The History of Inguinal Hernia Surgery

One may wonder why they should read a review detailing the history of hernia repair. This is a question I asked myself when my chief, Professor Lloyd Nyhus, demanded it of his residents. As a novice surgeon, I didn’t understand how learning the history of an operation could make me a better surgeon. But with time, I came to realize that by studying the history of a procedure, I would understand the principles that must be applied for success.

Inguinal herniorrhaphy techniques have developed through the ages as knowledge of groin anatomy has improved. Through an appreciation of this evolution, modern approaches incorporating the lessons of the past have become safer and more effective. A failure to understand this history only results in repeating the mistakes of the past. The purpose of this review is to aid the modern hernia surgeon in the quest to perform a better inguinal hernia repair, no matter the choice of approach, whether it be open anterior or posterior, primary repair or mesh reinforced, laparoscopic or robotic.

Hernia and the Ancients

The word “inguinal” derives from the Latin word for groin, “inguen,” and repair of a hernia has been called a herniorraphy. The etymology of the word “hernia” originates from the Greek word “hernios,” meaning an offshoot or bud, and the suffix “-rrhaphy” comes from the Greek word “rhaptein,” meaning to stitch or sew. Today, we use the term “hernioplasty” instead of herniorraphy because of the incorporation of a mesh patch into the repair.

There is evidence of inguinal hernias dating back to the ancient Egyptians, Phoenicians and Greeks, who described hernias and ways of treating them. In the mummified remains of the pharaoh Merneptah (1215 b.c.e.), a large wound in the groin with the scrotum separated from the body may be evidence of the earliest attempt at hernia surgery. The writings of the Roman physician Celsus are some of the earliest accounts of the hernia and its repair, dating back to the first century c.e. His approach of closing the external ring was the best the medical world had to offer for nearly two millennia. Removal of the testicle became a routine part of the operation for centuries, as advocated by Galen. In Europe in the Middle Ages, French surgeon Guy de Chauliac (1298-1368) borrowed heavily from the writings of the famous Arabic surgeon, Albucasis, proposing six different treatments for inguinal hernia. His surgical textbooks became the standard for another 300 years.

Hernia Repair In the Renaissance

The organized and detailed study of hernias began during the Renaissance, with the renowned French surgeon Ambroise ParÉ. In his book, “The Apologie and Treatise,” ParÉ provided a detailed account of the hernia operation, describing how the hernia contents should be reduced into the abdominal cavity and how the peritoneum should be sewn up. Surgical approaches, however, were limited by a lack of understanding of anatomy until the mid-1700s, sometimes called “the Age of Dissection,” or the Anatomic Era. Many famous surgeons made contributions to the understanding of hernias, including John Hunter, who in 1790 pointed out the congenital nature of some indirect hernias. English surgeon Sir Astley Cooper played a large role in the understanding and treatment of hernias. Not only did Cooper describe venous obstruction as the first step in the cascade of events in a strangulated hernia that leads to necrotic bowel, but it was his monograph in 1804 that had the largest impact. In it, he described the fascia transversalis, and showed that it was the main barrier to herniation. He also showed its extension behind the inguinal ligament into the thigh as the femoral sheath and the pectineal part of the inguinal ligament, now known as Cooper’s ligament. Many others contributed to our understanding of groin anatomy, including Hasselbach, Camper, Scarpa, Richter and Gimbernat. Their names live on in anatomic components of the inguinal region.

Several novel techniques were tried. William Wood, an English surgeon, took the hernia sac, folding it back on itself and using it as a sort of plug at the internal ring. The external ring would be sutured closed. A first assistant to Theodor Billroth in Vienna, Vincenz Von Czerny, simply tied off the hernia sac, and sutured closed the external ring without opening the canal—essentially the same operation as Celsus, from the first century. Unsurprisingly, these techniques did not stand up to scrutiny, with most patients experiencing a recurrence. In fact, like in ancient times, many surgeons in the 1800s left the wound open to close by secondary intention in the hope this scar would strengthen the repair. This was known as the McBurney operation, named after American surgeon Charles McBurney.

Hernia Repair Enters The Modern Era

The big change came to inguinal hernia repair because of a collision of events. In 1867, surgeon Edoardo Bassini was stabbed with a bayonet while serving as a soldier in the war to unify Italy. While undergoing a prolonged recovery from his injuries, he studied anatomy at the University of Parvia. Armed with his new understanding of the importance of anatomy, Bassini traveled to train with the masters of the period: Theodor Billroth in Vienna, Bernhard Langerbeck in Berlin, and Joseph Lister in London. He became the director of surgical pathology at the University of Padua in 1882, and undertook detailed dissections of the groin region. With his newly acquired understanding of anatomy, Bassini developed the first modern approach to inguinal hernia repair. He devised a surgical method that involved dissection of the layers of the inguinal canal and then reconstruction of the posterior wall of the inguinal canal.

By 1889, Bassini had operated on 274 hernias, and collected data on 216 patients over almost five years. He identified eight recurrences (a rate of 4%), 11 postoperative infections (5%), and no reported deaths among the 251 nonstrangulated repairs. To put that into contemporary perspective, the Billroth clinic at the time had a mortality rate of 6% and a recurrence rate of 33%.

The study of anatomy continued to play an important role in the history of modern hernia repair. Chester McVay, while still a student at Northwestern University, in Chicago, published three seminal papers on the anatomy of the inguinal region with his teacher, the anatomist Dr. Barry Anson. In 1939, as an intern at the University of Michigan Hospital, McVay published a paper entitled “A Fundamental Error in the Bassini Operation for Direct Inguinal Hernia.” Although he went on to spend his entire career in a small town in South Dakota, McVay made a major contribution to improving the understanding of groin anatomy and altered Bassini’s repair accordingly. The repair he created has been called the Anson-McVay repair.

In 1945, a Canadian surgeon, Earle Shouldice opened an outpatient hernia clinic applying the principles of the Bassini repair but further modifying it by adding an additional suture line to the reconstruction of the posterior wall. The results of his clinic were later published extensively by surgeon Robert Bendavid, establishing a new standard for recurrence, at 1%.

Mesh Reinforcement

Although hernia repair based on anatomic principles was established following Bassini’s work, hernia recurrence and disability following repair remained problems. The concept of a reinforced repair was introduced to resolve these issues. The earliest attempts date back to Henry Orlando Marcy, a Boston surgeon, who recommended kangaroo tendon in 1887. It was not until Wallace Carothers, working for Dupont, discovered a method for creating synthetic polymers in 1935, that led to Melick using nylon as a reinforcement. By the 1960s, Dr. Richard Newman had performed more than 1,600 inguinal hernia repairs using polypropylene. In 1968, in Los Angeles, Dr. Irving Lichtenstein first introduced the plug technique for femoral and recurrent inguinal hernia repair, using a rolled cylindrical or ‘cigarette’ Marlex mesh plug. This idea evolved to hand-rolling more of a cone shape, and even to preshaped mesh inserts.

In 1987, Lichtenstein published a series of patients with repairs using Marlex mesh. This experience involved more than 6,000 patients followed from two to 14 years, with a recurrence rate of 0.7%. His technique became known as a “tension-free” repair and was popularized by Dr. Parvez Amid, who went on to modify and teach the approach. Using this new approach, inguinal hernia repair became an outpatient procedure that could be performed under local anesthesia.

At approximately the same time, Dr. Arthur Gilbert developed a plug-and–patch, tension-free approach at his hernia clinic in Florida. Although extremely successful, the approach was later modified by Dr. Gilbert into the Prolene mesh system, which reinforced both sides of the floor. In New Jersey, Dr. Ira Rutkow, who studied Gilbert’s technique, popularized a version of the plug-and-patch and taught his method extensively. Both Gilbert’s and Rutkow’s repairs, along with Amid’s modifications of the Lichtenstein approach, remain the basis for most open inguinal hernia repairs performed today.

The study of the anatomy of the groin led another group of surgeons to approach inguinal hernia repair in a totally new direction—from a posterior approach. It goes back to 1876, when Annandale of Edinburgh presented his concept of a preperitoneal approach and then by Trait in 1891, who reported an intraperitoneal approach. Cheatle in 1921, and later Henry in 1936, proposed a posterior approach for inguinal and femoral hernias, but it wasn’t until the late 1950s that Lloyd Nyhus and his associates popularized a posterior approach for inguinal hernias, including direct ones. It was Algerian surgeon Rene Stoppa, who, in 1972, introduced the concept of an open posterior approach with a mesh prosthesis without fascial closure—the technique that became the basis of minimally invasive repairs. Dr. Raymond Read reported a mesh repair sutured in place with an opening for the cord structures in 1979, but because of failures through the slit made for the cord and at the sutured edges, Professor George Wantz began using a version of the Stoppa repair with a giant mesh covering the entire myopectineal orifice.

The Laparoscopic Approach

In 1979, inguinal hernia repair was forever altered when South African surgeon, Ralph Ger, practicing in New York City, applied a posterior clip approach laparoscopically that he had previously performed in an open approach. His work was reported in the Annals of the Royal College of Surgeons of England in 1982 (64[5]:342-344), but failed to gain a following until laparoscopy for general surgeons grew in popularity with the advent of laparoscopic cholecystectomy in 1989. Many surgeons worldwide then began to investigate how a laparoscopic approach based on previous posterior as well as anterior tension-free approaches could be performed. Some of the first were Dr. Leonard Schultz in Minnesota, with his plug-and-patch transabdominal laparoscopic approach, and Dr. Robert Fitzgibbons in Nebraska, as well as Dr. Morris Franklin in Texas, with their own intraperitoneal onlay mesh (IPOM) approaches. These techniques fell out of favor, however, due to complications with the plugs, the intraperitoneal mesh or recurrence because of failure to adhere to the principles previously established by the open posterior approach.

Two different approaches, the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP), both emulating the open posterior approaches of Nyhus, Wantz and Stoppa, soon became the basis for today’s minimally invasive inguinal hernia repair. Surgeons working independently, including Drs. Ferzli, McKernan, Voeller, Payne, Arregui, Duncan and myself (Felix), as well as many others, became reluctant pioneers, developing techniques and instruments necessary to duplicate the concepts of the open posterior approach. In 2009, Dr. Jorge Daes, an accomplished laparoscopic surgeon in Colombia, introduced E-TEP, which was a variation of the TEP procedure, allowing surgeons to apply the laparoscopic approach to patients in whom visualization is restricted because of limited space.

The debate on whether the TAPP, TEP or E-TEP approach is best; whether fixation is necessary; or what mesh should be used began, and has continued until today. What became apparent from all the different surgeons and slightly different techniques, however, was that there are certain underlying principles, steps or rules that should be followed for the minimally invasive repair to have both short- and long-term success. These concepts were published in the Annals of Surgery, 25 years after the first successful laparoscopic repairs were reported (Ann Surg 2017;266[1]:e1-e2).

Robotic Hernia Repair

In 1999, the first robotic TAPP (R-TAPP) inguinal hernia repair was performed in Europe by Dr. Jacques Himpens, and in the United States by Dr. Barry Gardiner. Most of the early R-TAPP procedures, however, were reported in conjunction with robotic prostatectomy. By 2015, reports of stand-alone R-TAPP were published. On the International Hernia Collaboration (IHC), a social media platform for hernia surgeons established in 2012, the growth of robotic inguinal hernia repair was stimulated through video education and collaboration. Pioneers of the robotic approach, like Dr. Conrad Ballecer from Arizona, presented their techniques and were critiqued by surgeons who had extensive experience with the laparoscopic approach. The techniques used to perform R-TAPP soon came to mimic those of laparoscopic TAPP, and reported outcomes were similar. The robotic approach, however, allowed more surgeons to adopt a minimally invasive approach, and many applied it to situations that were extremely difficult for conventional laparoscopy—such as post–radical prostatectomy, mesh removal and giant scrotal hernias.

Inguinal hernia repair has come a long way from amputation to reconstruction and from large open incisions to minimally invasive approaches assisted by robots. What has been constant through this evolution is that the repairs need to be based on anatomic considerations and that certain principles need to be applied. When we look closely at the history of inguinal hernia repair just presented, we find that the steps taken to perfect the current minimally invasive repairs duplicate those taken by surgeons who developed open approaches.

It is my hope that surgeons will continue to study the past to guide their efforts to advance the safety and efficacy of repairs they presently perform and ones they may develop in the future. A failure to understand our history will result in repeating the mistakes of the past. We do not need to rediscover the wheel, but rather improve upon it.

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Dr. Felix is a general surgeon from Pismo Beach, Calif., and a member of the editorial advisory board of General Surgery News. Dr. Rouse is associate anatomical pathologist, Huron Perth Healthcare Alliance, Stratford, Ontario, and adjunct professor, Department of Pathology and Lab Medicine, Western University, London, Ontario, Canada.

This article is from the August 2021 print issue.