By M. Wes Love, MD
Hernia is a problem which has plagued humankind since the beginning of written history. From the Greek word “hernios” meaning “bud” or “offshoot”, it was originally thought to be a problem that was created and exacerbated by coughing. Treatments originally consisted of stooping and bending, which were erroneously thought to reduce the bulging and improve the symptoms. Surgical fixation was poorly understood and attempts to perform surgery were messy affairs that were frequently fatal.
By the Middle Ages the concept of a “truss” had come into play and was for a time considered to be the standard of care for groin hernias. Although this was a technological advancement, it was hardly a solution. Interest in anatomy and cadaver study improved understanding of the problem, but still left us lacking a consistent solution. Sir Astley Cooper, who contributed much of our current anatomical understanding of the inguinal region and its many layers (to the point that “Coopers Ligament” bears his name today) once wrote “No disease treated surgically involves from surgeon so broad knowledge and skills as hernia and its many variants.”
In the 19th century technological advancements had progressed to the point that anesthesia and invasive surgical procedures were beginning to be routinely achievable as more than just a race against blood loss. Iterations of repairs were issued based on three concepts: 1. aseptic technique, 2. high ligation of the hernia sac, and 3. narrowing of the defect in the inguinal canal. While not flawed in theory, a problem manifested with concept three: tension. At the time, repairs consisted of closing the anterior fascial layers over the defect and were essentially doomed to failure. Recurrence rates were 100 percent at four years, and mortality was as high as seven percent. We were clearly still missing something.
Born in Pavia, Italy in 1844, Eduardo Bassini was the son of field workers and likely never intended to become a surgeon. He graduated from the university of Pavia at age 22, and one year later was wounded by a bayonet in the battle of Villa Glori. This left him with a wound to his iliac fossa which developed a colonic fistula. He spent a long time recovering from this injury and was cared for by surgeon Luigi Porta. Porta recognized the potential held by young Bassini, who had taken an anatomical interest in how to best repair his own injury. Based on his encouragement, Bassini eventually attained a professorial post in Padua and devoted his research to the study of the inguinal region. Driven by his personal experiences and encouragement of those around him, Bassini indeed revolutionized the repair of inguinal hernia. On Christmas Eve, 1884, Bassini performed the first of his “Bassini Repairs” on a patient who had an inguinal hernia. The patient recovered well, and there is no documentation of hernia recurrence. The breakthrough achieved by Bassini was his recognition that in order to prevent recurrence, merely covering the defect with more anterior layers was not sufficient. Instead, surgeons needed to close the “floor” of the inguinal canal to essentially obliterate the defect prior to also covering it with anterior layers.
As the Bassini repair gained prominence, multiple variations were described which were still based on the principle of floor closure. Shouldice described a method of imbricating the transversus fascia and sequentially reapproximating canal in layers. With the discovery of a technique to create synthetic polymers, Lichtenstein utilized the technology to describe a repair consisting of reinforcing the defect with synthetic “marlex” mesh. This gave rise to the principle of “tensionless” hernia repair to offload some of the disruptive forces onto a piece of synthetic material instead of the patient’s own tissue. These modifications dropped recurrence rates to less than three percent. However, all these advancements were in INGUINAL hernias. Ventral hernia did not enjoy the same success.
Attempts to correct ventral hernia were met with the same frustration, but not the same improvements. In ancient times, ventral hernias were limited to umbilical hernias, and sequelae of survivors of abdominal wounds from battle. However, as general abdominal surgery became more feasible, patients began to present with “incisional” hernias. It was soon recognized that simply primarily repairing central abdominal defects with suture had a very high recurrence rate. Given that upwards of 20 percent of primary laparotomy patients would go on to develop an incisional hernia, efforts at achieving a successful repair persisted.
Ventral hernia repair would not enjoy a significant advancement until the era of synthetics. Initial attempts at synthetic reinforcement centered around placement of silver wire mesh anterior to the fascia in an “onlay” fashion. Given the potential issues with a silver mesh implant in the soft tissue, this was transitioned to polypropylene mesh as it became more available. Initial iterations were heavy weight “marlex”, which is mostly of historical significance in the modern era. Attempts at “underlay” in an open fashion were described to capitalize on the force distribution of mesh placed in between the intra-abdominal pressure and the diseased tissue, which was considered an improvement in “onlay” technique. This unfortunately gave rise to the realization that synthetic material placed directly in the peritoneal cavity can be fraught with complications such as adhesions and fistula disease.
Jean Rives and Rene Stoppa issued a description of the “Rives-Stoppa” repair which utilized rectus myofascial release to offset tension at the midline and allow the layers of the abdominal wall to telescope upon one another. In 1975 Stoppa described the first open preperitoneal repair with mesh. The two aforementioned techniques were recognized to complement each other well, and recurrence rates were lower. However, the technique was considered difficult, not easily reproducible, and thus did not gain widespread popularity. Fast forward to the early 90’s when plastic surgeon Ramirez described the anterior “separation of components” which also facilitated release of tension from the abdominal wall similar to the Rives-Stoppa repair, but this time in an anterior instead of posterior fashion. It was unfortunately met with the same disdain as an overly complex solution for a seemingly simple problem of a “hole” in the abdominal wall.
As advancements in the field of surgery continued, laparoscopy emerged on the scene. The first laparoscopic inguinal hernia repair was described by Fletcher in 1979, and advanced by Schulz in 1990 when he described placing a mesh plug directly into the inguinal canal laparoscopically. On the heels of this, the transabdominal pre-peritoneal (TAPP) and totally extraperitoneal (TEP) repairs would be developed which are the mainstream of inguinal hernia repair today. In 1991 LeBlanc described a case series of five patients who underwent laparoscopic ventral hernia repair utilizing an intraperitoneal mesh coverage of the abdominal wall defect without defect closure. This eventually gave rise to the era of laparoscopic intraperitoneal onlay mesh (IPOM) repair for ventral hernia. The issue of the repair being mislabeled as an “onlay” when it is in fact an “underlay” is something to be aware of for those with a keen drive for proper semantics. This repair was also predicated on the desire for a tension free repair, which was thought to be achieved by not closing the defect, and instead covering it with a widely overlapping piece of synthetic mesh.
The problem here was two-fold: 1. The same issues with placing mesh directly into the peritoneal cavity persisted. 2. While recurrence rates were initially less than 10 percent, long term recurrence rates increased as over time the mesh fixation failed, and the mesh was pushed into the defect like any other hernia contents. A bevy of mesh products with “barrier coatings” touting the ability “to prevent adhesions and permit safe intraperitoneal placement” flooded the market. These devices eventually proved an inability to maintain stability against ever changing physiologic forces. The issue at the center of both problems was that mesh is not living tissue. It cannot regenerate or adapt the way the natural abdominal wall can. Over time, synthetic material succumbs to the forces of the abdominal wall if used solely as a barrier over a hernia defect. Eventually, surgeons recognized that we didn’t need better mesh, we needed a better technique.
Interest resurged in the ability to use mesh to reinforce a natural tissue repair by acting as an agent of force distribution, while placing it in a location in the abdominal wall which allowed it to both be below the defect yet out of the abdominal cavity. You might wonder: “But wasn’t just such a repair described by those French guys in the 70’s?”, and if so, you are correct.
Ventral hernia began to be understood as more than a hole in need of a patch. The abdominal wall began to be seen as a complex multilayered organ instead of a slab of tissue with a defect in it. As the field of abdominal wall reconstruction began to coalesce into a real specialty, interest in these more complex techniques began to re-emerge.
The advent of robotic surgery served to bolster interest in the subject, as well as attract new minds to the problem. Both open and minimally invasive techniques involving bilateral myofascial release and extraperitoneal underlay mesh began to be described more frequently. Novistky expanded on the concept of posterior myofascial release with his description of the transversus abdominus release (TAR). Carbonell described the robotic “double dock” technique which essentially allowed a completely robotic reproduction of the original open bilateral rectus myofascial release described by Rives and Stoppa. This also allowed continued dissection to perform TAR bilaterally as well, facilitating the repair of even massive loss of domain defects in a minimally invasive fashion.
As techniques improved and we learned from the mistakes of our past, we began to be plagued by the remnants of those mistakes. Recurrent hernia surgery involving complex mesh complications became a mainstay problem of abdominal wall reconstruction. Patients with hostile abdomens and massive adhesive disease did not make good candidates for minimally invasive repair given the lack of safe intraperitoneal working space. These patients could still be repaired in an open fashion, but it was not until Daes described the “enhanced view totally extraperitoneal repair” that a potential minimally invasive solution for such patients began to emerge. Originally intended to create a method of minimally invasive repair for large loss of domain inguinal hernias, the technique expanded upon the TEP repair to include entry into the preperitoneal space and development of a massive peritoneal flap well away from the inguinal region to create enough working space for minimally invasive repair of massive defects with large hernia contents. Belyansky and Daes expanded the indication for the procedure to ventral hernia by describing trocar entry into the rectus sheath, dissection of the posterior rectus sheath away from the muscle from within the sheath, crossing over to the opposite rectus sheath by way of the preperitoneal space below the linea alba, and essentially performing the famous French repair from the 1970’s in not only a minimally invasive, but also totally extraperitoneal fashion. This addressed hostile adhesions in the peritoneal cavity by avoiding entry into that cavity entirely. This repair also facilitated further posterior myofascial release such as TAR from within this vantage point if necessary.
We have come from an era where violation of the abdomen meant almost certain death, to struggling to invent a method of repair of our incisions beyond simple suture closure. Next, we began struggling to handle the complications of our inventions which were supposed to improve our complication rates. We created complex open repairs which were successful, but considered more trouble than they were worth to the average general surgeon. We have finally entered an era were not only can we provide a safe method of abdominal wall reinforcement to even complex abdominal wall patients, but we can do it in a minimally invasive fashion, which often allows the repair to be performed in an outpatient setting. Like every advancement in medicine, we are often slow to accept that which is beginning to manifest as superior. It is often not a bad phenomenon. Our nature to be skeptical of the “new” in favor of the “proven”, even if the “proven” is not perfect, is protective of our patients. It may prevent them from further harm incurred by subjecting them to an “experiment.” While this is an admirable trait amongst physicians, it can be prohibitive. This is particularly true among general surgeons. However, I would postulate that in the case of abdominal wall reconstruction, it is no longer an experiment. If this history lesson has provided you with nothing else, consider it a challenge to engage in the fascinating and progressive history of hernia repair. Put down the coated mesh, the trans-fascial sutures and the abdominal tacks. Dust off that Netter diagram of the layers of the abdominal wall, and dive backwards into the 1970s. Ask yourself, “Am I truly happy with the long-term outcomes of the procedure that is currently my go to hernia repair? Is my expectation that such a “simple” problem should have a quick simple solution actually fundamentally flawed?” One of the oldest surgical problems in the world isn’t going away. The onus is ours to strive such that our patient’s next hernia repair could well be their last.
Wes Love, MD specializes in minimally invasive general surgery with the Cahaba Valley Surgical Group.