514 T H E B R I T I S H J O U R N A L O F S U R G E R Y

liable to carcinoma than those who had it for a duodenal ulcer.

preceding gastric operation is difficult and easily missed. The possibility must always be kept in much help and encouragement. mind, especially when symptoms recur after a long silent period. Dysphagia may be due to peptic oesophagitis or to an early carcinoma. h z m i a is

may also be the first sign of a new lesion. A weight record should be kept as a matter Of routine and any unexplained loss of weight should be taken seriously.

Acknowledgements.-I would like to thank the surgical staff of The London Hospital for permission

The diagnosis of gastric carcinoma after a to analyse their cases. My special thanks are due to Mr. J. E. Richardson and Dr. Denys Jennings for

REFERENCES DOLL, R.3 AVERY JONES, F., and BUCKATZSCH, M. M.

(I951), Spec. Rep. Ser. med. Res. Coun., Lond., No. 276.

enterology, 27, 210.

143, 173.

a common late Of partial gastrectomy, but it FREEDMAN, M. A*, and BERNE, C. J. (1954), Gastro-

HELSINGEN, N., and HILLESTAD, L. (1956), Ann. Surg.,

PACK, G. T., and BANNER, R. L. (1958), Surgery, 44,1024.

REPAIR OF EPIGASTRIC INCISIONAL HERNIA

BY DONALD YOUNG, O.B.E., T.D. CONSULTANT SURGEON, WARRINGTON INFIRMARY

MOST surgeons who operate in the upper abdomen meet from time to time large ventral hernie occurring after epigastric incisions. Farquharson (1955) reminded us that “there is a wide defect in the musculature, with smooth and regular margins which are easily defined. The hernia takes the form of a diffuse bulge through the defect; it reduces spon- taneously as soon as the patient lies down, and there appears to be no risk whatever of strangulation. This type of hernia can be controlled fairly well by a belt

Wells (1956) reported his method of repair by lateral incision and medial displacement of the anterior rectus sheath on both sides with overlap of the two displaced sheaths. He also mentioned that “tension of the anterior rectus sheath is invariably greater than that of the posterior sheath”.

This paper offers an explanation of the reason for this tension, and demonstrates a repair based on anatomical principles.

FIG. 587.-Diagram of the normal anatomy in the upper epigastrium.

fitted with a suitable pad, and the patient is usually satisfied with such treatment-which is fortunate, since operative repair may be a matter of the greatest difficulty.”

Gibson (1916) thought it was possible to close even the largest post-operative hernia by the use of relieving incisions in the anterior sheath parallel to the midline suture line. In 1920 he reported 8 successful cases treated by releasing incisions made before or after suturing of the refreshed fascia1 edges, the first done ‘‘in 1914 on the spur of the moment in an effort to give a patient a competent abdominal wall because she was a physical training instructor ”. When seen six years later there was no recurrence, and the functional result was perfect.

Watson (1938)~ in cases of traumatic herniae of the linea alba, advocated overlapping broad flaps of fascia reinforced on each side by additional flaps of fascia from the anterior sheath of the rectus muscle.

Mair (1948) also advised, as a reinforcement, a reflected flap of anterior rectus sheath 3 or 4 in. long and 1-2 in. broad.

FIG. 588.-Diagram showing the anatomy of an epigastric incisional hernia. The broken lines show the position of the incisions made through the anterior sheath.

ANATOMY In the epigastrium the anterior sheath is composed,

for the most part, of the aponeurosis of the external oblique muscle which in this area arises from the costal margin, and also of the anterior lamina of the aponeurosis of the internal oblique (Fig. 587). The posterior sheath is composed, for the most part, by the aponeurosis of the transversus muscle and by fascia arising from the posterior lamina of the internal oblique. Both these latter muscles have a long muscle span to their origins, and hence are able to stretch more easily than the external oblique with its shorter muscle distance.

For the past ten years I have been using a repair which has successfully closed large epigastric incisional herniae (Table I ) . The repair is based on the following principles :-

I. In epigastric incisional hernia, the hernia is not due to a muscle defect, but occurs because the muscle belly has been pulled laterally by retraction of the joined anterior and posterior sheaths (Fig. 588).

R E P A I R O F E P I G A S T R I C I N C I S I O N A L H E R N I A 515

2. Just as releasing a curtain loop allows a curtain to fall straight, so muscle, if unimpeded, tends to lie in a straight line. A vertical incision through the external oblique aponeurosis, near the lateral border of the rectus muscle, thus releases the rectus sheath,

distance from the lateral edge of the rectus muscle in the lower epigastrium.

The rectus muscle, with its adherent anterior and posterior sheaths, can now be brought to the midline. When both recti are freed the posterior sheaths from

PATIENT

s. L.

J. H. __-__

SEX

M.

F.

J. B. 1 F.

Wound sepsis after partial gastrectomy, July 14, 1948

Cholecystectomy, Nov. 14, I949

Cholecystectomy, Nov. 14, 1949

I M. F. H.

-- July 25. 1949 48 No recurrence Sept. 1959

July 7, 1950 57 No recurrence Sept. 1959. Par- tial gastrectomy Oct. 1954

July 27, 1950 58 Ventral hernia recurred following incision of abscess in lower end of scar May 22, 1954

----

H. J.

c. M. n.

M.

F.

Partial gastrectomy, April

Partial gastrectomy May 31,

10, I951

1951

Table I.-REPAIR OF EPIGASTRIC INCISIONAL HERNI~E

~

March 14, 1952 41 No recurrence Sept. 1959

Oct. 28, 1952 60 No recurrence Sept. 1959. Cholecystectomy July 1,9sg, through right paramedian 1 x 1 - sion

-

~ , 1 I

M. C.*

G. S.

T.H. A.

B. B.

n. H.

W. J.

A. W.

DATE OF AGE AT CAUSE OF HERNIA I REPAIR I REPAIR 1

M

M.

M.

M.

M.

M.

M.

_-

REMARKS

Wound sepsis after partial gastrectomy, Sept. 3, 1952

Sepsis following high right paramedian incision, May 10, I954

Wound sepsis after partial gastrectomy, Oct. 3, I952

Wound sepsis after partial gastrectomy, Oct. 8, 1951

July 14, 1953 50 No recurrence Sept. 1959

Feb. 10, 1955 51 Secondary hzmorrhage into -___

wound followed by sepsis

Oct. 31, 1955 59 No recurrence Dec. 1959

Sept. 17, 1957 5 5 No recurrence Sept. 1959 - - ~ -

No recurrence when last seen in I A w . 30, 1950 I 46 I I955 Cholecystectomy, June 20,

I949

69

-- 37

No recurrence Aug. 1959

No recurrence Sept. 1959

G. S .

J. C.

Wound sepsis after partial Feb. 3, 1958 gastrectomy, Mar. 26, 1954 I

M.

M.

Repair of perforated duo- 1 May 5.1958 denal ulcer. Mav 10. IQA7

Sepsis after repair of ventral hernia, Feb. 10,1955

- Secondary suture after per- forated duodenal ulcer, May 9,1954

Midline incision for per- May 21, 1958 forated duodenal ulcer,

Dec. 30. 1958

May 4,1959

54

62

5 1 I N O recurrence Sept. 1959

Secondary hzmorrhage into wound on 9th day. No recur- rence March 1959

No recurrence Sept. 1959

* This oatient srates that he has had a small lumn annear oonosite his navel on threeoccasions. IL onlv occurred while he was strainine in a squatting position-at-work,~and~each~ttime~he has-bcen-Lde- t d ;epli,e--ihe~ lump -bf-pressure with a ~fingkr when he stood up. Recent careful examination failed to reveal any obvious defect at this site, but he must have had a small protrusion of retroperitoneal fat through a defect in the posterior sheath near the lateral edge of the rectus.

allowing the rectus muscle to move easily in or near to the midline so that both bellies of this muscle can be approximated in the midline with the minimum of tension.

OPERATIVE TECHNIQUE After elliptical excision of the old scar tissue and

some of the excess skin, skin-flaps are raised as far as the costal margin. The medial boundary of the rectus muscle is defined on either side of the hernia by a small incision, and the anterior sheath separated from the posterior sheath with scissors. While tension with three or four artery forceps is applied on the medial aspect of the anterior sheath, its lateral border is incised a finger’s breadth medial to the costal margin in the upper epigastrium and the same

either side can be brought together with a con- tinuous chromic catgut suture, plicating the redundant peritoneum in the process. If the peritoneum has been opened it can be closed as a separate layer. The anterior sheaths are now approximated, using interrupted figure-of-eight linen sutures. The skin is closed with interrupted linen sutures, using alternate vertical mattress and simple sutures. Meticulous hzmostasis usually obviates the need to drain, but if the skin is loose and serum collection a possibility, suction drainage, as advised by Wells, is indicated. If local anesthesia is used, the bleeding is minimal.

DISCUSSION The success which Wells has had with his opera-

tion may be explained by his use of the lateral incision

516 T H E B R I T I S H J O U R N A L O F S U R G E R Y

of the anterior sheath. This incision allows the recti to approximate, and once more to lie in the position Nature intended for them. T h e posterior sheath arises from such a length of muscle, encircling almost

Displacement of anterior sheath

Site of medial incision

Site of lateral /incision

Knife cut opened out- \\ / L

Displacement of posterior sheath by stretching of long

muscle attachment

-Rib , margin

FIG. 58g.-Diagram showing anatomy of the posterior sheath.

the entire abdominal cavity, that it exerts no restrain- ing influence in this inward movement (Fig. 589).

Gibson has remarked that “the surprising feature i n the after-result of these cases is the lack of weakness of the abdominal wall where the fascia gapes

as a result of being pulled away”. Immediately after the operation, however, the lateral weak spot is covered not only by thinned-out muscle, but posteriorly has the internal oblique and transversus muscle fascia as a firm support. In m y series there is only one case of herniation through this area (see Table I ) . Recently I had to perform a cholecystectomy on a patient for whom I repaired an epigastric incisional hernia seven years ago, using the technique described above. At operation it was found that the anterior sheath had grown over the bare muscle gap in a thin but definite layer, and the rectus muscle appeared to be of normal thickness.

SUMMARY A method of repair of epigastric incisional hernia

is offered, with an anatomical explanation for its effectiveness.

REFERENCES FARQUHARSON, E. L. (~gs-j), Ann. R . Coll. Surg. Engl.,

GIBSON, C. L. (1916), Ann. Surg., 63, 442. -- (1920), Ibid., 72, 214. MAIR, G. B. (1948), The Surgery of Abdominal Hernia,

17, 386.

294. London: Arnold. WATSON, L. F. (1938), Hernia. London: Kimpton. WELLS, C. A. (1956), Ann. R. Coll. Surg. Engl., 19,

316.

WILMS’ TUMOUR: LOBECTOMY FOR PULMONARY METASTASIS

A CASE REPORT

BY LEONARD HAAS AND ANTHONY D. M. JACKSON

THE prolonged survival of a patient following treat- ment of a n uncomplicated Wilms’ tumour (nephro- blastoma) is no longer unusual (Gross and Neuhauser, 1950.; N g and Low-Beer, 1956), but it has not previously been recorded following surgical removal of a pulmonary metastasis.

The case described below has several unusual features-the lung metastasis was slow-growing, and the patient survived for more than six years after its removal. Unfortunately he succumbed to a local recurrence with widespread abdominal dissemination, but not until IIQ years after the original nephrectomy.

CASE REPORT David B. (3874/52), born Jan. 23, 1942, was first seen

at the age of 4: years on account of a three months’ history of left-sided abdominal pain. A large tumour was felt in the left loin, and there was no excretion of dye by the left kidney on intravenous pyelography. Laparotomy at another hospital in September, 1946, disclosed a large retroperitoneal tumour arising from the left kidney. This tumour was considered to be inoperable and, because of its vascularity, no biopsy was carried out.

The patient was transferred to The London Hospital, where the clinical findings were confirmed. Radiography of the lungs showed no evidence of metastases. In December, 1946, a course of deep X-ray therapy was commenced; irradiation was given to the upper abdomen with anterior

and posterior, directly opposed, parallel fields, field size 15 x 15 cm. (220 kV., 15 mA., focus-skin distance 50 cm., filtration 0.5 cm. copper plus I mm. aluminium). The dose was initially 50 r and was later increased to IOO r giving a total incident dose (with back-scatter) of 650 r per field, spread over 16 days.

Following radiotherapy the abdominal tumour was considerably reduced in size and a further operation was performed on Jan. 21, 1947, by the late Mr. Charles Donald.

AT OPERATIoN.-The tumour was found to arise from the upper pole of the left kidney. It was adherent to the under surface of the diaphragm, although there was no actual invasion of neighbouring structures. The kidney, together with the turnour, was dissected free with some difficulty, and the whole mass finally removed.

PATHOLOGICAL REPoRT.-The specimen consisted of the left kidney (10 x 6 x 3 cm.) showing several smooth yellow nodules both on the surface and at the hilum. On section, collections of well-encapsulated nodules occupied the upper pole and central part of the kidney, with a further mass at the hilum. The cut surface of the nodules was firm and showed patches of haemorrhage. The ureter was not identified. The histological appearances were those of a Wilms’ tumour. In view of the subsequent clinical course it is of special interest that the tendency towards differentiation of tubules was more marked than usual.

After operation the whole upper abdomen was irradi- ated with a wide-field bath, one posterior and two anterior