Title: War Surgery and Medicine

Author: Stout, T. Duncan M.

Publication details: Historical Publications Branch, 1954, Wellington

Part of: The Official History of New Zealand in the Second World War 1939–1945

This text is the subject of: ‘Something of Them Is Here Recorded’: Official History in New Zealand

Conditions of use

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Operative Procedure

The conditions present in hernia may be:

(1)	A congenital indirect sac starting at the internal abdominal ring and passing down the canal for a variable length, the maximum extending to the scrotum and being continuous with the tunica vaginalis.
(2)	Weakness in the musculature of the abdominal wall, especially in the region of the inguinal canal. page 410
(3)	Attenuation of the structures of the inguinal canal with consequent stretching and bulging of the abdominal wall in this region.
(4)	Direct herniation due to the bulging of the peritoneum through weakened areas of the inguinal canal.

It is obvious that the operative measures to be adopted must vary with the conditions present in the individual case. In the simple indirect hernia the removal of the sac should bring about cure.

When the musculature is much weakened and, in consequence, stretching and bulging of the inguinal region has taken place, with eventually the formation of a direct hernial sac, the simple removal of this sac cannot be expected to bring about permanent repair. Some tautening and strengthening is essential. It is well known that this function is carried out in the body by the fascial layers, so it is natural to employ methods which utilise the fascial tissues available. Unfortunately the transversalis fascia is often fragmentary, especially in the worst cases.

Overlapping of the external oblique aponeurosis is simple and of considerable value. The rectus sheath can often be utilised to strengthen the weak inner part of the canal, either by turning back a flap or by splitting the sheath and suturing the lower part to Poupart's ligament. A combination of methods is frequently available and useful.

The utilisation of muscle in the repair is against surgical principles except in so far as the alteration in insertion may make the muscular action more efficient. This would be brought about by the alteration in the insertion of the conjoint tendon, bringing the tendon lower to cover over the weak internal portion of the canal. The tendon may be partly split to enable this to be done or simply stitched lower down to the pubis.

The stitching of the muscular part of the conjoint tendon to Poupart's ligament as in Bassini's operation damages the muscles and interferes with their action, and can only be effective by the formation of fibrous tissue at the site of suture and the production of a new fascial layer.

The use of fascial strips provides support by the incorporation of the strips in the tissues and the formation of fresh fibrous tissue around them, and the silk lacing produces the same kind of result, encouraging the production of much fibrous tissue.

Essentially, operation in all but the simplest cases entails a plastic repair of the inguinal part of the abdominal wall, if possible brought about without interference with muscular action. Fortunately the proportion of simple cases is high. There are many types of page 411 herniation and many degrees of severity and no one technique can deal with them all. It is essential to suit the technique to the individual case and apply sound general surgical principles. One must occasionally admit that no surgical repair is possible and that other methods of partial relief are all that can be offered the patient.