Modified Bassini's repair: Our experience in a rural hospital setup
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.118276
Background: Inguinal hernia is a leading cause of work loss and disability. Recurrence and other complications can occur after hernia repair. The aim of this study wasto evaluate the effectiveness of Modified Bassini's Herniorraphy in themodern days of surgery. Materials and Methods : This is a retrospective study carried out in the MGM HospitalKamothe from 2005 to 2010. Only unilateral uncomplicated inguinal hernia cases were included.All patients had undergone Modified Bassini's repair. They were followed for 3 years and the complication and recurrence rates were noted. Result: A total of 254 patients were operated by Modified Bassini's repair only and 241 patients were followed completely and included in the study. The average age was 52.12 + 17.22 years. The mean operation time was 25 + 5.9 min. The mean hospital stay was 3 + 1.1 days. Post-operative pain was minimal in all patients, and was controlled by simple analgesia. Return to work was after 4 weeks. Hematoma and seroma formation requiring drainage were observed in one and two patients, respectively. Scrotal swelling was observed in two patients, which subsided within 2 weeks. Five patients developed urinary retention. No hydrocele, ischemic orchitis or recurrence was found during the follow-up. Wound infection was noted in one patient, which was treated by dressing and oral antibiotics. Recurrence was noted in two (0.83%) patients in the follow-up period of 3 + 0.44 years. Conclusion: Tissue repairs are still used in economically poor patients who cannot afford mesh, with similar results of prosthetic material repair that are commonly used in modern hospitals. Keywords: Hernia, inguinal hernia, Modified Bassini′s herniorraphy
In 1887, Edoardo Bassini introduced his method of successful inguinal hernia repair. The repair with mesh by the Lichtenstein technique, about 23 years ago, opened a new era in the repair. [1],[2],[3] Further still, the pre-peritoneal mesh placement may be taking over the Lichtenstein repair. [4] Undoubtedly, these newer techniques are having lower complication rates, but the cost is too high with non-availability in many areas, tendency to fold and wrinkle, movement that may lead to mesh failure, as the groin is a very mobile area, and chronic groin sepsis; that requires mesh removal. [5]
This is retrospective study that has been carried out in the settings of a rural hospital at MGM Kamothe during 2005 to 2010. All the patients were booked at first admission and their recordsw maintained. They were called for follow-up at 3 months and; 6 months, and then annually for 3 years. The operation was performed under general anesthesia or spinal anesthesia. The procedure was started by the standard inguinal approach and incision was made at the suprainguinal crease. Thereafter, the superficial fascia and deep fascia were divided to expose the external oblique aponeurosis. The external oblique aponeurosis was cut to open the inguinal canal. This cut was extended and the superficial inguinal ring was cut open to explore the cord. The spermatic cord was opened layer by layer and the hernial sac was exposed. The neck of the sac was dissected till proximal to the deep inguinal ring. Herniotomy was performed and the sac was ligated flush with the peritoneal cavity at the dissected point. Deep inguinal ring was assessed to admit only the tip of the little finger of the surgeon and repair was performed if the deep inguinal ring was found to be larger than this size or if it was lax. Thereafter, the patient was asked to strain or cough and, for procedures under general aneshesia, the anesthetist was asked to give a deep breath to the patient. It was ensured that there was no bulge of hernial sac at the deep inguinal ring. If a bulge was found then the repair was reassessed and; the excess peritoneal sac was excised further deep if required. These patients were excluded from the study. The conjoined tendon was then sutured to the inguinal ligament with prolene 1. In this repair, extreme care was taken to ensure that no suture was applied under tension and, if a tension was suspected, a Tanner slide incision was made. External inguinal ring was then repaired with the remaining prolene 1. Skin and subcutaneous tissue were approximated with silk 3/0. Perioperative antibiotic cover was achieved with Inj. Taxim 1 g intravenously 12 hourly and Inj Gentamicyn 80 mg intravenously 12 hourly for 24 h. Post-operative dressings were changed every third day and stitches were removed after 7 days. The patient was discharged on the thirdpost operative day. Post-operative dressings were changed under strict aseptic precautions. Inclusion criteria We included patients having unilateral uncomplicated primary inguinal hernias. Exclusion criteria Patients under 13 years of age were excluded. Also, patients with diabetes mellitus and chronic obstructive air way disease were excluded from the study. Patients with associated inguinoscrotal disease, such as hydrocele and; spermatocele, and those with obstructed or strangulated hernia were also excluded. Patients with recurrent hernia were also excluded from this study.
All the 300 patients in this series were males. The peak incidence was found in the fourth and fifth decades of life. Inguinal hernia was direct in 178 and indirect in 122 patients; of which 254 patients were included in the study. Of these patiens, 241 patients had a regular follow-up for the next 3 years; and 13 patients were lost to follow-up. The average age was 52.12 + 17.2 years, with an age range of 17-80 years, and 157patients had an age of 50 years and over. The mean operation time was 25 + 5.9 min. One hundred and ten (45.64%) patients required repair of the deep ring. In 57 (23.65%) patients, Tanner slide incision was required. The mean hospital stay was 3 + 1.1 days. Post-operative complications recorded are listed in the [Table 1]. Hematoma and seroma formation requiring drainage were observed in one and two patients, respectively. Scrotal swelling was observed in two patients, which subsided within 2 weeks. Five patients developed urinary retention; they were catheterised by a simple rubber catheter and were able to pass urine normally thereafter. No patient was having hydrocele during follow-up. No patient presented with ischaemic orchitis during the 3 years of follow-up. Wound infection was noted in one patient, which was treated by dressing and oral antibiotics. Three patients developed post-operative neuralgia, which was treated by carbamazepine or local anesthetic injection. Recurrence was noted in two (0.83%) patients in a follow-up period of 3 + 0.44 years. These patients were then treated by a Lichenstein hernioplast.
In the past few decades, there has been tremendous revolutionsin the field of hernia surgeries. Two important revolutions are mesh and laparoscopic repair. This has further enhanced the armamentarium of hernia repair, which already had more than 70 types of pure tissue repairs. Therefore, today, surgeons must often choose the operative technique that is suitable for both themselves and the patient from this array of techniques.However recurrence stilloccurs, although at a minimal rate, and this indicates that neither of the operative techniques isbetter than the other. Also, different levels of complexity and severity exist among inguinal hernias. [6] This problem is further compounded by the fact that everyone is becoming increasingly conscious on the subject of cost-effectiveness as surgeons are trying to combine two or more procedures in a single operation. [7] Our hospital is in the periphery, but recording of cases was good. Patients coming to the hospital werefollowed-up there itself as the hospital is the only referral cente in that area. The hospital stay and the use of commonly available medicines is not a big problem, especially in peripheral hospitals. On the contrary, the local purchase of medicines and the purchase of prosthetics by poor patients is a financially sensitive subject. Keeping in view this scenario, most of the surgeons in the peripheral hospitals are still using thetissue repair techniques for the treatment of inguinal hernia. Although Lichtenstien repair is considered the best method currently available to treat inguinal hernias, [8] and with the advent of laparoscopic surgery, even better results have been attained. The deficiency with our setting is non-availability of options, especially in the peripheral hospitals. There should be no hesitation in using more traditional methods of repair like the Bassini or the Shouldice repair. Some authors believe that the increasingly unacceptable recurrence rates may also be due to diminishing efficiency in the technical skill and familiarity with groin anatomy amongst the surgical students because of lack of training in this field. [2] In our study, we have found the recurrence rate to be less than 1%. Pinter and Markus in their study of 343 hernia repairs by the Shouldice method have reported a recurrence rate as low as 0.9%. [9] Although Lichtenstein's repair has been found to be useful and advantageous even in the patients with strangulated inguinal hernia, but this does not mean that tissue repairs are contraindicated for such patients, as is also indicated in the surgical literature. [10] In this study, the perioperative antibiotic cover was provided by Taxim and gentamicyn, whereby in patients operated by Lichtenstien's technique, the cover is provided by the same antibiotics. Thus, the cost of antibiotic was same for both techniques. Modern surgery should not only be oriented on the modern techniques but also be oriented on the cost-effectiveness of the surgery . Data analyzing biochemical and hormonal factors reveal that serum C-reactive protein (CRP) levels rise more in Lichtenstein (138.4 ± 72.5 mg/L) than in Bassini repair (137.2 ± 55.9 mg/L). [11] A difference in the levels of vascular endothelial growth factor and basic fibroblast growth factor, whose production is also regulated by interferongamma and interleukin-10, has been observed in a comparative study between Bassini hernia repair and Lichtenstein repair; however, the exact effect is still in the process of evaluation. [12] Hence, the tissue repair procedures should not be considered as historical interest only because they present important alternatives in patients where the method of mesh placement is not suitable for either technical or financial reasons. [2]
Although Lichtenstein's and laparoscopic repair of the inguinal hernia are the gold standard approaches, but the tissue repair procedures still held good. An efficiently learned and adequately performed tissue repair is not a primitive method that is to be avoided; rather, it has comparable results. Tissue repairs hold good even today in the deserving patients, and selected settings when undertaken without hesitation where necessary.
[Table 1]
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