Overview
Definition:
The Bassini repair is a historical open surgical technique for the treatment of inguinal hernias, described by Edoardo Bassini in 1889
It involves approximating the transversalis fascia and the conjoined tendon to the inguinal ligament, creating a reinforced posterior wall of the inguinal canal
This method aimed to reduce recurrence rates by strengthening the weakened inguinal floor.
Epidemiology:
Inguinal hernias are extremely common, affecting an estimated 1-3% of the general population
Indirect inguinal hernias are the most prevalent type
While the Bassini repair itself is largely historical, understanding its principles is crucial for appreciating the evolution of modern hernia repair techniques
Its recurrence rates, though lower than previous methods, were still significant compared to modern mesh repairs.
Clinical Significance:
While not a primary surgical technique in modern practice due to higher recurrence rates compared to mesh repairs, the Bassini repair holds significant historical and educational value
It represents a pivotal step in the development of tension-based hernia repairs and provides a foundational understanding of the anatomical principles involved in supporting the inguinal floor
Awareness is essential for understanding the rationale behind subsequent advancements and for recognizing its historical context in surgical literature, particularly relevant for DNB and NEET SS examinations which may include historical aspects.
Historical Context And Rationale
Predecessors:
Prior to Bassini, hernia repairs were often palliative or had very high recurrence rates
techniques were rudimentary
The focus was primarily on reducing the hernia contents, not on long-term repair of the anatomical defect.
Bassini Innovation:
Bassini's key innovation was the anatomical reconstruction of the posterior wall of the inguinal canal
He identified the weakened transversalis fascia and conjoined tendon as the primary issue in indirect inguinal hernias and sought to suture these structures to the inguinal ligament to create a more robust repair.
Tension Theory:
The Bassini repair is a tension repair, meaning the approximation of tissues creates tension
This tension was believed to provide the necessary support, but it also contributed to pain and recurrence due to tissue breakdown over time
This contrasted with later non-tension or mesh-based repairs.
Surgical Technique Principles
Patient Positioning:
The patient is typically placed in a supine position.
Incision:
A curvilinear incision is made over the inguinal canal, extending from the pubic tubercle laterally.
Hernia Sac Management:
The external oblique aponeurosis is divided longitudinally
The cord structures are identified and mobilized
The hernia sac is dissected, reduced into the peritoneal cavity, and ligated if necessary.
Posterior Wall Reconstruction:
This is the core of the Bassini repair
The transversalis fascia is incised and then sutured to the conjoined tendon (internal oblique and transversus abdominis muscles) and the inguinal ligament
This creates a shelf or reinforced floor for the inguinal canal
Specifically, three layers of sutures were typically placed: the transversalis fascia to the conjoined tendon, the conjoined tendon to the inguinal ligament, and finally the external oblique aponeurosis is closed over the repaired area.
Indications And Contraindications
Indications:
Historically, the Bassini repair was indicated for all types of inguinal hernias, particularly indirect inguinal hernias
It was considered a definitive repair at the time of its description.
Contraindications:
Absolute contraindications were minimal, primarily related to the patient's overall fitness for surgery
Relative contraindications might include severe tissue friability or significant infection, where a tension-free repair would be preferred if available.
Comparison With Modern Techniques
Recurrence Rates:
The recurrence rate for the Bassini repair is generally reported to be higher than modern mesh-based repairs
Early studies indicated rates around 10-15%, though this varied widely
Modern Lichtenstein or TAPP/TEP repairs with mesh have recurrence rates below 5%.
Tension Vs Tension Free:
The Bassini repair is a tension repair, leading to potential issues like chronic pain, wound dehiscence, and delayed healing
Tension-free repairs using prosthetic mesh (e.g., polypropylene) redistribute tension and offer superior outcomes and patient comfort.
Evolution Of Practice:
The development of prosthetic materials and a better understanding of tissue mechanics led to the widespread adoption of tension-free repairs, largely supplanting the Bassini technique for routine inguinal hernia repair in most surgical centers.
Key Points
Exam Focus:
Understand the anatomical structures Bassini approximated: transversalis fascia, conjoined tendon, and inguinal ligament
Recognize it as a historical tension repair
Be aware of its significantly higher recurrence rates compared to mesh repairs.
Clinical Pearls:
While you won't perform a Bassini repair in contemporary practice, grasp the surgical philosophy of anatomical reconstruction
This understanding informs the rationale behind why certain layers are reinforced in different hernia repair techniques
Its historical significance is often tested in surgical history questions for postgraduate exams.
Common Mistakes:
Confusing the Bassini repair with modern mesh techniques
Underestimating the impact of tension on surgical outcomes
Failing to recall the specific anatomical layers Bassini aimed to approximate for posterior wall reinforcement.