The method of Bassini for relief of inguinal hernia, more or less modified to meet individual demands, seems to have become of late years the most popular and widely adopted. The incision is made over the most prominent part of the tumor, extending as far downward upon the scrotum as necessary, and upward to near the anterior superior spine. Through it the external ring, with its pillars, is exposed, and then the sac, by a dissection long and sufficiently wide to fully reveal it. The exposure is made more complete by dissection of the aponeurosis of the external oblique from the level of the external ring upward and outward for an inch or so above the external ring. By seizing the edges of the aponeurosis on each side with forceps and retracting there is now afforded an excellent view of the hernia proper. (See [Fig. 611].)
Fig. 613
Park’s method of utilization of sac, showing its isolation and one way of employment in making the suture further represented in [Fig. 614].
By careful dissection the sac and cord are identified and isolated, while the sac is opened and its edges held apart by forceps, after which it is carefully separated from the other structures of the cord. After thus isolating the sac, and with the least possible disturbance of the cord and of the testicle, it is ligated as high as the internal ring, or, if possible, higher yet. This leaves the cord uninjured; its size should next be reduced by cutting away all superfluous tissue. Some operators remove all the veins, but this seems unpromising and dangerous.
Fig. 614
Park’s operation. Continuous suture made with a long thin sac.
By all this dissection and reduction the inguinal canal has been temporarily, cleared, and the sac having been elevated, ligated, and cut away it becomes now a question of what to do with the cord. The lower surfaces of the external oblique and of Poupart’s ligament are next freed, the edge of the internal oblique, of the transversalis with its fascia, the outer border of the rectus and the conjoined tendon being all exposed to view by whatever dissection may be required, all fat and areolar tissue being removed. The cord is finally disposed of by holding it out of the way, usually by a loop of gauze, while the deep layer of the external oblique and the external portion of Poupart’s ligament are sewed to the muscle edges of the internal oblique and transversalis, as appears in [Fig. 612], by a line of sutures which include the conjoined tendon, at the lower angle of the wound, which should be affixed to the outer border of the rectus. In the deeper portion of every such wound there is danger of injury to the external iliac vessels as well as to the epigastric. For the escape of the cord, and to avoid its undue constriction, an opening should be left for it, i. e., a new internal ring, adapted for the purpose and not too small. This is made by not suturing the upper part of the wound. The cord being afforded this exit is now dropped, and the edges of the external oblique are brought together over it, the sutures extending well downward, but being omitted at the lower portion, where a new external ring is thus left, only not of its original size, but sufficiently large to accommodate the cord.
Such are the essentials of the Bassini method, which has been modified by Halsted in such a way that the cord, reduced as much as possible, usually by removal of most of its veins, is now not left within the inguinal canal, but transplanted entirely outside of the external oblique, escaping at the upper part of the incision and requiring no further accommodation in its course toward the testicle. In children, or even in adults with very small veins, he does not so reduce the cord. After isolation, opening and transfixion of the upper end of the sac, and its secure ligation, he drops the stump back into the abdomen. The muscular and tendinous layers of the ring and abdomen are united also, by layers, with quilted sutures.