The Rives Technique: Treatment of Groin Hernias with Mersilene Mesh by an Inguinal Approach
The term groin hernia, as used by Fruchaud, expresses the fact that all hernias of this anatomical region result from a single basic defect, a defect of the transversalis fascia. All groin hernias pass through this “myopectineal orifice.” When the quality
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The term groin hernia, as used by Fruchaud, l expresses the fact that all hernias of this anatomical region result from a single basic defect, a defect of the transversalis fascia. All groin hernias pass through this "myopectineal orifice." When the quality of the local structures is adequate, the use of a prosthesis is not indicated, but when the local structures are weak, especially in the case of recurrent hernias, it is mandatory to replace or reinforce the transversalis fascia with a prosthesis placed in the preperitoneal space, as described by Rives et al. 2 as early as 1965. The prosthesis is not simply sutured to the edges of the defect, but placed behind the abdominal wall; the prosthetic material is cut larger than the orifice, and its adherence to the posterior surface of the abdominal wall is guaranteed by intraabdominal pressure. In 1965, one of us focused attention on the interesting possibilities of the preperitoneal midline approach according to the publications of A.K. Henry,3 H. Mahorner and G.M. Goss,4 and L.M. Nyhus et al. 5 (Fig. 58.1). This procedure was later developed and popularized by others in France and more recently in the United States. At the same time, one of us described and developed an original technique of hernioplasty using a Mersilene® mesh placed in the preperitoneal space, through an inguinal incision, as a substitute for the transversalis fascia. This technique is described in detail below.
Patients and Methods FromJanuary 1970 to December 1994, 2065 hernias in 1758 patients were treated in our department. Nine percent had a recurrent hernia. Previous surgeries numbered one to four. Three percent of hernias were strangulated. The average age was 55 years, with a range of 16 to 89 years. The sex ratio was 4.5 males to 1 female. We inserted prostheses, using Rives's technique with Mersilene,6--13 through an inguinal approach in 694 hernias, a midline approach in 179 hernias (in 104 patients), and a laparoscopic approach in 12 hernias (12 patients). We also performed 342 McVay and 838 Bassini-Shouldice repairs.
Technique In 80% of our cases, the Rives operation was performed under spinal anesthesia. Local anesthesia is also valuable, but we have had little experience with it. Except in cases with strict medical indications for local or regional anesthesia, the choice is generally left up to the patients. Performed through an inguinal incision, the dissection does not differ from classic hernioplasties. When the posterior wall of the inguinal canal is completely exposed, an assessment can be made to determine the final choice of a prosthetic repair. The transversalis fascia is then divided longitudinally from the internal ring to the pubic tubercle, taking care to avoid the inferior epigastric vessels (Fig. 58.2). A thorough blunt dissection reveals the inguinal ligament, the femoral sheath, and the Cooper's ligament. The fibers of the transversus arch are retracted, and the posterior aspect of the abdominal wall is separated from the peritoneum by blunt dissection. The site f
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