World J. Surg. 26, 748-759, 2002

DOI: 10.1007/s00268-002-6297-5

O

WORLD Journal of

SURGERY 9 2002 by the Socidt~ Internationale de Chirurgie

Surgical History History of Treatment of Groin Hernia W.Y. Lau, M.D. Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Published Online: March 26, 2002 Abstract. The history of open surgery for groin hernia has gone through many stages of development, including the ancient era (ancient times to the fifteenth century), the era of the start of herniology (fifteenth to seventeenth centuries), the anatomic era (seventeenth to nineteenth centuries), the era of repair under tension (nineteenth to mid-twentieth century), and the era of tensionless repair (mid-twentleth century to the present). Five principles of modern hernia repair developed through these periods of development: antiseptic/aseptic hernia operation, high ligation of the sac, tightening of the internal ring, reconstruction of the posterior inguinal floor, and tensionless repair. Interestingly, many of the initial attempts at laparoscopic hernia repair did not adhere to the recognized principles of hernia surgery learned from open surgery. It is only when the transabdominal preperitoneai mesh repair and the totally extraperitoneai approach, which adhere to the basic principles, are considered that the results of laparoscopic hernia repair procedures can improve and the recurrence of hernia decrease.

Hernias have been a subject of interest since the dawn of surgical history. The history of hernia repair is the history of surgery [1]. There have been a number of erudite reviews on the history of hernia and its treatment [1-6]. This review focuses on the historical evolution of the treatment of groin hernia, highlighting the establishment of the principles of treatment from the perspective of surgeons. The treatment of groin hernia can be divided into several eras.

Ancient Era (Ancient Times to Fifteenth Century)

Inguinal hernia (Greek hernios: offshoot or bud), presenting as a bulge in the groin, was memorialized on a statuette by the ancient Greeks [4]. The Egyptian Papyrus of Ebers (circa 1552 Bc) contains an observation on hernias: "when you judge a swelling on the surface of a belly.., what comes o u t . . , caused by coughing" [1, 5]. The mummy of Pharaoh Merneptah (nineteenth dynasty, 1224-1214 BC) showed a large wound in the groin, with the scrotum separated from the body [7], from which Thorwald inferred that surgery had been performed on a scrotal hernia [8]. The mummy of Ramses V (twentieth dynasty, 1156-1151 sc) had an unmistakable hernial sac in the groin [9]. Whether hernia

Correspondence to: W.Y. Lau, M.D., e-mail: [email protected]

operations were done at that time is still debatable [10]. Tightly fitting bandages were used as treatment for inguinal hernia by physicians in Alexandria, and a 900 BC Phoenician statuette depicts a bilateral inguinal hernia so treated [4, 11], Ancient Greeks (Hippocrates, 400 BC) differentiated between hernia and hydrocele" The former was reducible and the latter transilluminable [11]. Taxis was recommended for stangulation [4]. Aulus Cornelius Celsus (?-AO 50) introduced Greek and Alexandrian medicine to Rome. Trusses were widely employed; operation was advised for pain, especially in the young, but not with large protrusions or when the symptoms of strangulation supervened. An incision was made in the scrotum just below the pubis, and the sac was dissected from the cord and excised, the wound being left open to granulate. If large, it was cauterized to enhance scar formation[l, 4, 11]. Galen (AD 200) thought that herniation was produced by rupture of the peritoneum with stretching of overlying fascia and muscles [4]. Paul of Aegina (AO 700) distinguished between incomplete inguinal hernia (bUbonocele) and the complete form (scrotal) [4]. For the latter, he recommended ligature of both sac and cord with amputation of the testicle [12]. The work of Paul of Aegina, however, constitutes a regression from the classic surgeons of Alexandria and the Roman Celsus, as it includes routine sacrifice of the testicle [1]. Then came the long, dark Middle Ages, which have been described by historians as a period of decline and stagnation, surgery in eclipse, and centuries of ignorance [13]. During this time Albucasis, the great Moorish surgeon (AD 1013-1106), also described removing the testes during operations of the "ruptured hernia" of the groin [1]. It was not until William of Salicet (circa 1210-1277), 13 centuries after Celsus, that excision of the testicle as an essential part of the operation for the care of hernia was rejected again [1, 14]. Guy de Chauliac in 1363 wrote Chirugia Magna, distinguishing for the first time inguinal from femoral herniation. He also developed a method for reducing strangulated hernias by taxis, conducting these manipulations on patients in the Trendelenberg position [4]. During the years that led to the Renaissance, limited knowledge about hernias accumulated. Surgery on hernias was primitive, and it was usually carried out to save a life.

Lau: History of Groin Hernia Era of the Start of Herniology (Fifteenth to Seventeenth Centuries)

New surgical knowledge flourished during the Renaissance, and the foundation of hemiology was begun during this period. Antonio Benivieni (1440?-1502), the founder of pathologic anatomy, kept careful clinical notes and followed up his patients with autopsies. These notes, published in 1507 by his friend Rosati under the title De Abditis Morborum Causis [The Hidden Causes of Illness] contained reports of various types of hernia [13]. Ambroise Parr, in his book The Apologie and Treatise [15], devoted an entire chapter to hernias. Par6 described the hernia operation in detail and gave an account of how the hernial contents should be reduced into the abdominal cavity and the peritoneum sewn up. When the "rupture" cannot be treated "by reason of the great solution of the continuity of the relaxt, or broken Peritoneum," Par6 advised the use of the golden ligature, or the punctus aureus, the golden thread or golden tie. He gave a detailed description of the technique and illustrated the instruments and the diverse trusses for controlling hernias. He severely condemned the itinerant hemiotomists who produced castration [1]. In 1556 Pierre Franco, an itinerant Swiss barber-surgeon, introduced a grooved dissector that allowed him to divide the ring of the constriction of a strangulated hernia without risking damage to the bowel. He recommended reducing the contents and closing the defect with linen suture [1, 4, 11, 16]. In 1559 Kaspar Stromayr published the book Practica Copiosa. Stromayr, for the first time, made a distinction between indirect and direct hernias. Removing the testis was sanctioned in operations for hernias of the indirect type but not for other forms [1, 11, 17]. Anatomic Era (Seventeenth to Nineteenth Centuries)

As autopsy and anatomic dissection spread throughout Europe after the Renaissance, knowledge about groin herniation accumulated rapidly. In 1700 Littr6 reported a Meckel's diverticulum in a hernia sac [18], and in 1731 De Garengeot described a similar situation involving the appendix [19]. In 1721 Cheselden successfully operated on a strangulated right scrotal hernia [20], an operation that had been done more than 200 years earlier by Kaspar Stomayr [17]. Heister (1724) distinguished indirect from indirect inguinal hernias [21], a distinction that had been demonstrated by Stomayr [17]. Heister, unlike Stomayr, pointed out the futility of sacrificing the testicle in men with direct inguinal herniation [17]. Sir Percival Pott described the pathophysiology of strangulation in 1757 and recommended surgical management [22], and in 1785 Richter reported on partial enterocele [23]. John Hunter in 1790 pointed out the congenital nature of some indirect hernias, the processus vaginalis being continuous with the tunica vaginalis [24]. Scarpa in 1814 described hernia en glissade (sliding) [25]. Astley Cooper implicated venous obstruction as the first step of the cascade in the circulatory failure of strangulation, "by a stop being put to the return of blood through the veins which produces a great accumulation of this fluid and a change of its color from the arterial to the venous hue." Nevertheless, ligation, the insertion of setons, and castration remained the mainstays of treatment prior to Astley Cooper's 1804 monograph [26]. Knowledge culminated during the early nineteenth century in complete anatomic understanding of the inguinal canal. Pott

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(1757) [22], Richter (1785) [23], Camper (1801) [27], Scarpa (1814) [25], and Morton (1841) [4] all published in this field. In 1793 de Gimbernat described his ligament and advocated medial rather than upward division of the constriction in strangulated femoral hernias. This maneuver avoided damage to the inguinal ligament and the serious bleeding that sometimes followed [28]. In 1804 Cooper defined the fascia transversalis. He distinguished this layer from the peritoneum and demonstrated that it was the main barrier to herniation. He carefully delineated the extension of the fascia transversalis behind the inguinal ligament into the thigh as the femoral sheath and the pectineal part of the inguinal ligament--Cooper's ligament [26, 29, 30]. In 1811 Colles, who had worked as a dissector for Cooper, described the reflected inguinal ligament [31]. In 1814 Hesselbach described his triangle and the iliopubic tract [32]. In 1817 Cloquet described the processus vaginalis and observed that it was rarely closed at birth. He also described his "gland," which is so important in the differential diagnosis of lumps in the groin [33]. Despite these important advances in the knowledge of anatomy and the introduction of anesthesia in 1846 [34], surgery on hernias made little progress during the first half of the nineteenth century, as any attempt to open the inguinal canal was followed by severe sepsis and recurrence of the hernia [4]. The status of hernia repair at that time was chaotic [35]. It was generally agreed that infection encouraged scarfing and led to low rates of recurrence. Most surgeons who used an inguinal approach excised the sac and left the wound open to heal by secondary intention (i.e., McBurney procedure) [36]. With introduction of the hypodermic syringe, a number of surgeons injected sclerosants, with miserable results [4]. Velpeau in 1837 used iodine, and Pancoast in 1847 used tincture of cantharides [9]. Erichsen in 1888 pointed out that these methods are dangerous and ineffective and should be abandoned [37]. Although a revival of the technique led Turner to believe that injection held out a prospect for cure of the hernia [38], it was recognized that peritonitis was a risk. Injection finally became obsolete [9]. The management of gangrenous intestine within a strangulated intestine by gut resection and primary anastomosis was advocated by Erichsen in 1888 [37], a practice supported by Franks in 1893 to be the operation of choice for such a condition [39]. It became routine practice within a short time [9]. The anatomic era established the basic knowledge for future development. Sepsis, however, remained the main obstacle for hernia surgery.

Era of Hernia Repair under Tension (Nineteenth to Midtwentieth Century)

Lister introduced antiseptic surgery about 1870. This was followed by Halsted's introduction of gloves in 1896 [11]. When yon Mickulicz translated antiseptic surgery to aseptic surgery in 1904, the scene was set for the techniques of modem hernia surgery to develop [40]. Marcy, who had been a pupil of Lister, published on antiseptic hernia surgery in 1871. In his operation, the unopened hemial sac was returned above the external ring, which was sutured deeply [41]. In 1874 Steele reported on a "radical operation for hernia." The hernia sac was returned unopened, and the external ring was

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freshened and sutured deeply around the cord [42]. In 1876 Czerny in Germany described pulling the sac down through the external ring and excising it, allowing the ligated neck to retract and invert at the internal ring [43]. Kocher in Switzerland transplanted the twisted sac anterolaterally, with a suture passed through the external oblique aponeurosis. All of this was accomplished through the external inguinal ring [4]. Lucas-Championnirre in 1881 became the first to split the external oblique aponeurosis, lay open the inguinal canal, and imbricate the roof during closure. The sac was excised under direct vision down to the inguinal ring [44]. MacEwen in 1886 operated through the dilated external ring, but he folded up the peritoneal sac and fixed it around the internal ring to act as a cord, adding some deep stitches to close the inguinal canal [45]. Thus three of the modem principles of inguinal surgery, first used by Marcy in 1871 [41], were further refined: antisepsis/ asepsis, high ligation of the sac, and tightening of the internal ring [35]. Unfortunately, these procedures failed to achieve the goal of radical cure of inguinal herniation. When Billroth reviewed the European experience in 1890 [4] and Bull did likewise for the United States in 1891 [46], the mortality rate due to sepsis, peritonitis, hemorrhage, and various operative errors was significant (2-7%). Recurrence after 4 years was practically 100%. Most surgeons were so discouraged that after excising the sac they, like the Ancients, left the wounds open to heal by secondary intention (McBurney procedure), relying on scar formation to prevent recurrence [4]. Bassini's epoch-making reports changed the way hernias were managed [47-51]. Bassini tried many methods to repair hernias, but there was an extremely high incidence of recurrence. He came up with a solution: Instead of obliterating the canal with deep suturing of the rings, he reconstructed the canal physiologically, thus recreating internal and external openings with anterior and posterior walls. Bassini not only sutured the conjoint transversalis abdominis and obliquus internus to the inguinal ligament, his "triple layer" included the fascia verticalis Cooperi (transversalis fascia), which was divided from the pubis to 1 inch beyond the internal inguinal ring. The retroperitoneal space was entered, allowing the peritoneal sac to be dissected up into the iliac fossa for high ligation. At the medial end of the repair, the suture included the anterior rectus sheath. He emphasized closing the floor from below upward to restore the valve-like mechanism. His operation had many original features: restoration of obliquity, use of transversalis fascia, use of the rectus sheath, bilateral repairs, management of cryptorchidism, and use of interrupted nonabsorbable (silk) sutures. He was also the first to present such a large series with careful follow-up. His mortality and infection rates were the best to date. He rarely used drains, and he discontinued the use of postoperative trusses. Early ambulation was encouraged [4]. Bassini's initial reports were to the Italian Society of Surgery at Genoa in 1887 [47], the Italian Medical Association at Pavia later in the same year [48], and the Italian Surgical Society at Naples in 1888 [49]. Bassini published his celebrated monograph, which contains beautiful illustrations, in 1889 [50]. His paper published in Germany in 1890 made Bassini's work widely recognized [51]. Zimmerman and Veith stated the position of Bassini in hernia surgery as "Overnight, hernial surgery and classical antiquity gave way to that of today . . . . The role of Bassini as the creator of modem hernia surgery stands unchallenged" [52].

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At around the same time, Williams S. Halsted developed an operation independently for the treatment of inguinal hernia [53]. The major difference between the Bassini procedure and this operation (commonly referred to as the Halsted I procedure) was transposition of the cord to a position above the external oblique aponeurosis. Minor technical differences include ligation of superfluous veins about the cord to reduce its size and sectioning fibers of the internal oblique muscle and sometimes the transversus abdominis muscle to permit more lateral displacement of the internal ring [4]. Both Bassini and Halsted established the fourth principle of inguinal herniorrhaphy: reconstruction of the posterior inguinal floor [35]. The recognition of the importance of the posterior inguinal wall as it relates to both the cause and the treatment of hernia is credited to many investigators [1]. Lockwood emphasized the importance of adequate repair of the fascia transversalis [54], as did Paul W. Harrison, who considered fascia transversalis a key factor in the anatomy of groin hernia [1]. The next landmark in inguinal hernia surgery was the use of the iliopectineal ligament (Cooper ligament, ligamentum pubicum superius) to anchor the medial parietal wall in the repair. This ligament was first used by Georg Lotheissen of Vienna in 1898 at the suggestion of Narath, when he found the inguinal ligament destroyed in a patient with recurrent hernia. He successfully substituted the iliopectineal ligament and repeated the procedure in a series of 12 patients [1, 55]. This innovation was ignored until it was revived by Seeling and Tuholske [1] and Chester B. McVay and Barry J. Anson [56]. Another ligament, the iliopubic tract, is also important to the full understanding of hernia repair. Depicted by Hesselbach and described by Thomson later during the same century, its use advocated the anterior approach by Clark and Hashimoto and by Griffith; and its importance in the preperitoneal approach to repair has been emphasized by Nyhus et al [1]. In 1945 Lytle brought attention to the shutter mechanism of the deep inguinal ring [57] and how it could be repaired in the fascia transversalis layer without losing its function [58]. It was not until 1956 that Fruchaud introduced the concept of the myopectineal orifice and fascia transversalis tunnel for all groin hernias [59]. Anson and colleagues then offered their classic dissection and evaluation of musculoaponeurotic layers in 1960 [60]. It was with these two important developments that the anatomy of the groin hernia became more fully understood. Bassini's procedure was adopted widely soon after its introduction. Further developments in hernia surgery took two different directions. The first comprised retrograde steps, and corruptions were rapidly introduced [4]. The earliest and most pernicious was that of Bull [46] and Coley [61], who sutured the intemal oblique muscle and aponeurosis over the cord, which emerged at the pubic end of the repair. This procedure was adopted by Fergusson, who also advised that the floor of the inguinal canal not be examined and divided, and the cord be left undisturbed to avoid instances of testicular atrophy [62]. Brenner in 1898 described "reinforcing" the repair by suturing the cremaster. The "triple layer" became the obliquus intemus muscles supplemented by the cremaster, and the extraperitoneal space was no longer entered to ensure the highest possible ligation of the peritoneal sac [63], another serious corruption of the Marcy-Bassini strategy. The second direction entailed modifications of Bassini's procedure that improved it. Andrews in 1895 recommended imbrication, or "double-breasting," the external oblique aponeurosis in

Lau: History of Groin Hernia

front of the cord [64], as Lucas-Championnirre had originally carried out in 1881 [44]. The Shouldice repair [65] is a direct descendent of Marcy, Bassini, and Halsted's emphasis on repair of the transversalis fascia and Andrew's imbrication of the external oblique aponeurosis. The Canadian Shouldice repair was developed during the 1950s by Shouldice, Obney, and Ryan; and it was first described during the late 1960s [1, 65]. Typically, the procedure is performed under local anesthesia [1].

Era of Tensionless Hernia Repair (Mid-twentieth Century to the Present)

The Bassini repair soon led to the realization that tension on the pubic end of the repair resulted in pain and could lead to recurrence at that site, especially when the conjoint tendon was atrophic. Wrlfler designed the anterior relaxing incision in the rectus sheath to overcome this problem [66]. Berger, after making an incision in the anterior rectus sheath, sutured the lateral flap down to Poupart's ligament [67]. In 1903 Halsted abandoned cord skeletonization to avoid hydrocele and testicular atrophy and adopted Andrews' imbrication and the Wflfler-Berger technique of a relaxing incision and a rectus sheath flap (Halsted II operation) [68]. Unlike Berger, he did not repair the defect in the sheath. McVay and Anson pointed out in 1940 that the rectus fascia, a portion of the transversalis fascia that inserts into the lateral border of the rectus muscle underneath the transversus abdominis aponeurosis, is strong enough to prevent subsequent incisional herniation (Spigelian) [69]. Ponka [70] credited Farr (1927) [71], Fallis (1938) [72], and Rienhoff (1940) [73] with continuing the use of the relaxing incision, which has been popularized in the United States by McVay and Anson [69] and as the "slide" by Tanner [74] in Europe. An alternative for solving the problem of repair under tension is to use material foreign to the repair site. Marcy was the first surgeon to use animal sinew, recommending kangaroo tendon in 1887 [75]. He also experimented with ox, whale, and deer tendon for the hernia operation (hernioplasty). McArthur in 1901 darned his inguinal repair with a pedicle strip of external oblique aponeurosis [76]. Because this layer may be insufficient, Kirschner [77], followed by Gallic and Le Mesurier [78], brought fascial grafts from the fascia lata of the thigh, pedicled or free, to repair inguinal hernias. Sir Geoffrey Keynes championed these techniques in the United Kingdom. He recommended the fascia lata strip operation for inguinal hernia and a flap of anterior rectus aponeurosis sutured to Cooper's ligament for femoral hernia [79]. From these beginnings a large combative literature developed during the 1930s and 1940s, reporting the use of various natural organic prostheses. Sames, as late as 1975, recommended that the vas deferens be used as a suture for hernia repair [80]. The dust of these controversies has now largely settled. Homologous and heterologous fascia has no value in hernioplasty. It is, after all, implanted foreign organic matter and undergoes complete phagocytic degeneration after a time [11]. Mair pioneered the use of skin and split skin (cutis) as a repair material [81]. These materials can now be forgotten; they were abandoned largely because of the persistence of their epidermal components, which develop cysts of sebum and hair [82]. Metallic materials used have included silver mesh filigree [83, 84], tantalum sheets [85], tantalum gauze [86-88], stainless steel

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wire [89], and vitallium [90]. Initial high expectations were not met, with subsequent reports of metal fragmentation, sinus formation, tissue erosion, and hernia recurrence [9]. The discovery of synthetic polymers by Carothers in 1935 [9] led to the use of nylon (a polyamide) in hernia repair by Melick [91]. A total of 25 herniorrhaphies were performed using nylon multifilament no. 0 as the suture material. Tissue reaction has been minimal and wound healing satisfactory in all cases. The idea of hernial repair using a darning technique dated back to Handley in 1918 [92]. The lack of good suture material limited the development of this technique. The bioacceptability of nylon makes it a good suture for darning. The Moloney et al. darning technique [93] using nylon, first reported in 1948, soon became popular and remained so up to the early 1990s [9, 94]. The search for the "ideal" prosthetic biomaterial has been ongoing for a long time. Yet there is no currently available form of "ideal" prosthesis that is universally acceptable [95]. During the 1950s Cumberland [96] and Scales [97] developed eight still pertinent criteria for the ideal implantable biomaterial, enumerated more recently by Hamer-Hodges and Scott [98]: The material should not be physically modified by tissue fluids; should be chemically inert; should not excite an inflammatory or foreign body reaction; should be noncarcinogenic; should not produce a state of allergy or hypersensitivity; should be capable of resisting mechanical strains; should be capable of being fabricated in the form required; and should be capable of being sterilized. The nonmetallic synthetic prostheses tested for hernia repair and that have since disappeared from the repertoire include Fortisan fabric [99, 100], polyvinyl alcohol sponge (Ivalon) [101], nylon net [102], nylon mesh [103], Silastic [104], Teflon [polytetrafluoroethylene (PTFE)] [105-107], and carbon fiber [108, 109]. Three biomaterials currently in widespread use throughout the world for hernia repair are (1) polyester mesh; (2) polypropylene mesh; and (3) the expanding (e)-PTFE patch [95]. A polyester polymer from ethylene glycol and terephthalic acid was developed in 1939 [110]. This material, known as Dacron, was machine-knitted into a fabric mesh and marketed by Ethicon (Somerville, N J, USA) under the trade name Mersilene. All products described as polyester mesh, Dacron mesh, or Mersilene mesh refer to essentially the same product [95]. An extensive clinical experience has developed with mesh repair for ventral incisional hernias and inguinal hernias using polyester mesh [110118]. Polyester mesh was the first popular nonmetallic mesh to stand the test of time. It remains in active clinical use, although its use has decreased as polypropylene mesh has become popular. The mesh has the advantages of adaptability, pliability, and tolerance in tissues and to infection [95]. Polypropylene mesh was first introduced as Marlex 50 by Usher in a series of experimental and early clinical papers reported from 1959 to 1963 [119-121]. The results of this mesh on hernia repair were good [122-124]. In 1963 an improved version of Marlex was introduced by Usher and marketed by C.R. Bard (Bellerica, MA, USA) as Marlex mesh [95]. All products described as polypropylene mesh, Marlex mesh, Prolene mesh (Ethicon), and Surgipro (US Surgical Corporation, Norwalk, CT, USA) are similar products. This mesh has had an enormous impact on surgery and has become the most popular mesh available for surgical implantation. Numerous reports have attested to its usefulness even in the presence of infection [125-137]. Polypropylene mesh induces an inflammatory reaction and scarring, and this characteristic led to

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the recommendation that direct contact with bowel should be avoided [138]. Boyd, however, pointed out that when the mesh was applied directly over bowel, although dense scar formed between the intestine and the mesh, which complicated abdominal reentry, it was otherwise not a problem because the mesh could be cut and resutured in the same manner as fascia. Also even in those instances in which the mesh directly covers intestine but without skin coverage, a fibrinous exudate seals the wound within 24 hours, and in 7 to 10 days granulation tissue grows between the mesh interstices; by 14 to 21 days, a skin graft can be performed or full-thickness flaps rotated over the mesh [131]. Polytetrafluoroethylene was first discovered accidentally in 1938 by Plunkett of E.I. du Pont de Nemours and Company [139]. In 1963 Shinsaburo Oshige of Sumitoma Electric Industries (Osaka, Japan) discovered a process for expanding PTFE to produce a structure with vastly improved mechanical strength [140]. The technique for expanding PTFE (e-P'ITE) was ultimately refined by Gore [141]. The e-PTFE was radically expanded to provide a sheet material for surgical repair of hernias by W.L. Gore and Associates (Flagstaff, AZ, USA) as Gore-Tex Soft Tissue Patch (STP) [95]. Gore-Tex STP has been shown to be stronger than Marlex, Prolene, or Mersilene mesh and is equivalent to these materials in terms of suture retention strength [95, 142, 143]. Several variations of the Gore-Tex STP have been marketed to facilitate the tissue-prosthesis interface or to prevent adhesions on the peritoneal surface. Since its first clinical use in 1983, Gore-Tex STP has been found to be an effective biomaterial for a wide array of clinical problems [95], including hernia repair [ 144158]. Long-term follow-up data are now becoming available [95]. The availability of synthetic prosthetic materials that can be used clinically for hernia repair with good results opens the door to tensionless hernia repair without the use of tension-relaxing incisions. There have been three main ways in which tensionless hernia repair using synthetic prosthetic materials have been developed. The first way is to use mesh to repair the posterior inguinal canal. Although polyester, polypropylene, and e-PTFE meshes have been used by many surgeons for hernia repair before him, Irving Lichtenstein is the surgeon who popularized and introduced tensionless prosthetic repair of groin hernias into everyday, commonplace, outpatient practice under local anesthesia [11]. The idea of local anesthesia for repair of hernias was reported by Harvey Cushing at the turn of the century [159, 160], a method that Halsted had been largely responsible for introducing [161]. However, Lichtenstein advocated his technique of hernia repair as an office procedure under local anesthesia, and he also pioneered the idea that hernia surgery is special, that it must be performed by an experienced surgeon and cannot be delegated to the unsupervised trainee doing "minor" surgery. The key feature of Lichtenstein's technique is the "tensionless" operation. In February 1989 Lichtenstein and associates [162] reported on 1000 consecutive patients with primary repair of inguinal hernia using a "tension-free" repair employing a Marlex mesh prosthesis to bridge the direct floor of the groin without approximating the tissue defect. The mesh is sutured to the inguinal ligament laterally and to the rectus sheath and "conjoint tendon" above. A slit is fashioned in the lateral end of the mesh to fit around the emerging cord. The "tails" of the slit are overlapped around the cord structures at the deep ring. At the follow-up evaluation at 1 to 5 years, no recurrences and no infection had occurred. In an

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editorial in the same journal issue, Peacock [163] concluded that, "The modern biologically based concept for repair of groin hernia acquired during adult life is application of a patch, avoidance of tension, and use of local anesthesia so that the result can be tested intraoperatively." Thus the fifth principle of hernia repair, tensionless repair, was finally consolidated by Lichtenstein. The Lichtenstein repair became popular soon after its introduction. Against the simplicity and success of Lichtenstein's repair, other more popular techniques, such as the Shouldice repair and laparoscopic methods, have real problems with competition [11]. The second way of doing tensionless hernia repair is the concept of using a giant unsutured mesh. Stoppa and colleagues [164] first described their use of a large, unsutured Dacron prosthesis for repair of difficult groin hernias using a preperitoneal approach via a low midline incision in 1975. The easy, bloodless dissection in the preperitoneal spaces of Retzius and Bogros, the excellent exposure of the "musculopectineal orifice" to be repaired, and the opportunity to repair several inguinal floor defects by a single approach appealed to the authors. They chose a Dacron patch because of its adaptability, pliability, and tolerance in tissues and to infection. They used a patch that was six "to ten times larger than the area of the hernia defect and simply placed the mesh in the preperitoneal space, relying on initial fixation by intraabdominal pressure on the muscular layers and later fixation by tissue adhesion and ingrowth into the prosthesis [95]. Using this method of repair, Stoppa and Warlaumont [165] reported a long-term recurrence rate of 1.4% among 604 repairs. Similar good results were achieved by Von Damme [166] and Wantz [167], who used a technique similar to that of Stoppa. Such a technique has now become known as giant prosthetic reinforcement of the visceral sac (GPRVS) [95, 167]. In a review of the treatment of complicated groin and incisional hernias in 1989, Stoppa emphasized the value of prosthetic repair with polyester mesh for huge and recurrent hernias. He noted that when properly placed in the preperitoneal space the mesh acts as artificial nonabsorbable endoabdominal fascia, making the abdominal wall instantly and definitely pressure-tight and hernia-resistant [168]. The third method for tensionless repair of groin hernias is to plug the inguinal canal with synthetic prosthetic materials. The idea of plugging the internal canal to prevent the emergence of herniated tissue is not new. During the mid-1830s, Pierre Nicholas Gerdy plugged the inguinal canal with an inverted fold of skin, scrotal or otherwise, maintained in position by both sutures and creation of a caustic-induced inflammatory response [169]. During the same era, C.W. Wutzer proposed temporary placement of a foreign body (i.e., a wooden hernia plug, pushing the scrotal skin and testicle in front of it) to help invaginate and hold tissue until the inguinal canal was closed by inflammatory adhesions [170]. Wutzer's primitive device would eventually go through countless modifications, with some of the best known European and American surgeons using the apparatus [171]. In 1886 William MacEwen [45] attempted to plug the inguinal canal with a bundled-up or multiply-pleated portion of the hernial sac that was "secured to the abdominal circumference of the [internal] ring." These efforts all failed, and the concept of plugging fell into disfavor and eventually disuse. With the availability of safe and easy-to-use prosthetic materials, the concept of plugging was reexamined by Irving Lichtenstein. In 1968 he began using a rolled cylindrical or "cigarette" Marlex mesh plug as treatment of femoral and recurrent inguinal

Lau: History of Groin Hernia

hernias and reported on its efficacy in 1974 [172]. After dissecting and inverting the hernia sac, a cylindrical plug was created by rolling a 2 x 20 cm or longer piece of Marlex mesh into a solid cigarette configuration. The plug was inserted into the femoral or recurrent inguinal defect, and several anchoring sutures were placed. Long-term follow-up has demonstrated the efficacy of this type of cigarette plug repair [173-179]. In 1993 Lichtenstein and associates [174] wrote, "A plug is preferable to a patch for several reasons. First, it forms a complete Occlusion of the defect without tension. Second, its slight extension into the preperitoneal cavity prevents the protrusion of omentum or bowel into a cul-de-sac that an onlay patch might create. Finally, a plug is obviously a much stronger barrier and can be fixed to a small rim of scar tissue. Laying down a secure fiat patch with adequate overlap requires a wider dissection of tissue." In 1987 Bendavid devised a clever umbrella-shaped Marlex prosthesis for insertion from below into the preperitoneal space through the femoral defect for treatment of femoral hernia. This umbrella consists of an 8 cm disk of Marlex with a stem to facilitate handling and ease of insertion. The stem is eventually resected when the disk portion has been properly inserted and sutured. This operation could be achieved with no hernia recurrence, in up to 81 repairs [2, 180]. In 1989 Bendavid described complete mesh reconstruction of the groin floor and inguinal ligament using polypropylene mesh prepared as a three-leafed "Fletching" [2]. This complicated prosthetic repair is indicated for repair of multirecurrent groin hernias in which total destruction of the inguinal ligament may have occurred and the defect extends to the anterior superior iliac spine. He reported only 1 recurrence among 26 such complicated cases. At around the same time, Arthur Gilbert, after experimenting with Lichtenstein-type rolled cylindrical plugs for treatment of primary indirect hernias, improved on the device's design by taking a flat piece of mesh and fashioning it into a cone or umbrella shape [181-183]. He believed that the umbrella plug represented an improvement over the cigarette plug because "the opened umbrella configuration attaches itself to the deep side of the abdominal wall in a greater circumference than did the previous rolled plug" [184]. Rutkow and Robbins began using hand-fashioned "umbrella" plugs in 1989 [171]. In mid-1993 they reported their good results on almost 1700 hand-rolled "umbrella" mesh-plug hernioplasties [185-187]. In 1993 Rutkow and Robbins helped develop, and the C.R. Bard Company began to market, a preformed umbrella hernia plug (PerFix) made out of Marlex mesh. This was the first ready-to-use device and consisted of a fluted outside layer combined with an inside arrangement of eight mesh "petals." Rutkow and Robbins found the premade plug simpler to use than attempting to improvise a hand-rolled hernia plug at the operating table, noted thai their operating times using a premade versus a handrolled device decreased an average of 4 minutes per case [171]. In 1995 RutkOw and Robbins authored the first scientific article in a peer-reviewed journal on premade plugs [188]. It is important to note that the repair technique used by Rutkow and Robbins places a Marlex plug into the hernial defect. In some pantaloon hernias, with two separate and distinct defects, placement of two or even more plugs has been appropriate. Also a second piece of fiat Marlex mesh is placed using sutureless technique on the anterior surface of the posterior wall of the inguinal canal from the pubic tubercle to above the internal

753

ring. The lateral portion of the preshaped onlay patch includes an aperture for the spermatic cord. This split section is sutured back onto itself to provide an opening for the cord while functioning as a pseudointernal ring. The onlay mesh is intended solely to strengthen the direct space in an indirect repair and the area of the internal ring in a direct repair [171]. By 1998 various other preformed hernia plug-like devices had also become commercially available. The mesh-plug hernioplasty is now a widely accepted technique. There are criticisms of the mesh plug after long-term follow-up. After implantation, and depending on their looseness, mesh plugs shrink up to 75%, thus failing to secure the repair. A loose or soft plug, which can be collapsed by pinching it between two fingers (the pinch test), loses size during the patient's own scarring process. As a result, the anchoring sutures of the plug pull through the margin of the hernia defect, leading to recurrence of the hernia. More importantly, after scarification and shrinkage, even a soft plug assumes a cartilage-like consistency, which can erode into the bladder [189]. The mesh patch shrinks approximately 20% during the scarring process after hernia repair [189, 190]. The problems associated with contraction of the mesh patch can be circumvented by using a sufficiently large piece of mesh to provide adequate mesh-tissue interface beyond the boundary of the hernia defect and by maintaining adequate laxity of the mesh while it is being fixed to the abdominal wall tissue [190].

History of Development of Approaches to Groin Hernia Repair

A duality between the development of the scrotal or groin approach to inguinal herniation and the transabdominal, internal, superior, upper, or posterior approach has marked the history of herniology [4]. Surgery on inguinal hernias from the beginning was directed not only at the bulge of the hernia in the groin but also at the potentially fatal hazards of bowel obstruction and strangulation. While the ancient Greeks were using the scrotal approach, the Hindus were practicing laparotomy when intestinal obstruction supervened. As alluded to previously, Franco [16], who devised an incision of the fascial constriction using a groove dissector, was the greatest contributor to herniology during the Middle Ages. He also advised that when extraperitoneal lysis failed intraperitoneal taxis be attempted after incising the peritoneal sac at the ring [4, 16]. Considerable argument ensued as to the advantages of intraperitoneal versus extraperitoneal reduction of herniated bowel, the latter being safer because the peritoneal cavity was not contaminated but carrying the risk of reductio en masse [4]. When Marcy in 1892 published his classic book on hernia [191], he coupled details of his repair of the deep inguinal ring with a translation from the French of celiotomy performed for inguinal herniation in 1749. Just before Bassini introduced his operation, Tait was recommending midline abdominal section for groin herniation [192]. LaRoque in 1919 described a superior transperitoneal grid:iron incision combined with a Bassini repair [193]. Banerjee in 1932 described intraperitoneal herniorrhaphy for inguinal hernia [194]. With introduction of the procedures by Bassini, Shouldice, and Lichtenstein and the mesh-plug repair discussed before, the transinguinal or anterior approach becomes the conventional ap-

754

proach for elective inguinal hernia operation. Laparotomy is done only when the strangulated hernia contents contain nonviable gut or gut of doubtful viability. Condon described the anterior iliopubic tract repair using the traditional anterior approach through the inguinal canal [195]. This method, however, evolved from the use of the iliopubic tract in operations done by the preperitoneal or posterior approach. The concept of the preperitgneal approach, according to Nyhus [196, 197], apparently was first presented by Thomas Annandale of Edinburgh in 1876. Annandale did not perform a fascial repair [1]. Meade [198] traced it back to 1743. Bates [199] of Seattle, advanced the preperitoneal concept. Cheatle [200] in 1920, perhaps under the influence of earlier English procedures by Tait [192], performed median abdominal section through the linea alba but did not enter the peritoneal cavity. Instead, after the recti were spread and with the patient in Trendelenberg position, the peritoneum was spread upward away from the bladder and the brim of the pelvis. Any inguinal and femoral peritoneal protrusions were reduced and amputated, exposing both sides of the groin from above. He described leaving the distal sac in the inguinal canal and suturing the internal ring from above as necessary. Dealing easily with herniation of the bladder, he applied his approach to both inguinal and femoral herniation. The next year Cheatle changed to a transverse Pfannenstiel incision [201]. He advised against the use of this approach for direct herniation, probably because Hesselbach's triangle was obscured behind the retracted rectus muscle. Cheatle's reports were ignored until his preperitoneal approach was rediscovered 15 years later by A.K. Henry [202], who repaired femoral defects not with the pubic periosteal flap Cheatle had used but with a pectineus fascial pedicle. He commented that the "variably developed unreliable conjoint tendon" was easier to sew from this route. High ligation of the peritoneal sac was obviously guaranteed. Henry also recommended suturing the internal ring when it was enlarged. In 1942 Jennings and Anson revived the preperitoneal approach in the United States [203]. In 1950 McEvedy [204] in England modified the Cheatle-Henry approach by using a unilateral incision obliquely placed in the lateral portion of the rectus sheath, dividing the underlying fascia, retracting the rectus muscle medially, and approaching the femoral herniation from above in the preperitoneal plane. McEvedy commented on the excellent view of Asley Cooper's ligament and sutured the conjoint tendon to it for closure of the femoral canal. At about the same time, in the United States at the Mayo Clinic, Musgrove and McCready [205] recommended the Cheatle-Henry approach for femoral herniation. In 1954 Mikkelsen and Berne [206] in Los Angeles reported a large series of femoral and inguinal herniations that they had repaired similarly. Read [207] and McVay [208] are among those who have reported on this approach, but it was Nyhus and associates who established it firmly as a sound operation based on detailed anatomic and clinical studies [133, 196, 197]. In 1959 they used for the first time a synthetic mesh (Ivalon) to buttress the posterior wall repair [209]; the preperitoneal approach has been favored by French surgeons as well [165, 168, 210]. Rignault recommended it together with the use of prosthesis [210]. Stoppa used this approach for GPRVS [165, 168]. Rosenthal and Waiters [211] of the United States used the preperitoneal approach to repair hernias with a prosthesis. Malangoni and Condon [212] recommended the

World J. Surg. Vol. 26, No. 6, June 2002

preperitoneal approach for incarcerated and strangulated hernias. Because of the contributions of Nyhus, J.F. Patino of Bogota has proposed that the preperitoneal approach and repair be known as the Nyhus operation [1], although this Nyhus eponym was first used as far back as in 1963 by Henry Harkins [213]. Credit for the first laparoscopic repair predates the revolution started by laparoscopic cholecystectomy. It is interesting to note that many of the initial attempts at laparoscopic hernia operation did not adhere to the recognized principles of hernia repair learned from open surgery. In fairness to these early pioneers, limited instrumentation rather than ignorance of the principles of hernia surgery may have been responsible for these initial laparoscopic approaches. Subsequent improvements in technology allowed a return to established principles [35]. The first patient to be treated by laparoscopic closure of the neck of the sac was hnder the care of P. Fletcher of the University of the West Indies and was operated on November 24, 1979 [1L 214]. Ger first reported the operation in 1982, using a Michel clip introduced laparoscopically to close the neck of the sac [214]. Ger and associates subsequently reported a series of 12 patients whose internal ring defects were closed using Michel clips at laparoscopy, and one patient was treated laparoscopically using a specially designed stapler [215]. The results of these operations would not be good, as there was no attempt to repair the posterior inguinal floor. Initial techniques of simple closure of the peritoneal neck by Ger and associates [214, 215] have gradually given way to attempts to repair the hernial defect. Bogojavlensky treated inguinal and femoral hernias laparoscopically by means of a preperitoneal patch [216]. The technique did not become popular because it was difficult to perform at that time. Popp [217] reported a laparoscopic inguinal hernia repair by suturing dehydrated dura mater over the inguinal area. The use of dura mater is obsolete now. Sehultz and associates [2t8] in 1990 reported 20 patients who were treated by a laparoscopic approach in which the peritoneum was opened and a plug of polypropylene mesh inserted in the internal ring. The inguinal area was covered with an additional piece of mesh that was not sutured in place. The peritoneum was reapproximated using titanium clips that had been developed for cystic duct and artery clipping during laparoscopic cholecystectomy. Follow-up ranged from 3 to 11 months. One recurrence was reported, and the average return to unrestricted activity was 3.3 days, with return to the workplace in 3.9 days. Schultz and associates documented their ability to perform outpatient laparoscopic herniorrhaphy with minimal discomfort, insignificant complications, and early return to productive activity. However, the technique of laparoscopic nonstapled plug and mesh has a high hernia recurrence rate. Schultz and associates [218], and Corbitt [219] noted a 2-year recurrence rate of 25% with this technique. The technique was subsequently modified by eliminating the plug, increasing the mesh size, and stapling the mesh in place [35], with improved results. Similarly, in an early experience using a transabdominal intraperitoneal onlay polypropylene mesh in 50 patients reported by Filipi and associates [220] and Redmond and associates [221], three patients with direct hemias experienced recurrence, and four others developed extensive adhesions to the mesh [220-222]. The laparoscopic transabdominal intraperitoneal onlay has gradually been replaced by the transabdominal preperitoneal mesh repair [223-230] and totally extraperitoneal approach [231237]. The success of these two techniques is based on fixation of

Lau: History of Groin Hernia

prosthetic mesh to the classifically defined structures during open herniorrhaphy in the transversus abdominis aponeurotic arch, pubic tubercle, iliopectineal ligament, and iliopubic tract. Indeed, it is not until these preferred laparoscopic approaches adhere to the basic principles of open hernia repair that the results of laparoscopic hernia operation can improve and recurrences decrease [35]. The initial limited understanding of the anatomic structures of the inguinal region, when viewed posteriorly, led to reports of nerve entrapment syndromes such as meralgia paresthetica [238-241]. Such syndromes are caused by injuries to the lateral femoral cutaneous nerve or the femoral branch of the genitofemoral nerve. Also, the avoidance of stapling in the "triangle of doom" (space between the spermatic vessels and vas deferens) avoids injuries to the external iliac vessels, which lie behind the peritoneum in this space [35].

755 Resumen. La historia indica que la cirugia abierta de la hernia inguinal ha transitado por muchas etapas de desarrollo, incluyendo la era antigua (desde la Antigiiedad hasta el siglo XV), la era del comienzo de la herniologla (siglos XV a XVII), la era anat6mica (siglos XVII a XIX), la era de la reparaci6n bajo tensi6n (siglo XIX a mitad del sigio XX) y la era de la reparaci6n libre de tensi6n (desde mitad del siglo XX al presente). A trav6s de estos periodos se desarrollaron cinco principios de la moderna reparaci6n quinlrgica: la operaci6n antis6ptica/as6ptica, la ligadura alta del saco, el estrechamiento del anillo inguinal profundo, la reconstrucci6n del piso posterior del canal inguinal y la reparaci6u libre de tensi6n. Es interesante que muchos de los primeros intentos de reparaci6n laparosc6pica no adhirieron a los principios estableeidos con la experiencia de ia reparaci6n abierta. Fue s61o cuando comenz6 la realizaci6n de ia reparaci6n transabdominal con malla y la t6cnica totalmellte extraperitoneal, procedimientos que si adhieren a los principios bdsicos, que los procedimientos iaparosc6picos de reparaci6n lograron mejores resultados y menores tasas de recurrencia.

References Conclusions

The history of treating groin hernias has evolved from life-saving procedures for strangulated hernia in the past to elective shortstay surgery for uncomplicated hernias today. In this new era of evidence-based medicine, any hernia repair procedure must be carefully evaluated concerning its benefits and its costs. Benefits must be measured in clinical, social, and economic terms. Similarly, benefits are evaluated across the whole patient environment and across the whole health care system. It is no longer adequate to demonstrate that some procedures work, These procedures must be evaluated in properly conducted randomized controlled trials to eliminate compounding variables [11]. The most popular operations among surgeons, at present, are the Shouldice repair, the Lichtenstein repair, and the laparoscopic methods of transabdominal preperitoneal repair and the tota!ly extraperitoneal repair. The Shouldice and Lichtenstein repairs have the distinct advantages that they can be carried out under local anesthesia and their postoperative complication rates and long-term recurrence rates are low. The Lichtenstein repair has the added advantage that it is a simpler operation with a shorter learning curve than the Shouldice repair. Laparoscopic procedures have the advantages that they are less painful, patients can return to work in a shorter time, and bilateral repairs are most suitable. The disadvantages of the laparoscopic technique include significantly higher operative costs and the risks inherent in general anesthesia. Moreover, the long-term recurrence rates are not known. R~sum~. L'histoire de la chirnrgie traditionnelle pour hernie de I'aine a travers~ plusieurs ~tapes: I'~re ancienne (jusqu'au 15~ si~cle), I'~re du d~but de la herniologie (15~ au 17~ si~cles), I'/~re anatomique (I7/~ au 19~ si~cles), I'~re de la r~paration sous tension (19~ au milieu du 20/~ si~cle) et I'~re de la r~paration sans tension (milieu du 20~ jusqu'/t pr6sent). A travers ces p~riodes, cinq principes diff~rents ont vu le jour: operation de hernie antiseptique/aseptique, ligature haute du sac, r~tr~cissement de l'orifice interne, reconstruction du planeher inguinal post~rieur et r~paration sans tension. I1 est int~ressant de constater que beaucoup des interventions initiales sous laparoscopie n'ont pas adh~r~ aux principes reconnus, appris tout au long de la chirurgie traditionnelle pour hernie inguinale. Ce n'est que depuis qu'on pratique les techniques de cure par voie d'abord laparoscopique transp~riton~ale et totalement extrap~riton~ale que les r~sultats de la laparoscopie ont commenc~ /~ s'am~liorer et que le taux de r~cidive a baiss~.

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