Accepted Manuscript

Lloyd Nyhus and Rene Stoppa: Preperitoneal Inguinal Pioneers

Preston L. Carter, MD

PII: S0002-9610(16)30080-0
DOI: 10.1016/j.amjsurg.2015.12.016
Reference: AJS 11849

To appear in: The American Journal of Surgery

Received Date: 24 November 2015

Accepted Date: 27 December 2015

Please cite this article as: Carter PL, Lloyd Nyhus and Rene Stoppa: Preperitoneal Inguinal Pioneers,
The American Journal of Surgery (2016), doi: 10.1016/j.amjsurg.2015.12.016.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
 ACCEPTED MANUSCRIPT

Preston L. Carter, MD
plandejcarter@hotmail.com;preston.l.carter.civ@mail.mil

North Pacific Surgical Association Historian Lecture

PT
presented at the 102nd annual meeting
Portland, Oregon

RI
November 13, 2015

SC
Benjamin Franklin said famously that in life nothing is certain except death and taxes.

U
With apologies to the Founding Father, the likelihood of developing an inguinal hernia –
AN
especially for men – may not be far behind. Gravity, the aging process, and the

evolutionary upright position are all factors which combine to make adult groin hernias a
M

common human malady.

D
TE

In addition to being inconvenient, the risk for hernias to progress in size and develop the

potentially life-threatening complication of trapped bowel is well known. Physicians

EP

have recognized these risks since antiquity, but progress toward effective treatment was

minimal until the development of anesthesia and antisepsis. During the past century,
C

these two medical milestones allowed surgeons to make great therapeutic progress.
AC

Better understanding of regional anatomy, and improved safety of prosthetics has led to

many surgical alternatives for hernia repair. While it is true that inguinal hernia repairs

are often viewed in teaching hospitals as humdrum intern-level cases, any experienced

hernia surgeon can attest to the significant technical challenges sometimes encountered in

repair of groin hernias.

 ACCEPTED MANUSCRIPT

Today, along with a very brief overview of the evolution of inguinal hernia surgery, I

recognize the contributions of two 20th century hernia leaders, Lloyd Nyhus and René

Stoppa. In large measure, their insights with open preperitoneal hernia surgery form the

PT
foundation for the current enthusiasm for laparoscopic inguinal hernia repairs. Dr.

RI
Nyhus, a Washington native, later to became a leading international hernia authority,

literally “wrote the book” on the subject with his landmark textbook, Hernia. Dr.

SC
Stoppa, a French surgeon, was an early advocate of the deployment of prosthetic mesh

U
sheets in the preperitoneal pelvic space, particularly for treatment of the special
AN
challenges posed by giant or multiply recurrent hernias.
M

To better appreciate Nyhus and Stoppa’s contributions, some historical context is in

order. Surgery’s oldest known document, the Edwin Smith papyrus, makes no
D

reference to hernia, but other ancient sources document that though hernias were clearly
TE

known to the earliest physicians, little in the way of treatment could be offered beyond

hope and prayer. Little changed until the Renaissance. At that time, Ambroise Paré, a
EP

leading surgeon of the era, claimed cures for some neonatal hernias by fashioning crude
C

trusses from paper-maché, and keeping the patient at bedrest with the expectation that
AC

“in progresse of time and age, [the hernia] will grow thicker and knit together”. Paré also

took pride in his cases having been “delivered from the hands of Gelders, who are greedy

of children’s testicles for the great gaine they receive from thence”. [1] Gelders, or

professional castrators, were barber-surgeons who apparently advised parents of a child

with a hernia that castration offered the path to cure. Presumably, subsequent
 ACCEPTED MANUSCRIPT

inflammation and suppuration might have sealed the inguinal defect, albeit at great cost to

the patient!

Another 16th century surgeon, Pierre Franco, authored the first monograph dedicated to

PT
hernia. His “Traite des hernies” described successful reduction of strangulated hernia by

RI
surgically enlarging the hernia ring followed by manual reduction. In the preanesthetic

era, his statement that this reduction is “never easy because the intestines are smooth and

SC
slippery” is likely droll understatement. [2] Caspar Stromayr, a German surgeon of the

U
same era, emphasized the importance of complete removal of indirect sacs to the level
AN
of the internal ring. As with Franco, achieving high ligation without anesthesia was

probably no mean feat. Stomayer’s legacy also includes a manuscript entitled Practica
M

copiosa which emphasized the importance of presurgical preparation. It also mentioned

that advance arrangements for collection of the surgical fee should be made, regardless of
D

how the operation turned out! “I will still expect my well-earned fee, for I have used and
TE

demonstrated my skill, effort, and labor exactly in the same manner as if [the patient]

had survived and recovered.” In this era, responsibility for surgical outcomes were
EP

divided between this promise that the operator would give his best effort, and God’s
C

Will. [3]
AC

The advent of effective anesthesia and antisepsis in the mid 19th century led to major

advances in hernia therapy. Repair methods developed by Bassini, Halsted, McVay,

Shouldice, and Lichtenstein, among many others, are widely known A detailed review of

their similarities and differences is beyond the scope of this presentation. The common
 ACCEPTED MANUSCRIPT

thread in all of these classic repairs is the anterior approach to execute a “frontal attack”

on the inguinal or femoral defect.

Although the methods of these legendary surgeons resulted in far more successful

PT
outcomes than their predecessors, anterior approach surgery remained problematic in

RI
many cases of gigantic or multiply recurrent hernias. These challenges led to the

preperitoneal techniques pioneered by Drs. Nyhus and Stoppa.

U SC
Lloyd Nyhus was born in Mount Vernon, Washington, in 1923, and trained in surgery
AN
at the University of Washington under the mentorship of its longtime Chair in surgery,

Dr. Henry Harkins. Dr. Nyhus remained at the University of Washington for his early
M

academic career, from which he was later recruited to become Chair of Surgery in

Chicago at the University of Illinois, There he went on to a long and fruitful tenure in
D

academic surgery, achieving a well-deserved reputation as a medical author, editor, and

TE

recognized authority in many aspects of surgical practice. He held major leadership

positions in both the American College of Surgeons and the American Surgical
EP

Association. [4]
C
AC

The French surgeon, René Stoppa, was born in 1921 in French Algeria. Stoppa

interrupted medical school for World War II military service, returning to complete his

studies and surgical training after war’s end. His talents led him to a productive

academic career, first in Algeria, and later in Amiens, a city north of Paris, where he was

Surgeon-in Chief at a teaching hospital originally established for treatment of military

 ACCEPTED MANUSCRIPT

personnel by Napoleon. Dr. Stoppa was one of France’s leading academic surgeons

until his death in 2006. [5]

Nyhus and Stoppa both realized that there was significant advantage in approaching

PT
inguinal and femoral hernias posteriorly, utilizing the infraumbilical preperitoneal space

RI
to attain wide exposure of hernia defects in planes relatively undisturbed by prior hernia

interventions. In his original classic paper, Stoppa described the principle that when a

SC
large prosthetic mesh is implanted deep to the main abdominal wall musculature, it will

U
be stabilized without need for extensive suture fixation by transmitted intraabdominal
AN
pressure during the process of fibroblastic incorporation. [6]
M

Shortly after completion of his surgical residency, Dr Nyhus was challenged by his

mentor, Dr Harkins, to investigate the possibilities of new approaches in inguinal hernia

D

repair. Building on concepts earlier advocated, but never popularized by Cheatle and
TE

Henry, Nyhus and Harkins presented their initial experience with 50 cases of “posterior

ileopubic tract repair” at the 1957 NPSA meeting in Vancouver. [7] Although most of
EP

the repairs thereby reported were accomplished by direct suture closure of the hernia
C

defect after an open preperitioneal approach, Nyhus later noted that Ivalon sponge was
AC

added in one of these cases for a buttress. This is among the earliest reports of

preperitoneal prosthetic material in inguinal hernia surgery. In a later paper, the Nyhus

technique had evolved to include a recommendation for underlay Marlex reinforcement

of all preperitoneal explorations for recurrent inguinal hernia. [8]

 ACCEPTED MANUSCRIPT

Stoppa was concerned with the special challenges of giant or recurrent hernias,

conceiving that preperitoneal placement of a large synthetic mesh would not only

physically block all major inguino-femoral weaknesses, but would also be stabilized by

intraabdominal pressure and tissue adherence, thus reducing the necessity of extensive

PT
suturing. The incorporated mesh would become a durable neofascia. Stoppa’s “giant

RI
prosthesis” method proved highly effective for repair of complex, large, and recurrent

groin hernias which were less likely to be successfully repaired by previous methods. [9]

SC
Stoppa’s method was found to be useful in large incisional hernias as well.

U
AN
Nyhus and Stoppa’s methods form the foundation for all modern laparoscopic inguinal

hernia repairs. Except for differences in the method to expose the preperitoneal space,
M

and the dimensions and fixation strategies for the deployed mesh, all TAPP and TEP

hernia surgeons follow a trail pioneered by these visionaries. While there are pitfalls as
D

well as advantages to the posterior approach, utilization of the preperitoneal space for
TE

prosthetic based hernia repair has now become a well-recognized major advance in

hernia surgery, and since preperitoneal mesh is placed deep to the track of the inguinal
EP

sensory nerves, chronic postsurgical inguinal pain is likely less frequent than with mesh-
C

based open repairs.

AC

Nyhus and Stoppa’s understanding of utilizing the preperitoneal space for hernia repair

was aided by earlier contributions from another French surgeon, Henri Fruchaud. As

with Stoppa, war forced Fruchaud to interrupt his medical studies. During World War I,

Fruchaud served on the Western Front as a stretcher-bearer. His bravery (and exceptional
 ACCEPTED MANUSCRIPT

luck at survival!) is borne out by his four-time award of the Croix de Guerre for actions in

battles of the Marne, Verdun, Ypres, and the Somme. [10]

Late in his subsequent surgical career, Fruchaud published a detailed study of inguinal

PT
anatomy in his 1956 textbook, Anatomie chirurgicale des hernies de l’aine. [11] In this

RI
work, which reflected his decades of study and clinical experience, Fruchaud challenged

classical teachings on inguinal and femoral anatomy, and advanced revised concepts of

SC
the role of the transversalis fascia in groin hernias. Fruchaud coined the term

U
“myopectineal orifice” (encompassing Hesselbach’s triangle, the deep inguinal ring, and
AN
the femoral canal) as a key unifying anatomic structure which needed to be adequately

addressed for a groin hernia repair to be predictably effective.

M

As an aside, while preparing this talk, I discovered that Dr. William Gallie, a leading
D

Canadian surgeon of the early 20th century, and in 1937 the first NPSA Founder’s
TE

Lecturer , was also a hernia innovator of his time. In the 1920’s, Gallie utilized fascia

lata grafts as “living sutures” to repair inguinal floor defects. [12] In addition, Dr. Gallie
EP

was a mentor to Dr. Edward Shouldice, who went on to pioneer the eponymous procedure
C

which still endures in properly selected patients as a reliable tissue-based repair.

AC

Groin hernias, in all their many variations, will continue to be a common malady. An

aging and ever more obese population assures no shortage of future North American

patients. In the many medically underserved areas of the world, patients presenting with

advanced groin hernias will continue to tax surgeons’ ingenuity and technical skill.
 ACCEPTED MANUSCRIPT

Today’s surgical residents are well advised to learn to appreciate the difficult technical

challenges sometimes posed in groin hernia repair, and to avoid a cavalier one-solution-

fits-all treatment approach. Patients are served best when their surgeon has clearly

understands the subtleties of inguinal anatomy, appreciates the protean ways in which

PT
groin hernias may present, and makes an honest effort to individualize the repair plan.

RI
To do less fails to properly honor the pathfinders we remember today.

U SC
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

References

1. Zimmerman LO, Veith I; Great Ideas in the History of Surgery, 2nd Ed. Dover
Publications, New York ©1967, p.192.

2. Ibid. p.200.

PT
3. Ibid. p.223.

RI
4. Debord JR: Lloyd Milton Nyhus. Hernia 2009; 13:405-406.

5. Verhaeghe P, Bendavid R: René Stoppa (1921-2006). Hernia 2007; 11:1-3.

SC
6. Stoppa R, Petit J, Abourachid H et al. Procédé original de plastic des hernies de
l’aine: L’interposition sans fixation d’une prosthèse en tulle de Dacron par voie

U
médiane sous-péritonéale. Chirurgie 1973; 99: 547-551.
AN
7. Nyhus LM, Stevenson JK, Harkins HN: Preperitoneal herniorrhaphy: A
preliminary report in fifty patients. West J Surg Obst & Gynec 1959; 67:48-54.

8. Nyhus LM, Pollak R, Donahue PE: The preperitoneal approach and prosthetic
M

buttress repair for recurrent hernia. Ann Surg 1988; 208: 733-737.

9. Stoppa RE: The treatment of complicated groin and incisional hernias. World J
D

Surg 1989; 13: 545-550.

TE

10. Stoppa RE, Wantz GE: Henri Fruchaud, A man of bravery, an anatomist, a
surgeon. Hernia 1998; 2: 45-47.

11. Fruchaud H: Le Traitement Chirurgical des Hernies de L’Aine Chez L’Adulte,

EP

Doin & Co., Paris ©1956

C

12. Gallie WE, LeMesurier AB: Living sutures in the treatment of hernia. Can Med
Assoc J 1923; 13:469-480.
AC