Overview of Modern Surgical Techniques in Inguinal Hernia Repair
The era of effective hernia repair surgery dates back to the end of the nineteenth century. The model that Bassini created for dissecting and then rebuilding the inguinal canal became the foundation of technique to achieve better results. Other surgeons t
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Overview of Modern Surgical Techniques in Inguinal Hernia Repair Arthur I. Gilbert, Jerrold Young, and Rafael Azuaje
The ancient history of inguinal hernia is remarkable with many creative but mostly futile approaches to its treatment. One illustrated and informative resource for the work and workers of that era are the early chapters in Hernia Healers by Stoppa et al. [1]. The modern era of inguinal hernia repair began with the works of Bassini [2]. He recognized that the transversalis fascia was the Achilles tendon of the groin, the layer through which hernias develop. He proffered that to correctly repair an inguinal hernia the groin must be dissected layer by layer knowledgably and carefully from the skin into the preperitoneal space. Only then could the muscles, fascial elements, vessels, nerves and vassal structures be identified and preserved. His reconstruction began with the posterior wall opened. After checking for a femoral hernia he dissected the peritoneal sac to its true neck and ligated it there. He then used a three-layered interrupted suture repair to reconstruct the canal’s posterior wall. His deepest suture line included the lateral edge of the rectus muscle, the internal oblique muscle, the tranversus abdominus muscle, and the medial edge of the transversalis fascia. He approximated that four- layer composite to the lateral edge of the transversalis fascia and the inguinal ligament. He replaced the spermatic cord in its normal position and sutured the external oblique aponeurosis to comfortably re-create the obliquity of the canal and the external inguinal ring. In his earlier operations, starting in 1844, Bassini insisted his patients be awakened enough from anesthesia to perform straining motions to prove that his repair was sound. Bassini’s results for inguinal hernia repair was astounding compared to the poor results of other
A.I. Gilbert, M.D. (*) • J. Young, M.D. • R. Azuaje, M.D. De Witt Daughtery Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA Hernia Institute of Florida, 6200 Sunset Drive, #501 Miami, FL 33143, USA e-mail: [email protected]; [email protected]; [email protected]
surgeons of his time. With 90 % personal follow-up of 262 cases over 4 years, his failure rate was less than 3 %. He eventually reported this in a paper entitled, Nuovo metodo operativo per la cura dell’ernia inguinale. While some have noted that Bassini never specifically wrote about the importance of opening the posterior wall, illustrations by his devoted pupil, Catterina, clearly showed that he did open it and that he had described doing so in his own paper, Bassini’s operation for the radical cure of inguinal hernia [3]. Bassini’s true repair was altered and became known as the Modified Bassini Repair/North American Bassini Repair as was its impressive results. Many North American surgeons, influenced by Andrews, did not appreciate the importance of completely reconstructing the canal’s posterior wall. Most simply ligated the peritoneal sac and pulled the
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