Introduction to Hernia Section
Josef E. Fischer M.D.
The definitive and corrective surgery in the inguinal region seems to have begun by Marcy, a student of Joseph Lister, who apparently first recognized the importance of the transversalis fascia in reconstituting the internal ring closure. He used carbolized catgut with a two-suture technique in order to close the internal ring (Griffith, CA. Surg Clin North Am 1971;1:1309–1316; Read, RC. World J Surg. 1989;13:532–539). Although it is true that the only way to reconstruct the internal rings is to suture the transversalis fascia, this repair was incomplete in that it did not reef up the back wall of the inguinal canal nor did it ligate the hernia sac.
Eduardo Bassini (1844–1924), whose name is synonymous with the early repair of inguinal hernia, was born, educated, and received his training in Pavia, Italy. He served in the country’s 1866 war for independence as an army infantryman. This was unusual as he already was a physician. While serving, he sustained a bayonet wound to the groin and subsequently developed a wound infection and fecal fistula (Zimmerman, IM and Hellar. Surg Gynecol Obstet 1937;64:971). His chief of surgery in Pavia, Luigi Porta, was successful in treating Bassini’s wound and closing the fistula and then asked Bassini to remain as his assistant. Bassini later joined Billroth in the then-famous Vienna practice and studied various hernia operations. He came to the conclusion that there were two causes of the failure of procedures carried out at that time. The first was a one-layer tissue repair, which apparently was crude and non-anatomic, and the second was the larger internal opening through which the spermatic cord passed. To Bassini, it was necessary to reconstruct the internal ring using the transversalis fascia, thus repairing the underlying abdominal wall defect rather than simply dissecting out the hernia sac and ligating it.
Bassini’s contribution was to repair the transversalis fascia defect by reinforcing the canal’s posterior wall using a three-layer technique. Again, one should point out that the only way to correctly reproduce and reconstruct the internal ring anatomically is by repairing the transversalis fascia. Bassini also emphasized that it is important to open the external ring, dissect the cremasteric fascia, and thereby expose the anterior surface of the inguinal canal by opening the external oblique fascia. In his original article published in 1887, he incorporated the internal oblique and transversus abdominus muscles and transversalis fascia into a conjoint triple layer that he sutured to the shelving edge of Poupart’s ligament with interrupted silk sutures (Bassini, E. Atti Congr Associ Med Ital 1887;2:179). Bassini reported 262 repairs without mortality between 1885 and 1890, a remarkable record, with only 2.7% recurrence at 1 year (Koontz AR. Hernia. New York: Appleton-Century-Crofts; 1963).
William Halsted, in his variation of Bassini’s operation, not only incorporated the previous three layers, but attempted to add another layer to buttress the repair by approximating the external oblique fascia to Cooper’s ligament. In this Halsted I operation, the thinned spermatic cord was transplanted into the subcutaneous tissue (Halsted WS. Bull Johns Hopkins Hosp 1890; 1:12). My own observation in seeing patients who have had the Halsted repair is that the cord is sometimes quite sensitive. This repair was subsequently modified in 1903, 13 years after the initial report, when, during the Halsted II operation, the cord was placed under the external oblique fascia. For some strange reason, nobody seems to recall that Halsted gave up the Halsted I operation and thereafter practiced the Halsted II procedure (Halsted WS. Bull Johns Hopkins Hosp 1903;14:208).
Halsted also made a greater contribution, the relaxing incision, which is illustrated in Koontz’s book Hernia (Koontz AR. Hernia. New York: Appleton-Century-Crofts; 1963). This incision is much more medial than what is currently practiced, which is in the direction of the external oblique fibers. This takes some of the tension off of the repair in a protected area, in which the rectus muscle theoretically should keep a further intra-abdominal hernia from being manifest.