Bassini's Operation for Inguinal Herniation
Raymond C. Read, MD
During most of the 19th century, surgery for groin hernia
differed little from that described almost 2,000 years
earlier in Rome by Celsus. The main indications re-
mained pain, incarceration, and strangulation unrespon-
sive to taxis. An inguinoscrotal incision was made below
the external inguinal ring, and the peritoneal sac was
dissected, pulled down, ligated, and allowed to retract.
The pillars of the external ring were stitched around the
spermatic cord with deep sutures obliterating the distal
inguinal canal. In addition, the procedures of Gerdy
(1836), Wutzer (1838), Wood (1863), Kocher (1874),
Czerny (1877) and McEwen (1886) attempted to tampon-
ade the internal abdominal ring with invaginated skin or
hernial sac held there with sutures, wooden plugs,
escharotics, or trusses.1 Improved care was made possible
by the development of anesthesia, hemostasis, and anti-
sepsis, but many surgeons were slow to adopt these
advancements.
The state of herniology near the end of the century was
epitomized by Haidenthaller's report published in the
Arch f Klin Chir (1890). 2 Results from Billroth's clinic in
Vienna, along with data from other centers, were pre-
sented; German surgery was then recognized to be the
best in the world. Billroth's patients with inguinal hernia-
tion underwent 195 operations; 6% died from sepsis,
peritonitis, hemorrhage, or other operative complica-
tions. Alcohol injections to promote scarring often left
painful sloughs. The short-term recurrence rate was 31%.
One 19th century surgeon was reported to have re-
marked that the reason he didn't operate for inguinal
herniation was because he spent so much time applying
trusses to cases of those who did. The next article in this
German journal was by Bassini, 3 a comparatively un-
known Italian surgeon from Padua, a small town in the
marshes behind Venice. His report to an astonished
profession has rarely been equaled in its finality.
He described a series of 262 repairs for inguinal
herniation performed in 216 patients aged 1 to 69 years,
all but 4 of whom had been followed for 1 month to 4
years. Of the 251 without incarceration, only 1 died at 15
From the Central Arkansas Veterans Heahhcare Center; and the Department of
Surgery, University of Arkansas for Medical Sciences, Little Rock, AK.
Address reprint requests to Raymond C. Read, MD, 4300 West Seventh St,
2C100, Little Rock, AK 72205.
Copyright 9 !.999 by W.B. Saunders Company
1524-153X/99/0102-0001510.00/0
Operative T e c h n i q u e s i n G e n e r a l Surgery, Vol 1, No 2 (December), 1999: p p 105-115
days postoperatively of pneumonia. Three of the 11
treated for incarcerated or strangulated viscera died.
Thus, overall mortality was 1.5%, with a long-term
recurrence rate of 2.7%. Associated cryptorchidism was
treated in 17. Eleven wounds became infected (4.4%).
Bassini had previously presented his earlier results in
Italy4-7 and to the German Surgical Society, but his
publication in the Arch Klin Chir spread news of his
accomplishments worldwide. It caused a sensation. Al-
most overnight, surgeons flocked to Padua like it was
Mecca. Before detailing his technique, Bassini's rise from
obscurity to world acclamation will be documented. 8
The Man
Edoardo Bassini was born, 1844, into a wealthy family in
Pavia, located between Milan and Genoa, then under
Austrian rule. There he graduated from medical school at
the early age of 22 years and immediately joined Garibaldi
in the struggle for independence from Austria, France,
Spain, and the Papal states. Bayoneted in the groin, he
was taken prisoner. Infection and a fecal fistula devel-
oped, and Bassini was hospitalized for months before he
could return home. There he was successfully treated by
Porta (successor to Scarpa as Chairman of Surgery), who
gave him a teaching appointment. Bassini traveled exten-
sively, visiting Billroth in Vienna for a year (1873),
Nussbaum (Munich), Langenbeck (Berlin), and both
Spencer-Wells and Lister in London. He became a fervent
disciple of the latter, introducing antisepsis to Italy.
Academic advancement followed in anatomy, pathology,
and clinical surgery at Parma, La Spezia, and Padua,
where he was Chairman of Surgery (1888-1917). Recipi-
ent of many honors, simple, austere, moral, meticulous,
and a cautious operator who never married, he died in
1924 at the age of 80, 2 years after Halsted.
Bassini began his work on inguinal herniation in 1883.
He became discouraged with the repairs then in vogue.
Repeated recurrences were coupled with the finding at
autopsy that MacEwen's concertinered hernial sac ab-
sorbed. This experience led him to abandon the concept
of producing a scar under the external oblique aponeuro-
sis and expecting it to close the internal abdominal ring,
while allowing the spermatic cord to pass through the
inguinal canal. He decided to provide a new floor, new
inguinal rings, and restore the valvular obliquity of the
canal (analogous to the entry of the bile duct into the
105
106
duodenum and the ureter into the bladder), often de-
stroyed by large indirect herniae. Thus, a "radical" cure
(ie, not dependent on a postoperative truss) would be
obtained.
Development of his Operation
Confident in the principles and application of antisepsis,
hemostasis, and anesthesia (chloroform), Bassini, in
1884, began opening the external oblique aponeurosis,
the roof of the inguinal canal. He thus followed Bogros
(1823), 9 who used the anterior preperitoneal approach
for proximal (Hunterian) ligation of both the external
iliac and inferior epigastric arteries for aneurysm, and
Annandale (1876), 1~ the father of extraperitoneal herni-
orrhaphy. Lucas-Championierre, another student of Lister,
was the first to imbricate the external oblique aponeuro-
sis, and he later (1892) 11 claimed to have anticipated
Bassini in unroofing the inguinal canal. However, Bassini
went on to divide the transversalis fascial floor of the
inguinal canal as Bogros and Annandale had done earlier.
He then reconstructed a new floor, coupling it with
anteriolateral transplantation of the spermatic cord and
the internal abdominal ring.
Bassini first presented his work in April 1887, to the
Italian Society of Surgery in Genoa, Italy. 4 He described
42 herniorrhaphies in 38 patients. Later the same year in
Pavia, Italy, he reported to the Italian Medical Association
Raymond C. Read
on 72 operations in 63 men and 1 woman. 5 The next
year, 6 results of 102 repairs in 92 patients were given in
Naples, Italy to the Italian Surgical Society. He published
a 106-page book on hernia in i889, z detailing early
ambulation and reduced hospitalization. Its beautiful
illustrations and text were reprinted in a 1937 50th
anniversary volume 12published by his school, the Univer-
sity of Padua, Padua, Italy. In 1932, Catterina, a colleague
and the most important contributor to our understand-
ing of Bassini's technique, published an atlas (translated
into English in i934) 13 outlining the operation. It did not
become widely known outside of Italy (except by those
like Marcy who were corresponding members of Italian
surgical societies) until 1890 when, he published his
results in a widely read German journal. 3
Bassini's last publication on hernia (femoral) was in
1894.14 He politely refused to become involved in the
widespread arguments concerning priority and the many
modifications (corruptions) of his technique. This stand,
coupled with the paucity of illustrations, his failure to go
into enough detail regarding his technique (eg, he never
mentioned a word about encountering nerves), and his
insistence on his operation being applied to all candi-
dates, regardless of age, sex, or the type and size of the
defect, damaged the acceptance of his operation and
invited variations. Nevertheless, his operation was fre-
quently criticized unjustly by those who performed it
incorrectly.
Bassini's Operation for Inguinal Herniation 107

THE RADICAL OPERATION

The following description conforms to the original tech-

nique as described by Bassini's personal assistant, Ca-
terina, in his book as represented by Wantz.i5

1 Incision. Made in a skin fold, it extends 5 to 7 cm from the

pubic tubercle on a line toward the anterior superior iliac spine.
Early on, Bassini continued it into the scrotum. Camper's and
Scarpa's subcutaneous fasciae are then divided. (Adapted from
Wantz GE: The operation of Bassini as described by Attilio
Catterina. Surg Gynecol Obstet 1989; 168:67-80, fig 5, with
permission.)
108 Raymond C. Read

2 Aponeurosis of the external oblique muscle. This underlying roof of the inguinal canal is
transected from the superiomedial crus of the external inguinal ring to a point 1 cm lateral to the
internal ring identified 1 inch above the uppermost pulsations of the femoral artery. This superior entry
into the external oblique aponeurosis was designed so its closure would be cephalad to that of the
deeper repair. The two leaves of the cut external oblique aponeurosis are then separated from the
underlying internal oblique muscle and its cremaster extension by blunt dissection with the finger or
scalpel handle directed superficially against the aponeurosis. (Adapted from Wantz GE: The operation
of Bassini as described by Attilio Catterina. Surg Gynecol Obstet 1989; 168:67-80, fig 8, with
permission.)
Bassini's Operation for Inguinal Herniation 109

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3 Isolation of the cremaster muscle and the spermatic cord. This combined bloc of
tissue is bluntly encircled with the index finger and thumb of one hand and lifted en
masse off the pubic tubercle. The index finger of the other hand can then be easily
channeled underneath (Figure 2). A clamp or rubber drain is then passed. Isolation
from the underlying transversalis fascia floor of the inguinal canal is then gently
extended by blunt dissection to 1 to 2 cm beyond the internal abdominal ring, ending
up in the iliac fossa. The cremasteric muscular and fascial layer now have to be
separated from the enclosed spermatic cord. Unfortunately, Bassini, as with some other
details, did not spell out how he went about this. Apparently, he began a dorsal slit
close to the internal inguinal ring where the spermatic cord is incompletely wrapped.
Much of this phase of the dissection was performed bluntly with the fingers. From
his illustrations, which showed a mobile spermatic cord and divided branches off the
epigastric vessels, Bassini appeared to excise the cremaster muscle, along with its
genital nerve and blood supply. He showed at autopsy that, if left, the muscle atrophied
postoperatively. Fatty collections (lipomata) attached to the spermatic cord were
removed to reduce the diameter of the new internal abdominal ring. (Adapted from
Wantz GE: The operation of Bassini as described by Attilio Catterina. Surg Gynecol
Obstet 1989; 168:67-80, fig 9, with permission.)
110 Raymond C. Read

4 (A-B) Isolation of the hernial sac. Separation of the processus vaginalis was begun close to the internal abdominal ring where
the sac is freer than distally. In congenital hernias, where the hernia sac is continuous with the tunica vaginalis testis, the sac was
not removed but ligated with catgut suture, transected at its neck, and its distal portion was left or slit and inverted with sutures
behind the spermatic cord, similar to what is done for hydrocele. Regardless, Bassini opened sacs to inspect their content, separate
adhesions, etc. To rule out associated direct inguinal or femoral herniae, the divided peritoneal sac was fingered before its closure.
(Adapted from Wantz GE: The operation of Bassini as described by Attilio Catterina. Surg Gynecol Obstet 1989; 168:67-80, figs 11
and 13, with permission.)
Bassini's Operation for Inguinal Herniation 111

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5 Fascia transversalis floor of the canal. This was exposed by gently drawing the
spermatic cord downward and outward to stretch the transversalis fascia (anterior
lamina) as it overlies the inferior epigastric vessels near the neck of the sac. The floor
is then cut (not mentioned, but just implied by Bassini) lengthwise from the deep
inguinal ring to the pubis. The free edge of the triple layer (internal oblique and
transversus muscles and aponeuroses, along with the fascia transversalis) is then
picked up. Bassini used his thumb to separate off the underlying preperitoneal fat for
3 cm all around. By this maneuver, the epigastric vessels are loosened as they pass to
the rectus muscle. The superior pubic ramus with its attached ligament of Astley
Cooper, along with the back of the pubis, are thereby exposed. Injury to the urinary
bladder and the external iliac vessels are thus avoided.
Bassini's patients were younger, more muscular and smoked less than those seen
today. Perhaps for these reasons, he encountered fewer direct defects (19 of 251) with
nonincarcerated herniae (7.6%). If present, the pseudosac of a direct hernia,
consisting of stretched transversalis fascial floor, was excised and any extraperitoneal
fat or peritoneal sac inverted. (Adapted from Wantz GE: The operation of Bassini as
described by Attilio Catterina. Surg Gynecol Obstet 1989; 168:67-80, fig 14, with
permission.)
112 Raymond C. Read

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6 Repair. After dissection, the sac of an indirect hernia was twisted to evacuate content, ligated,
transfixed, and divided at its neck. Bassini incised the lateral musculature of the internal
abdominal ring (internal oblique and transversus) for 2 to 3 cm in the line of the incision, thus
allowing superiolateral explantation. To ensure high ligation of the sac, he dissected it for
approximately 2 cm "into the iliac fossa," so that its division was flush with the general peritoneal
cavity. He thereby anticipated Henry (1936), 16 who, from the posterior preperitoneal approach,
warned against distal ligation of the peritoneal sac at its false ring close to the internal abdominal
ring, rather than proximally at the true neck in the space of Bogros.
The construction of a new floor was carried out with 6 to 8 interrupted silk sutures, spaced 4
mm apart, extending 5 to 7 cm up from the pubic tubercle and 1 cm beyond the external inguinal
ring. Each was placed "like a purse string, passing in and out the triple layer twice," starting 2 to 3
cm back from its edge. The first sutures included the periosteum of the pubis, and both Henle's and
Colles' ligaments along with the rectus tendon and its sheath. The closure was thus inverted,
similar to the Shouldice multiple layer closure (the modern Bassini), thus providing a broad area of
fixation. The surgeon deflects and protects the underlying preperitoneal fat and inferior epigastric
vasculature while each suture i s placed. No sutures were inserted lateral to the internal abdominal
ring. l~ This structure is displaced 1 to 2 cm superiolaterally toward the anterior-superior iliac
spine as described previously. (Adapted from Wantz GE: The operation of Bassini as described by
Attilio Catterina. Surg Gynecol Obstet 1989; 168:67-80, fig 16, with permission.)
Bassini's Operation for Inguinal Herniation 113

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7 Closure of the external oblique aponeurosis over the transplanted spermatic cord.
(Adapted from Wantz GE: The operation of Bassini as described by Attilio Catterina. Surg
Gynecol Obstet 1989; 168:67-80, fig 17, with permission.)
114
Because Bassini's triple layer is stitched beneath the
mobilized spermatic cord to the iliopubic tract, femoral
sheath, and inguinal ligament, which were not distin-
guished one from the other, the spermatic cord is
transplanted above the plane of the internal oblique
muscle. The lower flap containing the inguinal ligament
was elevated to protect the underlying femoral vessels
while the two-bite purse-string sutures were inserted.
These were tied individually, medial to lateral. The last
was inserted 4 mm from the laterally retracted spermatic
cord, medial to the newly formed lateralized internal
abdominal ring.
The closure was tested for looseness of the internal
abdominal ring and the anesthesiologist was asked to
lighten the patient's anesthesia and encourage retching to
test the repair under direct vision. In women, the
operation is easier because the round ligament, their only
content of the inguinal canal, is simply divided and the
ring closed. The spermatic cord n o w rests on the recon-
strncted posterior wall of the inguinal canal, and the
external oblique aponeurosis is closed over it (see fig 8).
This is accomplished with a continuous silk suture
supplemented by interrupted sutures, allowing for the
formation of a new external inguinal ring. The subcutane-
ous layer is approximated with interrupted sutures, as is
the skin.
Like Halsted, Bassini insisted on strict antisepsis,
hemostasis, and precise technique with closure of dead
space and gentleness, all of which undoubtedly contrib-
uted to his excellent results. E. Willys Andrews, a
Chicago surgeon, visited Padua, Italy thrice and saw him
operate repeatedly. In 1899,18 he reported on this experi-
ence in great detail, validating Catterina's later account.
Andrews emphasized that Bassini's operation was carried
out in the preperitoneal plane, a finger being passed
intra- or extraperitoneally to guide suture placement.
This author, who popularized imbrication, pointed out
that Bassini accomplished the same thing with his
purse-string sutures. Wantz 15 suggests that Bassini origi-
nally operated on large, neglected hernias whose transver-
salis fascial floor of the inguinal canal had gone, with
deviation of the epigastric vasculature toward the pubis,
straightening the inguinal canal. Thus, there was superim-
position of the internal and external inguinal rings. Only
later, when he was seeing hernias earlier in their develop-
ment, did he routinely and purposely incise the floor of
the inguinal canal. Bilateral repair was undertaken when
indicated. Early in his experience, the w o u n d was
drained, later only with giant herniation. He encouraged
early ambulation and reduced the hospital stay by a third.
No truss was provided.
Bassini's technique, although labeled as the foundation
for many subsequent variations, was soon modified out
of all recognition, especially in North America. Halsted's
Raymond C. Read
initial procedure (1890) 19 transplanted the spermatic
cord to the subcutaneous position, thereby destroying
the obliquity of the inguinal canal, a valvular mechanism
to which Bassini had attached considerable importance.
The pampiniform plexus was also skeletonized, which
led to incidents of hydrocele and testicular infarction.
This experience, coupled with cases of femoral vein
thrombosis and bladder injury, prompted Halsted to
follow Bull and Coley (1891) 20 and Ferguson (1895) 21 in
designing a more superficial repair. The floor of the
inguinal canal was neither examined nor breached to
enter the preperitoneal plane. The cremaster muscle was
not excised. The internal oblique muscle was sutured to
Poupart's ligament, but over the spermatic cord. It was
left undisturbed in its muscular bed, making high liga-
tion of the hernial sac next to impossible.
It would be half a century before Shouldice, Obney,
and Ryan (1951-1953) 22 so successfully resurrected the
Bassini operation in its modern guise. During the inter-
val, a number of prominent surgeons, who had no right
to speak about the Bassini operation because they did not
follow his technique, attributed to the procedure recur-
rences resulting from their own improvisations.
In conclusion, the details of Bassini's operation for
inguinal herniation need to be k n o w n because they have
withstood a century of innovation. He, the father of
modern herniology, revolutionized the field and laid the
groundwork for the many advances we enjoy today.
REFERENCES
1. Read RC: The development of inguinal herniorrhaphy. Surg Clin
North Am 64:185-196, 1984
2. Haidenthaller J: Die radicaloperationen der hernien in de klinik
des prof Billroth 1877-89. Arch f Klin Chit 40:493-555, 1890
3. Bassini E: Ueber die behandlung des leistenbruches. Arch f Klin
Chir 40:429-476, 1890
4. Bassini E: Sulla cura radicale dell'ernia inguinale. Arch Soc Ital
Chit 4:379-382, 1887
5. Bassini E: Nuovo metodo per la cura radicale dell'ernia inguinale.
Atti d Congr d Assoc Med Ital 2:179-182, 1887
6. Bassini E: Sopra 100 casi di cura radicale dell'ernia inguinale.
Arch Soc Ital Chir 5:315-319, 1888
7. Bassini E: Nuovo Metodo Operativo per la Cura Dell'ernia
Inguinale. Padova, Properino, 1889, p 106
8. Read RC: The centenary of Bassini's contribution to inguinal
herniorrhaphy. AmJ Surg 153:324-326, 1987
9. BogrosAJ: Essai sur l'Anatomie Chirnrgicale de la Region Iliaque
et Description d'un Nouveau Procede Pour Faire la Ligature des
Arteries Epigastrique et Iliaque Externe. Paris, France, Didot le
Jeune, 1823
10. Annandale T: Case in which a reducible oblique and direct
inguinal femoral hernia existed on the same side and were
successfullytreated by operation. Edin MedJ 21:1087-1091, 1876
11. Lucas-ChampionierreJ: avec une etude statistique de deux cents
soixante-quinze operations et cinquante figures intercalees dans
le texte: Chirugie Operatoire: Cure Radicale des Hernies. Paris,
France, Paris Rueffet Cie, 1892
Bassini's Operation for Inguinal Herniation
12. Fasiani GM, Catterina A: Scritti di chirugia erniaria per commemo-
rare il cinquantenario delle operazione di Bassini (vol 1 and 2).
Padua, Italy, Universita di Padova, 1937
13. Catterina A: Bassini's Operation for the Radical Cure of Inguinal
Hernia. London, Lewis, 1934
14. Bassini E: Neue operations---Methode zur radical behandlurg der
Schenkelhernie. Arch Klin Chir 47:1-25, 1894
15. Wantz GE: The operation of Bassini as described by Attilio
Catterina. Surg Gynecol Obstet 168:67-80, 1989
16. Henry AK: Operation for femoral hernia by a midline extraperito-
neal approach. With a preliminary note on the use of this route
for reducible inguinal hernia. Lancet 1:531-533, 1936
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17. Harkins HN: The repair of groin hernias: Progress in the past
decade. S Clin North Am 29:1457-1482, 1949
18. Andrews EW: Major and minor technique of Bassini's operation,
as performed by himself. Med Record 56:622-624, 1899
19. Halsted WS: The radical cure of hernia. Johns Hopkins Hosp Bull
1:12-13, 1889
20. Coley WB: Review of radical cure of hernia during the last half
century. AmJ Surg 31:397-402, 1936 (editorial)
21. Ferguson AH: Oblique inguinal hernia, typic operation for its
radical cure. JAMA 33:6-14, 1899
22. Glassow F: The surgical repair of inguinal and femoral hernias.
Can Med AssocJ 108:308-313, 1973