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The Bassini tension problem (and does this affect the Kang direct repair)
I found this interesting quote from an abstract about the tension from the Bassini. There is a general difficulty of finding much about the surgical technique of the Bassini on the web, including either the original or the modified (corrupted?) version. Tension is supposed to be greater than the Shouldice, though, and, as far as I can tell, the recurrence rate is higher. This would be something to consider if you are thinking of choosing a Kang direct hernia repair, because Dr Kang uses a Bassini type approach with that repair.
Anyway, here’s a reason why that approach may fail.
“Tissues sutured under tension tend to pull apart but are prevented from doing so by the sutures; however, the tissues pulling on the sutures create an area of ischemic pressure necrosis where the suture meets the tissue.In more extreme cases in which the tension is greater than the strength of the tissues, the sutures simply tear the tissues and the hernia recurs.
Forcefully approximating the conjoined tendon to the inguinal or pectineal ligament in a Bassini or Cooper’s ligament-type repair in cases of a high arched myoaponeurotic upper border with a wide gap between the conjoined tendon and the inguinal or pectineal ligament creates tension, tissue necrosis, separation of the sutured tissues, and recurrence of the hernia. “
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5 Replies
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William
Dr Kang’s operation for an
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indirect
hernia is similar to a Marcy. On his last post, he said he is now still calling that the Kang repair. As you know, he performs totally different operation for a direct hernia. He said he was now calling that a Gibbeum (sp?) repair. That repair is supposed to be similar to the original Bassini, but I don’t think he has explained exactly what he does there.
It’s true that the Shouldice is supposedly based on the original Bassini, but I have no idea what that means either. I’ve looked around over the internet and have been unable to define the difference between the Shouldice and the Bassini, because you can’t really get much information on the Bassini.
There is a seemingly good version of a 4 layer Shouldice on youtube, though, by
biohernia. Here’s my understanding, though I’m just someone trying to understand this from afar.Ignoring the cremaster aspect of the Shouldice, here is how the four layers of the Shouldice are done.
For the first two layers, imagine the patient is lying on the operating table with his/her buttoned shirt on and the surgeon standing on his right side. The shirt represents the transversalis fascia, which is the border between the inguinal canal and the inner gut and hernia sac. The surgeon undoes the buttons (cuts the transversalis fascia) and pulls the right side of the shirt (where the buttons are on a man’s shirt) underneath the left side of the shirt and stitches that to the underside of the far left side of the shirt (in line with the left armpit). Then he takes the left side of the shirt (where the buttonholes are on a man’s shirt) and pulls that over the top of the right side of the shirt and stitches that in line with the right armpit (in the actual operation, this portion of the transversalis fascia is stitched to the inguinal ligament). That process is called the double breasting of the transversalis fascia and represents the first two layers. The one layer of the transversalis fascia has now been doubled up to form two layers for a stronger barrier against the hernia.
The surgeon in the biohernia video calls this the most important part of the shouldice. Indeed, in a study in 1994, they stopped right there with the Shouldice and the results were similar to the results of the four layer.
Concerning the final two layers, though, what I think is true, but have never heard or read anywhere, is that it’s almost a misnomer to refer to the rest as two more layers. The aponeurotic part of the transversus (conjoint tendon?) is pulled over and stitched to the inguinal ligament for the third layer. For the fourth “layer”, however, nothing else is pulled over (hence, not really another layer). This time the aponeurotic part of the same layer is stitched to the inner part of the external oblique just above the inguinal ligament. So that stitch is moved ever so slightly away from the inguinal ligament and I guess has a slightly different angle pulling on the aponeurotic part of the transversus (conjoint tendon). It’s not really much of a different “layer” of cover, but the slightly different angle maybe distributes the pressure a little away from the inguinal ligament is all I can imagine. Maybe like your two different arms pulling on a something from slightly different angles makes it easier to hold that thing in place(?)
The sutures are also run different in the shouldice than the bassini. So, with the shouldice, you have different tension bearing aspects sharing against the pressure of a direct hernia pushing through the transversalis fascia and the aponeuroses pulling against the inguinal ligament. I cant find good information on the Bassini, unfortunately, but as far as I can tell there isn’t as much distribution of the pull of the tissues against each other.
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I thought Dr Kang was a modified Marcy and Shouldice was a modified Bassini?
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It would be interesting to know if Lichtenstein used his mesh repair on all of his patients. Or if he varied the repair method based on what he found, and/or the type of hernia. It would also be interesting to try to understand how mesh became so popular. Was it a grassroots organic growth? Or something else. How did we get here?
That is the one thing that really shows the inherent bias in the Guidelines. One of the very first statements says that a pure tissue repair should only be used if mesh is not available. Who knows, maybe that’s why inexpensive mosquito netting is used in places that can’t afford the hernia netting made by the big companies.
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Let me apply a little skepticism to your post.
First, maybe reread the last paragraph that I quoted. The idea here seems to be that even if all tissue strengths were the same, the tension applied to the sutures could vary to some degree based on anatomy. Think of it like stringing an archer’s bow. The further you have to bend that bow both stringing it and pulling the string, the more tension on the string. That seems to be what it’s saying here. Perhaps this is what Watchful’s surgeon meant about “deep anatomy”, though he could have meant something totally different.
Second, if the tension is too strong, it seems possible that the sutures will be eating through the bite that is taken pulling the conjoint tendon side over to the inguinal ligament side. This is probably going to start immediately and the healing process to that tension may have trouble keeping up. I know I’ve read, or maybe heard it on one of the podcasts, that it’s usually not the sutures that fail, but the part of the body that they suture.
Third, there’s likely some weakness in the body collagen process already to even have a direct hernia, so although some healing is going to happen, the sutures are still probably going to be an element to the the continued success of the repair.
I’d love to avoid a mesh repair, but I need to be as realistic as possible.
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The body adapts to injury. The necrotic tissue gets replaced, the new collagen reforms to stronger collagen, healing happens. The initial tension is worth considering but it’s the results that matter.
In a way you are just following the logical path to the “tension-free” mesh repair concept. Which was/is a good idea to develop, but the prosthetic materials on the market today have new problems. The medical device makers have stopped trying to improve the concept (the revenue stream is very solid, the litigation has been priced in, there is no true device regulation), so here we are – lots of words, but no progress from the mesh suppliers. The meshes are all essentially the same as they were many decades ago.
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