Preperitoneal prosthetic herniorrhaphy.

Correspondence limiting screening to women over 35 years, but as there has not been an overwhelming demand for the interpretation of smears these days are past. Incidentally in our area, where the incidence of cervical cancer is falling,' there have been no fewer than five women with overt clinical cervical cancer in the past two years who were multiparous and under 30 years of age.-I am, etc., SIR,-For some time it has been my view that the operative treatment of inguinal hernia as most commonly performed is illogical and has certain disadvantages which would be best avoided if acceptable alternatives were available. The object of the operation of separating the general peritoneal cavity from the hernial sac at the level of its neck is achieved by an approach through the inguinal canal which disrupts its anatomy unnecessarily, and a repair effected by approximating the conjoint tendon to Poupart's ligament seeks to unite muscle to ligament, utilizing and distorting tissues which by the very presence of the hernia have demonstrated their incompetence. The first layer of the abdominal parietes to be transgressed in the development of a hernia is obviously the deepest layer, allegedly the fascia transversalis. It would seem logical, therefore, to reinforce the abdominal parietes at this level in order to prevent recurrent herniation; to do so in the plane of the conjoint tendon savours of " closing the stable door after the horse has bolted."' I have not, however, had any confidence in a repair based on suturing the fascia trans-versalis,1 as this tissue has always seemed to me to be insubstantial, and I have as an alternative taken to reinforcing this layer with a prosthesis. In order to overcome the aforementioned disadvantages of conventional hernia operations the following operative sequence has been evolved which I designate " preperitoneal prosthetic herniorrhaphy." A midline suprapubic incision2 carried out under muscle-relaxant anaesthesia and an extra-peritoneal approach to the inguinofemoral region enables a bilateral operation to be carried out if necessary and allows easy direct access to the hernial sac at its source. The hernial sac is either withdrawn into the abdominal cavity or divided at its neck and the defect in the peritoneum closed. A prosthesis of Marlex mesh' is sutured in position to the following points: the pubic tubercle, the periosteum of the superior pubic ramus, the ilio-pubic tract lateral to the internal inguinal ring, the anterior rectus sheath …