Arthur Keith, the anatomist who envisioned herniosis.

Arthur Keith (1866-1955) was a renowned anatomist who published 529 contributions emphasizing the interaction between structure, function, and patient care. His only practice was 4 years as a family doctor, although he later trained to be a surgeon. Ten of his many articles related to hernia; two (1906, 1924) dealt with etiology. In these he rejected Russell's congenital saccular theory of abdominal herniation, since the latter's assertions regarding peritoneal diverticula were not supported by embryological research. Instead, Keith became the first to hypothesize that defects in the belly wall of adults were brought about by pathological damage to fasciae, aponeuroses and tendons, secondary to systemic connective tissue disease abetted by aging. The pelvis was similarly afflicted, leading to vaginal prolapse, the most common hernia among women. Diverticula were likely to sprout from a weakened alimentary tract. He stated that prevention was a serious consideration. The surgical establishment, overburdened by dogmas accumulated from 5,000 years of being solely responsible for the care of patients with herniae, ignored his hypothesis for decades. However, recent research in herniology has made him a prophet.

The contributions of Usher and others to the elimination of tension from groin herniorrhaphy.

Relaxing incisions (Wolfler 1892) were eventually shown (Read and McLeod, 1981) to reduce but not eliminate wound tension after sutured herniorrhaphy of the groin. Reinforcing prosthetics became widely shunned because of morbidity until Usher et al (1958) introduced polyethylene, then polypropylene mesh (1963) for preperitoneal tensionless repair of large defects. Excellent long-term results were obtained, with his technique, by Collier and Griswold (1967). Patt (1967) envisaged its application to primary hernia. Reis (1899) introduced early ambulation. However, it was not until Leithauser (1943), Blodgett (1946), and others showed immediate rising accelerated wound healing and reduced complications that Farquharson (1955) began outpatient hernioplasty (in 1950) under local anesthesia (Cushing 1900). Bellis (1964) followed, performing tensionless repair in 25%. Rodriguez and Phillips (1967) described office herniorrhaphy, 30% undergoing polypropylene mesh coverage without tension. Lichtenstein (1970) reported mesh onlay reinforcement for sutured repair of large defects, discharge was within 24 hours. Martin et al (1982) began (in 1972) to treat all inguinal herniation in adults with polypropylene mesh "to avoid recurrences". Newman did likewise, using tension-free placement (Rodriguez et al) in the subaponeurotic plane. Encountering resistance to publication ("real surgeons don't use mesh") he, in 1980, asked Lichtenstein to publish and popularize the technique. Kelly (1898) introduced plug prosthestic repair of femoral herniation. Drainer and Reid (1972) used polypropylene mesh from below under local anesthesia. Lichtenstein and Shore followed, treating recurrent inguinal defects similarly. Gilbert (1989) applied the technique to indirect herniae. Usher and others deserve recognition for their contributions to the elimination of tension from herniorrhaphy.

Interstitial recurrence, with chronic inguinodynia, after Lichtenstein herniorrhaphy.

Not long after Lichtenstein and Shulman (1986) introduced their subaponeurotic repair, Nyhus (1989) expressed concern regarding subprosthetic incarceration. Even though interstitial recurrence was not encountered over the subsequent decade or more, one of us (AIG) was referred three cases over the past 3 years. Two men and a woman suffered from chronic inguinodynia 1-6 years following a Lichtenstein procedure for unilateral primary inguinal herniation. A mass, in an unusual location (spigelian line) was palpated in one, the other two required ultrasound studies for diagnosis. All at surgery revealed indirect sacs, and one also had a separate protrusion in the lateral triangle of the groin. Two were repaired laparoscopically, the other using a bilayer connected prosthetic device. Our hypothesis is that this painful complication is now appearing because of recent modifications to the operative technique. An overlay lax dome-shaped prosthesis cannot be relied on to always initially collapse the inguinal canal. Mini-dissection, by limiting exposure, may prevent placement of the keyhole in the mesh close enough to the internal inguinal ring. Studies are under way to determine the validity of these conclusions.

Milestones in the history of hernia surgery: prosthetic repair.

Billroth (1878) envisaged prostheses before Bassini's sutured cure (1887). Phelps (1894) reinforced with silver coils. Metals were replaced by plastic (Aquaviva 1944). Polypropylene (Usher 1962), resisting infection, became popular. Usher instituted tensionless, overlapping preperitoneal repair. Spermatic cord was parietalized, to obviate keyholing. Stoppa (1969) championed the sutureless Cheatle-Henry approach encasing the peritoneum. His technique, "La grande prosthese de renforcement du sac visceral" (GPRVS), was adopted by laparoscopists. Newman (1980) and Lichtenstein (1986) pioneered subaponeurotic positioning. Kelly (1898) inserted a plug into the femoral canal; Lichtenstein and Shore (1974) followed. Gilbert (1987) plugged the internal ring, and Robbins and Rutkow (1993) treated all groin herniae thus. Incisional herniation has been controlled by prefascial, retrorectus prosthetic placement (Rives-Flament 1973). ePTFE (Sher et al. 1980) is useful intraperitoneally, since it evokes few adhesions. Here, laparoscopy (Ger 1982) is competitive. Beginning in 1964 (Wirtschafter and Bentley), experimental and clinical studies have shown herniation may be associated with aging and genetic or acquired (smoking, etc.) systemic disease of connective tissue. These data, with prospective trials, all but mandate tensionless prosthetic repair.