1. A proficient understanding of groin anatomy is essential to successful inguinal hernia treatment.
2. Conservative management of asymptomatic inguinal hernias is acceptable.
3. Elective repair of inguinal hernias can be undertaken using a laparoscopic or open approach.
4. Laparoscopic inguinal hernia repair results in less pain and faster recovery, yet requires specialized training and equipment.
5. The use of prosthetic mesh as a reinforcement significantly improves recurrence rates, whether the repair is open or laparoscopic.
6. Recurrence, pain, and quality of life are important outcome factors.
The treatment of inguinal hernias is integral to the history
and current status of general surgery; evolution in the treatment
of inguinal hernias has paralleled technologic developments in the field.
The most significant advances to impact inguinal hernia repair have
been the addition of prosthetic materials to conventional repairs
and the introduction of laparoscopy to general surgical procedures.
Evidence of surgical repair of inguinal hernias can be traced
back to civilizations of ancient Egypt and Greece.1 Early
management of inguinal hernias involved a conservative approach
using trusses; however, the inefficacy of this approach prompted
the initiation of a surgical approach to the problem. As a consequence
of the primitiveness of the techniques, the treatment was often
worse than the disease itself. Surgery often involved routine excision
of the testicle, and wounds were closed with cauterization or left
to granulate on their own. Considering these procedures were performed
before the advent of the aseptic technique, it is safe to assume
that mortality was quite high. For those that did survive the operation,
recurrence of the hernia was commonplace.
Failure of these early techniques of hernia repair was based
on inadequate knowledge of groin anatomy and poor understanding
of the natural history of hernia formation. As the anatomy of the human
body was described via dissection study, the anatomy of the groin
became defined. From the late 1700s to the early 1800s, physicians
such as Hasselbach, Cooper, Camper, Scarpa, Richter, and Gimbernat
identified vital components of the inguinal region, and their contributions
are reflected in the current nomenclature. The progress in anatomic
understanding, coupled with the development of the aseptic technique,
led surgeons such as Marcy, Kocher, and Lucas-Championnière
to enter the inguinal canal and perform sac dissection, high ligation,
and closure of the internal ring. Results had improved, but recurrence
rates remained high with prolonged follow-up.
By demonstrating a comprehensive understanding of inguinal anatomy,
Bassini (1844–1924) transformed inguinal hernia repair
into a successful venture with minimal morbidity to the patient.
His operation involved dissection of the layers of the inguinal
canal to the transversalis fascia and then a reconstruction of the
floor of the inguinal canal in several layers. The success of the
Bassini repair over any of its predecessors ushered in an era of
tissue-based repairs. Modifications of the Bassini repair were ...