Antonio de Gimbernat and his time in Madrid: The Royal College of Surgery of San Carlos

The transformation of Spanish Surgery in a modern scientific discipline takes place within the Royal Colleges of Surgery, and in all of them the figure of Antonio de Gimbernat and Arbós stands out over the rest. After completing his studies at the Royal College of Surgery of Cadiz (Real Colegio de Cirugía de Cádiz), under the tutelage of Pedro Virgili and his teaching and surgical work at the Royal College of Surgery of Barcelona (Real Colegio de Cirugía de Barcelona), it is in his almost forty years of stay in Madrid when the surgeon reaches his highest scientific and professional achievements. In these years, he is responsible for the creation, operation and development of the Royal College of Surgery of San Carlos (Real Colegio de Cirugía de San Carlos), and it is then when most of his rare but important publications were released, such as the ‘New method for operating the crural hernia’, whereby Gimbernat is considered the father of the modern surgery of this pathology. Unfortunately, the socio-political circumstances, the state of international isolation of the country and the unfair treatment received by Antonio de Gimbernat in the last years of his life diminished the impact of the work and studies of the man who for many has been the most illustrious surgeon of this country (AU)

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Davide Fieschi: a pioneer of plug repair in groin hernia surgery.

Plug repair actually represents one of most recommended procedures in open groin hernia repair. It is generally recognized that Lichtenstein in 1968 first introduced the plug technique for femoral and recurrent inguinal hernia. The present paper backdates more than 50 years the first application of a plug due to an ingenious Italian surgeon named Davide Fieschi.

Crucial steps in the evolution of the preperitoneal approaches to the groin: an historical review.

Preperitoneal approaches to the repair of primary, bilateral, recurrent, inguinal, and femoral herniae, the most common abdominal protrusions, now dominate techniques of repair. The purpose of this review is to outline crucial steps which have led to this result. Abernethy (Surgical cases and remarks. Of the operation for the aneurysm. Cadell and Davies (Strand), London, pp. 149-176, 1797) introduced an operation to treat aneurysms of the external iliac artery, which was endorsed by Cooper (The anatomy and surgical treatment of abdominal hernia. Longman and Co, London, 1804). Bogros (Essai sur l'anatomie chirurgical de la region iliac et description d'un nouveau procede pour faire la ligature des arteries epigastric et iliaque externe. Th. Paris, no. 153. A Paris, de l'imprimerie de Didot le Jeune, imprimeur de la Faculte de Medicine, rue des Macons, Sorbonne no. 13, 1823) described his preperitoneal space which continues into the suprapubic space of Retzius. Annandale (Edinb Med J 21:1087-1091, 1876) initiated anterior preperitoneal repair. Cheatle (Br Med J 2:68-69, 1920, Br Med J 2:1025-1026, 1921) demonstrated the median posterior preperitoneal approach, resurrected by Henry (Lancet 1:531-533, 1936). McEvedy (Ann R Coll Surg Engl 7:484-496, 1950) modified the Cheatle-Henry procedure by using a unilateral oblique incision in the rectus sheath and underlying transversalis fascia with medial retraction of the rectus muscle. Estrin et al. (Surg Gynecol Obstet 116:547-550, 1963) reinforced this repair with prostheses attached to Cooper's ligament, thereby, eliminating tension. Anterior prosthetic preperitoneal repair was introduced by Usher et al. (Am Surg 24:969-974, 1958) using polyethylene and, later, polypropylene meshes which were not slit, since the spermatic cord was lateralized. Stoppa et al., beginning in 1965, performed giant prosthetic reinforcement of the visceral sac, covering Fruchaud's myopectineal orifice preperitoneally with extensive overlap. They used a posterior approach to avoid scarring in recurrent cases and to allow the exposure of large, bilateral, inguinal, and femoral sacs (Rev Med Picardie 1:46-46, 1972). Wantz (Surg Gynecol Obstet, 169:408-417, 1989) proposed a unilateral version. Gilbert (Am J Surg 163:331-335, 1992) described the anterior preperitoneal sutureless repair of groin herniation. He employed a two-layered prosthesis, the upper resting on the transversalis fascia, the lower in the space of Bogros. They were connected by a plug passed through the internal inguinal ring. Kugel (Am J Surg 178:298-302, 1999) described his anterior preperitoneal prosthetic repair of groin herniation through an abdominal gridiron incision. Laparoscopic repair of groin protrusions began in 1982 (Ger; Ann R Coll Surg Engl 64:342-344, 1982). In 1992, Arregui et al. (Surg Laparosc Endosc 2:53-58, 1992) and Dion and Morin (Can J Surg 35:209-212, 1992) reported on their transabdominal preperitoneal (TAPP) approach. To avoid intraperitoneal complications, Dulucq (Cahiers Chir 79:15-16, 1991) recommended a totally extraperitoneal (TEP) approach. These techniques incur fewer recurrences than open techniques and diminish postoperative pain. However, the operating time is longer, they are more expensive, and special skills are needed. In addition, general anesthesia is required. Thus, late in the 18th century, surgeons began incising the groin to treat aneurysms there. This experience led to the discovery of the preperitoneal space of Bogros, which, in the 1870 s, was employed for the anterior repair of groin herniation. The posterior preperitoneal approach became established in the 1920s-1960s, along with the use of prostheses. Laparoscopy was applied near the end of the century.

[The history of treatment of groin hernia]. / Rys historyczny leczenia chirurgicznego przepuklin.

Hernia (Greek kele/hernios--bud or offshoot) was present in the human history from its very beginning. The role of surgery was restricted to the treatment of huge umbilical and groin hernias and life-threatening incarcerated hernias. The treatment of groin hernia can be divided into five eras. The oldest epoch was ancient era from ancient Egypt to 15th century. The Egyptian Papirus of Ebers contains description of a hernia: swelling that comes out during coughing. Most essential knowledge concerning hernias in ancient times derives from Galen. This knowledge with minor modifications was valid during Middle Ages and eventually in the Renaissance the second era of hernia treatment began. Herniology flourished mainly due to many anatomical discoveries. In spite of many important discoveries from 18th to 19th century the treatment results were still unsatisfactory. Astley Cooper stated that no disease treated surgically involves from surgeon so broad knowledge and skills as hernia and its many variants. Introduction of anesthesia and antiseptic procedures constituted the beginning of modern hernia surgery known as era of hernia repair under tension (19th to middle 20th century). Three substantial rules were introduced to hernia repair technique: antiseptic and aseptic procedures. high ligation of hernia sac and narrowing of the internal inguinal ring. In spite of the progress the treatment results were poor. Recurrence rate during four years was ca. 100% and postoperative mortality gained even 7%. The treatment results were satisfactory after new surgical technique described by Bassini was implemented. Bassini introduced the next rule of hernia repair ie. reconstruction of the posterior wall of inguinal canal. The next landmark in inguinal hernia surgery was the method described by Canadian surgeon E. Shouldice. He proposed imbrication of the transverse fascia and strengthening of the posterior wall of inguinal canal by four layers of fasciae and aponeuroses of oblique muscles. These modifications decreased recurrence rate to 3%. The next epoch in the history of hernia surgery lasting to present days is referred to as era of tensionless hernia repair. The tension of sutured layers was reduced by incisions of the rectal abdominal muscle sheath or using of foreign materials. The turning point in hernia surgery was discovery of synthetic polymers by Carothers in 1935. The first tensionless technique described by Lichtenstein was based on strengthening of the posterior wall of inguinal canal with prosthetic material. Lichtenstein published the data on 1,000 operations with Marlex mesh without any recurrence in 5 years after surgery. Thus fifth rule of groin hernia repair was introduced--tensionless repair. Another treatment method was popularized by Rene Stoppa, who used Dacron mesh situated in preperitoneal space without fixing sutures. First such operation was performed in 1975, and reported recurrence rates were quite low (1.4%). The next type of repair procedure was sticking of a synthetic plug into inguinal canal. Lichtenstein in 1968 used Marlex mesh plug (in shape of a cigarette) in the treatment of inguinal and femoral hernias. The mesh was fixated with single sutures. The next step was introduction of a Prolene Hernia System which enabled repair of the tissue defect in three spaces: preperitoneal, above transverse fascia and inside inguinal canal. Laproscopic treatment of groin hernias began in 20th century. The first laparoscopic procedure was performed by P. Fletcher in 1979. In 1990 Schultz plugged inguinal canal with polypropylene mesh. Later such methods like TAPP and TEP were introduced. The disadvantages of laparoscopic approach were: high cost and risk connected with general anesthesia. In conclusion it may be stated that history of groin hernia repair evolved from life-saving procedures in case of incarcerated hernias to elective operations performed within the limits of 1 day surgery.

Femoral pseudo-hernias.

Before surgical intervention in the femoral area, doctors should be mindful of two situations in which surgery is not indicated and, in fact, may cause harm.

History of treatment of groin hernia.

The history of open surgery for groin hernia has gone through many stages of development, including the ancient era (ancient times to the fifteenth century), the era of the start of herniology (fifteenth to seventeenth centuries), the anatomic era (seventeenth to nineteenth centuries), the era of repair under tension (nineteenth to mid-twentieth century), and the era of tensionless repair (mid-twentieth century to the present). Five principles of modern hernia repair developed through these periods of development: antiseptic/aseptic hernia operation, high ligation of the sac, tightening of the internal ring, reconstruction of the posterior inguinal floor, and tensionless repair. Interestingly, many of the initial attempts at laparoscopic hernia repair did not adhere to the recognized principles of hernia surgery learned from open surgery. It is only when the transabdominal preperitoneal mesh repair and the totally extraperitoneal approach, which adhere to the basic principles, are considered that the results of laparoscopic hernia repair procedures can improve and the recurrence of hernia decrease.

[Littré's hernia--clinical aspects and review of the history]. / Geschichte und Klinik der Littré-Hernie.

In 1700, the French surgeon Alexandre de Littré described for the first time a new form of inguinal hernia. This hernia varied from the known forms of hernias in its clinical course and in the postmortem examination results performed by Littrè himself. The characteristic feature of this hernia was the fact that the entire circumference of the bowel wall was not part of the hernial sac, but only the antimesenteric part of the intestinal wall. The underlying pathomechanism was explained 100 years later by Meckel. In a scientific paper about hernias some years earlier, Richter described the intestinal wall hernia, and this initiated the confusing use of the clinical entity known as the Richter-Littré hernia in Germany. In this case report we describe the historic development of this entity.

Historical aspects of laparoscopic hernia repair.

The history of the surgical treatment of groin hernias is reviewed with emphasis on the events leading to the introduction and development of the management of these hernias by a laparoscopic approach. The reasons for a shift from an inguinal to an abdominal approach are presented, and the early results of the latter are considered together with the possible advantages and disadvantages. Both methods rely on the use of small or large pieces of mesh that replace the previous bulwark of hernia repairs, namely the rearrangement of tissue layers. Currently, the challenge of the laparoscopic approach is being met by those espousing the inguinal approach.

A selective history of groin herniorrhaphy in the 20th century.

Of the histories of the many operations available in a general surgeon's technical armamentarium, that of groin herniorrhaphy has been written about repeatedly. Many of these reports focus on developments prior to the twentieth century. This article, instead, details selective evolutionary changes relative to groin hernia surgery during the last nine decades. Among the surgeons discussed are Battle, Ferguson, La Roque, Cheatle, Gallie, Henry, Tanner, McVay, Shouldice, and Lichtenstein.

The Cooper ligament repair.

Although a Cooper ligament repair is a more extensive operation than most hernia repairs, it can be done safely with minimal morbidity and a very low recurrence rate. A generous relaxing incision and careful technique around the femoral vessels are required. Many surgeons would choose a Cooper ligament repair for direct, large indirect, and femoral hernias only. I have used it for all groin hernias in adults, primary or recurrent, regardless of the presenting defect. I believe it is the best hernia repair done today.