Sliding Indirect Inguinal HerniaMAX R. GASPAR, M.D., Long Beach,MORTON M. WOOLLEY, M.D., Los Angeles, andEUGENE J. JOERGENSON. M.D., Glendale

APPARENTLY sliding indirect inguinal hernia is stillan enigma to many physicians including surgeonswho repair large numbers of hernias. It is muchmore common than generally thought. The recur-rence rate following operation is high.The sac of the ordinary indirect inguinal hernia

is formed entirely by parietal peritoneum. Whenpart of the wall of the sac is formed by a viscus,the hernia is called a sliding hernia. Often themedial wall of the sac of an indirect inguinal herniais formed partially by bladder and its overlyingperitoneum. This is usually true in direct hernias.Such conditions cause no great additional problemsin repair and will not be considered here. However,when the posterior wall of the sac is formed by thebowel and its overlying visceral peritoneum, it is atrue sliding indirect inguinal hernia. The repair maybe difficult and does require careful consideration.Proper repair is dependent upon proper understand-ing of the pathological anatomical changes involved.

These hernias arise because of relaxation of tis-sues associated with advancing age and increasingobesity. An indirect hernial sac, large or small, isprobably present in all cases prior to the beginningof the sliding process. On the left side of the bodythe distal descending colon (iliac colon) is often inclose proximity to the internal inguinal ring andfrequently has a mesentery continuous with thesigmoid mesentery. At its base the lateral leaf ofthe mesentery is continuous with the posterior parie-tal peritoneum which forms the posterior wall of thehernial sac. As the retroperitoneal connective tissuesbecome infiltrated with fat and as the muscles andfasciae become weaker with age the posterior parie-tal peritoneum advances through the ring. The intra-mesenteric connective tissues, also infiltrated withfat, allow the peritoneal leaves of the mesentery toseparate and unfold. The lateral leaf of the mesen-tery follows the parietal peritoneum through thering. The bowel itself encroaches on the ring andslides through it and dilates it. The process is aug-mented by the increased intraabdominal pressureassociated with increased obesity. Eventually a large

Presented before the Section on General Surgery at the 85th AnnualSession of the California Medical Association, Los Angeles, April 29 toMay 2, 1956.

From the Los Angeles County General Hospital, the Department ofSurgery, College of Medical Evangelists, Los Angeles 33, and TheHarriman Jones Clinic-Hospital, Long Beach 2.

* From 2 per cent to 5 per cent of all indirectinguinal hernias are of the sliding variety. (Slid-ing hernias are those in which part of the wallof the sac is formed by a viscus.) The propor-tion of sliding hernias is even higher in the aged.Hernias of this kind are found almost exclu-sively in males and usually on the left side.

Preoperative diagnosis is not essential if thesurgeon can recognize the lesion at operation andknows how to repair it properly. The LaRoquetechnique in which the peritoneal cavity is en-tered above the internal ring allows accurate defi-nition of the pathological anatomy and effectiverepair of the hernia. It should be used in all truesliding indirect inguinal hernias.

loop of bowel and even the medial leaf of the mes-entery, may slide through the ring and form theposterior wall of the hernial sac.On the right side of the body a similar process

takes place, allowing the cecum to enter the internalring. In large hernias on the right side the entirececum, the ascending colon, the appendix, the ap-pendiceal mesentery, the terminal ileum and themesentery of the terminal ileum may form theposterior wall of the sac.

Sliding indirect inguinal hernia has been con-sidered to be comparatively rare. It has been re-ported in from 1 to 3 per cent of inguinal hernias.9At the Los Angeles County General Hospital, herniarepair is a relatively infrequent operation becauseof the press of more urgent surgical procedures.In the eight-year period from 1948 to 1955 inclu-sive, inguinal hernia repair was done in 2,688 cases.This number included 52 indirect sliding inguinalhernias, an incidence of 1.9 per cent of all inguinalhernia repairs. Ryan6 recently reported 313 cases,which constituted 5.06 per cent of all the inguinalhernia repairs or 6.75 per cent of all the indirectinguinal hernia repairs done in an eight-year period.In persons over 50 years of age the incidence was10.7 per cent of the indirect inguinal hernias re-paired. Sensenig and Nichols7 reviewed 1,200 casesof inguinal hernia and noted that 4.9 per cent weresliding hernias. In a series of 361 hernia repairs in305 patients done by one of the present authors(M. R. G.) there were 295 inguinal hernias of which246 were indirect, 13 of them sliding, an incidenceof 3.6 per cent of all the hernias, 4.4 per cent of

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the inguinal hernias and 5.5 per cent of the indirectinguinal hernias. Undoubtedly, as one's experiencewith this condition increases, he will recognize somehernias actually to be sliding and not merely largebowel adherent to the wall of the hernial sac.

Sliding indirect inguinal hernias occur almostexclusively in males. The authors found no reportedcase in a female. However, of the 52 cases studiedat the Los Angeles County General Hospital one wasin a woman 79 years of age.Most of the patients operated upon are elderly.

The average age at operation at the Los AngelesCounty General Hospital was 66 years. The youngestpatient in the present series was 38 years and theoldest 89 years. The incidence of sliding herniasin patients over the age of 50 years was nine timesthe incidence in younger persons. Forty-two andone-half per cent of the patients were over 70 yearsof age.The left side is involved much more frequently

than the right. In Ryan's6 series there were 4.5 timesmore sliding hernias on the left. In the Los AngelesCountv General Hosuital series there were 34 on theleft side and 18 on the right. In the previously men-tioned personal series (M. R. G.) there were 11 onthe left and two on the right. In Ryan's series therewere eight bilateral sliding hernias. The authors haveseen none. In the 52 cases at the Los Angeles CountyGeneral Hospital there were ten in which there wasan associated nonsliding inguinal hernia on theopposite side.Such hernias usually are of long duration before

operation. In the Los Angeles County General Hos-pital series the average duration before operationwas 13.1 years.

Almost one-half (46.2 per cent) of the herniasin the present series were reducible. Ryan reportedthat in his series 97 per cent were reducible. In theprivate series (M. R. G.) the hernia was reducible inall but two of the 13 cases.Symptoms and signs of intestinal obstruction are

reported to be infrequent. However, 21.1 per centof the patients in the Los Angeles County GeneralHospital series had some symptoms and signs ofobstruction. They were operated upon in emergency,which is indicative of the emergency nature of alarge number of the hernia repairs done at thishospital.The diagnosis often is unsuspected before opera-

tion. A large hernia of long standing in an elderlypatient should cause suspicion of a sliding hernia.The hernia frequently is difficult to reduce. If re-duced, the internal ring almost invariably is foundto be very large. Sometimes there is a history of atruss formerly being effective but no longer beingeffective. Roentgen examination with barium enemamay reveal colon outside of the abdominal cavity.

Although the colon shown by x-ray may be freewithin the sac of an inguinal hernia, it actually maybe part of the wall of the sac. Whether the herniais sliding or not should make no difference to anexperienced surgeon. The diagnosis will be made atthe operating table and he may proceed with theproper repair without difficulty.

TREATMENT

Accurate diagnosis of a sliding indirect inguinalhernia usually is not made until the sac is opened.For this reason it is important to open all indirectinguinal hernial sacs on the anterior surface so asto avoid opening into bowel which might be form-ing the posterior wall of a sliding hernia. If colonis found in the sac, it does not necessarily establishthe diagnosis of a sliding hernia. The colon may befree within the sac. It may be adherent to the wallof the sac by adhesions or by actual fusion of thelateral leaf of its mesentery to the parietal peri-toneum. Such fusion is the normal anatomical find-ing in those portions of the colon where a freemesentery is not present. The authors do not con-sider such hernias as true sliding inguinal hernias.However, when the posterior wall of the sac isdefinitely found to be composed of bowel, it is atrue sliding hernia. An inexperienced surgeon isliable to attempt dissection of the colon from thesac. This is impossible, for the colon actually formsthe wall of the sac. Such attempts are dangerous.The bowel may be entered or, more likely, the bloodsupply to it may be damaged.

Regardless of the type of repair the surgeon con-templates, his first maneuver must be to free theentire sac from the cord structures to well abovethe internal ring. This is usually done with relativeease.

There are many reports of reduction of the herniaentirely from the inguinal approach. Zimmermanand Laufmant0 described placing a purse-stringsuture about the neck of the sac extending as highon the anterior surface as possible and on the pos-terior side as close as is safe to the reflection of theperitoneum on the colon. As the purse-string ispulled together the bowel is turned upward and thesac is closed. The sac and bowel are reduced intothe abdominal cavity. The transversalis fascia thenis closed snugly about the cord to reconstruct theinternal ring. Further repair can be done accordingto the surgeon's usual method. Zimmerman andLaufman reported 24 cases in which this methodwas used, with no known recurrences, although thelength of time of follow-up was not stated. Thepatients reported by Sensenig and Nichols7 wereoperated upon by an inguinal approach. They men-tioned a "bottling" procedure which apparently at-

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tempts to reperitonize the mesentery of the bowelas is accomplished in the intraabdominal ap-proaches. In 53 cases they found seven recurrenthernias, a 13 per cent incidence of recurrence. Haganand Rhoads1 reported repairing 15 sliding inguinalhernias by the inguinal approach, and a recurrencerate of 55 per cent. Throughout the literature onthis subject there are frequent references to the highrecurrence rate by any method utilizing only theinguinal approach.

In Ryan's recent report of 313 cases of indirectsliding inguinal hernia the exact method of repairwas not described. However, it was made clear thatall of the repairs were done from the inguinal regiononly and were accomplished in much the same man-ner as described by Zimmerman and Laufman. Free-ing of the peritoneal sac from the transversalis fasciawell above the internal ring was emphasized, as wassnug closure of the internal ring after reduction ofthe bowel. The exceptionally high incidence of slid-ing indirect inguinal hernia in Ryan's series (6.75per cent of all indirect hernias) would lead one tobelieve that many indirect hernias in which colon ismerely seen at the internal ring were being classifiedas sliding hernias. However, he described the colonas being an average distance of 2.9 inches below thelevel of the internal ring. The recurrence rate in thatseries was remarkable-four recurrences in the seriesof 313 cases, and only one of these definitely knownto be a recurrent sliding hernia. In addition, hementioned another 558 patients with sliding indirectinguinal hernias who had been operated upon sub-sequent to the reported series, with no known recur-rences. He also reported 8,000 cases in which in-guinal hernia was repaired and the patient observedfor more than one year with only one recurrence ofindirect hernia.

Koontz2 in an historical review stated that Fiaschiin 1907 was the first to report opening the abdomenabove the inguinal canal in order to reduce and fixa sliding hernia and that Robbins in 1909 reportedit had been his practice for years to open the ab-domen through a rectus incision if there was anydifficulty in reducing a sliding hernia. LaRoque3 in1919 advocated a muscle-splitting incision above theinternal ring for all inguinal hernias. In 19324 hedescribed in detail the use of this procedure forsliding hernias. Moschcowitz,5 and many other in-vestigators have also described intraperitonealapproaches to hernias.

Williams9 in 1947 presented an excellent descrip-tion of the LaRoque type of repair of sliding indirectinguinal hernia. The authors were impressed by themethod at that time and began using it at the LosAngeles County General Hospital, and since thenhave recommended its use to the resident staff. Thegreatest drawback seems to be in the ability to un-

derstand the rather complicated maneuvers of theprocedure and to teach them to the residents.The hernial sac should be completely freed from

the cord to a level well above the internal ring. Theincision in the aponeurosis of the external obliquethen is extended upward 6 to 8 cm. above the inter-nal ring. At a level approximately 4 cm. above theinternal ring the external oblique and transversusabdominis muscles are split in the direction of theirfibers exactly as in the McBurney incision. Theperitoneum at this level is opened transversely. Onthe left side the proximal limb of the descendingcolon is seen entering the internal ring and the distallimb is seen emerging from the internal ring. By aprocess of traction on the bowel from above andpressure from below, the bowel is reduced com-pletely into the peritoneal cavity. Even with thisadvantage of traction and pressure, it is sometimesa tedious procedure to reduce the bowel. It wouldseem to be very difficult to do this entirely from theinguinal approach.On the right side the cecum is noted to be extend-

ing through the internal ring. The appendix andeven the terminal ileum may form part of the sac.Reduction is accomplished in the same manner asis done on the left side. As the bowel is drawn up-ward into the peritoneal cavity it is also drawnoutward through the McBurney-type incision. Thismaneuver obverts the colon and its mesentery sothat the surgeon views the posterior surface of thebowel rather than its anterior surface. On the leftit then is apparent that there is actually no lateralleaf of mesentery present in its usual position be-cause it has been spread out by the sliding process.Rather it is noted that the free surfaces of the peri-toneal sac represent the lateral leaf of the sigmoidmesentery and that this leaf can be reconstructedonly by reapproximating the free peritoneal edges.It is advisable to trim the edges considerably, forby so doing the excess peritoneal sac is obliterated.The edges are approximated with a continuous su-ture of chromic catgut which is carried down tothe base of the mesentery and then upward to theinferior margin of the transverse incision in theperitoneum. We now advocate that the base of themesentery be anchored to the iliac fascia with oneor more sutures. Williams did not describe this step.Fingers placed against the internal ring from theperitoneal side show that the sac has been com-pletely eliminated. The bowel is returned to theperitoneal cavity and the McBurney-type incisionclosed. It is of major importance that the internalring be closed snugly by approximating the trans-versalis fascia medial to the cord. Failure to carryout this step probably accounts for many recur-rences. Repair of the floor of the inguinal canal canbe done according to the surgeon's dictates.

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PeritoneelinCiSOrL

Musce splitting(It.r obl. nd trr

-Extension ofincision in -ext.oblique apon.

A.J6 zJbdJm) Periton-eumxDista limbof\m - Prciliac colon-i 3 of;(intreper- -r inttoneal. sur

imbiliac colonruperitonea3ur'face)

Intraperitoneal;;;suxrface of iliac

colon

-RETROPERITONEAL./surface of iliaccolon freed From5

cord_-,..Outer surFace oFant.par,ecal peritoneuE

5utureachrfl9j mesentery

to ilio.c,.~ jfasciaL

Ilia'c colon/(IntraperitonealIsurface)-

Inner srface ant.parietal peritoneuma4Outer surface of ant.-parietel peritoneum7en-

..SplitIncision

Int-riLng tobe closedsnugly ebo

corad titrigFigure 1.-Principles of the LaRoque maneuver for repair of sliding indirect inguinal hernia. See text for details.

COMMENT

As was stated earlier, the authors have found thisa difficult procedure to teach to residents, particu-larly in view of the fact that at Los Angeles CountyGeneral Hospital many of the residents assigned togeneral surgery are from specialized services suchas urology, gynecology, orthopedics and neurosur-gery. Some of them have attempted the LaRoqueprocedure when confronted with a sliding indirectinguinal hernia. It was obvious from the operativereports that they were not entirely familiar with itstechnical details. There were recurrences in seven

of the 52 cases repaired by the LaRoque method,most of them within a few months of operation,which tends to indicate faulty operative technique.Of the 13 patients with repair of sliding indirecthernia done by one of the authors (M. R. G.) inthe previously mentioned personal series, there wereno recurrences and most of the patients had beenobserved for more than two years after operation.

In spite of the rather high incidence of recurrencein the Los Angeles County General Hospital series,the authors are not inclined to abandon the LaRoqueprocedure, feeling that it is a much more logical

VOL 85, NO. 5 * NOVEMBER 1956

incisi.ori

.

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approach to the problem of sliding indirect inguinalhernia than the mere stuffing of the bowel into theperitoneal cavity and subsequent snug closure of theinternal ring. The "stuffing procedure" violates thefirst rule of hernia repair-high ligation of the sac.Obviously the sac cannot be ligated high if one ofits walls is composed of bowel. The bowel must bereconverted into an intraperitoneal structure inorder to eliminate the posterior wall of the sac. Theanterior wall is eliminated by resecting most of itand suturing the remainder so as to convert it intoa mesenteric structure. Exposure of the pathologicalprocess is more complete when viewed from theperitoneal cavity. Opening the lower peritoneal cav-ity presents no added operative hazard, even inelderly patients. If the operative hazard were ex-cessive, we would prefer excision of the cord andtesticle with complete closure of the ring after reduc-tion of the hernia from the inguinal approach. Theauthors believe that the LaRoque procedure has notreceived the attention it deserves and that when it isproperly taught and properly performed it is anideal method of dealing with these rather severeproblems.

211 Cherry Avenue, Long Beach 2.

REFERENCES

1. Hagan, W. H., and Rhoads, J. E.: Inguinal and femoralhernias, Surg., Gyn. and Obst., 96:226, Feb. 1953.

2. Koontz, A. R.: The operation for difficult sliding herniaof the large bowel, Am. Surg., 18:78, Jan. 1952.

3. LaRoque, G. P.: Permanent cure of inguinal and fem-oral hernia, Surg., Gyn. and Obst., 29:507, Nov. 1919.

4. LaRoque, G. P.: Intra-abdominal method of removinginguinal and femoral hernia, Arch. Surg., 24:189, Feb. 1932.

5. Moschcowitz, A. V.: Rational treatment of sliding her-nia, Ann. Surg., 81:330, Jan. 1925.

6. Ryan, E. A.: An analysis of 313 consecutive cases ofindirect sliding inguinal hernias, Surg., Gyn. and Obst.,102:45, Jan. 1956.

7. Sensenig, D. M., and Nichols, J. B.: Sliding hernias,Arch. Surg., 71:756, Nov. 1955.

8. Watson, L. F.: Sliding hernia, Internal Clin., 4:155,Dec. 1925.

9. Williams, C.: Repair of sliding inguinal hernia throughabdominal (LaRoque) approach, Ann. Surg., 125:612, Oct.1947.

10. Zimmerman, L. M., and Laufman, H.: Sliding hernia,Surg., Gyn. and Obst., 75:76, July 1942.

Discussion by GORDON K. SMITH, M.D., Los Angeles

Dr. Gaspar is to be complimented for the beau-tiful manner in which he has presented this difficultproblem. Explaining the mechanism of the combinedinguinoabdominal procedure is akin to explainingto your six year old son where your lap goes whenyou stand up. Unless you can visualize the anatomicfeatures both from the inguinal and the abdominalside it is almost impossible to understand it. I havebeen interested in the LaRoque procedure for manyyears. In addition to its application to sliding hernia,as suggested by Dr. Gaspar, we have increased thescope of this procedure and are also applying it toother forms of inguinal hernia. A recent five-yearstudy of patients admitted to the Hospital of theGood Samaritan, Los Angeles, for repair of recur-rent inguinal hernia showed that 61 per cent ofthese patients had recurrent indirect inguinal herniaand 8.7 per cent of these recurrences were sliding in-guinal hernia. This suggested that the initial proce-dure had failed to fulfill the cardinal requirements,viz., the complete obliteration of the hernial sac.Therefore, we now use it in (a) sliding inguinal her-nia, (b) recurrent indirect hernia with thin and fri-able sacs, (c) irreducible hernia with or withoutstrangulation of bowel or omentum, and (d) femoralhernia. Categorical statements have been made suchas that by Ryan of Canada who states that it is nevernecessary to open the abdominal cavity to repair asliding hernia. I am sure that I can handle this com-plicated anatomical derangement best with a com-bined inguinoabdominal approach, and therefore Iwill leave to the other surgeons their "stuffing" pro-cedure from the inguinal side alone. The ease withwhich the above mentioned forms of inguinal herniacan be handled by the combined incision is remark-able, and as one gains experience with the pro-cedure it decreases the total operating time. Ifirmly believe that anything that makes a procedureeasy for the surgeon reflects itself in a smooth post-operative course. Ryan reports one recurrence in8,000 operations for indirect inguinal hernia. Thisstatement indicates naivete or insufficent follow-up.

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