- Email: [email protected]
The history of open inguinal hernia repair
CURRENT REVIEWS IN GASTROINTESTINAL, MINIMALLY INVASIVE, & ENDOCRINE SURGERY
The History of Open Inguinal Hernia Repair James Johnson, MD, J. Scott Roth, MD, Jeffrey W. Hazey, MD, and Walter E. Pofahl II, MD Department of Surgery, Brody School of Medicine, Greenville, North Carolina INTRODUCTION The open inguinal hernia repair is the very cornerstone of general surgery. Understanding the nature of the repair and the anatomy conducive to a successful repair is a right of passage of any general surgeon. It begins early as a junior resident and continues through a career. This is analogous to the history of the inguinal hernia repair and the ongoing improvements of one of the oldest surgical procedures.
EVOLUTION OF UNDERSTANDING The development of the inguinal hernia repair began early enough, with the Egyptians recording the earliest clinical assessments, and evidence does exist that suggests that repairs were attempted.1,2 Initial management of herniation included trusses and occasional surgical intervention for pain. The Greeks were the first to employ taxis (hernia reduction).3 Celsus provided an operation for inguinal hernia that involved dissection of the sac from the cord structures with ligation of the sac and sparing of the testicle.4 This was done through an incision through the scrotum. These wounds were left open to granulate or cauterized. The major conflicts at this time regarding inguinal herniorrhaphy were whether to sacrifice the testicle. Celsus’s original operation did not; however, through the Middle Ages, it was bastardized to include testicular excision as routine. This can be seen as foreshadowing of the Bassini repair and how it was corrupted. The problem, of course, with any repairs done at this time was that there was no understanding of the anatomy of the region. Herniation was seen merely as a protrusion that needed to be replaced. This was done in the most expedient method possible without asepsis or anesthesia. Recurrence rates likely were not given a second thought, as immediate survival was the early surgeons major preoccupation. These operations were heroic measures done to save lives and not to reduce groin discomfort. The Age of Enlightenment brought a new understanding to inguinal hernia repair. The publication of De humani corporus fabrica by Andreus Vesalius in 1543 did not impact greatly on Correspondence: Inquiries to J. Scott Roth, MD, Department of Surgery, Brody School of Medicine, 600 Moye Boulevard, Greenville, NC 27834; fax: (252) 744-5775; e-mail: [email protected]
herniorrhaphy, but it does signify that the times had changed to dissection-based anatomy and with that a more detailed view of the inguinal hernia. Ambrose Pare published a detailed account of the repair of the inguinal hernia in the late 1500s.5 He described ligation of the hernia sac with return of the contents to the abdominal cavity and repair of the parietal peritoneum. These operations were done more often than one might think as Jacques de Beaulieu, a noted barber-surgeon of the late 1600s, was reported to have performed over 2000 hernia operations employing current techniques. This was in addition to performing 4500 lithotomies, his primary trade being a “cutter for stones.”6 As dissection and the knowledge of the inguinal region expanded, many advances were made in the conceptual understanding of the inguinal region and herniation. Stromayr delineated the direct from the indirect inguinal hernia in 1559.1 The identification of the inguinal canal was based on the work of many men at the turn of the 18th century: Pott, Richter, Camper, Scarpa, Morton, Gimbernat, Cooper, Colles, Hasselbach, and Hunter. This in turn was enhanced with Gimbernat’s ligament (1793), the transverse fascia and Cooper’s ligament (1804),7 Hasselbach’s triangle, and the iliopubic tract (1814).8 All names that are associated with a contemporary gross anatomy dissection of the inguinal region. Surgical intervention did not change much through the above period despite the advances in conceptual understanding. The anatomy of the region had been clarified, but surgical technique was limited without antisepsis and anesthesia. If an inguinal approach was used, the sac was excised and the wound was left to granulate, also known as the McBurney procedure. Attempts to open the inguinal canal resulted in high rates of sepsis and recurrence was the rule.3 Since antiquity, it had been known that infection with its pursuant scarring significantly decreased recurrence. A brief trial of injection of sclerosing agents was attempted: Pancoast in 1847 used cantharides.8 Results were poor, with no reduction in recurrence and peritonitis frequent. Antisepsis and anesthesia were needed at this point for proper repair of the inguinal hernia to develop.
EVOLUTION OF TECHNIQUE The development of the antiseptic technique by Lister (1870) and then the aseptic technique by Mickulicz (1904) made the process of surgery much safer. The use of anesthesia by Crawford Long on March 30, 1842 made the thought of an opera-
CURRENT SURGERY • © 2004 by the Association of Program Directors in Surgery Published by Elsevier Inc.
0149-7944/04/$30.00 doi:10.1016/j.cursur.2003.06.004
49
tion more palatable to patients. The initial publication of an inguinal hernia repair using antisepsis and anesthesia was by Marcy.9 The sac was returned through the external ring, and the external ring was sutured. This technique was used with minor modifications by surgeons such as Kocher and Czerny until Lucas-Championniere first split the external oblique aponeurosis and excised the sac at the level of the internal ring.8 Great strides had been made in technique. However, the mortality rate was found to be 2% to 7%, and the 4-year recurrence rate was approximately 100% after Billroth examined the literature in 1890.3 Clearly something was being missed. Edoardo Bassini changed all of this with a simple repair that required discreet knowledge of anatomy and attention to detail. It was such an excellent repair that it was immediately accepted and is still used today. Previously, attention had not been directed to the posterior floor of the inguinal canal, the transversalis fascia. Bassini, through an anterior approach, divided the external oblique, the cremaster, and, after dissecting the spermatic cord contents, the transversalis fascia. This provided excellent exposure to allow for a triple closure. This closure approximates the internal oblique, transversus abdominus, and the transversalis fascia superiorly with the inguinal ligament and iliopubic tract posteriorly. Cooper’s ligament is incorporated in the initial 2-3 sutures inferiorly. The external oblique is then closed over the cord. The Bassini repair provided an anatomically true repair of the hernia defect that recreated the internal and external rings. Done correctly and with attention to detail, the Bassini repair has a 1% to 2% recurrence rate for initial hernia repair.10 It also has an essentially 0% operative mortality rate when done with local anesthesia.11 When discussed in today’s standards, it is said to be not as good as a tension-free repair or patients may not return back to work as quickly. However, it was a vast improvement over a current mortality of 2% to 7% with a recurrence rate of 100%. The Cooper ligament repair (McVay repair) was another large step forward. The Bassini repair had an excellent initial repair recurrence rate; however, in recurrent hernias and large hernias, the recurrence rates increased. It was found by McVay through cadaver studies that the transversus abdominus and the transversalis fascia were inserted on Cooper’s ligament (ileopectineal ligament), not on the inguinal ligament. Approximately 25% of cadavers studied had a defect that involved a short insertion. The result was a posterior wall made solely of the transversalis fascia. This was later to be known as the myopectineal orifice named by Fruchaud in 1956. At the time, however, the discovery by McVay led to the use of Cooper’s ligament and of the iliopubic tract to anchor the inferior aspect of the posterior wall reconstruction. The repair requires a relaxing incision at the anterior rectus sheath, but it will repair the wall sufficiently to strengthen against direct, indirect, and femoral herniation through the myopectineal orifice.12 The Cooper’s ligament repairs require a more tedious and exact dissection, and there is an increased tension, despite relaxing incisions. It is still used today and has a recurrence rate of 1.5% to 15%. 50
Several variations to the Bassini or McVay have also proved useful. The most noteworthy being the Shouldice repair. The Shouldice repair is similar to the Bassini repair, except the repair uses running suture rather than interrupted suture for the reconstruction of the posterior wall. The Shouldice repair has a less than 1% recurrence rate, is performed usually under general anesthesia, and is a tribute to single-mindedness of an entire institution and how well an operation can be done by true experts. A true jump in operative technique, such as the one seen with the Bassini repair, was next seen with the use of prosthetics. The development of a truly tension-free repair could only be possible with the use of prosthetics. Despite the advances in anatomical understanding and surgical technique, tension remained a concern and was frequently sighted as the cause of recurrence. Marcy was the first to report the use of prosthetics with kangaroo tendon.13 Ox, deer, and whale tendon were also used. Homologous grafts such as fascia lata and external oblique pedicles were also used. They were all found to be of no value.4 The discovery of synthetic polymers such as Nylon provided an adequate material that could be used as a prosthetic and was first reported by Melick in 1942.14 A large number of materials have been tested, and currently three synthetics are used commonly today: polyester mesh (Dacron, Mersilene), polypropylene (Marlex, Prolene, Surgipro), and expanded polytetrafluouroethylene (e-PTFE, Gore-Tex). Three major techniques for a tension-free repair using prosthetics evolved from the work of many, but they are now mainly attributed to Stoppa and Lichtenstein. Lichtenstein and Shore first published a series on plug repairs of inguinal and femoral hernias in 1974.15 This technique involved rolling a 2-cm by 10-cm strip of Marlex into a plug and placing it into the defect after the hernia was reduced. The plug was then loosely tacked to the rim of the defect. The Marlex was later increased to 2 ⫻ 20 to allow for shrinkage over time with even better results.16 It should be well noted that this repair is a departure from the previous repair methods. The inguinal floor is not dissected and recreated as with the Bassini repair. In fact, a minimal dissection is done. The dissection is limited to allow exposure of 3 mm to 4 mm of a defect shelf and to reduce the hernia sac. Shulman reported a series of 1402 recurrent inguinal hernia repairs with a recurrence rate of 2%. The study had a 20-year follow-up time.17 A concern since the initiation of prosthetics has been the incidence of infection. A survey of 3019 primary inguinal hernia repairs with mesh reported an infection rate of 0.03%.18 A recurrence rate of 0.02% was found in the same study. The plug method can be used with a discreet hernia defect in the myopectineal orifice or a defect at the femoral canal. It may also be used for a recurrent hernia with a defect less than 3 cm. It allows the patient to immediately resume normal activity. There is also little postoperative pain because of minimal tissue dissection. The recurrence rate of the plug technique has consistently been reported as less than 2%.16 However, if the floor of the inguinal canal is obliterated, the defect of a recurrent hernia is larger than CURRENT SURGERY • Volume 61/Number 1 • January/February 2004
3 cm, or if there is an infected field, a Marlex plug is contraindicated. The Lichtenstein patch method of tension-free hernia repair was developed as an office procedure with local anesthesia.19,20 It is a repair that follows the anatomic findings that led up to the Bassini repair by patching the myopectineal orifice with Marlex mesh in a tension-free manner. It involves a simple dissection, Marlex mesh overlapping the defective area, and proper care to not damage local nerves: ilioinguinal, iliohypogastric, and genital nerves. The mesh is attached medially to the rectus sheath and laterally to the inguinal ligament/conjoint tendon. It has recently been described by Amid.21 General surgeons without a special interest in herniology were found to have excellent results that included a minimal infection rate and a recurrence rate of 0.5%.22,23 The Lichtenstein tension-free repair is a tough act to follow. It can be done with great success by experts and generalists alike, it has a worldwide incidence of recurrence of less than 1%, it can be done under local anesthesia, has a very low infection rate, and is fast and simple. It does not have the postoperative pain associated with the Bassini and Shouldice repairs because of the decreased tissue dissection required and patients can return to work quickly. However, some hernias are large and can recur despite the best attempts previously mentioned. The third method to repair groin hernias in the modern and in a tension-free manner was developed by Stoppa and associates and has been named the giant prosthesis for the repair of the visceral sac (GPRVS). It was first reported in 1975 and is the true extension of the anatomic discoveries that took leading surgeons over a hundred years to deduce. The GPRVS is an excellent hernia repair technique for multiple, recurrent, or very large hernias.24 Simply put, a large piece of mesh is used to replace the weakened transversalis fascia below the line of Douglas. The large piece of Dacron is placed in the preperitoneal space and acts as a nonabsorbable barrier to prevent further herniation. The hernia sac is reduced; however, the defect is not closed. It covers the myopectineal orifice of Fruchaud bilaterally and is not sutured. It is as tension free as a hernia repair can be done. Wantz et al reported a series of 646 hernia repairs consisting mainly of recurrent or large inguinal hernias with a recurrence rate of less than 2% once Mersilene (Dacron) was used as the prosthetic.25 A survey of the literature in that same report displayed a usual recurrence rate of less than 2%. Billroth, Halsted, Bassini, Kocher, and all of the great men of the past would be amazed to see the result of their progress with regard to the repair of the inguinal hernia. We take it for granted in this day and age. However, before Bassini’s repair, the recurrence rate for inguinal hernia repair was 100% and the mortality was 2% to 7%. Now, Cooper, Scarpa, and Hunter would be amazed that several operations are available to the general surgeon that will not only repair an inguinal hernia with a reported rate of recurrence rate of less than 1%, but also have a 0% mortality associated with them. Crawford Long would also be impressed with the idea of operations such as the Lichtenstein being done in an office setting with local anesthesia. CURRENT SURGERY • Volume 61/Number 1 • January/February 2004
The surgeons responsible for the current state of open hernia would be pleased with the current outcomes, but how would they feel about the advances made even greater by the advent of laparoscopy?
REFERENCES 1. Patino JF. A history of the treatment of hernia. In: Nyhus
LM, Condon RE, editors. Hernia. 4th ed. Philadelphia: Lippincott: 1995: 3–15. 2. Ruffer MA. In: Moodie RL, editor. Studies in the paleopa-
thology of Egypt. Chicago: University of Chicago Press; 1921. 3. Read RC. The development of inguinal herniorrhaphy.
Surg Clin N Am. 1984;64:185-196. 4. Devlin HB, Kingsnorth A, O’Dwyer PJ, et al. General
introduction and history of hernia surgery. In: Devlin HB, Kingsnorth A, editors. Management of Abdominal Hernias. 2nd ed. London: Chapman and Hall; 1998:1-13. 5. Pare A. In: Keynes G, editor. The Apologie and Treatise.
London: Falcon Educational Books; 1951. 6. Porter R. The Greatest Benefit to Mankind. New York:
W.W: Norton and Company; 1997; 277–281. 7. Cooper A. The Anatomy and the Surgical Treatment of In-
guinal and Congenital Hernia I. London: T: Cox; 1804. 8. Lau WY. History of treatment of groin surgery. World
J Surg. 2002;26:748-759. 9. Marcy HO. A new use of carbolized cat gut ligatures. Bos-
ton Med Surg J. 1871;85:315-316. 10. Bendavid R. Hernia repairs: open techniques. In Neu-
mayer L, editor. Inguinal Hernia Management in the New Millenium. 28th Annual Spring Meeting of the ACS; 2000. 11. Terranova T, Battocchio F. The Bassini operation. In:
Nyhus LM, Baker RJ, Fischer JE, editors. Mastery of Surgery, 3rd ed. New York: Little, Brown and Company; 1997:1807-1816. 12. Rutledge RH. Cooper ligament repair of groin hernias. In:
Nyhus LM, Baker RJ, Fischer JE, editors. Mastery of Surgery, 3rd ed. New York: Little, Brown and Company; 1997:1817-1825. 13. Marcy HO. The cure of hernia. JAMA. 1887;8:589-592. 14. Melick DW. Nylon suture. Ann Surg. 1942;115:475-476. 15. Lichtenstein IL. Simplified repair of femoral and recurrent
inguinal hernia by a “plug” technic. Am J Surg. 1974;128: 439-444. 16. Shulman AG. Prosthetic mesh plug repair of femoral and 51
recurrent inguinal hernias: the American experience. Ann R Coll Surg Engl. 1992;74:97-99.
21. Amid PK. How to avoid recurrence in Lichtenstein ten-
17. Shulman AG, Amid PK, Lichtenstein IL. The “plug” re-
22. Shulman AG. A survey of non-expert surgeons using the
pair of 1402 recurrent inguinal hernias. Arch Surg. 1990; 125:265-267. 18. Shulman AG, Amid PK, Lichtenstein IL. The safety of
mesh repair for primary inguinal hernias: results of 3,019 operations from five diverse surgical sources. Am Surg. 1992;58:255-257. 19. Lichtenstein IL. Herniorrhaphy. A personal experience
with 6,321 cases. Am J Surg. 1987;153:553-559. 20. Lichtenstein IL, Schulman AG, Amid PK. The tension-
free hernioplasty. Am J Surg. 1989;157:188-193.
52
sion-free hernioplasty. Am J Surg. 2002;184:259-260. open tension-free mesh patch repair for primary inguinal hernias. Int Surg. 1995;80(1):35-36. 23. Stoppa RE, Petit J, Henry X. Unsutured Dacron prosthe-
sis in groin hernias. Int Surg. 1975;60:411-415. 24. Rutledge RH. Cooper ligament repair of groin hernias. In:
Nyhus LM, Baker RJ, Fischer JE, editors. Mastery of Surgery, 3rd ed. New York: Little, Brown and Company; 1997:1859-1869. 25. Wantz GE. Giant prosthetic reinforcement of the visceral
sac. The Stoppa groin hernia repair. Surg Clin North Am. 1998;78:1075-1087.
CURRENT SURGERY • Volume 61/Number 1 • January/February 2004
The History of Open Inguinal Hernia Repair James Johnson, MD, J. Scott Roth, MD, Jeffrey W. Hazey, MD, and Walter E. Pofahl II, MD Department of Surgery, Brody School of Medicine, Greenville, North Carolina INTRODUCTION The open inguinal hernia repair is the very cornerstone of general surgery. Understanding the nature of the repair and the anatomy conducive to a successful repair is a right of passage of any general surgeon. It begins early as a junior resident and continues through a career. This is analogous to the history of the inguinal hernia repair and the ongoing improvements of one of the oldest surgical procedures.
EVOLUTION OF UNDERSTANDING The development of the inguinal hernia repair began early enough, with the Egyptians recording the earliest clinical assessments, and evidence does exist that suggests that repairs were attempted.1,2 Initial management of herniation included trusses and occasional surgical intervention for pain. The Greeks were the first to employ taxis (hernia reduction).3 Celsus provided an operation for inguinal hernia that involved dissection of the sac from the cord structures with ligation of the sac and sparing of the testicle.4 This was done through an incision through the scrotum. These wounds were left open to granulate or cauterized. The major conflicts at this time regarding inguinal herniorrhaphy were whether to sacrifice the testicle. Celsus’s original operation did not; however, through the Middle Ages, it was bastardized to include testicular excision as routine. This can be seen as foreshadowing of the Bassini repair and how it was corrupted. The problem, of course, with any repairs done at this time was that there was no understanding of the anatomy of the region. Herniation was seen merely as a protrusion that needed to be replaced. This was done in the most expedient method possible without asepsis or anesthesia. Recurrence rates likely were not given a second thought, as immediate survival was the early surgeons major preoccupation. These operations were heroic measures done to save lives and not to reduce groin discomfort. The Age of Enlightenment brought a new understanding to inguinal hernia repair. The publication of De humani corporus fabrica by Andreus Vesalius in 1543 did not impact greatly on Correspondence: Inquiries to J. Scott Roth, MD, Department of Surgery, Brody School of Medicine, 600 Moye Boulevard, Greenville, NC 27834; fax: (252) 744-5775; e-mail: [email protected]
herniorrhaphy, but it does signify that the times had changed to dissection-based anatomy and with that a more detailed view of the inguinal hernia. Ambrose Pare published a detailed account of the repair of the inguinal hernia in the late 1500s.5 He described ligation of the hernia sac with return of the contents to the abdominal cavity and repair of the parietal peritoneum. These operations were done more often than one might think as Jacques de Beaulieu, a noted barber-surgeon of the late 1600s, was reported to have performed over 2000 hernia operations employing current techniques. This was in addition to performing 4500 lithotomies, his primary trade being a “cutter for stones.”6 As dissection and the knowledge of the inguinal region expanded, many advances were made in the conceptual understanding of the inguinal region and herniation. Stromayr delineated the direct from the indirect inguinal hernia in 1559.1 The identification of the inguinal canal was based on the work of many men at the turn of the 18th century: Pott, Richter, Camper, Scarpa, Morton, Gimbernat, Cooper, Colles, Hasselbach, and Hunter. This in turn was enhanced with Gimbernat’s ligament (1793), the transverse fascia and Cooper’s ligament (1804),7 Hasselbach’s triangle, and the iliopubic tract (1814).8 All names that are associated with a contemporary gross anatomy dissection of the inguinal region. Surgical intervention did not change much through the above period despite the advances in conceptual understanding. The anatomy of the region had been clarified, but surgical technique was limited without antisepsis and anesthesia. If an inguinal approach was used, the sac was excised and the wound was left to granulate, also known as the McBurney procedure. Attempts to open the inguinal canal resulted in high rates of sepsis and recurrence was the rule.3 Since antiquity, it had been known that infection with its pursuant scarring significantly decreased recurrence. A brief trial of injection of sclerosing agents was attempted: Pancoast in 1847 used cantharides.8 Results were poor, with no reduction in recurrence and peritonitis frequent. Antisepsis and anesthesia were needed at this point for proper repair of the inguinal hernia to develop.
EVOLUTION OF TECHNIQUE The development of the antiseptic technique by Lister (1870) and then the aseptic technique by Mickulicz (1904) made the process of surgery much safer. The use of anesthesia by Crawford Long on March 30, 1842 made the thought of an opera-
CURRENT SURGERY • © 2004 by the Association of Program Directors in Surgery Published by Elsevier Inc.
0149-7944/04/$30.00 doi:10.1016/j.cursur.2003.06.004
49
tion more palatable to patients. The initial publication of an inguinal hernia repair using antisepsis and anesthesia was by Marcy.9 The sac was returned through the external ring, and the external ring was sutured. This technique was used with minor modifications by surgeons such as Kocher and Czerny until Lucas-Championniere first split the external oblique aponeurosis and excised the sac at the level of the internal ring.8 Great strides had been made in technique. However, the mortality rate was found to be 2% to 7%, and the 4-year recurrence rate was approximately 100% after Billroth examined the literature in 1890.3 Clearly something was being missed. Edoardo Bassini changed all of this with a simple repair that required discreet knowledge of anatomy and attention to detail. It was such an excellent repair that it was immediately accepted and is still used today. Previously, attention had not been directed to the posterior floor of the inguinal canal, the transversalis fascia. Bassini, through an anterior approach, divided the external oblique, the cremaster, and, after dissecting the spermatic cord contents, the transversalis fascia. This provided excellent exposure to allow for a triple closure. This closure approximates the internal oblique, transversus abdominus, and the transversalis fascia superiorly with the inguinal ligament and iliopubic tract posteriorly. Cooper’s ligament is incorporated in the initial 2-3 sutures inferiorly. The external oblique is then closed over the cord. The Bassini repair provided an anatomically true repair of the hernia defect that recreated the internal and external rings. Done correctly and with attention to detail, the Bassini repair has a 1% to 2% recurrence rate for initial hernia repair.10 It also has an essentially 0% operative mortality rate when done with local anesthesia.11 When discussed in today’s standards, it is said to be not as good as a tension-free repair or patients may not return back to work as quickly. However, it was a vast improvement over a current mortality of 2% to 7% with a recurrence rate of 100%. The Cooper ligament repair (McVay repair) was another large step forward. The Bassini repair had an excellent initial repair recurrence rate; however, in recurrent hernias and large hernias, the recurrence rates increased. It was found by McVay through cadaver studies that the transversus abdominus and the transversalis fascia were inserted on Cooper’s ligament (ileopectineal ligament), not on the inguinal ligament. Approximately 25% of cadavers studied had a defect that involved a short insertion. The result was a posterior wall made solely of the transversalis fascia. This was later to be known as the myopectineal orifice named by Fruchaud in 1956. At the time, however, the discovery by McVay led to the use of Cooper’s ligament and of the iliopubic tract to anchor the inferior aspect of the posterior wall reconstruction. The repair requires a relaxing incision at the anterior rectus sheath, but it will repair the wall sufficiently to strengthen against direct, indirect, and femoral herniation through the myopectineal orifice.12 The Cooper’s ligament repairs require a more tedious and exact dissection, and there is an increased tension, despite relaxing incisions. It is still used today and has a recurrence rate of 1.5% to 15%. 50
Several variations to the Bassini or McVay have also proved useful. The most noteworthy being the Shouldice repair. The Shouldice repair is similar to the Bassini repair, except the repair uses running suture rather than interrupted suture for the reconstruction of the posterior wall. The Shouldice repair has a less than 1% recurrence rate, is performed usually under general anesthesia, and is a tribute to single-mindedness of an entire institution and how well an operation can be done by true experts. A true jump in operative technique, such as the one seen with the Bassini repair, was next seen with the use of prosthetics. The development of a truly tension-free repair could only be possible with the use of prosthetics. Despite the advances in anatomical understanding and surgical technique, tension remained a concern and was frequently sighted as the cause of recurrence. Marcy was the first to report the use of prosthetics with kangaroo tendon.13 Ox, deer, and whale tendon were also used. Homologous grafts such as fascia lata and external oblique pedicles were also used. They were all found to be of no value.4 The discovery of synthetic polymers such as Nylon provided an adequate material that could be used as a prosthetic and was first reported by Melick in 1942.14 A large number of materials have been tested, and currently three synthetics are used commonly today: polyester mesh (Dacron, Mersilene), polypropylene (Marlex, Prolene, Surgipro), and expanded polytetrafluouroethylene (e-PTFE, Gore-Tex). Three major techniques for a tension-free repair using prosthetics evolved from the work of many, but they are now mainly attributed to Stoppa and Lichtenstein. Lichtenstein and Shore first published a series on plug repairs of inguinal and femoral hernias in 1974.15 This technique involved rolling a 2-cm by 10-cm strip of Marlex into a plug and placing it into the defect after the hernia was reduced. The plug was then loosely tacked to the rim of the defect. The Marlex was later increased to 2 ⫻ 20 to allow for shrinkage over time with even better results.16 It should be well noted that this repair is a departure from the previous repair methods. The inguinal floor is not dissected and recreated as with the Bassini repair. In fact, a minimal dissection is done. The dissection is limited to allow exposure of 3 mm to 4 mm of a defect shelf and to reduce the hernia sac. Shulman reported a series of 1402 recurrent inguinal hernia repairs with a recurrence rate of 2%. The study had a 20-year follow-up time.17 A concern since the initiation of prosthetics has been the incidence of infection. A survey of 3019 primary inguinal hernia repairs with mesh reported an infection rate of 0.03%.18 A recurrence rate of 0.02% was found in the same study. The plug method can be used with a discreet hernia defect in the myopectineal orifice or a defect at the femoral canal. It may also be used for a recurrent hernia with a defect less than 3 cm. It allows the patient to immediately resume normal activity. There is also little postoperative pain because of minimal tissue dissection. The recurrence rate of the plug technique has consistently been reported as less than 2%.16 However, if the floor of the inguinal canal is obliterated, the defect of a recurrent hernia is larger than CURRENT SURGERY • Volume 61/Number 1 • January/February 2004
3 cm, or if there is an infected field, a Marlex plug is contraindicated. The Lichtenstein patch method of tension-free hernia repair was developed as an office procedure with local anesthesia.19,20 It is a repair that follows the anatomic findings that led up to the Bassini repair by patching the myopectineal orifice with Marlex mesh in a tension-free manner. It involves a simple dissection, Marlex mesh overlapping the defective area, and proper care to not damage local nerves: ilioinguinal, iliohypogastric, and genital nerves. The mesh is attached medially to the rectus sheath and laterally to the inguinal ligament/conjoint tendon. It has recently been described by Amid.21 General surgeons without a special interest in herniology were found to have excellent results that included a minimal infection rate and a recurrence rate of 0.5%.22,23 The Lichtenstein tension-free repair is a tough act to follow. It can be done with great success by experts and generalists alike, it has a worldwide incidence of recurrence of less than 1%, it can be done under local anesthesia, has a very low infection rate, and is fast and simple. It does not have the postoperative pain associated with the Bassini and Shouldice repairs because of the decreased tissue dissection required and patients can return to work quickly. However, some hernias are large and can recur despite the best attempts previously mentioned. The third method to repair groin hernias in the modern and in a tension-free manner was developed by Stoppa and associates and has been named the giant prosthesis for the repair of the visceral sac (GPRVS). It was first reported in 1975 and is the true extension of the anatomic discoveries that took leading surgeons over a hundred years to deduce. The GPRVS is an excellent hernia repair technique for multiple, recurrent, or very large hernias.24 Simply put, a large piece of mesh is used to replace the weakened transversalis fascia below the line of Douglas. The large piece of Dacron is placed in the preperitoneal space and acts as a nonabsorbable barrier to prevent further herniation. The hernia sac is reduced; however, the defect is not closed. It covers the myopectineal orifice of Fruchaud bilaterally and is not sutured. It is as tension free as a hernia repair can be done. Wantz et al reported a series of 646 hernia repairs consisting mainly of recurrent or large inguinal hernias with a recurrence rate of less than 2% once Mersilene (Dacron) was used as the prosthetic.25 A survey of the literature in that same report displayed a usual recurrence rate of less than 2%. Billroth, Halsted, Bassini, Kocher, and all of the great men of the past would be amazed to see the result of their progress with regard to the repair of the inguinal hernia. We take it for granted in this day and age. However, before Bassini’s repair, the recurrence rate for inguinal hernia repair was 100% and the mortality was 2% to 7%. Now, Cooper, Scarpa, and Hunter would be amazed that several operations are available to the general surgeon that will not only repair an inguinal hernia with a reported rate of recurrence rate of less than 1%, but also have a 0% mortality associated with them. Crawford Long would also be impressed with the idea of operations such as the Lichtenstein being done in an office setting with local anesthesia. CURRENT SURGERY • Volume 61/Number 1 • January/February 2004
The surgeons responsible for the current state of open hernia would be pleased with the current outcomes, but how would they feel about the advances made even greater by the advent of laparoscopy?
REFERENCES 1. Patino JF. A history of the treatment of hernia. In: Nyhus
LM, Condon RE, editors. Hernia. 4th ed. Philadelphia: Lippincott: 1995: 3–15. 2. Ruffer MA. In: Moodie RL, editor. Studies in the paleopa-
thology of Egypt. Chicago: University of Chicago Press; 1921. 3. Read RC. The development of inguinal herniorrhaphy.
Surg Clin N Am. 1984;64:185-196. 4. Devlin HB, Kingsnorth A, O’Dwyer PJ, et al. General
introduction and history of hernia surgery. In: Devlin HB, Kingsnorth A, editors. Management of Abdominal Hernias. 2nd ed. London: Chapman and Hall; 1998:1-13. 5. Pare A. In: Keynes G, editor. The Apologie and Treatise.
London: Falcon Educational Books; 1951. 6. Porter R. The Greatest Benefit to Mankind. New York:
W.W: Norton and Company; 1997; 277–281. 7. Cooper A. The Anatomy and the Surgical Treatment of In-
guinal and Congenital Hernia I. London: T: Cox; 1804. 8. Lau WY. History of treatment of groin surgery. World
J Surg. 2002;26:748-759. 9. Marcy HO. A new use of carbolized cat gut ligatures. Bos-
ton Med Surg J. 1871;85:315-316. 10. Bendavid R. Hernia repairs: open techniques. In Neu-
mayer L, editor. Inguinal Hernia Management in the New Millenium. 28th Annual Spring Meeting of the ACS; 2000. 11. Terranova T, Battocchio F. The Bassini operation. In:
Nyhus LM, Baker RJ, Fischer JE, editors. Mastery of Surgery, 3rd ed. New York: Little, Brown and Company; 1997:1807-1816. 12. Rutledge RH. Cooper ligament repair of groin hernias. In:
Nyhus LM, Baker RJ, Fischer JE, editors. Mastery of Surgery, 3rd ed. New York: Little, Brown and Company; 1997:1817-1825. 13. Marcy HO. The cure of hernia. JAMA. 1887;8:589-592. 14. Melick DW. Nylon suture. Ann Surg. 1942;115:475-476. 15. Lichtenstein IL. Simplified repair of femoral and recurrent
inguinal hernia by a “plug” technic. Am J Surg. 1974;128: 439-444. 16. Shulman AG. Prosthetic mesh plug repair of femoral and 51
recurrent inguinal hernias: the American experience. Ann R Coll Surg Engl. 1992;74:97-99.
21. Amid PK. How to avoid recurrence in Lichtenstein ten-
17. Shulman AG, Amid PK, Lichtenstein IL. The “plug” re-
22. Shulman AG. A survey of non-expert surgeons using the
pair of 1402 recurrent inguinal hernias. Arch Surg. 1990; 125:265-267. 18. Shulman AG, Amid PK, Lichtenstein IL. The safety of
mesh repair for primary inguinal hernias: results of 3,019 operations from five diverse surgical sources. Am Surg. 1992;58:255-257. 19. Lichtenstein IL. Herniorrhaphy. A personal experience
with 6,321 cases. Am J Surg. 1987;153:553-559. 20. Lichtenstein IL, Schulman AG, Amid PK. The tension-
free hernioplasty. Am J Surg. 1989;157:188-193.
52
sion-free hernioplasty. Am J Surg. 2002;184:259-260. open tension-free mesh patch repair for primary inguinal hernias. Int Surg. 1995;80(1):35-36. 23. Stoppa RE, Petit J, Henry X. Unsutured Dacron prosthe-
sis in groin hernias. Int Surg. 1975;60:411-415. 24. Rutledge RH. Cooper ligament repair of groin hernias. In:
Nyhus LM, Baker RJ, Fischer JE, editors. Mastery of Surgery, 3rd ed. New York: Little, Brown and Company; 1997:1859-1869. 25. Wantz GE. Giant prosthetic reinforcement of the visceral
sac. The Stoppa groin hernia repair. Surg Clin North Am. 1998;78:1075-1087.
CURRENT SURGERY • Volume 61/Number 1 • January/February 2004