The internal approach for inguinal herniae.

WHILE recurrences occur after inguinal hernia operations no-one can be completely satisfied with the operations practised. During the last 50 years repeated attempts have been made to introduce an internal approach for the repair of inguinal herniae, but these have never proved popular and the inguinal canal incision remains the routine operation; possibly the time has now arrived for a reappraisal of the position. In 1919 La Roque in America had described an approach through the routine inguinal incision, the extraperitoneal space being entered through a small muscle-splitting incision about an inch above the internal ring. By 1924 he had operated on 500 cases, and in 1932 reported on 1,700 cases, with a very low recurrence rate. His operation never seems to have become popular despite a plea for it by Williams (1938). In England Sir Leanthal Cheatle was the first to describe the extraperitoneal approach (1920). He used a vertical rectus-splitting incision, but later (1921) preferred a Pfannenstiel; he mobilised and isolated the processus vaginalis from the vas and vessels and then divided it; the distal end was either excised or ligated as low as possible. He carried out no repair and ended by examining the opposite side through the same incision; no follow-up of his series was ever published. Henry (1936a) redescribed Cheatle's approach, via a midline incision, at first recommending it for femoral and then for inguinal herniae (1936b). In the inguinal case he repaired the internal ring by suturing the edges of the transversalis fascia firmly round the cord. The extraperitoneal approach and midline incision were also advocated by Jennings and his associates (1942). However, Jennings later returned to the orthodox method as he found that the inability to repair anything other than the transversalis fascia was unsatisfactory in large indirect herniae (Jennings 1960).