The Bassini Hernia Repair Technique

The Bassini hernia repair, developed by Italian surgeon Edoardo Bassini in the late 19th century, represents a significant historical advancement in the surgical treatment of inguinal hernias. Although this hernia repair technique has largely been replaced by modern methods, particularly tension-free mesh repairs, it remains a critical part of surgical history and education.

The Bassini repair was revolutionary, reducing hernia recurrence rates dramatically compared to prior methods. It is based on the anatomical reconstruction of the inguinal canal by suturing the conjoint tendon to the inguinal ligament, aiming to restore the normal anatomy without the use of mesh.

The Foundation of Tension-Free Repair

Unlike the tension-free repairs that have become the standard in modern hernia surgery, the Bassini technique relies on creating tension by suturing tissues together. This was intended to restore the integrity of the inguinal canal’s posterior wall but contrasts sharply with the principles of tension-free repair that minimize recurrence and postoperative pain.

The Role of Surgical Technique and Mesh Integration

The key features of the Bassini repair include its avoidance of prosthetic materials and its reliance on the patient’s own tissues to repair the hernia defect. This method does not utilize mesh, setting it apart from contemporary techniques, which use synthetic materials to reinforce the repair site and support tissue integration.

The Bassini Technique Procedural Steps

The procedural steps involved in the historic Bassini technique included:

1. Initial Incision and Canal Exposure: The surgery commences with a precise skin incision along the inguinal canal, stretching from the pubic tubercle to the midpoint of the inguinal region. This strategic incision grants the surgeon access to both the inguinal canal and the hernia sac.
2. Locating and Preparing the Hernia Sac: Within the confines of the inguinal canal, the hernia sac is meticulously identified and isolated from adjacent tissues, including, in males, the spermatic cord. This isolation is crucial for the subsequent steps of repair.
3. Management of the Hernia Sac: The sac may undergo an inspection after being opened, followed by either reduction (repositioning into the abdominal cavity) or excision (removal), with the sac’s neck securely ligated to prevent recurrence.
4. Reinforcement of the Canal’s Posterior Wall: The essence of the Bassini repair lies in suturing the conjoint tendon—a fusion of the internal oblique and transversus abdominis muscles—to the inguinal ligament (also known as Poupart’s ligament). This suturing extends from the pubic tubercle to the internal ring, carefully excluding the rectus abdominis muscle and the fascia transversalis from the suture line.
5. Narrowing the Internal Ring: Adjustments to the internal ring may be made to reduce the risk of an indirect hernia making a comeback. This is achieved by narrowing the ring judiciously to avoid impinging on the spermatic cord’s pathway.
6. Layered Closure of the Inguinal Canal: Following the structural reinforcement, the inguinal canal is meticulously closed in layers, with special attention to the realignment of the external oblique aponeurosis. This step ensures the integrity of the repair and the anatomical restoration of the inguinal region.
7. Finishing Touches: The procedure concludes with the skin being sutured or stapled shut, followed by the application of a sterile dressing to the wound site.

Advantages and Considerations

The Bassini method offered advantages such as avoiding mesh-related complications, but it also presented significant disadvantages, including higher recurrence rates and increased postoperative pain due to the tension on sutured tissues. These limitations have led to its decline in use in favor of tension-free mesh repairs.

Types of Hernias Suitable for the Bassini Technique

The Bassini repair was historically utilized for indirect and direct inguinal hernias. These are hernias that appear in the groin area, either following the pathway of the inguinal canal (indirect) or resulting from a weakness in the inguinal canal floor (direct).

Types of Hernias Not Typically Repaired with the Bassini Technique

The Bassini technique is not suitable for repairing femoral hernias, incisional hernias, umbilical hernias, hiatal hernias, or large or complex hernias. These types of hernias require different surgical approaches, often involving mesh or more advanced techniques due to their anatomical locations or complexities.

Comparison of the Bassini Tension-Free Mesh Hernia Repair with Other Techniques

When compared to the Lichtenstein tension-free mesh repair and other modern techniques, the Bassini repair has fallen out of favor due to its higher recurrence rates and the postoperative discomfort associated with tension repairs. Tension-free mesh repairs, including the Lichtenstein method, provide more durable reinforcement of the inguinal canal and allow for quicker recovery times with less postoperative pain. Laparoscopic mesh repairs offer a minimally invasive alternative with even faster recovery, although they require general anesthesia, contrasting with the local or regional anesthesia that can be used for the Bassini repair.

In contrast, the Shouldice repair, another tension-based method, offers an improved recurrence rate over the Bassini technique through a more complex four-layer reconstruction but still does not match the effectiveness of tension-free mesh repairs.

Dr. Iskandar’s Thoughts

Bassini is mostly used these days in the emergency setting as a bailout option when mesh-based repairs are not doable due to the risk of infection, as in the case of strangulated hernias. It is rarely performed in the elective setting, where the shouldice method is preferred in my practice. 

Conclusion

In summary, the Bassini hernia repair technique, while an important step in the evolution of hernia surgery, has been largely superseded by methods that reduce the risk of recurrence and enhance patient recovery. Its use in modern surgical practice is limited to specific scenarios where mesh is contraindicated or unavailable. The development and adoption of tension-free mesh repairs have set a new standard in hernia surgery, reflecting ongoing advancements in surgical techniques and materials.