Under the Knife
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Short Stay, Fast Track
Rebels and Revolutions: Bassini and Lichtenstein
MEDICINE, ANATOMY AND surgery make abundant use of eponyms, names derived from the person who first invented or described an instrument, anatomical structure, condition, illness or operational procedure. Italian eponyms are indisputably the most enchanting: the Finochietto retractor, the Mingazzini test, the Donati stitch, the Scopinaro procedure, the Monteggia fracture, the sphincter of Oddi, the lacunae of Morgagni, Pacchioni’s granulations, the fascia of Scarpa, the Valsalva manoeuvre and the Bassini repair. It was in Italy – Padua, to be more precise – that genuine insight into how the human body functioned first developed. There, in the sixteenth century, a man from Brussels called Andries van Wezel broke the thousand-year-old tradition of uncritically applying ancient wisdom from books. He started cutting into corpses to find out the truth for himself. In his renowned book De Humani Corporis Fabrica (On the Fabric of the Human Body), published in 1543, Van Wezel – better known by his Latinised name Andreas Vesalius – showed not only how the human body is constructed but also that, for more than a thousand years, the wisdom in all the old books had been completely wrong.
Two hundred years later, at the same university in the same city, Giovanni Battista Morgagni did the same thing again, but now focusing on the diseased human body. He was the first to describe the course of diseases in living patients, and then to conduct autopsies after the patients died to see what had been wrong with them. Like that of Vesalius, his 1761 book De Sedibus et causis morborum per anatomem indagatis (Of the Seats and Causes of Diseases Investigated through Anatomy) was a great success. It was thanks to the work of these two men that medical science could develop based on facts, rather than on tradition.
But then the focus of scientific development shifted to other countries. Italy came under the influence of large foreign powers that intervened in its domestic politics and enjoyed fighting out their wars on the Italian peninsula. The country of Italy as we know it today has only been in existence since 1870. Before that, it was a collection of individual kingdoms and republics. The south was part of the French empire. In the middle was the Papal State, under the rule of the pope. The north was divided into a number of small states under the influence of yet other states. The unification of all these separate parts was partly due to the efforts of bandit and guerrilla fighter Giuseppe Garibaldi. Garibaldi led a small army of nationalists, who fought against both the French and the pope. France soon retreated, needing its armies more urgently in its war against Germany, but the pope succeeded in delaying the inevitable for another three years with a victory over a small group of freedom fighters in Rome in 1867.
In 1861, Pope Pius IX had called on all Catholics around the world to come and fight for the Papal State. Those who heeded the call were assigned to an army unit known as the Papal Zouaves. It was one of the Papal Zouaves who wounded a soldier from Garibaldi’s small army in the right groin with his bayonet. That unfortunate freedom fighter was Edoardo Bassini, a twenty-one-year-old recently graduated doctor who had joined the nationalists as an infantryman. His uncle had fought shoulder-to-shoulder with Garibaldi and had become a national hero. Under the leadership of the valiant Cairoli brothers, Edoardo and his unit of seventy men had advanced within reach of Rome. They could see the dome of St Peter’s Basilica on the horizon. With 300 men, the Zouaves were in the majority when the opposing parties met in the orchards of Villa Glori, on a hill a few kilometres from the Tiber in the late afternoon of 23 October 1867. The skirmish – which lasted about an hour – became known as the ‘scontro di Villa Glori’ (clash of Villa Glori) and led to a temporary suspension of the campaign against the Papal State.
So there he lay, the young Edoardo Bassini, under an almond tree near Rome in the autumn sun, with a gaping wound in his groin. Perhaps the doctor investigated the severity of his injury with his finger. It was not bleeding heavily, but the hole was deep, passing right through his abdominal muscles. It must have given him a particularly good view of the various layers of his abdominal wall and he would have been able to feel each of them individually. It may have been there, under that tree, that the idea was born that would later make him so famous.
Bassini was taken as a prisoner-of-war and treated, under guard, by former professor of surgery Luigi Porta in the university hospital in Pavia. The wound was down in the right lower abdomen and started to leak faeces. Bassini developed life-threatening peritonitis, but after a few days his fever retreated and the flow of excrement from the wound lessened. The bayonet had apparently pierced his caecum, the short cul de sac of intestine at the beginning of the great bowel. If it had been a little lower, the large blood vessels to his leg would have been pierced and he would have bled to death under the almond tree. A little higher and the large intestine would have been damaged and Edoardo would not have survived the peritonitis. He was extremely lucky – he recovered fully from his injuries and was set free a few months later.
Having lost his taste for fighting, Bassini rediscovered his interest in surgery and set out to learn more. He went to see all the great surgeons of his time: Theodor Billroth in Vienna, Bernhard von Langenbeck in Berlin and Joseph Lister in London. Back in the now-unified Italy, he became a professor at the University of Padua, the city of Morgagni and Vesalius. There, in 1887, he presented his fundamental solution to a problem that had not been solved in more than 3,000 years of surgery: how to treat a groin hernia.
A groin hernia is one of the most common conditions affecting humans. The mummy of Pharaoh Rameses V, who died in 1157 BC, shows clear signs of a groin hernia. The medical term is inguinal hernia, literally meaning ‘a breach of the groin’. Twenty-five per cent of men and three per cent of women will develop a groin hernia at some point in their lives. The cause is a congenital weak spot in the left and right lower abdominal wall.
The abdominal wall comprises three muscles lying one on top of the other. That is clear to see in the different layers in a slice of bacon. From the inside to the outside, these are the transverse abdominal muscle, the internal oblique muscle and the external oblique muscle. On both sides of the body, there is a hole in each of these three layers of muscle. Together, these three holes form a tunnel known as the inguinal canal.
Men are more likely to contract a hernia than women because, before they are born, their testicles have passed through the inguinal canal on their way from the abdomen to the scrotum. That can weaken its resistance to the high pressure in the abdominal cavity. In some cases, the inguinal canal is already so weak at birth that a groin hernia can develop in the early years of life. It can, however, still be robust enough to withstand the pressure for many years and only rupture much later. That is why groin hernias are most common among young children and the elderly.
That weak spot where the intestines protrude is known as the hernial gate. A hernia of the groin is also known as a rupture, but that term is misleading. A rupture of the abdominal wall refers only to the inguinal gate, and that in itself is not the problem. A groin hernia only causes complaints or complications if the contents of the abdominal cavity start herniating through the ruptured wall. The protruding intestines are still surrounded by the peritoneum. This is called the hernial sac. The protrusion of the hernial sac through the hernial gate (the inguinal canal) can be seen or felt on the outside as a subcutaneous swelling just above the groin crease. When the patient lies flat on his back, the hernial sac and intestines fall back inside and the swelling disappears. As with an umbilical hernia, the intestines can also become trapped in the hernial gate and strangulated. That causes a life-threatening incarcerated groin hernia.
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Hernia
Hernia is Latin for rupture. Although the word rupture suggests a tear or a crack, the medical term for these is not hernia, but fissure. Hernia is used only for a tear or crack through which something protrudes. It is used for two completely different conditions. A crack can develop in
one of the intervertebral discs in the spine, through which the soft core of the disc (the nucleus pulposus) can protrude. This is known as a hernia nuclei pulposi, spinal disc herniation or a ‘slipped disc’. If the protrusion presses against one of the nerve roots that leave the spine from the spinal cord, it can cause a radiating pain in the area supplied by that nerve root. In the case of a back hernia, the pain therefore radiates to the leg while, with a neck hernia, it radiates to the arm. The second form of hernia is the protrusion of the peritoneum through a rupture or weak spot in the abdominal wall. With an umbilical hernia, this weak spot is the umbilical opening, through which the umbilical cord once passed. In the case of a diaphragmatic hernia, it is the hole where the oesophagus passes through the diaphragm. With an incisional hernia, the weak spot is an old scar while, with a femoral hernia, it is the hole through which the blood vessels pass from the abdomen to the leg. With a groin hernia, the weak spot is the inguinal canal, through which – in the case of men – the testicles have moved down to the scrotum. That is why groin hernias are more common among men.
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Until Bassini, the treatment of a groin hernia focused on the result of the hernia rather than its cause; in other words, on the protruding hernial sac, but not on the hernial gate. The Mesopotamians, Egyptians and Greeks already had trusses to press groin hernias back inside and, from Roman times until well after the Middle Ages, groin hernias were also treated surgically. Firstly, the swelling could be seared from the outside with a branding iron. The benefit of this almost inhuman treatment is, however, not clear. It was probably applied simply because that was what was prescribed in the thousand-year-old book by the Arab surgeon Albucasis. Secondly, there was the real operation, which was already performed before the start of the Common Era. That entailed making an incision over the swelling, holding the hernial sac at the top, twisting it and stitching it up to seal it off. In the fourteenth century, French surgeon Guy de Chauliac preferred to use a golden thread for this procedure. The testicle would often die off following the operation. In the case of an incarcerated groin hernia, the patient was hung upside down to make the incision in the swelling, so that the contents of the hernia could be pushed back inside more easily. If, however, the incarcerated intestine was already strangulated, the patient would usually die. In the nineteenth century, methods improved as surgeons started working more hygienically and patients were anaesthetised. Nevertheless, until Bassini, they would still restrict themselves to removing the hernial sac, without treating the hernial gate. Consequently, there was always a risk that the problem would recur within a short time.
Bassini realised that the hernial sac was not the cause of the problem, but the effect. He focused on the cause, the weak spot, and spent many years studying the different layers of the inguinal canal. The basis of the Bassini procedure was restoration of the original anatomy of the abdominal wall after removing the hernial sac. This idea of operating not only to fix what was wrong but also restore the normal situation was new in surgery.
To reconstruct the original situation, however, you need to know exactly what that situation was. That means not only knowing what the body looks like normally (i.e. the normal anatomy of the abdominal wall), but how it has been changed by the groin hernia. It was therefore a happy coincidence that Bassini worked out his idea in Padua, at the university where Vesalius had laid out the basis for normal, and Morgagni for abnormal, anatomy. Bassini described his method in 1889 as a ‘nuovo metodo operativo per la cura radicale dell’ernia inguinale’, a new surgical method for the definitive repair of a groin hernia.
This was his revolutionary idea: cut open all parts that no longer comply with the normal anatomical situation and stitch them up again to reconstruct the abdominal wall as it ought to be. As he lay under the almond tree, Bassini must have been able to feel in the war wound that had gone through every layer of his own abdominal wall that this is easier said than done. He must have already understood back then that each of those layers play their own role in maintaining the solidity of the whole and therefore have to be repaired in their own way to treat a groin hernia.
Although seven different layers can be distinguished in the abdominal wall, Bassini discovered that they can be divided into three functional units, all of which have a distinct role to play in the abdominal wall and therefore have to be addressed differently in treating a groin hernia. Firstly, there is the protective covering, consisting of the skin, the subcutaneous tissue and the external oblique abdominal muscle. This layer does not contribute to the solidity of the abdominal wall, as it cannot sufficiently resist the pressure from inside the abdomen. Secondly, below the protective covering, is the muscle layer, comprising the internal oblique abdominal muscle, the transverse muscle and the transverse fascia or ‘second peritoneum’. This muscular layer has to withstand the pressure in the abdomen all on its own, and is therefore the key to the problem. Below that, lastly, is the hernial sac, formed from the peritoneum. Like the first layer, the hernial sac does not contribute to the strength of the abdominal wall.
With a groin hernia, the hernial sac protrudes through the muscle layer to form a swelling which is covered only by the protective layer. Bassini first cut open all the layers of the disrupted abdominal wall (the protective layer and the muscles) and then stitched up the muscle layer with strong silk thread – just like a fat man, whose belly has burst through the buttons of his shirt and sticks out under his pullover, tries to push it back by buttoning his shirt back up and tucking it into his trousers. Bassini described 262 patients operated on with excellent results.
Unfortunately, the Bassini repair was not adequate for treating severe hernias. In many cases, the essential muscle layer is so weakened by the groin hernia that it can no longer be used for reconstruction (in other words, the shirt is too small). Then additional solidity has to be provided. Metal wire, rubber and nylon were all used, but the body could not tolerate these materials and they broke easily. The solution eventually presented itself through space travel, where materials have to comply with very high requirements. The parachutes used to brake manned spacecraft were made of a polyethylene plastic that could withstand extreme forces. This material would have been assigned to the annals of history if it had not been applied in two very prominent products.
In 1957, it was used to make hula hoops, and in 1958 surgeon Francis Usher used a woven mesh of the material to repair a groin hernia. Scar tissue fuses the synthetic material with the surrounding tissues, restoring their original solidity. Usher placed the mesh deep in the abdominal wall, between the hernial sac and the muscle layer – as though the fat man gives up on the buttons on his shirt and puts on a robust undershirt instead.
Bassini had given surgery a second objective. An operation must now not only solve a problem but also, as far as possible, restore the original situation. The next major step in treating groin hernias would again affect surgery as a whole. It was taken by Irving Lichtenstein, an American surgeon with a private clinic, the Lichtenstein Hernia Institute, on Sunset Boulevard in Beverly Hills, Los Angeles. He operated on his groin hernia patients using a variation on the regular Bassini method, but what made his procedure so exceptional was that his patients were anaesthetised locally and, after the final stitch, could get up from the operating table themselves and go straight home. That was a truly revolutionary concept. When he presented his treatment procedure in 1964, surgeons were dumbstruck. Until then, patients would spend several days, or even weeks, in a hospital bed after undergoing a groin hernia repair.
What Lichtenstein did was, figuratively speaking, exactly in line with Bassini’s idea: to restore the normal situation as quickly as possible after the problem had been solved. Bassini was talking about the normal situation of the abdominal wall, Lichtenstein of the patient as a whole. That means not lying in a hospital and simply waiting, but being back at home and going about your daily business: walking, eating, drinking, taking a shower, working and so on. There proved to be no rea
son at all to lie in bed after a groin hernia operation.
We now know that you can not only walk around after many operations, but that it actually leads to fewer complications. In 2004, surgeons around the world were once again amazed when Danish surgeon Henrik Kehlet showed that this principle applied with major intestinal operations. Enhanced recovery, which Kehlet called ‘fast-track surgery’, was a combination of getting out of bed and eating and drinking normally as soon as possible, good painkillers, and ‘short stay’ – going home after one or two days in hospital. Until 2004, we surgeons literally forbade patients who had undergone bowel surgery to eat a single mouthful until they had passed wind. We had rinsed their intestines completely, intravenously administered fluids so that they did not have to drink and fitted a urinary catheter so that they could stay in bed and not have to get up to use the toilet. They would stay in hospital for at least two weeks, and no one was surprised when they developed strange complications like bowels that suddenly stopped working, lungs filling with fluid, bedsores and pressure ulcers or thrombosis in the legs. Since 2004, the intestines are no longer rinsed, patients are given a sandwich a couple of hours after the operation, we administer only the minimum of fluid through a drip, so that they can feel thirsty themselves and want to drink, and they get out of bed as soon as possible, for example to use the toilet without the need of a catheter. The fast-track concept has now been adopted in all branches of surgery, from groin hernia repairs to hip replacements.