in the evolution of herniorraphy. Bassini’s repair emphasizes both the high ligation of the hernia sac in the internal ring, as well as suture reinforcement of the posterior inguinal canal.  e operation utilizes a deep and super cial closure of the inguinal canal. Inthe deep portion of the repair, the canal is repaired by interrupted sutures a xing the transversalis fas­cia medially to the inguinal ligament laterally.  is requires an incision through the transversalis fascia.  e super cial closure is provided by the external oblique fascia.

In addition to Bassini’s contributions, the  rst true Cooper’s ligament repair, which a xes the pectineal ligament to Poupart’s ligament and thereby repairs both inguinal and femoral hernia defects, was introduced by Lotheissen in 1898. McVay further popularized the Cooper’s ligament repair with the addition of a relaxing incision to reduce the increased wound tension.

 e advances in groin hernia repair in the century following Bassini have shared the primary goal of reducing long-term hernia recurrence rates. To this end, e orts have been directed at developing a repair that imparts the least tension on the tissues that are brought together to repair the hernia defect. Darn repairs were  rst introduced in the early 20th century to reduce wound tension by using either autologous tissue or synthetic suture to bridge the gap between fascial tissues. Muscle and fascial  aps were attempted without consistent success. In 1918, Handley introduced the  rst use of silk as a prosthetic darn and nylon followed several years later. How­ever, it was found that heavy prosthetic material increased the risk of wound infection, and the silk suture ultimately lost its strength over time.  e use of autologous or syn­thetic patches was also attempted in order to reduce wound tension and improve rates of recurrence.  e  rst patches, beginning in the early 20th century, consisted of silver wire  ligree sheets that were placed along the inguinal canal. Over time, the sheets su ered from metal fatigue leading to hernia recurrence. Reports of the wire patches eroding into adja­cent inguinal structures and even the peritoneal cavity itself caused even more concern with this technique.  e modern synthetic patch, made of a plastic mono lament polymer (polyethylene), was introduced by Usher in 1958. Lichten­stein, who developed a sutureless hernia repair using a plastic

from internal ring to pubic tubercle, and the posterior sur­face of the transversalis is cleaned of its preperitoneal attach­ments. As the rst layer of the repair, the free edge of the lower transversalis ap is sutured in a continuous, imbricated fashion behind the upper ap to the posterior surface of the upper transversalis fascia and the lateral component of the posterior rectus sheath. is running suture layer is started medially at the pubic tubercle and carried up to and through the internal ring, thereby tightening the transversalis fascia around the cord at its entrance to the inguinal canal. e rst layer is not tied but continued in a running fashion from lateral to medial as a second layer closing the upper transver­salis ap to the base of the lower edge as well as the inguinal ligament. is second layer progresses medially to the pubic tubercle where it is tied to the original tail that started the rst layer. e third layer of continuous suture starts at the tight­ened internal ring and brings together the conjoined tendon (the internal oblique and transversus abdominis aponeuroses)