range was from 15 to 75 years. The

greatest number of indirect hernias occurred between 30 and 55 years, while direct hernia was equally common in the older age-groups. No relationship of recurrence rate to age could be demonstrated.

It is the policy of the unit to encourage patients to lose weight before operative repair is undertaken. Of 72 patients for whom both height and weight were known, 23 were overweight even for large-framed individuals. Surprisingly they did not have a higher recurrence rate than thinner patients.

During 1958-9 exactly half the cases were operated on under local anaesthetic. It so happened that the number of recurrences was exactly the same in the local anaesthetic and the general anaesthetic groups.

Direct inguinal hernia (Table Z) recurred more frequently than indirect (Table 11). Only I case of femoral hernia recurred (Table ZZZ).

Eighty cases of primary indirect inguinal hernia were operated on by 13 different registrars, of varying experience, with a recurrence rate of 14 per cent. The results of 58 cases operated on by the consultant and

--I Total 23 - 1-qY-l-7- * There were 1 1 male and 12 female patients.

Table IV.-DETAILS OF PATIENTS* WITH RECURRENT INGUINAL HERNIA

HERNIA RECURRENCE NO. OF PATIENTS

~---------l----

Total 23 I - 1 2 3 1 5 i I 22

7 years (range, 4-10 years). *All patients were male. The average follow-up period was

t Three patients have had a third successful operation.

2 senior registrars were better with a recurrence rate of 10 per cent. This feature was even more pointed in the cases of primary direct inguinal hernia, where 5 out of 14 cases operated on by registrars have recurred but only 2 out of 30 operated on by the consultant and senior registrars. These figures would appear significant despite a possible bias for the more difficult cases being operated on by the more senior surgeons (TubEe IV).

The teaching of the unit is that inguinal hernia should be repaired according to the principles de- scribed by Lytle (1945, 1961). Particular attention is paid to tightening the internal ring and repairing the transversalis fascia, the posterior wall being further reinforced as necessary. Uniformity is not, however, enforced on the registrars and other techniques were used in some cases. The sac was excised in all cases of indirect hernia but in only half the cases of direct hernia. In 4 cases of direct hernia and 2 cases of indirect hernia, orchidectomy was performed and in I the hernia recurred. A small number of cases had a classic Bassini (1890) repair with or without a Tanner (1942) slide. One case of femoral hernia occurred 3 months after a Bassini-type repair. All femoral hernias were operated on by the low approach, the sac excised, and the hernial orifice closed.

KNOX E T AL. : COLOSTOMY CLOSURE 669

Indirect:- Non-recurrent Recurrent

Direct

Comparison of the different suture materials suggested that linen thread gave better results than braided silk, but this may be explained by the fact that they were not used equally by all surgeons. Thirty-three posterior walls were reinforced with a polyvinyl sponge insert. Only 2 of these had a

Table V.-TIME OFF WORK POSTOPERATIVELY IN MALE PATIENTS WITH INGUINAL HERNIA

34 3 days to 6.5 3 months

7 I week to 6.6

13 I week to 8 3 months

13 weeks

- I I I

T Y P E OF HERNIA 1 ,,..& 1 TIME RANGE 1 A v E ~ ~ ~ k ~ M E

recurrence after the sponge had been removed because of infection. These were the only cases of significant sepsis in the whole series, and repair at a later date was successful in each case.

Only 2 out of 14 cases of sliding hernia recurred and this corresponds with the personal experience of Maingot (1961). Two out of 13 cases of pantaloon- type hernia recurred.

Classification of occupation into three groups of physical stress gave no clear difference in recurrence rate, nor did there appear to be any relationship between time off work postoperatively and recurrence rate (Table V) . It would be of great interest eco- nomically to know the optimum time for return to full activity. During the past year patients on this unit, including manual workers, have returned to full duties 3-4 weeks after herniorrhaphy without obvious ill-effects.

Marsden (1958) stated that only 80 per cent of recurrences occurred within 10 years. In this study most of the recurrences appeared within 4 years, although some only came to light as a direct result of the survey. Over half of the recurrences appeared within 18 months (Fig. I).

The incidence of an inguinal hernia on the opposite side at the same time, previously, or subsequently was very high in this series (21 per cent indirect and 44 per cent direct). Chronic bronchitis is very common in Sheffield but it was not possible, in this retro- spective series, to correlate this with the high incidence

11 Primary hernia- d i r e c t inguinal

FIG. 1.-Time of recurrence nomogram for 24 cases. In this series there were 6 cases appearing for the first time as recurrent hernia and all had been repaired more than 20 years previously.

of bilateral direct hernia in the older age-group. Prostatism was no more common in cases of direct than indirect hernia.

Acknowledgements.-I would like to record thanks to Mr. D. H. Randall, Consultant Surgeon, for permission to report these cases and for his advice in the preparation of this paper. I would also like to thank the secretarial and records staff of the United Sheffield Hospitals who have given much valuable assistance.

REFERENCES BASSINI, E. (1890), Arch. klin. Chir., 40, 426. LYTLE, W. J. (I945), Br. J . Surg., 32, 41. -- (1961), Proc. R. SOC. Med., 54, 967. MAINGOT, R. (1961), Ibid., 54, 967. IV~ARSDEN, A. J. (1958), Br.J. Surg., 46, 234. -- (I959), Lancet, I, 461. TANNER, N. C. (1g42), Br.J. Surg., 29, 285.

CLOSURE OF COLOSTOMY

BY A. J. S . KNOX, SURGICAL REGISTRAR, ROYAL DEVON AND EXXETER HOSPITAL, EXETER

F. D. H. BIRKETT, SURGICAL REGISTRAR, GUY'S HOSPITAL, LONDON

AND c. D. COLLINS SENIOR SURGICAL REGISTRAR, BRlSTOL ROYAL INFIRMARY, BRISTOL

SUMMARY In this review of 179 patients in whom colostomy

closure was performed the mortality from the operation was 2.2 per cent and the morbidity from faecal fistula was 23 per cent. This operation, there- fore, should not be regarded as a minor procedure.

Complications in patients with diverticular disease following colostomy closure are lowest when the operation is carried out 3 months or more after

resection. After resection of a carcinoma, complica- tions are lowest if the colostomy closure is carried out after z months.

~~

THE mortality and morbidity associated with both benign and malignant disease of the colon have been greatly reduced by a better understanding of the indications for and the use of a colostomy (Devine,