Bassini Hernia Repair
Bassini Hernia Repair: An Overview
Introduction to the Technique
- Purpose: The Bassini hernia repair is used for treating inguinal hernias.
- Method: It involves suturing the transversalis fascia and the conjoined tendon to the inguinal ligament behind the spermatic cord using a monofilament nonabsorbable suture.
Advantages and Suitability
- Robust and Cost-effective: The Bassini repair is straightforward and cost-effective, making it suitable for limited-resource settings where expensive prosthetics are unavailable.
- Utility in Specific Scenarios: Especially useful where the use of mesh is not feasible, such as in contaminated fields.
Modifications and Comparison with Other Techniques
- Modified Bassini Repair: Involves high ligation of the hernia sac and reconstruction of the inguinal floor.
- Comparison with Lichtenstein’s Mesh Repair (LMR):
- Simplicity: LMR is considered simpler than the Modified Bassini’s Repair (MBR).
- Operating Time: MBR takes more operating time than LMR.
- Complications: Common complication in both is seroma formation.
- Recurrence Rate: Higher in MBR, with two recurrences noted in a comparative study, as opposed to none in LMR.
Recurrence Rate and Durability
- Recurrence and Effectiveness: The Bassini repair, despite its advantages, has a higher recurrence rate compared to Lichtenstein/mesh repair.
- Long-term Durability: It is still valued for its low recurrence rate and long-term durability with minor complications.
Conclusion
- Role in Surgical Practice: While not the first choice in many settings due to the availability of simpler techniques like the Lichtenstein repair, the Bassini repair remains a valuable option in the surgical repertoire, particularly in resource-limited environments or specific clinical situations.
Bassini Repair Technique
Principle
- Introduction: The Bassini repair, first described in 1890 by Bassini, focuses on fixing a triple layer.
- Layers Involved: This includes the fascia transversalis, the transversus abdominis muscle, and the internal oblique muscle, attached to the inguinal ligament.
- Important Consideration: Often, this method is performed without splitting the transversalis fascia, leaving a weak spot.
Procedure
-
Incision and Preparation:
- Incision of the transversalis fascia and preparation of both flaps.
-
Bassini Suture:
- Initially, the Bassini suture is placed at the medial end.
- The stitch goes cranially through the internal oblique muscle, the transversus abdominis muscle, and the edge of the transversalis fascia, and then caudally through the lower edge of the transversalis fascia, the reflex ligament, and the pubic periosteum.
- A non-absorbable, monofilament suture of size 2-0 is recommended, initially not tied.
- Caution: Deep stitching through the periosteum can lead to bleeding or persistent postoperative pain.
-
Additional Single Knot Stitches:
- Additional single knot stitches are placed laterally at approximately 0.7 cm intervals, catching the inguinal ligament caudally.
- These stitches are also clamped and not immediately tied.
-
Inguinal Ligament and Injury Prevention:
- Stitches at the inguinal ligament should not be directly at the lower edge to avoid pulling up the ligament and opening the femoral hernia portal.
- Stitches should alternate approximately 3 mm and 6 mm from the lower edge.
- Caution: Avoid deep stitching through the ligament to prevent injury to the underlying femoral vessels.
-
Reconstruction of the Internal Inguinal Ring:
- The final stitch reconstructs the internal inguinal ring.
- A Hegar stick size 11-12 or a little finger should still comfortably fit.
- Once all stitches are placed from the pubic tubercle to the internal inguinal ring, they are tied in reverse order.
- Caution: Do not tie the sutures too tightly to avoid circulatory disturbances and tissue necrosis.
-
In Case of High Suture Tension:
- For high tension, such as in cases of ‘internus high stand’, an incision of the anterior rectus sheath is recommended for relief.
- Incise medially from the muscle edge, leaving a few centimeters wide rectus sheath stem distally to avoid compromising blood flow.
-
Completion of the Procedure:
- After repositioning the spermatic cord, the external oblique aponeurosis is closed.
- The procedure is concluded with a subcutaneous and skin suture.
Important Notes
- Attention to Technique: Accuracy in suture placement and avoiding too deep stitches are essential for the success of the operation.
- Prevention of Complications: Careful handling of sutures to prevent circulatory disturbances and tissue damage.
Complications of Bassini Hernia Repair
Common Complications
-
Scar Tenderness:
- Most frequent complication, occurring in both Bassini and Lichtenstein repairs.
-
Erythema:
- Redness around the surgical site.
-
Scrotal Swelling:
- May arise from fluid accumulation or inflammation.
-
Neuralgia:
- Postoperative nerve pain.
-
Superficial Wound Infection:
- Infection at the incision site.
-
Funiculitis:
- Inflammation of the spermatic cord.
-
Seroma Formation:
- Development of a pocket of serous fluid.
-
Wound Hematoma:
- Localized bleeding outside of blood vessels.
-
Urinary Retention:
- Inability to empty the bladder completely.
Testicular Complications
- Ischemic Orchitis and Testicular Atrophy:
- Can manifest 24 to 72 hours postoperatively.
Recurrence Rate
- Variability: Ranges from 10-40% in non-specialized centers.
- Study Findings: A lower recurrence rate of 3.7% reported in a single-center cohort study.
Bassini Hernia Repair: An Overview
Introduction to the Technique
- Purpose: The Bassini hernia repair is used for treating inguinal hernias.
- Method: It involves suturing the transversalis fascia and the conjoined tendon to the inguinal ligament behind the spermatic cord using a monofilament nonabsorbable suture.
Advantages and Suitability
- Robust and Cost-effective: The Bassini repair is straightforward and cost-effective, making it suitable for limited-resource settings where expensive prosthetics are unavailable.
- Utility in Specific Scenarios: Especially useful where the use of mesh is not feasible, such as in contaminated fields.
Modifications and Comparison with Other Techniques
- Modified Bassini Repair: Involves high ligation of the hernia sac and reconstruction of the inguinal floor.
- Comparison with Lichtenstein’s Mesh Repair (LMR):
- Simplicity: LMR is considered simpler than the Modified Bassini’s Repair (MBR).
- Operating Time: MBR takes more operating time than LMR.
- Complications: Common complication in both is seroma formation.
- Recurrence Rate: Higher in MBR, with two recurrences noted in a comparative study, as opposed to none in LMR.
Recurrence Rate and Durability
- Recurrence and Effectiveness: The Bassini repair, despite its advantages, has a higher recurrence rate compared to Lichtenstein/mesh repair.
- Long-term Durability: It is still valued for its low recurrence rate and long-term durability with minor complications.
Conclusion
- Role in Surgical Practice: While not the first choice in many settings due to the availability of simpler techniques like the Lichtenstein repair, the Bassini repair remains a valuable option in the surgical repertoire, particularly in resource-limited environments or specific clinical situations.
Bassini Repair Technique
Principle
- Introduction: The Bassini repair, first described in 1890 by Bassini, focuses on fixing a triple layer.
- Layers Involved: This includes the fascia transversalis, the transversus abdominis muscle, and the internal oblique muscle, attached to the inguinal ligament.
- Important Consideration: Often, this method is performed without splitting the transversalis fascia, leaving a weak spot.
Procedure
-
Incision and Preparation:
- Incision of the transversalis fascia and preparation of both flaps.
-
Bassini Suture:
- Initially, the Bassini suture is placed at the medial end.
- The stitch goes cranially through the internal oblique muscle, the transversus abdominis muscle, and the edge of the transversalis fascia, and then caudally through the lower edge of the transversalis fascia, the reflex ligament, and the pubic periosteum.
- A non-absorbable, monofilament suture of size 2-0 is recommended, initially not tied.
- Caution: Deep stitching through the periosteum can lead to bleeding or persistent postoperative pain.
-
Additional Single Knot Stitches:
- Additional single knot stitches are placed laterally at approximately 0.7 cm intervals, catching the inguinal ligament caudally.
- These stitches are also clamped and not immediately tied.
-
Inguinal Ligament and Injury Prevention:
- Stitches at the inguinal ligament should not be directly at the lower edge to avoid pulling up the ligament and opening the femoral hernia portal.
- Stitches should alternate approximately 3 mm and 6 mm from the lower edge.
- Caution: Avoid deep stitching through the ligament to prevent injury to the underlying femoral vessels.
-
Reconstruction of the Internal Inguinal Ring:
- The final stitch reconstructs the internal inguinal ring.
- A Hegar stick size 11-12 or a little finger should still comfortably fit.
- Once all stitches are placed from the pubic tubercle to the internal inguinal ring, they are tied in reverse order.
- Caution: Do not tie the sutures too tightly to avoid circulatory disturbances and tissue necrosis.
-
In Case of High Suture Tension:
- For high tension, such as in cases of ‘internus high stand’, an incision of the anterior rectus sheath is recommended for relief.
- Incise medially from the muscle edge, leaving a few centimeters wide rectus sheath stem distally to avoid compromising blood flow.
-
Completion of the Procedure:
- After repositioning the spermatic cord, the external oblique aponeurosis is closed.
- The procedure is concluded with a subcutaneous and skin suture.
Important Notes
- Attention to Technique: Accuracy in suture placement and avoiding too deep stitches are essential for the success of the operation.
- Prevention of Complications: Careful handling of sutures to prevent circulatory disturbances and tissue damage.
Complications of Bassini Hernia Repair
Common Complications
-
Scar Tenderness:
- Most frequent complication, occurring in both Bassini and Lichtenstein repairs.
-
Erythema:
- Redness around the surgical site.
-
Scrotal Swelling:
- May arise from fluid accumulation or inflammation.
-
Neuralgia:
- Postoperative nerve pain.
-
Superficial Wound Infection:
- Infection at the incision site.
-
Funiculitis:
- Inflammation of the spermatic cord.
-
Seroma Formation:
- Development of a pocket of serous fluid.
-
Wound Hematoma:
- Localized bleeding outside of blood vessels.
-
Urinary Retention:
- Inability to empty the bladder completely.
Testicular Complications
- Ischemic Orchitis and Testicular Atrophy:
- Can manifest 24 to 72 hours postoperatively.
Recurrence Rate
- Variability: Ranges from 10-40% in non-specialized centers.
- Study Findings: A lower recurrence rate of 3.7% reported in a single-center cohort study.