The history of inguinal hernia surgery

Summary

The article reviews the history of inguinal hernia surgery. At various times, different procedures and diverse materials were used for hernia repair. However, the effectiveness and safety of inguinal hernia repair emerged only after the anatomic features of the inguinal region had been elucidated in a monograph by Henri Fruchaud „Anatomie des hernies de l’aine” published in 1956. The Italian surgeon Edoardo Bassini began a new era in herniology. For a longtime, his classic procedure with its modifications was the most popular in surgical practice. In 1959, Lloyd M. Nyhus proposed inguinal hernia repair according to the concept of the pre-abdominal (posterior) approach that later became the basis for developing the transabdominal preperitoneal hernia repair (TAPP). In 1992, M. Arregui performed the first ТАРР using a prolene mesh. In 1986, Irving Lichtenstein proposed the concept of „tension-free repair”. Basing on his concept, Lichtenstein described an open technique of inguinal hernia repair, which now bears his name and is popular in surgical practice. In 1993, the term „extraperitoneal hernia repair” first appeared in an article by Edward H. Phillips. However, J. Dulucq developed the modern ТЕР technique. Currently, three tension-free inguinal hernia repairs (TAPP, ТЕР and Lichtenstein procedure) and one tension inguinal hernia repair (Shouldice procedure) dominate in inguinal hernia surgery.

Keywords:

inguinal hernia – hernia repair – history of surgery

The history of herniology dates back thousands of years. The earliest documented attempts at inguinal hernia repair can be traced back to ancient times. There are references to hernia-related findings in historical artifacts, such as mummies. For instance, the mummy of Ramses the 5th, who lived in 1151 BC, exhibited a large hernial sac in the groin area. Similarly, the mummy of Pharaoh Merneptah, who lived in 1224 BC, showed signs of an incision above the inguinal region and the absence of a testicle on that side, indicating a probable attempt at inguinal hernia repair [1,2,3].

Throughout history, a wide range of materials was used for hernia repair, including gold, silver, tin, bronze, copper, and iron threads. Various objects like pins, screws, and nails made of wood, iron, or ivory were employed in hernia treatments. However, many of these early methods lacked proper justification and proved to be ineffective [4,5].

In 300 BC, Hippocraticum mentioned hernias in his writings, where he described different types of hernias and analyzed their occurrence based on the patient’s profession. Celsus, a renowned Roman writer, provided a detailed description of strangulated hernias and proposed his method for inguinal hernia repair. During the early years of the Common Era, several doctors introduced their own procedures for hernia repair, including Claudius Galenus, Aretaios of Cappadocia, Aetius (a court physician to Byzantine Emperor Justinian), Paul of Aegina, and others. Aetius emphasized the complexity of hernia repair and advised that it should only be performed by an experienced specialist, while recommending non-surgical approaches whenever possible [5,6,7].

For many centuries, inguinal hernia repair often involved the removal of the testicle. However, there were some doctors who attempted to preserve it during the procedure. Among them were William of Salicet (around 1250 AD), Mondino de Luzzi from Bologna, Guido Lafranchi from Paris, and Roland of Parma [5,8,9].

In one of his essays, the famous British surgeon and medical popularizer William Heneage Ogilvie remarked, “I know over a hundred surgeons whom I would definitely allow to remove my gall bladder, but only one would be permitted to expose my inguinal canal” [10].

The term “hernia” is derived from the Latin word “prolapse,” which means “falling out.” The earliest mentions of hernia date back to approximately 1552 BC in Ancient Egypt [11,12]. The term “inguinal hernia” was first used by the French military surgeon Henri Fruchaud in his groundbreaking scientific paper titled “Anatomie des hernies de l’aine,” published in 1956 [13]. Fruchaud succeeded in organizing and consolidating knowledge on the topographical relationships of the inguinal region. He specifically described the preperitoneal anatomy, introduced the concept of the “myopectineal orifice”, distinguished between inguinal and femoral hernia development, and departed from Lotheissen’s ideas. Fruchaud systematically justified the principles of hernia repair proposed at that time by Bassini, McVay, and Anson [14]. Fruchaud also emphasized that the anterior abdominal wall possessed a genetically determined weak area and that inguinal hernias were inherent in human nature, stating that “a healthy human is always a hernia carrier, even without knowing it.”

Building upon Fruchaud’s monograph, surgeons later implemented preperitoneal and laparoscopic approaches to inguinal hernia repair. Fruchaud’s concepts have since become the foundation for these techniques, emphasizing the importance of restoring the strength of the entire myopectineal orifice, rather than just focusing on the hernia site [15,16,17]. Another key figure in the development of modern inguinal hernia repair methods was Italian surgeon Edoardo Bassini, whose procedure remained widely popular in surgical practice for an extended period [18].

During this time, hernia surgery had an empirical and ineffective nature. Figures like Pierre Franco and Ambroise Paré advocated for non-surgical approaches, recommending the use of a strong bandage [19]. Henry O. Marcy focused solely on closing the deep inguinal ring without considering other elements of the inguinal canal [20]. D. Cantemir regarded hernia repair via laparotomy as the most suitable approach [21].

Bassini acknowledged and built upon Marcy’s theory but recognized what his predecessor had not understood: suturing the deep inguinal ring alone was insufficient without strengthening the posterior wall of the inguinal canal. To address this, Bassini utilized the transverse fascia as the primary mechanism for reconstructing the inguinal canal. He sutured it together with the aponeurosis of the abdominal external oblique muscle to the inguinal ligament, incorporating the Tanner relaxation technique (a vertical relaxation incision of the front sheet of the rectus muscle fascia) [22, 23].

The Bassini procedure became a favored method for treating patients with inguinal hernia. However, the author’s reported relapse rate of 2.9% was significantly underestimated. In the early 20th century, numerous publications indicated recurrence rates exceeding 20% or more after applying the Bassini technique. Specifically, the technique proved ineffective for large direct inguinal hernias, as the fixation of highly placed and atrophied muscles to the inguinal ligament did not reliably strengthen the posterior wall of the inguinal canal. This led to the development of various modifications of the original Bassini procedure [22].

Among the early modifiers of the Bassini procedure were William Stewart Halsted and Edmund W. Andrews, who introduced their technique known as the “North American Bassini Repair,” which quickly gained worldwide recognition [24]. In his 1938 monograph titled “Hernia,” L. Watson chronologically listed 248 methods of surgical treatment for inguinal hernias from 1872 to 1935, with over 90% of them involving Bassini modifications [22,23].

In 1959, Lloyd M. Nyhus introduced the concept of the pre-abdominal (posterior) approach for inguinal hernia repair [25]. His technique involved dividing the anterior layer of the rectus sheath and resecting the rectus muscle more medially. Subsequently, the hernia gate was closed by fixing the anterior layer of the sheath to the inguinal ligament.

Building on Nyhus’s technique, Jean Rives proposed prosthetic reinforcement of the inguinal canal in 1965 [26]. René Stoppa further developed this idea in 1969 by suggesting the placement of a large Dacron mesh in the preperitoneal space, allowing for simultaneous repair of bilateral inguinal hernias [27]. In 1975, Stoppa described the Giant Prosthetic Reinforcement of the Visceral Sac (GPRVS) technique, which involved immersing and positioning the mesh under the parietal peritoneum at the preperitoneal level in the myopectineal orifice.

The Nyhus and Stoppa techniques are utilized to a limited extent by surgeons for hernia repair due to high tissue trauma and significant postoperative pain associated with them. However, the principle of the “open preperitoneal technique,” as Nyhus referred to it, has evolved to include various approaches such as transabdominal preperitoneal (TAPP), trans-inguinal preperitoneal (TIPP) by Pe´lissier, Kugel’s posterior technique, transrectus preperitoneal (TREPP), ONSTEP, Ugahary technique, Wantz, and Rives techniques. Some of these techniques involve anterior dissection (TIPP, ONSTEP, Rives), while others use posterior dissection without entering the inguinal canal (Kugel’s, TREPP, Ugahary, Wantz) [15,36,37,38,39,40,41].

In 1953, Edward Earle Shouldice proposed a multilayer repair of the posterior wall of the inguinal canal, known as the Shouldice procedure. This technique involved strengthening the transverse fascia with four layers of fascia and aponeuroses of the internal oblique muscle [42].

By the mid-20^th century, the concept of radical inguinal hernia repair had solidified, focusing on strengthening the posterior wall of the inguinal canal and the deep inguinal ring. While effective for small hernias, tensioning the tissues during convergence often led to recurrence in patients with larger hernias.

Dominance of the Bassini technique and its modifications continued until 1986 when Irving L. Lichtenstein introduced the concept of “tension-free repair” (TFR) [43]. This marked the differentiation between herniorrhaphy (non-mesh surgery) and hernioplasty (mesh surgery) in the literature. The Lichtenstein technique involved attaching a prolene mesh to the inguinal ligament, pubic tubercle, and abdominal internal oblique muscle. The mesh filled the posterior wall of the inguinal canal, eliminating tissue tension that occurred during the duplicature formation in the Bassini procedure. By 1993, the Lichtenstein procedure had been technically refined and quickly gained popularity in practical surgery due to its simplicity and the introduction of the “tension-free repair” concept [37,38,44,45,46].

Although the Lichtenstein procedure showed excellent results in terms of postoperative complications, patient rehabilitation, and low recurrence rates, it addressed only the issue of tension-free repair for inguinal hernias. The installation of a mesh according to this technique did not fully close the myopectineal orifice and was inadequate for preventing and treating femoral hernias [15, 16, 45]. Vulnerable aspects of the Lichtenstein procedure included cosmetic effects, manipulation of the spermatic cord, and the selection of mesh hole diameter above the deep inguinal ring [47].

Starting from the second half of the 20^th century, the use of prolene mesh became widespread in inguinal hernia repair, and the concept of “tension-free repair” became the predominant approach in herniology. With advancements in endoscopic technologies, the development of inguinal hernia repair through laparoscopic access began.

P. Fletcher was the first to use laparoscopy for inguinal hernia repair in 1979 when he attempted to strengthen the deep inguinal ring in a direct inguinal hernia. His experience led to the formulation of technical recommendations that later defined the transabdominal preperitoneal hernia repair (TAPP) method [15]. While Ralph Ger, the Head of the Gynecology Department at Nassau University Medical Center, is often attributed to be the first to perform laparoscopic herniorrhaphy in 1982, he acknowledged Dr. Fletcher as the true pioneer [48].

Ralph Ger made significant contributions by providing the first detailed analysis of the advantages of laparoscopic inguinal hernia repair based on his own experience. These advantages included improved cosmetic outcomes, lower incidence of postoperative neuralgia, minimal risk of spermatic cord damage, reduced postoperative pain, and the ability to treat bilateral inguinal hernias simultaneously [49].

In 1992, M. Arregui performed the first TAPP procedure using a prolene mesh. His technique involved dissection of the preperitoneal space under laparoscopic guidance from the abdominal cavity, without the need for posterior wall dissection of the inguinal canal [50]. The term “extraperitoneal hernia repair” was first used in an article by Edward H. Phillips in 1993 [51]. J. Dulucq developed the “total extraperitoneal hernia repair” (TEP) technique, which involved preperitoneal space dissection using gas or liquid and the placement of a mesh on the myopectineal orifice. The TEP technique aimed to reduce the risk of organ damage and prevent adhesion formation. However, it was considered technically complex and required a highly skilled surgeon [38].

Indeed, laparoscopic and endoscopic methods of inguinal hernia repair have become common in abdominal surgery. In addition to TAPP and TEP techniques, other approaches such as transinguinal preperitoneal mesh-plasty (TIPP) and MINI (a combination of TEP and TAPP) are also utilized [15,52,53,54,55].

The modern evolution of inguinal hernia treatment methods aligns with the prophetic words of Irving L. Lichtenstein, who predicted a significant advancement in hernia repair over the last century. He anticipated that although numerous hernia repair methods would emerge, only a few standard procedures would suffice to treat all types of hernias [43].

Many revolutionary approaches to inguinal hernia repair did not withstand the test of time and practice, proving to be unsuccessful. For example, the “plug&- patch” technique, which involved inserting a mesh patch into the deep inguinal ring using a laparoscope, often led to mesh migration and hernia recurrence [38].

CONCLUSION

The history of inguinal hernia treatment is complex and fascinating. It has gone through various stages, from conservative approaches to highly advanced and anatomically based repair techniques. The progress in surgical tactics for inguinal hernias has relied on anatomical innovations, advancements in anesthesiology and asepsis, and technical means that have simplified the hernia repair procedure. Today, the Lichtenstein procedure, TAPP, and TEP techniques are considered the acceptable methods for tension-free repair of inguinal hernias in surgical practice

Conflict of interests

The authors declare that they have not conflict of interest in connection with this paper and that the article has not been published in any other journal, except congress abstracts and clinical guidelines.

Prof. Serhii Vasyliuk – MD, PhD,

Department of Traumatology, Orthopaedics and Emergency Military Surgery,

Ivano-Frankivsk National Medical University,

Ivano-Frankivsk, Ukraine

e-mail:surifnmu@gmail.com