Brief History

An appreciation of the history of hernia surgery may prevent us repeating the mistakes of the past and put in perspective the knowledge that has been accumulated in order to allow development of the successful techniques used today.

The high prevalence of hernia, for which the lifetime risk is 27% for men and 3% for women has resulted in this condition inheriting one of the longest traditions of surgical management. The Egyptians (1500 BC), the Phoenicians (900 BC) and the Ancient Greeks (Hippocrates, 400 BC) diagnosed hernia. During this period a number of devices and operative techniques have been recorded. Attempted repair was usually accompanied by castration, and strangulation was usually a death sentence.

Greek and Phoenician terracottas (Fig. 14.1) illustrate general awareness of hernias at this time (900-600 BC) but the condition appeared to be a social stigma and other than bandaging, treatments are not recorded. The Greek physician Galen (129-201 AD) was a prolific writer and one of his treatises was

Figure 14.1. Greek terracotta illustrates general awareness of hernias around 900 BC.

a detailed description of the musculature of the lower abdominal wall in which he also describes the deficiency of inguinal hernia. He described the peritoneal sac and the concept of reducible contents of the sac.

During the dark time of the Middle Ages there was a decline of medicine in the civilized world and the use of the knife was largely abandoned and few contributions were made to the art of surgery, which was now practised, by itinerants and quacks. With the rise of the universities such as the appearance of the school of Salerno in the 13th century, there was some revival of surgical practice. At this time three important advances in herniology were made: Guy de Chauliac, in 1363, distinguished femoral from inguinal hernia. He developed taxis for incarceration, recommending the head-down, Trendelenburg position. Guy was French and studied in Toulouse and Montpelier and later learned anatomy in Bologna from Nicole Bertuccio. Guy wrote extensively about hernia in his book Chirurgia principally about diagnosis and methods of treatment. He described four surgical interventions one of which was a herniotomy without castration, another consisting of cauterization of the hernia down to the os pubis and third consisting of transfixion of the sac to a piece of wood by a strong ligature. His fourth method however was conservative treatment with bandaging and several weeks bed rest accompanied by enemas, bloodletting and special diet. At the time he was the authorative expert on hernia:

• Hernia surgery has a 3500-year history.

• Castration was an essential part of the earliest operations for hernia, which carried with it an obvious stigma.

• The Dark Ages until the 16th century halted further progress in effective treatment.

Figure 14.2. Sir Astley Paston Cooper (1768-1841). Surgical Anatomist, London, England.

• Femoral hernia was distinguished from inguinal hernia in the 14th century. The renaissance brought burgeoning anatomic knowledge, now based on careful cadaver dissection. William Cheselden successfully operated on a strangulated right inguinal hernia on the Tuesday morning after Easter 1721. The intestines were easily reduced and adherent omentum was ligated and divided. The patient survived and went back to work. Without adequate interventional surgery some patients survived hernia strangulation when spontaneous, preternatural fistula occasionally followed infarction and sloughing of a strangulated hernia. Cheselden's Margaret White survived for many years 'voiding the excrements through the intestine at the navel' after simple local surgery for a strangulated umbilical hernia. The closure of such a fistula in the absence of distal bowel pathology was described by Le Dran, who had noted that it was quite common for poor people with incarcerated hernias to mistake the tender painful groin lump for an abscess and incise it themselves. He found that these painful wounds with faecal fistulas required no more than cleaning and dressing.

The great contribution of the surgical anatomists was between the years 1750 and 1865 and was called the age of dissection. The main contributors were Antonio Scarpa and Sir Astley Cooper and few major advances in our knowledge of the anatomy of the groin have been made since this time. The names of these great anatomists are Pieter, Camper, Antonio Scarpa, Percival Pott, Sir Astley Cooper, John Hunter, Thomas Morton, Germaine Cloquet, Franz Hesselbach, Friedrich Henle and Don Antonio Gimbernat.

Astley Cooper's seminal monograph was written in 1804 (Fig. 14.2). Sir Astley Cooper (1768-1841) trained at St Thomas's hospital, London and became a surgeon at Guy's Hospital and from 1813 to 1815 was Professor of Comparative Anatomy of the Royal College of Surgeons. Cooper published six magnificent books, two of which covered the subject of hernia, which were liberally illustrated by his own hand from dissections he had performed personally. Cooper was a charismatic lecturer and socialite and had an extensive surgical practice, which included being Sergeant Surgeon to King George IV. Cooper's recognition of the transversalis fascia positions him as one of the most important contributors to present day surgery which emphasizes this layer as being the first layer to be breached in groin hernias.

The first accurate description of the ilio-pubic tract, an important structure utilized in many sutured repairs for inguinal hernia, was made by Jules Cloquet (1790-1883). Cloquet was Professor of Anatomy and Surgery in Paris and Surgeon to the Emperor. Cloquet researched the pathological anatomy of the groin in numerous autopsy dissections and their reconstruction in wax models. He was the first to observe the frequency of patency of the processus vaginalis after birth and its role in the production of a hernia sac later in life. Franz Hesselbach was an anatomist at the University of Wurzburg who described the triangle now so important in laparoscopic surgery which originally defined the pathway of direct and external and supravesical hernias. The triangle as defined today is somewhat smaller.

As so often in surgery a new concept was needed before further progress could be made in herniology. Two pioneers - the American Marcy (Marcy, 1887) and the Italian Bassini (1884) -vie for priority for the critical breakthrough. Both appreciated the physiology of the inguinal canal and both correctly understood how each anatomic plane, transversalis fascia, transverse and oblique muscles and the external oblique aponeuro-sis, contributed to the canal's stability. Bassini made another important advance when he subjected his technique to the scrutiny of the prospective follow-up. Bassini's 1890 paper is truly a quantum leap in surgery. He decided to open the inguinal canal and approach the posterior wall of the canal which he achieved by reconstruction of the inguinal canal into the physiological condition, a canal with two openings one abdominal the other subcutaneous and with two walls, one anterior and one posterior through the middle of which the spermatic cord would pass. Bassini dissected the indirect sac and closed it off flush with the parietal peritoneum. He then isolated and lifted up the spermatic cord and dissected the posterior wall of the canal, dividing the fascia transversalis down to the pubic tubercle. He then sutured the dissected conjoint tendon consisting of the internal oblique, the transversus muscle and the 'vertical fascia of Cooper', the fascia transversalis, to the posterior rim of Poupart's ligament, including the lower lateral divided margin of the fascia transversalis. Bassini stresses that this suture line must be approximated without difficulty; hence the early dissection separating the external oblique from the internal oblique must be adequate and allow good development and mobilization of the conjoint tendon.

Figure 14.3. Earle E Shouldice (1890-1965). Lecturer in Anatomy, University of Toronto, Canada.

The Bassini operation re-emerged as the Shouldice repair in 1950s (Fig. 14.3). Earl Shouldice (1890-1965) also promulgated the benefits of early ambulation and opened the Shouldice clinic, a hospital dedicated to the repair of hernias to the abdominal wall. A huge experience accumulated with an annual throughput of 7000 herniorrhaphies per year, enabled the surgeons at the Shouldice clinic to study the pathology in primary and recurrent hernias and to emphasize adjuncts to successful outcomes. Continuous monofilament wire was used in preference to other suture materials and the hernio-plasty incorporated repair of the internal ring, the posterior wall of the inguinal canal and the femoral region. The cremaster muscle and fascia with vessels and genital branch of gen-itofemoral nerve were removed and the posterior wall after division was repaired by a four-layer imbrication method using the ilio-pubic tract as its main anchor point. Until the introduction of mesh, the Shouldice operation became the goldstandard for inguinal hernia repair:

• The surgical anatomy of the groin, on which modern hernia surgery is based, was defined between 1750 and 1865.

• Bassini described his revolutionary operation in 1890.

• The Shouldice Clinic revived the Bassini operation in the latter half of the 20th century.

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