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 ...