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Editorial Jurnalul de Chirurgie, Iaşi, 2011, Vol. 7, Nr. 3 [ISSN 1584 – 9341] In contrast to Bassini’s repair, which proved essentially useful in direct hernia, Marcy’s technique was particularly indicated in indirect hernia 66 . His compatriots William Halsted (1852-1922) 67 , Edmund Andrews (1824-1904) 68 and Alexander Ferguson (1853-1912) 69 all made some adaptations to Marcy’s original technique 70 , and combined it with Bassini’s technique, so as to fit the procedure for both direct and indirect hernias. An original new method of posterior inguinal wall repair, already suggested by Albert Narath (1864-1924) and in 1898 followed by the Austrian Georg Lotheissen (1868-1935), consisted of using the pectineal ligament of Cooper for repair 71 . This technique got great acceptance after its reintroduction in 1949 by Chester McVay (1911-1987) and Barry Anson (1894-1874) 72 . However McVay’s postoperative low recurrence rates were never matched by other groups 73 . 20 TH CENTURY General developments in anaesthesia, introducing local forms of anaesthesia, had also their effect on inguinal hernia repair. As a resident in the Johns Hopkins Hospital in Baltimore, the young surgeon Harvey Cushing (1869-1939) (Fig.8) reported hernia surgery under local cocaine infiltration already in 1898 74 (Fig.9 a & b). Halsted later reported the experiences of his pupil in 1922. In the 20 th century 75 a new step forward was developed in the 1940’s by the Canadian surgeon Earle Shouldice (1891-1965) of Toronto 76 (Fig.10). Shouldice proposed a technique based on Bassini’s repair, however effectuated under local anaesthesia and consisting of a four layer muscular closure of the posterior wall, using continuous sutures 77 . His results in terms of recurrence rate were clearly superior to those obtained with previous methods 78 . The technique was taken over by many other teams from the USA or Europe 79 , and became for many years a standard operation 80 . Many surgeons progressively got persuaded that surgical techniques of hernia repair had to be adapted to specific types of inguinal hernia. It led several scientists to reconsider the anatomic principles of surgical hernia repair 81 , respectively to define and categorise the different types of hernia 82 . 66 See Marcy 1887. 67 Halsted originally brought the spermatic cord under the skin (the so-called Halsted I technique from 1889), but later abandoned his cord transposition technique and inbricated the aponeurotic flaps of the external oblique as proposed by Edward Wyllis Andrews: it became the so-called Halsted II repair. 68 See Andrews 1899. 69 Ferguson pointed first at the dangers of cord transposition in view of the testicular atrophy which could follow cord trimming and transposition. See Ferguson 1899 & 1907. 70 For a review on the contribution of these American surgeons, see Summers 1947. See also Rutkow 1993a, p.516. 71 See Lotheissen 1898. 72 See McVay 1948 and McVay & Anson 1949. 73 So did Berliner in 1994 report an 11% recurrence rate! See Berliner p. 203. 74 See Cushing 1898 & 1900. 75 For a selective history of inguinal hernia repair in the 20 th century, see Ira Rutkow 1993b. 76 See for a historic perspective on Earle Shouldice: Welsh & Alexander 1993, p. 454. 77 See Shouldice 1953. 78 For results of the Shouldice repair, see Shearburn & Myers 1969. 79 See Glassow 1984. 80 See Nicholson 1999. 81 For instance Henri Fruchaud (1894-1960). See also Stoppa & Van Hee 1998a. 82 Early classifications included those of Kaspar Stromayr in 1559, reiterated in 1844 by Astley Cooper (indirect and direct hernias), and more recently those by Casten D.F. in 1967 and Gilbert A.I. in 1989. 309
Editorial Jurnalul de Chirurgie, Iaşi, 2011, Vol. 7, Nr. 3 [ISSN 1584 – 9341] So did the Shouldice clinic propose a so-called TSD classification, according to T(ype), S(tage) and D(imension) of the hernia 83 . A more worldwide accepted classification was presented by Lloyd Nyhus 84 , who distinguished 4 types of hernia - Type 1: indirect hernia with normal inguinal ring - Type 2: indirect hernia with dilated inguinal ring - Type 3 A: direct hernia; 3 B: pantaloon hernia; 3 C: femoral hernia -- Type 4: recurrent hernia 85 . Fig. 8 Harvey Cushining, aged 29 Fig. 9a Cushing.Patient, three weeks after right hernia repair, with lstill present left hernia Fig. 9b Cushing.Same patient three weeks after left inguinal hernia repair Fig. 10 Earle Shouldice TENSION FREE REPAIR The various above cited operative techniques all induced a musculo-ligamental form of repair under tension. Such tension was held responsible for the since Bassini only slowly diminishing recurrence rates 86 . In various series, circa one out of ten patients indeed continued to develop a recurrence 87 . 83 See for details Robert Bendavid, 1994. 84 See Nyhus et al. 1993. 85 See Lloyd Nyhus 1993, pointing to the importance of the classification in relation to surgical repair. 86 So did Condon & Nyhus in 1989 report following recurrence rates: indirect hernia 0-7%; direct hernia 1-10%; 5-35% recurrent hernia. 87 See a Californian statistical report from 1983 (see Anonymous:‘Conceptualization and measurement of physiological health for adults’, 1983). 310
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