A case of direct inguinal hernia illustrating improvement in tone of the oblique musculature of the abdominal wall as a result of surgical repair of the hernia. Preliminary report

Abstract

THE common type of direct inguinal hernia is a diffuse bulge of the posterior inguinal canal with associated stretching of the transversalis fascia, arid the essential principle of all the different techniques of surgical treatment is the repair and strengthening of the stretched area. One of the standard methods is that of the ligamentous darn CASE REPORTThe patient was a man, aged 44, with a right inguinal hernia of two months' duration. He was a thin type, and the abdominal postural tone was poor, so that on standing the abdomen was protuberant and sagging. When asked actively to brace up his abdominal muscles, however, the abdomen became scaphoid in shape. The with fascia lata sutures, and in a previous communication (Patey, 1949) it has been shown that the direction of insertion of the sutures is of practical importance, in that better support is given to the weakened area if the sutures are inserted from below upwards and outwards so that they are tautened by the contraction of the internal oblique. T h e case herewith reported, in which this method of repair was adopted, would seem to show that more is involved than the mere local strengthening of a weakened area, and that the repair of the hernia may also have a beneficial effect on the whole of the oblique musculature of the corresponding side of' the abdominal wall. deficiency in postural tone was more marked in the obliques than in the recti, as could be readily demonstrated by a few simple tests. Thus when he was asked to give an expiratory strain, the lateral parts of the abdominal wall bulged. A convenient way to demonstrate these lateral bulges was to let the patient lie relaxed on his back on a couch, and then to get him slowly to raise his shoulders. The recti came into action with the beginning of the movement, but the oblique regions of the abdomen remained relatively flaccid so that they bulged with the increased intra-abdominal pressure. (Fig. 501). It was only when the shoulders had been raised a considerable way that the oblique muscles came fully into action and the bulges disappeared. This delay in synergic action of the oblique musculature under