Tension Repairs

Tension hernia repairs were the first successful surgical hernia repairs available to the modern surgeon.

These hernia repairs take a great deal of skill and time to learn. As with any skill, the benefit of these tension hernia repairs depends greatly on the knowledge, technique and experience of the hernia surgeon.

Once the hernia surgeon has mastered these techniques, it is difficult for them to abandon those skills for the newer, less demanding techniques. Therefore, it is more common for older hernia surgeons to still use the tension hernia repairs. Tension hernia repairs are being performed much less frequently now, but depending on the circumstances, this may be the only hernia repair possible. In those situations, it is recommended that you seek out a hernia surgeon who has experience with many types of hernia repairs, including the tension hernia repairs.

Shouldice Hernia Repair

The Shouldice technique of suture only hernia repair was developed by Dr. E. E. Shouldice at his clinic dedicated to hernia surgery in Toronto, Canada.

This type of hernia repair became widely acclaimed as the “gold standard” of open hernia repairs in the 1980’s, and was a favored tension hernia repair across North America and Europe. The essential steps in this hernia repair were first described by Dr. Robert Moran in 1968, and include: local anesthesia, ligation of the indirect sack, resection of the cremasteric fibers, incision of the entire posterior wall of the inguinal canal, double layer closure of the transversalis fascia with running continuous stainless steel sutures, a second double layer closure of the internal oblique muscle to the inguinal ligament, and relaxing incisions when indicated. The second double layer in the internal oblique muscle has little strength but is utilized to reduce the tension on the first two layers that were sutured in the transversalis fascia. An extremely detailed description of the dissection and precise suturing of this technique is presented by Dr. Bendavid in Nyhus and Condon’s text “Hernia”.

1. “Surgical treatment of hernia” Shouldice. Annual meeting of the Ontario Medical Association, District number 9, Sept 10, 1944.
2. “Shouldice inguinal hernia repair in the male adult: The Gold Standard? A multicenter controlled trial in 1578 patients” Hay, Boudet, Fingerhut, et al. Annals of Surgery 222(6):719-727, Dec 1995.
3. “Double layer of transversalis fascia for repair of inguinal hernias: results in 104 cases” Moran, Blick and Collura. Surgery 63(3):423-429, 1968.
4. “The Shouldice Repair” Bendavid. Chapter 12: “Hernia” fourth edition, Nyhus and Condon. J.B.Lippincott, Philadelphia, pp217-227, 1995.

Direct Suture Hernia Repair

The direct suture hernia repair (Bassini, McVay) is a very simple suture tension repair of the hernia defect.

This is most commonly performed when the hernia is discovered as a small part of a larger abdominal surgical wound and is simply included in the direct suture of the midline as part of a routine closure at the completion of the exploratory laparotomy. Another frequent occurrence for the direct repair is the small umbilical hernia or small Spigelian hernia defect only 1cm across, which is easily closed with a single stitch or two. The direct suture hernia repair is utilized when the more complex mesh reinforced hernia repairs are contraindicated due to a contaminated field (infection) or other reason. The most common direct suture hernia repair is a Bassini Repair followed by the McVay Repair. These procedures were the mainstay of inguinal hernia repair until the advent of routine mesh placement in primary (first time) inguinal hernias. The recurrence rate of these simple hernia repairs seems to be higher than the reinforced hernia repairs, but the operating room times are much shorter.