Bassini and the vanished art of pure tissue inguinal hernioplasty

L.A. Danto, in a communication published in this journal, 1 denounced the potential danger of all those surgical strategies meant to prevent the chronic inguinodynia arising after an inguinal hernia repair with the use of a prosthetic mesh, and the almost complete abandon of the traditional inguinal hernioplasty. As reported in many series, the incidence of postoperative inguinodynia is not the only increased complication after mesh hernioplasty. The nature and properties of the prosthetic material pose in fact a high risk of complications as protrusion, extrusion, infection and intestinal fistulization, and most importantly, once in place, is rigid, passive, adynamic, and aphysiological. In turn, this increase in complications seems not to have been counterbalanced by a long-lasting decrease in the recurrence rate.2 Assumed as standard of care, the mesh placement distorted the fundamental principles of surgery, and shifted inguinal hernia from a disease itself to a risk factor. Surgery of inguinal hernia is in fact becoming surgery of prevention of complications from mesh placement, forgetting that the mesh itself is the main complication of the hernia surgery. Surgery remains an art technically based on 4 principles: what is united is separated (dieresis); what is separated is united (synthesis); what is exceeding is removed (exeresis); and what is missed is added (prosthesis). The use of prosthetic materials has thus its main indication in case of lack of tissue to prevent recurrence. Bassini, following these basic principles, showed that in most patients this lack of tissue is only apparent, and that surgery of hernia is a surgery of synthesis and not of prosthesis. He showed that the mobilization and the use of the musculoaponeurotic triple layer for the repair is sufficient and effective.3,4 His astonishing results (2% of recurrences) 100 years ago show the way of the future and offer a valid alternative to the use of mesh. With this indiscriminate use of prosthetic materials arises also an important bioethical problem. The goal of medicine is beneficence. The first step to reach this goal is “primum non nocere” (nonmaleficence).5 It is also well known that there are several situations in medicine where decisions cannot be made without the risk of inflicting some burden to patients. This does not seem to be the case with inguinal hernioplasty. In fact, most of the procedures can be performed with cooptation of viable tissue (synthesis) without the insertion of a foreign body (prosthesis). Unfortunately, it seems that many surgeons have forgotten the surgical principles of Parè, thus failing to reach the real goal at stake: the good of the patient.