McVay Herniorrhaphy

Today we'll talk about the Cooper's Ligament Repair... a nice one to know for femoral hernias and situations where you need to avoid mesh prostheses...

Who was Sir Astley Cooper (1768-1841)?

At the wee age of 16 years old, as a budding surgical apprentice, he developed a groin hernia of his very own, which was managed by a truss. In 1804, he published his works on the Anatomy and Surgical Treatment of Hernia.

What are some of his eponymous anatomical structures?

1. Superior pubic / pectineal ligament
2. Suspensory ligaments of the breast
3. Fascial covering of the spermatic cord

What are the borders of Fruchaud's myopectineal orifice?

medial - rectus abdominus muscle
lateral - iliopsoas muscle
superior - internal oblique and transverse abdominus
inferior - Cooper's ligament and pubis

The inguinal ligament spans and divides the myopectineal orifice, running from the anterior superior iliac spine to the pubic tubercle. The spermatic cord crosses above and the iliac vessels cross below.

The myopectineal orifice is significant as it is a region of aponeurotic fibers that can attenuate, resulting in a groin hernia.

What types of hernias occur in the myopectineal orifice?

1. Direct Inguinal - through transversalis fascia (medial to inferior epigastric)
2. Indirect Inguinal - through inguinal ring (lateral to inferior epigastric)
3. Femoral - through femoral ring

All three types can be addressed using a Cooper's ligament repair...

What are the borders of the inner ring of the femoral canal?

lateral - femoral vein
anteromedial - iliopubic tract
posterior - Cooper's ligament

Who were the first surgeons to utilize Cooper's ligament in herniorrhaphy?

1. Giuseppe Ruggi (1892) - sutured inguinal ligament to Cooper's ligament
2. Georg Lotheissen (1897) - sutured the conjoint tendon to Cooper's ligament
3. Chester McVay (1942)

Chester McVay noted in his doctoral thesis that the normal insertion of the transverse abdominus and the transversalis fascia was on Cooper's ligament, and not the inguinal ligament. His technique for herniorraphy focused on reconstruction of these anatomical relationships.

What are key elements of the McVay Herniorrhaphy?

1. Suturing the transversalis arch to Cooper's ligament, from the pubic tubercle to the femoral vein.
2. Transition sutures to avoid the femoral vein and close the femoral canal, then suturing the transversalis arch laterally to the iliopubic tract.
3. Making a generous relaxing incision to decrease tension to the repair.

Give me details!

1. Begin with an inguinal approach, incising the skin and soft tissues after adequate local anesthesia.
2. Open the external oblique aponeurosis to the external ring.
3. Attempt to preserve the ilioinguinal nerve.
4. Mobilize the spermatic cord. Isolate it with a penrose.
5. Open the internal ring, incising the posterior wall of the inguinal canal towards the pubic tubercle (through the internal oblique aponeurosis and the transversalis fascia.)
6. Retract the spermatic cord superiorly and identify Cooper's ligament. Palpate for the femoral vessels.
7. Define the space between the femoral vein and the pubic tubercle from lateral to medial, with conversion of any femoral hernia sac into an inguinal one.
8. Hernia sacs can be opened to inspect for intraabdominal pathology if strangulation is suspected. Resection may be necessary, otherwise contents can be reduced.
9. Indirect hernia sacs can be isolated from the spermatic cord and transected at the level of the internal ring. Direct hernia sacs can be inverted in the repair.
10. Mobilize the transversus abdominus arch superiorly. Any attenuated transversalis fascia and internal oblique can be excised.
11. Place relaxing incision superior to pubic tubercle at the point of fusion of the external oblique aponeurosis and the anterior rectus sheath. This should extend superiorly for about 4-5 inches.
12. Place patient in Trendelenberg position to minimize intraabdominal injury.
13. The preperitoneal tissues can be carefully imbricated to keep them out of the repair if necessary.
14. Place interupted sutures (10) between the transverse abdominus arch and Cooper's ligament, beginning at the pubic tubercle towards the medial edge of the femoral vein. Place a clamp around the sutures to tie later.
15. Begin placing transition sutures (3) between the transverse abdominus arch, Cooper's ligament, and the iliopubic tract. The medial two of these sutures will be placed so they overlap in between the prior lateral sutures.
16. Continue placing interrupted sutures between the transversus abdominus arch and the iliopubic tract, creating a neo-internal ring.
17. Tie all the sutures from medial to lateral.
18. Return the cord to its natural position.
19. Close the external ring over the cord using a continuous 2-0 Vicryl, creating a neo-external ring.
20. Close skin according to preference.

Here's a picture, just before placement of the transition stitches!

Late... SG

Sources:
Nyhus and Condon's Hernia, 5th ed. (2002)
Hachisuka T. Femoral hernia repair. Surg Clin N Am 2003; 83: 1189-1205.