Home Books Zollinger's Atlas of Surgical Operations, 9e
Plate 212
Plate 212. In: Zollinger RM, Jr, Ellison E, Bitans M, Smith J. Zollinger R.M., Jr, & Ellison E, & Bitans M, & Smith J(Eds.),Eds. Robert M. Zollinger, Jr, et al.eds. Zollinger's Atlas of Surgical Operations. McGraw Hill; 2011. Accessed January 28, 2023. https://accesssurgery.mhmedical.com/content.aspx?bookid=430&sectionid=42074698
Plate 212. Zollinger RM, Jr, Ellison E, Bitans M, Smith J. Zollinger R.M., Jr, & Ellison E, & Bitans M, & Smith J(Eds.),Eds. Robert M. Zollinger, Jr, et al. (2011). Zollinger's Atlas of Surgical Operations. McGraw Hill. https://accesssurgery.mhmedical.com/content.aspx?bookid=430&sectionid=42074698
"Plate 212." Zollinger's Atlas of Surgical Operations Zollinger RM, Jr, Ellison E, Bitans M, Smith J. Zollinger R.M., Jr, & Ellison E, & Bitans M, & Smith J(Eds.),Eds. Robert M. Zollinger, Jr, et al. McGraw Hill, 2011, https://accesssurgery.mhmedical.com/content.aspx?bookid=430&sectionid=42074698.
Repair of Direct Inguinal Hernia (McVay)
Details of Procedure
A McVay primary tissue repair is infrequently performed as an initial herniorrhaphy, as it is associated with a high rate of recurrence. However in patients where mesh from a previous operation must be removed (e.g., chronic infection), some form of primary tissue repair is needed. The McVay procedure may be useful in these cases, especially when the femoral space must also be obliterated.
Instead of approximating the transversalis fascia and the aponeurotic margin of the transverse abdominal muscle to the iliopubic tract and to Poupart's ligament to repair either a direct or indirect hernia, the McVay repair attaches these musculotendinous structures to Cooper's ligament and the lacunar ligament medially and the inguinal ligament laterally. To accomplish this, it is necessary to retract the conjoined tendon upward and the cord downward, while the transversalis fascia adjacent to the pubic spine is freed from Cooper's ligament (Figure 1).
By blunt dissection and the use of a curved retractor (Figure 2), the region of Cooper's ligament can be visualized, and the external iliac vessels can be identified. As the conjoined tendon or internal oblique muscle is held upward, a firm aponeurotic margin of transverse abdominal muscle is exposed in order to facilitate the placement of interrupted sutures. As the bulge in this region is retracted upward and medially by an appropriate retractor, Cooper's ligament is clearly visualized as a white, fibrous ridge, deep in the wound at the innermost portion of the concavity and closely applied to the horizontal ramus of the pubis (Figure 2). Interrupted 00 silk sutures approximate the aponeurotic margin of the transverse abdominal muscle and the transversalis fascia to Cooper's ligament. The iliac vessels may be protected by the surgeon's left index finger or a narrow S retractor as the innermost suture is placed. The sutures are continued downward until the region of the pubic spine is included in the last one (Figure 3). Three to five interrupted sutures are usually required. In obese individuals it may be difficult to obtain an easy exposure in this location, and constant care must be exercised to avoid injury to the iliac vessels and to effect a complete and solid repair (Figure 4). Some operators prefer to make an incision in Cooper's ligament before placing the sutures in order to ensure a better fascial approximation. After the aponeurotic margin of the transverse abdominal muscle has been anchored as far medially to Cooper's ligament as can be done safely, more superficial sutures may be taken to approximate it to the iliopubic tract (Figures 4 and 5). Some surgeons prefer to reinforce the repair to Cooper's ligament by another row of sutures approximating Poupart's ligament to the aponeurosis of the transverse abdominal muscle (Figure 6). The suturing of the internal oblique muscle to Poupart's ligament is not considered worthwhile. The type of repair should be varied to suit the anatomic conditions encountered. A combination of the technique described may be advantageous to ensure a solid repair without tension upon the suture lines and an accurate approximation of fascia to fascia.
Care is routine. (See Plate 211.)