BAUMBER: GROIN HERNIA

cases the classic Kocher subcostal incision is used,

which allows a slightly better access to the region of
the renal pelvis and pedicle. In 2 instances nephrectomy was performed because the kidney was thought
Table VI.-TYPE
Operations
Nephrectomy
Y-V plasty
Hynes-Anderson

OF

OPERATION

No. of Kidneys
2

4
23

Total 29

Table VII.-RADIOLOGICALRESULTS
Radiological Result
Better
No change
Worse
Too early
Not known
(Nephrectomy)

No. of Kidneys
I1

-9
6
I

-2
Total 29

to be irrevocably damaged. These occurred relatively

early on in the series and our policy since has been
towards conservative surgery as far as possible.
Only two types of plastic procedures were used: a
Y-V-plasty as described by Foley (I937), and the
Hynes-Anderson (1949) pyeloplasty. The types of
operation are shown in Table VI. The choice between
these types of surgical procedure depended essentially
on the size of the renal pelvis.

RESULTS
The results of surgery for pelvi-ureteric obstruction are difficult to assess. If the results are judged
by pyelographic appearances they are usually disappointing. The radiological results are shown in

667

Table VZI, but it may well be that a long follow-up

from 5 to 10 years after operation will show more
encouraging results. However, rapid filling and
visualization of the ureter after surgical relief of the
obstruction denote success even if the cakes appear
radiologically unchanged. On the other hand, the
symptomatic results have been much more dramatic.
All patients who presented with abdominal pain have
had no further pain; neither have patients with
haematuria had further attacks of haematuria. Of the
9 patients who presented initially with symptoms of
urinary-tract infection, only I has had persistent or
recurrent infection. This child developed a recurrent
stricture (the only one in the series) as well as a stone
in the renal pelvis, and has had to have a repeat pyeloplasty and pyelolithotomy. His progress since the
second pyeloplasty has been uneventful. We are
most impressed by the ease with which a second
pyeloplasty could be performed after having used an
anterior transperitoneal approach on the first
occasion. T o date, none of the patients has developed
hypertension, but this possibility must be borne in
mind in a long-term follow-up.
REFERENCES
ANDERSON,J. C., and HYNES,W. (1g49), Br. J. Urol.,

21, 209.
ECKSTEIN,
H. B. (1968), in Paediatric Urology (ed.
WILLIAMS,D. I.), p. 149. London: Butterworths.
FOLN,F. E. B. (1g37),J. Urol., 38, 643.
JOHNSTON, J. H. (1969), Br. 3. Urol., 41, 724.
MURNAGHAN,
G. F. (I959), Ibid., 31, 370.
NIXON,
H. H. (1953), Ibid., 40, 601.
PATHAK,
I. G., and WILLIAMS,D. I. (1964), Ibid., 36,318.
SCOTT,
J. E. S . (1965)~2. Kinderchir. Grenzgeb., 2, 338.
WILLIAMS,D. I., and KARLAFTIS,
C. M. (1966), Br. J.
Urol., 38, 138.

GROIN HERNIA
BY C. D. BAUMBER
THE ROYAL INFIRMARY, SHEFFIELD

SUMMARY
I. The recurrence rate for primary inguinal hernia
operated on in this series was 12-2per cent.
2. The recurrence rate is higher for direct inguinal
hernia (16 per cent) than for indirect (11 per
cent).
3. Those cases operated on by less experienced
surgeons had recurrence more frequently (17 per cent)
than those operated on by senior surgeons (9 per
cent).
4. The incidence of hernia occurring in the
opposite side is high: 44 per cent in the case of direct
hernia and 21 per cent in the case of indirect hernia.
5. The prospects of a second or third successful
operation are good. Only 2 patients (less than I per
cent) in this series remain uncured; they are well
controlled by a truss.
6. The recurrence rate for femoral hernia is low.
7. There was no difference in the time off work
between those cases that did or did not subsequently
have a recurrence.

8. No relationship between recurrence rate and

age was demonstrated.

THISpaper is concerned with 234 patients with groin

hernia treated on routine operating lists between
1958 and 1964. They were all under the care of one
consultant surgeon in a teaching hospital, which also
has a service commitment for an area of Sheffield.
The average time of follow-up was just under 9 years
(range 6-11 years).
A simple pro forma was posted to each patient, a
reminder being sent if there was no reply within 3
weeks. If their reply said that they had had no further
trouble they were not examined. If they had had any
symptoms at all they were seen and assessed personally. Those who had been treated elsewhere for
recunence were asked for details, and in all these cases
their clinical notes were obtained for review.
The definition of recurrence was the same as that
used by Marsden (195g), Le., a weakness at the

668

BRIT. J. SURG., 1971, Vol. 58, NO. 9, SEPTEMBER

operation site necessitating a further operation or the

wearing of a truss.
Patients names were taken from the operating
register. Approximately one-third were excluded from
the series because either the original clinical records
were missing or incomplete or the survey forms were
returned by the Post Office as undelivered, the
latter being caused by extensive redevelopment in the
immediate vicinity of the Royal Infirmary. Patients
who died during the period of follow-up (12 per cent)
were also excluded, unless either they had been seen
in the clinic shortly before death or the relatives

+Lr.

HERNIA

NO. OF

PATIENTS

zz

Type
Right
Left
Bilateral?

12

RECURRENCE

RECURRENCE

HERNIA

N O . OF

PATIENTS

NO.

Type

No.

NO.

Percentage

7.2

Total 43

During 1958-9 exactly half the cases were operated

on under local anaesthetic. It so happened that the
number of recurrences was exactly the same in
the local anaesthetic and the general anaesthetic
groups.
Direct inguinal hernia (Table Z) recurred more
frequently than indirect (Table 11). Only I case of
femoral hernia recurred (Table ZZZ).
Eighty cases of primary indirect inguinal hernia
were operated on by 13 different registrars, of varying
experience, with a recurrence rate of 14 per cent. The
results of 58 cases operated on by the consultant and

9
I4

I
2

45

----

I-

1-qY-l-7-

Total 23

* There were 1 1 male and 12 female patients.

Table IV.-DETAILSOF PATIENTS*
WITH RECURRENT
INGUINALHERNIA
Table ZI.-DETAILSOF PATIENTS*
WITH INDIRECT
HERNIA
INGUINAL

Type

1I
___--

HERNIA

NO. OF

No.

144

RECURRENCE

RECURRENCE

No.

Percentage

16

1
7

* Only 13 female patients. Twenty-one

per cent of patients had an

inguinal hernia on the opposite side at some stage.
t Ten patients with bilateral hernia had a direct hernia on one side
and an indirect on the other.

specifically stated that there had been no further

trouble from the hernia prior to death.
As much information as could be obtained from
the original clinical notes was tabulated. Records of
indirect inguinal hernia, direct inguinal hernia, and
femoral hernia were kept separately. Pantaloon-type
inguinal hernia was included with the direct inguinal
hernia. Six patients with recurrent hernias (new to
this series) were grouped together with the results of
second operations on patients in the original series.

RESULTS
The age range was from 15 to 75 years. The
greatest number of indirect hernias occurred between
30 and 55 years, while direct hernia was equally
common in the older age-groups. No relationship
of recurrence rate to age could be demonstrated.
It is the policy of the unit to encourage patients to
lose weight before operative repair is undertaken. Of
72 patients for whom both height and weight were
known, 23 were overweight even for large-framed
individuals. Surprisingly they did not have a higher
recurrence rate than thinner patients.

~---------l----

Total 23
Total 138

HERNIA

NO. OF

PATIENTS

22

*All patients were male. The average follow-up period was

7 years (range, 4-10 years).

t Three patients have had a third successful operation.

2 senior registrars were better with a recurrence

rate of 10 per cent. This feature was even more
pointed in the cases of primary direct inguinal hernia,
where 5 out of 14 cases operated on by registrars have
recurred but only 2 out of 30 operated on by the
consultant and senior registrars. These figures would
appear significant despite a possible bias for the more
difficult cases being operated on by the more senior
surgeons (TubEe IV).
The teaching of the unit is that inguinal hernia
should be repaired according to the principles described by Lytle (1945, 1961). Particular attention is
paid to tightening the internal ring and repairing the
transversalis fascia, the posterior wall being further
reinforced as necessary. Uniformity is not, however,
enforced on the registrars and other techniques were
used in some cases. The sac was excised in all cases
of indirect hernia but in only half the cases of direct
hernia. In 4 cases of direct hernia and 2 cases of
indirect hernia, orchidectomy was performed and in
I the hernia recurred. A small number of cases had a
classic Bassini (1890) repair with or without a Tanner
(1942) slide. One case of femoral hernia occurred 3
months after a Bassini-type repair. All femoral
hernias were operated on by the low approach, the
sac excised, and the hernial orifice closed.

KNOX E T AL. : COLOSTOMY CLOSURE

Comparison of the different suture materials
suggested that linen thread gave better results than
braided silk, but this may be explained by the fact
that they were not used equally by all surgeons.
Thirty-three posterior walls were reinforced with a
polyvinyl sponge insert. Only 2 of these had a

The incidence of an inguinal hernia on the opposite

side at the same time, previously, or subsequently was
very high in this series (21 per cent indirect and 44
per cent direct). Chronic bronchitis is very common
in Sheffield but it was not possible, in this retrospective series, to correlate this with the high incidence

Table V.-TIME

OFF WORK POSTOPERATIVELY

IN MALE
PATIENTS
WITH INGUINAL
HERNIA

T Y P E OF

1 ,,..& 1
I

HERNIA

Indirect:Non-recurrent
Recurrent

34

Direct

13

11

TIME
RANGE

3 days to
3 months
I week to
3 months
I week to
1 3 weeks

669

Primary herniad i r e c t inguinal

A v E ~ ~ ~ k ~ M E
6.5

6.6
8

recurrence after the sponge had been removed because

of infection. These were the only cases of significant
sepsis in the whole series, and repair at a later date
was successful in each case.
Only 2 out of 14 cases of sliding hernia recurred
and this corresponds with the personal experience of
Maingot (1961). Two out of 13 cases of pantaloontype hernia recurred.
Classification of occupation into three groups of
physical stress gave no clear difference in recurrence
rate, nor did there appear to be any relationship
between time off work postoperatively and recurrence
rate (Table V ) . It would be of great interest economically to know the optimum time for return to
full activity. During the past year patients on this
unit, including manual workers, have returned to
full duties 3-4 weeks after herniorrhaphy without
obvious ill-effects.
Marsden (1958)stated that only 80 per cent of
recurrences occurred within 10 years. In this study
most of the recurrences appeared within 4 years,
although some only came to light as a direct result of
the survey. Over half of the recurrences appeared
within 18 months (Fig. I).

FIG. 1.-Time of recurrence nomogram for 24 cases. In this

series there were 6 cases appearing for the first time as recurrent
hernia and all had been repaired more than 20 years previously.

of bilateral direct hernia in the older age-group.

Prostatism was no more common in cases of direct
than indirect hernia.
Acknowledgements.-I
would like to record
thanks to Mr. D. H. Randall, Consultant Surgeon,
for permission to report these cases and for his advice
in the preparation of this paper. I would also like to
thank the secretarial and records staff of the United
Sheffield Hospitals who have given much valuable
assistance.
REFERENCES
E. (1890),Arch. klin. Chir., 40, 426.
BASSINI,
LYTLE,
W. J. (I945), Br. J . Surg., 32, 41.
-- (1961), Proc. R. SOC.Med., 54, 967.
MAINGOT,
R. (1961), Ibid., 54, 967.
IV~ARSDEN,
A. J. (1958), Br.J. Surg., 46, 234.

-- (I959), Lancet,

I, 461.

TANNER,
N. C. (1g42), Br.J. Surg., 29, 285.

CLOSURE OF COLOSTOMY
BY A. J. S . KNOX,
SURGICAL REGISTRAR, ROYAL DEVON AND EXXETER HOSPITAL, EXETER

F. D. H. BIRKETT,
SURGICAL REGISTRAR, GUY'S HOSPITAL, LONDON

AND

c. D. COLLINS

SENIOR SURGICAL REGISTRAR, BRlSTOL ROYAL INFIRMARY, BRISTOL

SUMMARY
In this review of 179 patients in whom colostomy
closure was performed the mortality from the
operation was 2.2 per cent and the morbidity from
faecal fistula was 23 per cent. This operation, therefore, should not be regarded as a minor procedure.
Complications in patients with diverticular disease
following colostomy closure are lowest when the
operation is carried out 3 months or more after

resection. After resection of a carcinoma, complications are lowest if the colostomy closure is carried
out after z months.
~~

THEmortality and morbidity associated with both

benign and malignant disease of the colon have been
greatly reduced by a better understanding of the
indications for and the use of a colostomy (Devine,