Hernia – (Hernia in English), derived from the ancient Greek word hernios, meaning a branch or outgrowth from the main stem. Extra-abdominal hernia, including inguinal hernia, incisional hernia, umbilical hernia, white line hernia, semilunar hernia and lumbar hernia. The evolution of human perception of hernia and abdominal wall surgical disorders epitomizes the development of surgery as a whole. Advances in surgical anatomy, asepsis, anesthesia and pain relief, material science, and minimally invasive techniques have all played a crucial role in the evolutionary history of hernia surgery. This section discusses the evolution of hernia surgery by period, represented by the historical development of the treatment of the most common inguinal hernia. I. Ancient understanding of inguinal hernias Inguinal hernias are commonly seen as localized masses that are both visible and palpable. It is a disease specific to the evolutionary process of mankind, i.e., after changing from crawling to upright, and is one of the first diseases recognized by man. Inguinal hernias have been documented as early as about 1552 BC. In The Egyptian Papyrus of Ebers mentions the observation of a hernia: “When you judge a protrusion on the surface of the abdomen …… it occurs …… by coughing caused by a cough”. In 900 BC, there is a Phoenician figurine that clearly shows the treatment of a hernia with a hernia belt in the time of Alexander. The identification of a hernia and a scrotal effusion was also described by Hippocrates in 400 B.C. The civilizations of the ancient Greek and Roman periods were also prominent in medicine. Celsus (before 50 A.D.) spread the medicine of the ancient Greek and Alexandrian periods to Rome. Hernia belts were widely used. Surgery was recommended for those patients with pain, but the incision was chosen at the scrotum below the pubic bone, and the hernia sac was excised after freeing it from the spermatic cord, while the wound was left open to heal by natural formation of a granulation scar, and cautery was given for large wounds to promote scar formation. Vascular ligation was used during surgery to stop bleeding and protect the testes, and these measures are considered to be the beginning of true hernia treatment. Galen (200 AD) followed Celsus’ idea that hernias were caused by rupture or stretching of the peritoneum, but advocated ligation of the hernia sac and spermatic cord by simultaneous removal of the testis. II. Medieval Europe and the Renaissance Age Medieval Europe entered a dark age for mankind due to the domination of religious theology, and the development of science was likewise greatly restricted. As surgical operations were despised due to their bloody and filthy nature, the practice was mostly composed of barbers, tailors, and other people. The use of a red-hot iron to stop bleeding was replaced by fine vascular ligation, and there was no anesthesia for the operations at that time, and these were predictably gruesome and brutal. The ancient Greek scholar of the time, Paulus Aegineta (700 AD), although accurately describing hernia surgery, advocated the routine removal of the G-sphere during surgery, which was certainly a step backwards compared to Celsus’ philosophy. It was not until about five hundred years later that William (c. 1210-1277) explicitly proposed the need to preserve the testes for hernia surgery. in 1363, Chauliac first distinguished between inguinal and femoral hernias in terms of site of onset. The European Renaissance (15th to mid-17th centuries) was a clear catalyst for the development of hernia and medicine in general. The rise of cadaveric anatomical studies led to a more comprehensive understanding of hernia and a consequent fundamental impetus in the development of hernia treatment. Ambroise Pare of Paris (1510-1590) is credited with being one of the founders of modern surgery, advocating the use of vascular ligation techniques to stop bleeding instead of hot oil or cautery, and elevating the surgeon from a craftsman to a respected profession. In his book The Apologie and Treatise, he documented how to return the contents of a hernia and close the peritoneum with gold sutures and condemned the surgical method of removing the G-sphere. Pierre Franco (c. 1500-1565) was a famous French surgeon who described in detail the surgery of hernias, including some early techniques on how to prevent damage to the testes and vas deferens, and the treatment of incarcerated hernias. He pointed out the fatal risk of incarcerated hernias, advocated their release in the event of strangulation, and invented a stripper with grooves to loosen the entrapped intestine. Astley Paston Cooper (1768-1841), a famous anatomist and physician, published “Treatise on Hernia” and “The Anatomy and Surgical Treatment of Abdominal Hernia”. Surgical Treatment of Abdominal Hernia”, Cooper first described the pubic comb ligament and the transversus abdominis fascia and recognized the role of the transversus abdominis fascia in the development of hernias, and his ideas are still relevant today. He argued that “as the internal oblique abdominal muscles, the transversus abdominis, rise from their point of attachment in the inguinal region, there is a layer of fascia that lies between them and the peritoneum from which the entire spermatic cord passes out of the abdominal cavity. This layer of fascia, which I will tentatively name the transversus abdominis fascia, varies in strength. On the iliac side it is very tough and on the pubic side it is very weak.” “The transversus abdominis tendon membrane and the transversus abdominis fascia are the main barriers against hernia formation in the inguinal region. The intact anatomy defends against inguinal hernia herniation. When this layer is damaged, a hernia can occur.” He also noted that “the transverse abdominal fascia extends deep down the inguinal ligament to the thigh and forms the femoral sheath and the pubic portion of the inguinal ligament (later named Cooper’s ligament)”. In 1793, de Gimbernat first proposed the trap ligament and advocated that in the management of an incarcerated femoral hernia, the stenosis should be freed medial to the femoral ring rather than the upper part o the femoral ring to avoid hemorrhage. In addition, due to advances in anatomy and the growing understanding of the inguinal canal, some important structures or pathological changes discovered during this period were named and used to this day, including: Littre’s hernia in 1700, which reported the contents of the hernia as a Meckel’s diverticulum, or Littre’s hernia; Richter’s hernia is the partial intestinal canal wall hernia reported by Richter in 1785. Hesselbach’s triangle is the inguinal triangle described by Hesselbach in 1814, who also introduced the concept of the iliopubic bundle; the “Cloquet” lymph node was introduced by Cloquet in 1817 and is important for the identification of inguinal masses. He also introduced the concept that the sphincter rarely closes at birth. Also, in 1814 Scarpa described sliding hernias and discovered superficial fascia, and in 1823 Bogros discovered the presence of an anterior peritoneal space in the inguinal region. III. Nineteenth century and modern surgery Although the understanding of the anatomy of hernia was further developed, the progress of surgical treatment of hernia remained slow until the middle of the nineteenth century. Believing that infection could increase wound scar formation and decrease hernia recurrence, physicians at the time still used the McBurney procedure, in which the hernia sac is removed and the wound is left open, relying on scar growth to prevent recurrence. After the introduction of syringes, some physicians had used iodine and zebra tincture injections to treat hernias, resulting in serious complications such as peritonitis. in 1888, Erichsen pointed out that the sclerotherapy injection method was both dangerous and ineffective, and eventually this method was abandoned. In 1888 and 1893, Erichsen and Franks used intestinal resection with intestinal anastomosis to manage strangulated hernias with intestinal necrosis. With Morton’s (1846) application of ether anesthesia to surgery, Lister’s (1870) pioneering of antiseptic surgery, Halsted’s (1890) use of sterile rubber gloves, and Von Mickulicz’s (1940) change from antiseptic surgery to aseptic surgery, these combined with a complete and detailed knowledge of human anatomy, the development of vascular clamp hemostasis techniques . These, together with a complete and detailed knowledge of human anatomy and the development of vascular clamp hemostasis techniques, enabled the rapid development of modern hernia surgery. Surgery was truly developed in its entirety. The famous Italian physician Edoardo Bassini (1844-1924) pointed out that inguinal hernia was due to the straightening and shortening of the inguinal canal. In 1889, he published his famous monograph with beautiful illustrations, and in 1890 his thesis was published in Germany. Because of his excellent work and his deep understanding of hernia, Bassini’s position as the founder of modern hernia surgery was unshaken when he said: “After a long dark night, hernia surgery and the traditional and ancient methods of treatment have finally been replaced by modern hernia surgery, although this method is still considered by countless others to be in need of modification and adjustment .” In the more than 100 years since Bassini’s hernia repair, more than 200 modified surgical methods have emerged, the most typical being the Halsted procedure in 1889, the Furguson procedure in 1890 and the McVay procedure in 1948. However, the basic principles of their treatment of hernias converged. William Steward Halsted of the Johns Hopkins School of Medicine, one of the leading modern surgeons in the United States, created two procedures similar to the Bassini procedure, which differed from the Bassini in that the spermatic cord was placed under the skin in the Halsted I procedure. Halsted proposed to fold and suture the external abdominal oblique muscle without displacing the spermatic cord, which is called Halsted II. In addition, Halsted also ligated excessive spermatic veins to reduce the volume of the spermatic cord and incised the internal oblique muscle fibers and sometimes the transversus abdominis muscle to allow easier lateral displacement of the internal ring. a reduction incision in the rectus abdominis fascia was first reported in his 1903 paper. After observing some of the complications of the Halsted I operation, in 1899 Ferguson warned surgeons “not to touch the spermatic cord, for it is the sacred path that carries the indispensable and vital element that ensures the longevity of our race”. His procedure involved suturing the internal oblique and transversus abdominis muscles on the superficial surface of the spermatic cord to the medial surface of the inguinal ligament, without moving the spermatozoa under the skin. The tangential edges of the external oblique abdominal tendon are then sutured contralaterally or with overlapping sutures. Andrews first used the overlapping tile approach to repair inguinal hernias in 1895. He strengthened the posterior wall of the inguinal canal by suturing the superior lobe of the extra-abdominal oblique tendon membrane, the united tendons to the oblique border of the inguinal ligament, with the spermatic cord lying superficial to the extra-abdominal oblique tendon membrane, and then suturing the inferior lobe of the extra-abdominal oblique tendon membrane to its superior lobe to cover the spermatic cord. In 1898, an Austrian surgeon, George Lotheissen, in a patient with multiple recurrent hernias, found a disruption of the inguinal ligament and replaced it with a partial suture of the pubic comb ligament (Cooper’s ligament) to the medial part of the joint tendon arch to strengthen the posterior wall for repair with success. In 1958, McWay introduced the anatomical concept of Cooper’s ligament for repair, and the procedure was eventually named the McVay repair. In the early twentieth century, Harvey Cushing performed hernia repair under local anesthesia; in 1920, Cheatle invented the anterior peritoneal repair using a median incision for unilateral or bilateral inguinal hernia repair; McEvedy established the paramedian approach; and in 1936, Henry used this approach to repair femoral hernia successfully. The preperitoneal repair of inguinal and femoral hernias used to be called the Cheatle-Henry approach, but this approach was later improved significantly by Nyhus and is now known as the Nyhus approach. Edward Earle Shouldice, a famous Canadian hernia surgeon, created the Shouldice repair in 1953. The main focus of this procedure is to repair the transversus abdominis fascia, usually under local anesthesia, with the main points being the high ligation of the hernia sac, incision of the transversus abdominis fascia, and strengthening of the posterior wall of the inguinal canal by repeated folding of the transversus abdominis fascia using nonabsorbable sutures or monofilament wires, with impressive surgical results. In 1956, the French scholar Fruchaud introduced the concept of myopubic foramen. It illustrated the common anatomical basis of inguinal hernia, direct hernia and femoral hernia, where all hernias in the inguinal region occur in this weak area, and is also considered as the anatomical basis of modern hernia surgery. As early as the nineteenth century the famous surgeon Billroth (1829-1894) predicted that if we could artificially create a tissue with the same density and toughness as the fascia and tendons, then the secret of the radical hernia cure was discovered. Historically, metallic materials that have been used are gold, silver, tantalum and stainless steel wire. However, they were abandoned because the metals were not resistant to fracture due to folding, sinus tract formation, and tissue erosion. After the middle of the last century, due to the rapid development of materials science, the emergence of various modern synthetic materials has also brought profound changes to the treatment of hernia. Currently, the more widely used non-absorbable hernia patch materials are: 1. polyester polymer, also known as polyester, first introduced in 1954 under the trade name Mersilene; 2. polypropylene, marketed in 1962 under the trade name Marlex; 3. expanded polytetrafluoroethylene (ePTFE), also known as Teflon, marketed in 1977. In addition, there are a number of absorbable meshes including Dexon and Vicryl. In 1959 Usher reported the successful application of polypropylene mesh for repair in patients with abdominal wall hernias. His many pioneering contributions laid the foundation for the successful application of mesh for preperitoneal repair, and later, such as Stoppa (1973) and Rives (1974), reported on the technique of preperitoneal placement of patches, known as the “giant patch reinforced visceral sac (GPRVS)”. In 1989, Lichtenstein, an American hernia specialist, changed the concept of Bassini method repair from the previous surgical practice and first introduced the concept of “tension-free hernia repair”, in which an artificial material is implanted into the posterior wall of the inguinal canal to repair the hernia defect, increasing the efficiency of the operation and improving the time and outcome of the patient’s postoperative recovery. The result was a more efficient surgery and improved recovery time and outcome. On this basis, synthetic patches have been widely used. The concept of “tension-free hernia repair” is certainly a revolutionary change in the history of hernia surgery. Schumpelick (2001) introduced the concept of lightweight large mesh patches. Various composite new materials and new patches have been introduced to further promote the development of hernia surgery. With the development of minimally invasive surgery, laparoscopic techniques also began to be applied to the treatment of inguinal hernia. Since Ger performed the first laparoscopic hernia repair in 1982, several improvements have been made, with Arregui proposing transabdominal preperitoneal repair (TAPP) in 1991, Fitzgibbons and colleagues proposing intraperitoneal mesh repair (IPOM) in the same year, and McKernan and Lar completing completely laparoscopic preperitoneal repair (TEP) in 1992, respectively. repair (TEP), respectively, which led to the development of laparoscopic hernia repair techniques. Currently, laparoscopic hernia repair is gradually gaining recognition and widespread use because of its advantages of minimal trauma and rapid postoperative recovery. Throughout the history of hernia surgery for thousands of years, it is easy to find that the evolution and development of hernia surgery is actually a microcosm of the development of the whole surgery. Many great figures and surgeons emerged from the development of hernia surgery, such as Bassini, Halsted, Lichtenstein and others, who still inspire generations of surgeons to think about and improve the occurrence and treatment of hernia. It is from the understanding of this disease, from the combination with modern technology, that hernia surgery has evolved. History shows that there is no best, only better, and this is also true for hernia surgery.