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INTRODUCTION

A hernia is defined as an area of weakness or complete disruption of the fibromuscular tissues of the body wall. Structures within the cavity contained by the body wall can pass through, or herniate through, such a defect. While the definition is straightforward, the terminology is often misrepresented or misused. It should be clear that hernia refers to the actual anatomic weakness or defect, and hernia contents describes those structures that pass through the defect.

Inguinal hernias are among the oldest known afflictions of humankind, and surgical repair of the inguinal hernia is the most common general surgery procedure performed today.1 Despite the high incidence, the technical aspects of inguinal hernia repair continue to evolve with new surgical advancements.

INGUINAL HERNIA

History

The word “hernia” is derived from a Latin term meaning “a rupture.” The earliest reports of abdominal wall hernias date back to 1500 BC. During this early era, abdominal wall hernias were treated with trusses or bandage dressings. The first evidence of operative repair of a groin hernia dates to the first century AD. The original hernia repairs involved wide operative exposures through scrotal incisions requiring orchiectomy on the involved side. Centuries later, around 700 AD, principles of operative hernia repair evolved to emphasize mass ligation and en bloc excision of the hernia sac, cord, and testis distal to the external ring. The first report of groin hernia classification based on the anatomy of the defect (ie, inguinal versus femoral) dates to the 14th century, and the anatomical descriptions of direct and indirect types of inguinal hernia were first reported in 1559.

Bassini revolutionized the surgical repair of the groin hernia with his novel anatomical dissection and low recurrence rates. He first performed his operation in 1884, and published his initial outcomes in 1889.2 Bassini reported 100% follow-up of patients over a 5-year period, with only five recurrences in over 250 patients. This rate of recurrence was unheard of at the time and marked a distinct turning point in the evolution of herniorraphy. Bassini’s repair emphasizes both high ligation of the hernia sac in the internal ring as well as suture reinforcement of the posterior inguinal canal. The operation also utilizes a deep and superficial closure of the inguinal canal. In the deep portion of the repair, interrupted sutures affixing the transversalis fascia medially to the inguinal ligament laterally repair the canal. This requires an incision through the transversalis fascia. The external oblique fascia provides the superficial closure.

In addition to Bassini’s contributions, Lotheissen in 1898 introduced the first true Cooper’s ligament repair, which affixes the pectineal ligament to Poupart’s ligament and thereby repairs both inguinal and femoral hernia defects. McVay further popularized the Cooper’s ligament repair with the addition of a relaxing incision to reduce increased wound tension.

The advances in groin hernia repair ...

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