Bassini's Operation for Inguinal Herniation

Raymond C. Read, MD

During most of the 19th century, surgery for groin hernia differed little from that described almost 2,000 years earlier in Rome by Celsus. The main indications re- mained pain, incarceration, and strangulation unrespon- sive to taxis. An inguinoscrotal incision was made below the external inguinal ring, and the peritoneal sac was dissected, pulled down, ligated, and allowed to retract. The pillars of the external ring were stitched around the spermatic cord with deep sutures obliterating the distal inguinal canal. In addition, the procedures of Gerdy (1836), Wutzer (1838), Wood (1863), Kocher (1874), Czerny (1877) and McEwen (1886) attempted to tampon- ade the internal abdominal ring with invaginated skin or hernial sac held there with sutures, wooden plugs, escharotics, or trusses.1 Improved care was made possible by the development of anesthesia, hemostasis, and anti- sepsis, but many surgeons were slow to adopt these advancements.

The state of herniology near the end of the century was epitomized by Haidenthaller's report published in the Arch f Klin Chir (1890). 2 Results from Billroth's clinic in Vienna, along with data from other centers, were pre- sented; German surgery was then recognized to be the best in the world. Billroth's patients with inguinal hernia- tion underwent 195 operations; 6% died from sepsis, peritonitis, hemorrhage, or other operative complica- tions. Alcohol injections to promote scarring often left painful sloughs. The short-term recurrence rate was 31%. One 19th century surgeon was reported to have re- marked that the reason he didn't operate for inguinal herniation was because he spent so much time applying trusses to cases of those who did. The next article in this German journal was by Bassini, 3 a comparatively un- known Italian surgeon from Padua, a small town in the marshes behind Venice. His report to an astonished profession has rarely been equaled in its finality.

He described a series of 262 repairs for inguinal herniation performed in 216 patients aged 1 to 69 years, all but 4 of whom had been followed for 1 month to 4 years. Of the 251 without incarceration, only 1 died at 15

From the Central Arkansas Veterans Heahhcare Center; and the Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AK.

Address reprint requests to Raymond C. Read, MD, 4300 West Seventh St, 2C100, Little Rock, AK 72205.

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days postoperatively of pneumonia. Three of the 11 treated for incarcerated or strangulated viscera died. Thus, overall mortality was 1.5%, with a long-term recurrence rate of 2.7%. Associated cryptorchidism was treated in 17. Eleven wounds became infected (4.4%). Bassini had previously presented his earlier results in Italy 4-7 and to the German Surgical Society, but his publication in the Arch Klin Chir spread news of his accomplishments worldwide. It caused a sensation. Al- most overnight, surgeons flocked to Padua like it was Mecca. Before detailing his technique, Bassini's rise from obscurity to world acclamation will be documented. 8

The Man

Edoardo Bassini was born, 1844, into a wealthy family in Pavia, located between Milan and Genoa, then under Austrian rule. There he graduated from medical school at the early age of 22 years and immediately joined Garibaldi in the struggle for independence from Austria, France, Spain, and the Papal states. Bayoneted in the groin, he was taken prisoner. Infection and a fecal fistula devel- oped, and Bassini was hospitalized for months before he could return home. There he was successfully treated by Porta (successor to Scarpa as Chairman of Surgery), who gave him a teaching appointment. Bassini traveled exten- sively, visiting Billroth in Vienna for a year (1873), Nussbaum (Munich), Langenbeck (Berlin), and both Spencer-Wells and Lister in London. He became a fervent disciple of the latter, introducing antisepsis to Italy. Academic advancement followed in anatomy, pathology, and clinical surgery at Parma, La Spezia, and Padua, where he was Chairman of Surgery (1888-1917). Recipi- ent of many honors, simple, austere, moral, meticulous, and a cautious operator who never married, he died in 1924 at the age of 80, 2 years after Halsted.

Bassini began his work on inguinal herniation in 1883. He became discouraged with the repairs then in vogue. Repeated recurrences were coupled with the finding at autopsy that MacEwen's concertinered hernial sac ab- sorbed. This experience led him to abandon the concept of producing a scar under the external oblique aponeuro- sis and expecting it to close the internal abdominal ring, while allowing the spermatic cord to pass through the inguinal canal. He decided to provide a new floor, new inguinal rings, and restore the valvular obliquity of the canal (analogous to the entry of the bile duct into the

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106 Raymond C. Read

duodenum and the ureter into the bladder), often de- stroyed by large indirect herniae. Thus, a "radical" cure (ie, not dependent on a postoperative truss) would be obtained.

Development of his Operation Confident in the principles and application of antisepsis, hemostasis, and anesthesia (chloroform), Bassini, in 1884, began opening the external oblique aponeurosis, the roof of the inguinal canal. He thus followed Bogros (1823), 9 who used the anterior preperitoneal approach for proximal (Hunterian) ligation of both the external iliac and inferior epigastric arteries for aneurysm, and Annandale (1876), 1~ the father of extraperitoneal herni- orrhaphy. Lucas-Championierre, another student of Lister, was the first to imbricate the external oblique aponeuro- sis, and he later (1892) 11 claimed to have anticipated Bassini in unroofing the inguinal canal. However, Bassini went on to divide the transversalis fascial floor of the inguinal canal as Bogros and Annandale had done earlier. He then reconstructed a new floor, coupling it with anteriolateral transplantation of the spermatic cord and the internal abdominal ring.

Bassini first presented his work in April 1887, to the Italian Society of Surgery in Genoa, Italy. 4 He described 42 herniorrhaphies in 38 patients. Later the same year in Pavia, Italy, he reported to the Italian Medical Association

on 72 operations in 63 men and 1 woman. 5 The next year, 6 results of 102 repairs in 92 patients were given in Naples, Italy to the Italian Surgical Society. He published a 106-page book on hernia in i889, z detailing early ambulation and reduced hospitalization. Its beautiful illustrations and text were reprinted in a 1937 50th anniversary volume 12 published by his school, the Univer- sity of Padua, Padua, Italy. In 1932, Catterina, a colleague and the most important contributor to our understand- ing of Bassini's technique, published an atlas (translated into English in i934) 13 outlining the operation. It did not become widely known outside of Italy (except by those like Marcy who were corresponding members of Italian surgical societies) until 1890 when, he published his results in a widely read German journal. 3

Bassini's last publication on hernia (femoral) was in 1894.14 He politely refused to become involved in the widespread arguments concerning priority and the many modifications (corruptions) of his technique. This stand, coupled with the paucity of illustrations, his failure to go into enough detail regarding his technique (eg, he never mentioned a word about encountering nerves), and his insistence on his operation being applied to all candi- dates, regardless of age, sex, or the type and size of the defect, damaged the acceptance of his operation and invited variations. Nevertheless, his operation was fre- quently criticized unjustly by those who performed it incorrectly.

Bassini's Operation for Inguinal Herniation 107

THE RADICAL OPERATION

The following description conforms to the original tech- nique as described by Bassini's personal assistant, Ca- terina, in his book as represented by Wantz.i5

1 Incision. Made in a skin fold, it extends 5 to 7 cm from the pubic tubercle on a line toward the anterior superior iliac spine. Early on, Bassini continued it into the scrotum. Camper's and Scarpa's subcutaneous fasciae are then divided. (Adapted from Wantz GE: The operation of Bassini as described by Attilio Catterina. Surg Gynecol Obstet 1989; 168:67-80, fig 5, with permission.)

108 Raymond C. Read

2 Aponeurosis of the external oblique muscle. This underlying roof of the inguinal canal is transected from the superiomedial crus of the external inguinal ring to a point 1 cm lateral to the internal ring identified 1 inch above the uppermost pulsations of the femoral artery. This superior entry into the external oblique aponeurosis was designed so its closure would be cephalad to that of the deeper repair. The two leaves of the cut external oblique aponeurosis are then separated from the underlying internal oblique muscle and its cremaster extension by blunt dissection with the finger or scalpel handle directed superficially against the aponeurosis. (Adapted from Wantz GE: The operation of Bassini as described by Attilio Catterina. Surg Gynecol Obstet 1989; 168:67-80, fig 8, with permission.)

Bassini's Operation for Inguinal Herniation 109

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3 Isolation of the cremaster muscle and the spermatic cord. This combined bloc of tissue is bluntly encircled with the index finger and thumb of one hand and lifted en masse off the pubic tubercle. The index finger of the other hand can then be easily channeled underneath (Figure 2). A clamp or rubber drain is then passed. Isolation from the underlying transversalis fascia floor of the inguinal canal is then gently extended by blunt dissection to 1 to 2 cm beyond the internal abdominal ring, ending up in the iliac fossa. The cremasteric muscular and fascial layer now have to be separated from the enclosed spermatic cord. Unfortunately, Bassini, as with some other details, did not spell out how he went about this. Apparently, he began a dorsal slit close to the internal inguinal ring where the spermatic cord is incompletely wrapped.

Much of this phase of the dissection was performed bluntly with the fingers. From his illustrations, which showed a mobile spermatic cord and divided branches off the epigastric vessels, Bassini appeared to excise the cremaster muscle, along with its genital nerve and blood supply. He showed at autopsy that, if left, the muscle atrophied postoperatively. Fatty collections (lipomata) attached to the spermatic cord were removed to reduce the diameter of the new internal abdominal ring. (Adapted from Wantz GE: The operation of Bassini as described by Attilio Catterina. Surg Gynecol Obstet 1989; 168:67-80, fig 9, with permission.)

110 Raymond C. Read

4 (A-B) Isolation of the hernial sac. Separation of the processus vaginalis was begun close to the internal abdominal ring where the sac is freer than distally. In congenital hernias, where the hernia sac is continuous with the tunica vaginalis testis, the sac was not removed but ligated with catgut suture, transected at its neck, and its distal portion was left or slit and inverted with sutures behind the spermatic cord, similar to what is done for hydrocele. Regardless, Bassini opened sacs to inspect their content, separate adhesions, etc. To rule out associated direct inguinal or femoral herniae, the divided peritoneal sac was fingered before its closure. (Adapted from Wantz GE: The operation of Bassini as described by Attilio Catterina. Surg Gynecol Obstet 1989; 168:67-80, figs 11 and 13, with permission.)

Bassini's Operation for Inguinal Herniation 111

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5 Fascia transversalis floor of the canal. This was exposed by gently drawing the spermatic cord downward and outward to stretch the transversalis fascia (anterior lamina) as it overlies the inferior epigastric vessels near the neck of the sac. The floor is then cut (not mentioned, but just implied by Bassini) lengthwise from the deep inguinal ring to the pubis. The free edge of the triple layer (internal oblique and transversus muscles and aponeuroses, along with the fascia transversalis) is then picked up. Bassini used his thumb to separate off the underlying preperitoneal fat for 3 cm all around. By this maneuver, the epigastric vessels are loosened as they pass to the rectus muscle. The superior pubic ramus with its attached ligament of Astley Cooper, along with the back of the pubis, are thereby exposed. Injury to the urinary bladder and the external iliac vessels are thus avoided.

Bassini's patients were younger, more muscular and smoked less than those seen today. Perhaps for these reasons, he encountered fewer direct defects (19 of 251) with nonincarcerated herniae (7.6%). If present, the pseudosac of a direct hernia, consisting of stretched transversalis fascial floor, was excised and any extraperitoneal fat or peritoneal sac inverted. (Adapted from Wantz GE: The operation of Bassini as described by Attilio Catterina. Surg Gynecol Obstet 1989; 168:67-80, fig 14, with permission.)

1 1 2 Raymond C. Read

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6 Repair. After dissection, the sac of an indirect hernia was twisted to evacuate content, ligated, transfixed, and divided at its neck. Bassini incised the lateral musculature of the internal abdominal ring (internal oblique and transversus) for 2 to 3 cm in the line of the incision, thus allowing superiolateral explantation. To ensure high ligation of the sac, he dissected it for approximately 2 cm "into the iliac fossa," so that its division was flush with the general peritoneal cavity. He thereby anticipated Henry (1936), 16 who, from the posterior preperitoneal approach, warned against distal ligation of the peritoneal sac at its false ring close to the internal abdominal ring, rather than proximally at the true neck in the space of Bogros.

The construction of a new floor was carried out with 6 to 8 interrupted silk sutures, spaced 4 mm apart, extending 5 to 7 cm up from the pubic tubercle and 1 cm beyond the external inguinal ring. Each was placed "like a purse string, passing in and out the triple layer twice," starting 2 to 3 cm back from its edge. The first sutures included the periosteum of the pubis, and both Henle's and Colles' ligaments along with the rectus tendon and its sheath. The closure was thus inverted, similar to the Shouldice multiple layer closure (the modern Bassini), thus providing a broad area of fixation. The surgeon deflects and protects the underlying preperitoneal fat and inferior epigastric vasculature while each suture i s placed. No sutures were inserted lateral to the internal abdominal ring. l~ This structure is displaced 1 to 2 cm superiolaterally toward the anterior-superior iliac spine as described previously. (Adapted from Wantz GE: The operation of Bassini as described by Attilio Catterina. Surg Gynecol Obstet 1989; 168:67-80, fig 16, with permission.)

Bassini's Operation for Inguinal Herniation 113

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7 Closure of the external oblique aponeurosis over the transplanted spermatic cord. (Adapted from Wantz GE: The operation of Bassini as described by Attilio Catterina. Surg Gynecol Obstet 1989; 168:67-80, fig 17, with permission.)

114 Raymond C. Read

Because Bassini's triple layer is stitched beneath the mobilized spermatic cord to the iliopubic tract, femoral sheath, and inguinal ligament, which were not distin- guished one from the other, the spermatic cord is transplanted above the plane of the internal oblique muscle. The lower flap containing the inguinal ligament was elevated to protect the underlying femoral vessels while the two-bite purse-string sutures were inserted. These were tied individually, medial to lateral. The last was inserted 4 mm from the laterally retracted spermatic cord, medial to the newly formed lateralized internal abdominal ring.

The closure was tested for looseness of the internal abdominal ring and the anesthesiologist was asked to lighten the patient's anesthesia and encourage retching to test the repair under direct vision. In women, the operation is easier because the round ligament, their only content of the inguinal canal, is simply divided and the ring closed. The spermatic cord now rests on the recon- strncted posterior wall of the inguinal canal, and the external oblique aponeurosis is closed over it (see fig 8). This is accomplished with a continuous silk suture supplemented by interrupted sutures, allowing for the formation of a new external inguinal ring. The subcutane- ous layer is approximated with interrupted sutures, as is the skin.

Like Halsted, Bassini insisted on strict antisepsis, hemostasis, and precise technique with closure of dead space and gentleness, all of which undoubtedly contrib- uted to his excellent results. E. Willys Andrews, a Chicago surgeon, visited Padua, Italy thrice and saw him operate repeatedly. In 1899,18 he reported on this experi- ence in great detail, validating Catterina's later account. Andrews emphasized that Bassini's operation was carried out in the preperitoneal plane, a finger being passed intra- or extraperitoneally to guide suture placement. This author, who popularized imbrication, pointed out that Bassini accomplished the same thing with his purse-string sutures. Wantz 15 suggests that Bassini origi- nally operated on large, neglected hernias whose transver- salis fascial floor of the inguinal canal had gone, with deviation of the epigastric vasculature toward the pubis, straightening the inguinal canal. Thus, there was superim- position of the internal and external inguinal rings. Only later, when he was seeing hernias earlier in their develop- ment, did he routinely and purposely incise the floor of the inguinal canal. Bilateral repair was undertaken when indicated. Early in his experience, the wound was drained, later only with giant herniation. He encouraged early ambulation and reduced the hospital stay by a third. No truss was provided.

Bassini's technique, although labeled as the foundation for many subsequent variations, was soon modified out of all recognition, especially in North America. Halsted's

initial procedure (1890) 19 transplanted the spermatic cord to the subcutaneous position, thereby destroying the obliquity of the inguinal canal, a valvular mechanism to which Bassini had attached considerable importance. The pampiniform plexus was also skeletonized, which led to incidents of hydrocele and testicular infarction. This experience, coupled with cases of femoral vein thrombosis and bladder injury, prompted Halsted to follow Bull and Coley (1891) 20 and Ferguson (1895) 21 in designing a more superficial repair. The floor of the inguinal canal was neither examined nor breached to enter the preperitoneal plane. The cremaster muscle was not excised. The internal oblique muscle was sutured to Poupart's ligament, but over the spermatic cord. It was left undisturbed in its muscular bed, making high liga- tion of the hernial sac next to impossible.

It would be half a century before Shouldice, Obney, and Ryan (1951-1953) 22 so successfully resurrected the Bassini operation in its modern guise. During the inter- val, a number of prominent surgeons, who had no right to speak about the Bassini operation because they did not follow his technique, attributed to the procedure recur- rences resulting from their own improvisations.

In conclusion, the details of Bassini's operation for inguinal herniation need to be known because they have withstood a century of innovation. He, the father of modern herniology, revolutionized the field and laid the groundwork for the many advances we enjoy today.

REFERENCES

1. Read RC: The development of inguinal herniorrhaphy. Surg Clin North Am 64:185-196, 1984

2. Haidenthaller J: Die radicaloperationen der hernien in de klinik des prof Billroth 1877-89. Arch f Klin Chit 40:493-555, 1890

3. Bassini E: Ueber die behandlung des leistenbruches. Arch f Klin Chir 40:429-476, 1890

4. Bassini E: Sulla cura radicale dell'ernia inguinale. Arch Soc Ital Chit 4:379-382, 1887

5. Bassini E: Nuovo metodo per la cura radicale dell'ernia inguinale. Atti d Congr d Assoc Med Ital 2:179-182, 1887

6. Bassini E: Sopra 100 casi di cura radicale dell'ernia inguinale. Arch Soc Ital Chir 5:315-319, 1888

7. Bassini E: Nuovo Metodo Operativo per la Cura Dell'ernia Inguinale. Padova, Properino, 1889, p 106

8. Read RC: The centenary of Bassini's contribution to inguinal herniorrhaphy. AmJ Surg 153:324-326, 1987

9. Bogros AJ: Essai sur l'Anatomie Chirnrgicale de la Region Iliaque et Description d'un Nouveau Procede Pour Faire la Ligature des Arteries Epigastrique et Iliaque Externe. Paris, France, Didot le Jeune, 1823

10. Annandale T: Case in which a reducible oblique and direct inguinal femoral hernia existed on the same side and were successfully treated by operation. Edin MedJ 21:1087-1091, 1876

11. Lucas-Championierre J: avec une etude statistique de deux cents soixante-quinze operations et cinquante figures intercalees dans le texte: Chirugie Operatoire: Cure Radicale des Hernies. Paris, France, Paris Rueffet Cie, 1892

Bassini's Operation for Inguinal Herniation 115

12. Fasiani GM, Catterina A: Scritti di chirugia erniaria per commemo- rare il cinquantenario delle operazione di Bassini (vol 1 and 2). Padua, Italy, Universita di Padova, 1937

13. Catterina A: Bassini's Operation for the Radical Cure of Inguinal Hernia. London, Lewis, 1934

14. Bassini E: Neue operations---Methode zur radical behandlurg der Schenkelhernie. Arch Klin Chir 47:1-25, 1894

15. Wantz GE: The operation of Bassini as described by Attilio Catterina. Surg Gynecol Obstet 168:67-80, 1989

16. Henry AK: Operation for femoral hernia by a midline extraperito- neal approach. With a preliminary note on the use of this route for reducible inguinal hernia. Lancet 1:531-533, 1936

17. Harkins HN: The repair of groin hernias: Progress in the past decade. S Clin North Am 29:1457-1482, 1949

18. Andrews EW: Major and minor technique of Bassini's operation, as performed by himself. Med Record 56:622-624, 1899

19. Halsted WS: The radical cure of hernia. Johns Hopkins Hosp Bull 1:12-13, 1889

20. Coley WB: Review of radical cure of hernia during the last half century. AmJ Surg 31:397-402, 1936 (editorial)

21. Ferguson AH: Oblique inguinal hernia, typic operation for its radical cure. JAMA 33:6-14, 1899

22. Glassow F: The surgical repair of inguinal and femoral hernias. Can Med AssocJ 108:308-313, 1973