Hernias are so ubiquitous that even in this era of superspecialization, hernia repairs belong to the general surgeon. The history of hernia repairs reflects the evolution of surgery itself. Over the centuries, thanks to the ingenuity of some of the greatest names in surgical history, hernia repair has matured from a reckless effort with near 100% recurrence, to its current position as routine standard of care. Today, the maturation of young surgeons can be marked by their ability to repair these defects.
Inguinal hernias and their attempted repairs can be traced to ancient times, when the Egyptians and Greeks experimented with external trusses or transscrotal high ligation of hernia sacs.1 Open repairs have undergone numerous iterations, from ligation to orchiectomy, eventually progressing to tissue repairs as understanding of the anatomy improved. Published accounts of early hernia repairs started with Ambroise Paré in the late 1500s.2 As the antiseptic, then aseptic, technique joined with the anesthetic revolution, hernia surgery became safer and more formalized in the mid-1800s.3 Since then, there have been numerous evolutions and revolutions in technique.
A myriad of approaches to hernia repair persist because no technique has eliminated the two looming problems associated with repair: pain and recurrence. Three key advancements, however, have substantially decreased the incidence of these complications. The tissue repair developed by Eduardo Bassini in 1888 and the tension-free repair with onlay mesh developed by Irving Lichtenstein in 1984 both dramatically reduced recurrence rates compared with historic methods. The third advancement, the introduction of the laparoscopic hernia repair, as reported by Ger, Shultz, and Corbitt in 1990, has improved the incidence of chronic pain.
Inguinal anatomy is complicated, and the price for a poor understanding of its complexity is chronic pain and recurrence for the patient. Laparoscopy has flipped the lens with which we approach the inguinal hernia from the anterior abdominal wall to the retroperitoneal arena, adding to the intricate anatomical knowledge required for a successful procedure. The mastery of this approach requires more mentored practice than open techniques, but ultimately decreases chronic neurologic pain while preserving the low recurrence rate associated with the tension-free repair. While open inguinal hernia repair is the quintessential intern case, the laparoscopic approach is appropriately allocated to the senior surgical resident.
The articles that follow chronicle the journey that surgeons have taken throughout history to repair these abdominal wall defects. When reviewing these seminal works, make note of the struggles, limitations, nuances, and especially the remaining challenges with regard to hernia repair. When performing these operations, you may hear, “I thought it would be a routine hernia.” Those who accept the challenge of building a practice around hernia repairs, however, will tell you, “There is no routine hernia.” Inguinal hernias are ubiquitous, technically demanding to repair, and worthy of scientific and surgical rigor. It is one of the most important problems surgeons address, and the hernia surgeon is the quiet champion of many grateful patients who enjoy an improved quality of life as the result of our efforts.
The radical cure of inguinal hernia in the male.
Halsted WS
Ann Surg. 1893;17(5):542–556.Takeaway Point: The Halsted hernia repair has mortality and recurrence rates low enough to recommend routine surgical repair of inguinal hernias.
Commentary: In this article, Dr. Halsted presents his method for primary inguinal hernia repair, accompanied by his initial 3-year experience at Johns Hopkins Hospital. At the time of publication, operative repair for groin hernias was associated with high morbidity and very high recurrence rates. Dr. Halsted argues in this article that his technique carries low mortality and recurrence rates and thus routine surgical repair should be attempted for all hernias. In addition to the description of the Halsted technique, it is interesting to note several of the details surrounding the procedure in the 1890s: standard postoperative bed rest of 21 days, Dr. Halsted’s assessments of the stages of wound healing and strength, and his avoidance of “tissue constriction” as part of aseptic technique. Scientific reporting has evolved considerably since this report was published, and the details of the series are not always clear. Although the Halsted technique is not standard today (see c, below), his procedure represents a major advancement in hernia repair. His recommendation that all hernias should be repaired is no longer standard of care (see g, below); however, his report demonstrated for the first time the safety and potential utility of herniorraphy.
Introduction: At the time of this publication, most surgeons would operate for “radical cure” of inguinal hernia only in situations of strangulation or inability to retain the hernia with a truss. The ability to operatively repair hernia defects with an acceptable long-term success rate had not been previously established, and most operations involved only ligation of the sac.
Objectives: Dr. Halsted, prior to this article, had published a description of his new technique for recreating the inguinal canal. Dr. Bassini of Padua had published a very similar technique during the same year. In this article, Dr. Halsted compares the two techniques, presents his outcomes, and makes recommendations for the routine operative repair of groin hernias.
Trial Design: Prospective single-institution case series.
Participants: All patients undergoing herniorraphy at a single institution.
Intervention: Groin hernia repair using the Halsted or McBurney method. In comparison to the Bassini repair which always brings the cord through the internal ring, Halsted places the cord structures above the external oblique. Postoperatively patients were kept on bed rest for 21 days.
Primary Endpoint: Hernia recurrence.
Secondary Endpoints: Wound infection, death.
Sample Size: 82 patients from one institution, enrolled between 1889 and 1893.
Statistical Analysis: Descriptive.
Baseline Data: 82 total patients: 5 femoral hernias, 76 inguinal hernias, 1 umbilical hernia. 64 males, 18 females. Five patients underwent McBurney repair, and 58 underwent Halsted repair. Age ranged from 14 months to 58 years. Follow up was variable, ranging from <1 month to 3 years.
Outcomes: Two out of the five hernias treated with McBurney repair recurred. There were no recurrences in the 58 cases of Halsted repair, which healed “per primum,” but six recurrences occurred in cases complicated by wound infection or noncompliance.
Conclusion: Routine repair of inguinal hernia can be performed with low risk of mortality and a low rate of recurrence.
Limitations: Single-institution case series only. Limited baseline data and variable follow-up. Patient population was not homogenous: pediatric and adult patients; inguinal, femoral, and umbilical hernias were included. No statistical analysis was performed.
Short-stay surgery (Shouldice technique) for repair of inguinal hernia.
Glassow F
Ann R Coll Surg Engl. 1976;58(2):133–139.Takeaway Point: The Shouldice technique allows for successful repair of groin hernias with immediate postoperative ambulation and short hospital stay.
Commentary: There are several components to the Shouldice technique for inguinal hernia repair, including local anesthetic, extensive dissection of the internal ring, early ambulation, and early return to work. This is a very large single-surgeon series of this technique with low recurrence rates. The author argues that this technique will result in significant decreases in healthcare and lost wage costs from groin hernias. Of note, Dr. Glassow evaluated recurrence as his only outcome measure in making his case for the adoption of these changes. It is worth noting that although mesh repairs are now the most common technique for repair of inguinal hernias, the Shouldice Hospital in Toronto continues to perform only the repair described in this study for over 7000 hernias per year, with results similar to those seen in this series.
Introduction: When this study was published, the average length of stay following groin hernia repair in the United States was 5.7 days, and was associated with significant hospital and loss of wage costs. A few small case series had appeared indicating that early postoperative ambulation and shorter length of hospital stay were associated with fewer complications, including recurrence, but the practice had not been clearly established.
Objectives: The intention of this article is to demonstrate that, using a standardized technique for the repair, a short hospital stay and an early return to normal activity are compatible with a low recurrence rate.
Trial Design: Retrospective single-surgeon case series.
Inclusion Criteria: All groin hernia repairs performed by a single surgeon at Shouldice Hospital in Toronto.
Exclusion Criteria: Combined inguinal and femoral hernias.
Intervention: The Shouldice technique consists of local anesthesia, complete dissection around the internal ring to identify secondary defects, tissue reconstruction of the posterior inguinal canal, immediate ambulation after repair, and discharge after 72 hours with skin staples removed and without a dressing on the surgical site. Patients whose occupations do not require heavy activity return to work the following week; laborers return to work within 4 weeks.
Endpoints: None (retrospective case series).
Sample Size: 14,982 total repairs by a single surgeon from 1945 to 1973 at the Shouldice Hospital in Toronto.
Statistical Analysis: Descriptive.
Baseline Data: 14,982 herniorrhaphies performed; 123 ipsilateral combined inguinal and femoral hernias excluded. 13,108 primary herniorrhaphies, 1874 recurrences. 7863 primary indirect repairs, 3814 primary direct repairs, 798 combined indirect and direct, and 633 primary sliding hernias. Of recurrent hernia repairs, there were 627 indirect, 927 direct, 249 combined indirect and direct, and 71 sliding hernias.
Outcomes: Overall recurrence rate for primary hernia repair was 0.6% (73 of 13,108) with annual follow-up from 1 to 21 years in more than 95% of the sample. 18 of 1874 patients (1%) who underwent repair of recurrent hernia experienced additional recurrence.
Conclusion: Repair of groin hernias may be successfully performed using local anesthesia with early ambulation and short stay without an increase in recurrence. Long-term follow-up in a large single-surgeon series suggests that inguinal and femoral recurrence rates may decrease with increasing surgeon experience.
Limitations: Single-institution and single-surgeon data; large variability in length of follow-up. Retrospective report without secondary outcome data (death, wound infection, length of stay). No comparison group.
The tension-free hernioplasty.
Lichtenstein IL, Shulman AG, Amid PK, Montllor MM
Am J Surg. 1989;157(2):188–193.Takeaway Point: The Lichtenstein tension-free repair demonstrated no recurrences in 1000 consecutive repairs with follow-up ranging from 1 to 5 years.
Commentary: Dr. Lichtenstein and colleagues present a review of the factors that contribute to hernia recurrence: suture line tension, iatrogenic apposition of nonanatomic structures, and inherent weakness of the aponeurotic tissue in which medial and lateral sutures are placed. He then presents a description of his tension-free repair with polypropylene mesh under local anesthesia. This article is primarily the description of a new technique. He does present a results section, where he states that after 1000 consecutive cases, followed for 1–5 years, there have been no recurrences. He does not give any information about his patients or any specific follow-up data. Despite the lack of outcomes data in this preliminary descriptive paper, the technique he describes has replaced primary tissue repair to become the mainstay of herniorraphy.
Introduction: At the time of publication, previous large studies had demonstrated a recurrence rate of at least 10% following primary repair of inguinal hernias using the techniques of Bassini, Halsted, Shouldice, and McVay. Lack of adequate follow-up in most reports led to extreme variability in outcomes. Lichtenstein proposes that the cause of recurrent hernia is the tension created by approximating normally unopposed tissues.
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