HISTORY AS A GUIDE TO A MODERN SURGEONS APPROACH

Listen during your consultation and be convinced that your surgeon is thinking about what is best for your personal and individual situation. Then a smooth and successful repair will be accomplished. Organized surgeons must integrate technique, craft, art, science, data bits and experience at stages of preoperative evaluation and planning and during the steps of surgery. Surgical procedures require accomplishing many successful steps, not one cut-and–paste maneuver. At times the steps are obvious, simple and fast. At other times, repair is elusive, complex and tedious. Each problem requires an individual solution. Frequently the solutions are similar, but rarely exactly identical. An experienced surgeon knows that ”there are no small operations, only small operators.” The “easiest” procedures sometimes result in the “biggest problems.” Loss of focus  during “mass production” can result in errors.

 

When a surgeon states, ”I always (only) do the XXX technique,” he declares that he is a technician. His technique will be effective most of the time. A good craftsman would embellish the basic technique to provide for individuality based on his previous experience. An artist will create new solutions to improve the results. All decisions must be based on experience, science, results, technique, craft and art; and then executed within the context of normal and abnormal anatomy, individual associated tissue factors and socioeconomic needs.

 

Influential advertising campaigns of contemporary clinics or institutions proclaim that their way is gospel. Surgeons will be successful most of the time rigidly adhering to one selected technique.

 

In Europe, Surgeons were satisfied for decades with a Bassini Repair, which was described before 1900. Americans however had poor results.

 

The reason is that  they omitted a step in identifying layers of tissue. The skills of local anesthesia dependable in the 1930’s were lost in the sixties until the pressure of the Canadian, Shouldice Clinic forced Americans to relearn it. This Clinic focused only on hernia repair by one technique and did not have general anesthesia available. The Shouldice Clinic did embellish the Classical Bassini Repair with the imposition of multiple reinforcing layers and accomplished enviable results employing the same method in rapid sequence for multitudes. Again, some results in the US were not equivalent to Canada because of misinterpretation of the description the same layer lost during adaption of the Bassini. Americans who understood the Canadian technique were successful.

 

Other Americans strove to further improve techniques based on wound requirement and new materials. Irving Lichtenstein, MD in California emphasized the avoidance of tension, not only to improve wound healing, but also to improve comfort and utilized mesh to create a reproducible Tension-Free Technique. Theoretically the impenetrable plastic mesh would insure the absence of recurrence. Local anesthesia was easily used and the procedure accomplished easily on an ambulatory basis.

 

Nyhus and Condon investigated a different approach, approaching the inguinal area from behind by making an incision in the stronger tissues away from groin. Their attempt to repair the hernia with the flimsy innermost tissue layers was not successful.

 

This preperitoneal approach, however, was expanded first by Stoppa in Europe, then Wantz in NY by under-laying an added wide layer of mesh in this deep preperitoneal layer behind those weak groin tissues but occluding all defects susceptible to herniation and sandwiching the large mesh between the weak abdominal wall and the peritoneal sac. These were open operations with significant incisions and generally reserved for recurrent hernias.

 

In the last decade, using video laparoscopic equipment, the deep technique of inlay mesh reconstruction was successfully adapted accessing deep the same  tissue plane through small punctures further minimizing postoperative pain, disability and scarring. The telescopic system connected to a video monitor also allows convenient magnification. The technique still in 2016 has not penetrated the majority of the surgical community despite excellent results, less postoperative pain, less wound infection and quicker return to normal activity.

 

Many other variations were devised for many reasons and Surgeons attached their names for eternal notice. Some developed shortcuts to provide economy of time in light of devaluation of surgical expertise. "Patches with plugs" were then used to fill defects quickly without defining anatomy. He must define and know the individual anatomy and identify all defects. One solution does not solve all similar problems. Individual tissues vary in strength. Habit does not replace thinking.

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    A. Douglas Heymann,
    MD, FACS.
    Over 50 years of experience.

    Dr. Heymann

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