What are the surgical steps for a Bassini repair in an adult male patient with a diagnosed inguinal hernia?

Surgical Steps for Bassini Repair

Critical Preface: Bassini Repair is Obsolete for Modern Practice

The Bassini repair should not be performed as a primary technique for inguinal hernia repair in contemporary surgical practice, as mesh repair demonstrates significantly superior outcomes with 0% recurrence rates compared to 19% with tissue repair techniques like Bassini. 1

Modern guidelines from the European Hernia Society and World Journal of Emergency Surgery strongly recommend mesh repair as the standard approach for all non-complicated inguinal hernias due to dramatically lower recurrence rates without increased infection risk. 1, 2

Historical Context and Current Relevance

The Bassini technique, introduced in 1887, represents a fundamental historical milestone in hernia surgery but has been superseded by tension-free mesh repairs. 3 Comparative randomized trials demonstrate that the Shouldice repair (a more advanced tissue technique) achieves only 6.1% recurrence rates, while Bassini repairs show 8.6% recurrence rates at 8.5 years follow-up. 4 Even these "improved" tissue repairs are inferior to modern mesh techniques.

When Bassini-Type Tissue Repair Might Be Considered

The only contemporary scenario where tissue repair without mesh may be appropriate is in small defects (<3 cm) with bowel necrosis or peritonitis where synthetic mesh is contraindicated. 1 In such contaminated fields (CDC class IV), primary tissue repair or biological mesh alternatives should be used instead of synthetic mesh.

Original Bassini Technique Steps (Historical Reference Only)

If performing the historical Bassini repair, the key technical principles include:

1. Incision and Exposure

• Make an oblique incision parallel to and above the inguinal ligament
• Divide the external oblique aponeurosis to expose the inguinal canal 3

2. Critical Step: Transversalis Fascia Division

• Divide the transversalis fascia completely - this is the fundamental distinguishing feature that allows proper mobilization 5
• This division enables the triple layer (transversalis fascia, transversus abdominis, internal oblique) to be mobilized without tension 5

3. Hernia Sac Management

• Identify and isolate the hernia sac
• Reduce or excise the sac contents
• Ligate the sac at the internal ring 3

4. Reconstruction

• Suture the mobilized triple layer (transversalis fascia, transversus abdominis, internal oblique) to the pubic tubercle and inguinal ligament using interrupted sutures 5
• The key principle is achieving approximation without tension through proper mobilization 5
• Reconstruct the inguinal canal by closing the external oblique aponeurosis 3

Why This Technique Fails Modern Standards

The Bassini repair has been criticized particularly by North American surgeons due to unacceptably high recurrence rates. 5 The fundamental problem is that inguinal hernias have a metabolic origin involving collagen defects, making pure tissue approximation inherently prone to failure regardless of technical execution. 6

Modern Alternative: What Should Actually Be Done

For clean surgical fields, perform Lichtenstein tension-free mesh repair (mesh placed anterior to transversalis fascia), which provides superior outcomes, is easier to learn and teach, and avoids complications associated with preperitoneal dissection. 6 Laparoscopic approaches (TAPP or TEP) offer additional advantages including lower chronic pain rates, faster recovery, and ability to identify occult contralateral hernias present in 11.2-50% of cases. 1, 7