In memoriam León Herszage (1931–2016)

Que amistades que son ciertas nadie las puede turbar.

True friendship can never be broken.

Miguel de Cervantes Saavedra (1547–1616)

Argentina’s Honourable member of the proud Argentine School of Abdominal Wall Surgery.

In a profession where fame and recognition are the sought after currencies, where pretense and arrogance crawl beneath the surface, Leon Herszage was a paragon of sincerity, simplicity, selflessness, affection, generosity. Nothing mattered but to teach, to love and to be loved. Those of us who knew him truly, could not withhold a tear.

From the dawn of the last century, the surgical school and traditions of Argentina have been generously blessed by the presence of surgeons whose inclination and dedication to the pathology of the abdominal wall is still felt today. Names such as Posadas, Finochietto, Corbellini, Squirru, Goñi-Moreno, Zavaleta, Uriburu, Albanese, Alché, Zaidman, de Dominicis, Vázquez, Barrionuevo, del Valle, San Martín, Restano and Abravanel, among many others, popularized their personal techniques for many years, some of which are still in use today. None of the foregoing names however realized nor foresaw the importance of creating a school to deal with the emerging discipline of Abdominal Wall pathology and surgery.

In the words of León Herszage: “…it was the reorganisation of the hospitals in Buenos Aires in 1970 that gave rise to departmentalization. At the Alvear Hospital, then one of the great healthcare centres with several general surgery theatres, in addition to the specialities, the new division chief created sections to incorporate all activities, assigning a Head for each section among the ward surgeons and incorporating to these, residents and trained surgeons. All sections (thorax, head and neck, proctology, breast, etc.) were organised under the direction of a surgeon specialized in that pathology. However, there was one sector, “the Cinderella of the general surgery service: The Abdominal Wall”, for which there was no one with an interest in shouldering that responsibility. With good judgement, whoever was the Head, selected the most skilled of surgeons and placed upon him the task of organizing and developing that speciality. The person chosen was Jorge Barroetaveña who, from that moment started his activity with bibliographical searches, fresh cadaver dissections, clinical and surgical programs. In 1971, I joined the surgical staff and immediately partnered with Dr. Barroetaveña to commence a fervent stage of growing, applied research”.

Thus in 1971, León Herszage, already a trained surgeon, devoted all his attention to the new discipline alongside Jorge Barroetaveña (1917–1995). When they assumed the responsibility of developing this evolving field of abdominal wall pathology, León Herszage pitched in with the devotion and detail that characterized all his activities. He began in 1970 with the dissemination of the concepts of Nyhus, Condon and McVay, and displaying the concepts and teachings of Fruchaud with respect to the deep posterior structures of the abdominal wall, as the etiopathogenic basis for the repair of hernia defects. He stressed the importance of the function of the abdominal parietes regarding its relationship to the respiratory system with its variations of intra-abdominal pressures. As León himself said of Barroetaveña, in an intimate biography published in Rev. Hispanoam. Hernia (2015): “… From then on, our dissections and case analyses immediately allowed us to advance in understanding and applying the norms that transformed this activity, in Argentina, into a school of abdominal wall surgery”. They collaborated closely from 1971 to 1980. Later, León Herszage was named the surgeon-in-chief of the abdominal wall section of the Hospital Pirovano in Buenos Aires, where he worked with passion and mastery for 25 years (1982–2007). Still, they continued to cooperate and have left us several important books, among which The Surgery of Eventrations (1988) which was the culmination of the previous works: Eventrations in incisions and the Mc Burney access route (1975), and Hernias of the Groin. Current Surgical Procedures. Anatomophysiological concepts (1984), adding up to six editions. His concern and passion for hernias, led León Herszage to meet the best surgeons, who perhaps because of their close social background, were mainly South American in origin, surgeons such as Máximo Deysine, from New York, who from 1996 on, organized several annual courses at his hospital running until 2001. In February 1997, as told by his surgical scrub nurse Elisabet Giménez, Dr. Wantz travelled to Argentina specifically to get to know Dr. Herszage and his methods of operating hernias and eventrations, which he undertook under local anaesthesia and without postoperative confinement or restrictions; once the operative field exposed, Leon decided which technique he would use according to the needs of each patient. Once the surgery ended, Léon would ask the patient to cough, saying: “Break everything!” When the operation was over, the patient would leave, walking without instruction to rest; his typical words were “You can do whatever you want: eat what you want, drive, ride a bicycle, whatever!” The basis for this rationale was biological: the greater the movement, the better the scarring and better the quality of collagen. He even operated with music selected by the patient. Several famous abdominal wall surgeons attended his courses: George Wantz in 1996; Alfonso Albanese and Alejandro Copello in 1997; Parviz Amid and Robert Bendavid in 1998; Roger Simmermacher in 1999; Arthur Gilbert in 2000, and Franz Ugahary his last one in 2001. Besides, many other surgeons visited his service, such as J.B. Flament, Paul Jaret or Ana Rath.

These prestigious surgeons agreed that León Herszage was a close, kind, friend with a tremendous knowledge of abdominal wall defects and their treatment. The contribution of León Herszage to the healing of infected wounds with sucrose is known worldwide. He revolutionized the world of “surgery under local anaesthesia” without pretense nor desire for recognition or glory in his country. He has left numerous videos and publications on this issue.

When his duties at the Hospital Pirovano were over, he continued working in private practice and contributing to the important books about hernia with chapters in Incisional Hernias by Schumpelick-Kingsnorth (2000), Abdominal Wall Hernias: Principles and Management (2001) by Robert Bendavid, in the 2002 edition of Hernia by Nyhus, Abdominal Wall Hernias (2003) by Juan Carlos Mayagoitia, and in what was his final collaboration in 2012 published by us, Fernando Carbonell Tatay and Alfredo Moreno Egea, Eventrations: other abdominal wall and internal hernias.

León Herszage has always participated in the most important world meetings on the abdominal wall as member of the scientific committee, now emeritus, of the American Hernia Society (AHS), and as reviewer for the journal Hernia of the European and Americas Hernia Societies. He has always maintained a close relationship with these media and also worked with the same passion with Hispanic surgeons and societies as a member of the scientific committee of the Sociedad Hispanoamericana de Hernia (SoHaH) and of the Rev. Hispanoam. Hernia.

León Herszage was a visionary for his times, a humanist with relentless vitality, always present at the most important meetings and in his words “he never got off the bicycle”. His last presentation (a few months before he prematurely left us) we enjoyed his presence in Temuco (Chile) in 2015, during the Abdominal Wall Surgery course run by the SoHAH. He was radiant, perfect in his qualities and mental capacity, greatly admired by all the attending colleagues.

Among his other passions, Leon was an advisor to the Buenos Aires Zoo to which he went visiting with the various international guests. He invariably showed proudly a majestic jaguar of such beauty that often, the tour was the highlight of the passage in the beautiful city of Buenos Aires! Other interests had been odontology which captivated him from early youth, graphology and Gestalt psychotherapy, as we may see in his web page (http://​www.​lherszage.​com/​cv.​htm). These titles reflected his humanistic dimension.

Fernando Carbonell Tatay MD

Abdominal Wall Surgeon

Valencia (Spain), February 16th, 2016