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“Protect yourself from the menace of life long complications following inguinal hernia repair surgery with mesh”

 

There is no place to mesh prostheses in inguinal hernia repairs now because no mesh technique of “Dr. Desarda Repair” is available with superior results.

1] OPERATION TECHNIQUE

(For Non-Medical persons)

This is a pure tissue repair that resembles the Lichtenstein mesh repair in its simplicity. The author claims results that are superior or equal to Shouldice and Lichtenstein repairs in low frequency of complications and most importantly no recurrences. The repair is remarkable in its simplicity and any body’s first thought upon understanding the basics of the operation will be: why didn't someone think of this before?

The external oblique is incised similarly to the way it is done in the other anterior approach repairs. The spermatic cord is dissected free the same way it is done in all the other anterior approach repairs. The sac are dissected free as usual and generally cut away. The herniated organs are returned to the abdomen as usual.

The upper flap of the external oblique aponeurosis is sutured to the inguinal ligament, behind the spermatic cord. Then the external oblique is incised again, 1-2 centimeters above the inguinal ligament, simultaneously creating (1) a new lower edge to the upper flap, and (2) a "strip," or in my words a patch, made out of a strip of external oblique that is several centimeters wide. The upper edge of this "patch" is sutured to the internal oblique. The result is that a "patch" of external oblique aponeuroses is in place behind the spermatic cord, similarly to the way a Lichtenstein patch would be in place behind the spermatic cord. The difference is, that (1) this is a patch of living tissue and (2) the strip of external oblique aponeurosis is still attached normally to external oblique muscle and contractions of the external oblique muscle have a dynamic affect on countering intra-abdominal pressure, rather than merely static effect that the non-living patch used in a Lichtenstein repair, would have.

The new lower edge of the upper flap is sutured to the original upper edge of the lower flap, above the spermatic cord -- that is, the external oblique is closed similarly to the way it is closed in Bassini, McVay, and Shouldice repairs. However it is the newly created lower edge of the upper flap that is being used, instead of its original upper edge; the original lower edge of the upper flap has previously been sutured to the inguinal ligament. Thus, when the operation is completed, there are 2 layers of external oblique: one under the cord and one above it, instead of only one layer, above the cord, as in normal anatomy, and as in Bassini, McVay, and Shouldice repairs.

2] OPERATION TECHNIQUE (For Medical persons): Skin and fascia are incised through a regular oblique inguinal incision to expose the external oblique aponeurosis. The thin, filmy fascial layer covering it is kept undisturbed as far as possible. The thinned out portion is usually seen at the top of the hernia swelling, extending and fanning out to the lower crux of the superficial ring.

        The external oblique is cut in line with the upper crux of the superficial ring, which leaves the thinned out portion in the lower leaf so a good strip can be taken from the upper leaf. The external oblique, which is thinned out as a result of aging or long standing large hernias, can also be used for repair if it is able to hold the sutures. The cremasteric muscle is incised for the herniotomy and the spermatic cord together with the cremasteric muscle is separated from the inguinal floor. The sac is excised in all cases except in small direct hernias where it is inverted. The medial leaf of the external oblique aponeurosis is sutured with the inguinal ligament from the pubic tubercle to the abdominal ring using PDSII no.1 (Monofilament Polydioxanone violet, Ethicon) continuous sutures. The first two sutures are taken in the anterior rectus sheath where it joins the external oblique aponeurosis. The last suture is taken so as to narrow the abdominal ring sufficiently without constricting the spermatic cord (Figure1). Each suture is passed first through the inguinal ligament, then the transversalis fascia, and then the external oblique. The index finger of the left hand is used to protect the femoral vessels and retract the cord structures laterally while taking lateral sutures.

        A splitting incision is made in this sutured medial leaf, partially separating a strip with a width equivalent to the gap between the muscle arch and the inguinal ligament but not more than 2 cms. This splitting incision is extended medially up to the pubic symphisis and laterally 1–2 cms beyond the abdominal ring. The medial insertion and lateral continuation of this strip is kept intact. A strip of the external oblique, is now available, the lower border of which is already sutured to the inguinal ligament. The upper free border of the strip is now sutured to the internal oblique or conjoined muscle lying close to it with PDSII no.1 (Monofilament Polydioxanone violet, Ethicon) continuous sutures throughout its length (Figure2). The aponeurotic portion of the internal oblique muscle is used for suturing to this strip wherever and whenever possible to avoid tension; otherwise, it is not a must for the success of the operation. This will result in the strip of the external oblique being placed behind the cord to form a new posterior wall of the inguinal canal.

At this stage the patient is asked to cough and the increased tension on the strip exerted by the external oblique to support the weakened internal oblique and transversus abdominis is clearly visible. The increased tension exerted by the external oblique muscle is the essence of this operation. The spermatic cord is placed in the inguinal canal and the lateral leaf of the external oblique is sutured to the newly formed medial leaf of the external oblique in front of the cord, as usual, again using PDSII no.1 (Monofilament Polydioxanone violet, Ethicon) continuous sutures. Undermining of the newly formed medial leaf on both of its surfaces facilitate its approximation to the lateral leaf. The first stitch is taken between the lateral corner of the splitting incision and lateral leaf of the external oblique. This is followed by closure of the superficial fascia and the skin as usual.


FIG. 1. The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament and a splitting incision is taken.1=Medial leaf; 2= Interrupted sutures taken to suture the medial leaf to the inguinal ligament; 3= Pubic tubercle; 4= Abdominal ring; 5=Spermatic cord; and 6= Lateral leaf. 

FIG. 2. Undetached strip of external oblique aponeurosis forming the posterior wall of inguinal canal.1=Reflected medial leaf after a strip has been separated; 2= Internal oblique muscle seen through the splitting incision made in the medial leaf; 3= Interrupted sutures between the upper border of the strip and conjoined muscle and internal oblique muscle; 4=Interrupted sutures between the lower border of the strip and the inguinal ligament;       5=Pubic tubercle; 6= Abdominal ring; 7=Spermatic cord; and 8= Lateral leaf.

 

Mechanism of action:16 Contractions of the abdominal wall muscles pull this strip upwards and laterally against the fixed structures like inguinal ligament and pubic symphisis, creating tension above and laterally and turning the strip into a shield to prevent any herniation. This additional strength given by the external oblique muscle to the weakened muscle arch to create tension in the strip and prevent re-herniation is the essence of this operation. The shielding action of the strip of EOA can be elegantly demonstrated on the operating table by asking the patient to cough. Second important factor that prevents hernia formation in the normal individuals is anterior-posterior compression of the inguinal canal caused by the external oblique aponeurosis compressing against the posterior wall. This compression is lost if the posterior wall is weak and flabby due to absent aponeurotic extension cover.16 The strip of EOA sutured in this operation gives the aponeurotic cover to the posterior wall transversalis fascia again and restores this anterior-posterior compression effect during the raised intra-abdominal pressures (Fig.3) (Fig.4). The contraction of the external oblique muscle pulls anterior aponeurosis and the posterior placed strip also, naturally compressing the inguinal canal.

 

 

2] Different Techniques of Inguinal Hernia Surgery (For non medical persons)

Pushing or Pulling?

There are two ways for a surgeon to approach the herniated abdominal organs and the peritoneal sac which they have pushed through, and by which the organs will be surrounded: anteriorly and posteriorly. That is, hernia surgery can be performed using an anterior approach (Open surgery) or a posterior approach (Laparoscopic surgery). The organs need to be pushed or pulled back into the abdomen.

Anterior approaches: pushing

1] PART ONE: An anterior approach means making an incision over, or very near to, the area of the abdomen where the herniating abdominal organs are escaping from the abdomen. The incision is a 5 to 10 centimeter oblique (parallel to the inguinal ligament) incision, or a 5 centimeter left-right incision. After the skin, underlying fatty tissue, layers of fascia, and external oblique aponeurosis are cut thru, and then the adherent peritoneal sac is dissected free from surrounding tissues -- from "above." It may need to be cut open, and tugged on, stretched up and out, in order to be detached. After the sac is detached, the herniated organs are "pushed" back into the abdomen. Then the sac itself is dealt with also. It is either (1) cut away, and its stump is then ligated in order close up the space created when part of it was cut away, or (2) the whole sac, or what is left of it, may be pushed back into the abdomen. It is usually possible to handle the sac this way. But sometimes it is not. For example if the sac reaches all the way into the scrotum, it may not always be possible to tug the far end of the sac out of the scrotum, without causing to much damage, so the sac may be cut so that a piece of it is left in the scrotum, and the other portion pushed back into the abdomen, perhaps after being ligated.

Exactly where the sac protrudes can vary, not only from hernia spot to hernia spot, but, for example, an inguinal hernia can have a sac that protrudes through the "internal inguinal ring" and follows the inguinal canal up toward the "external inguinal ring." Such an "indirect" hernia often finally extends through the external ring, continues along inside the spermatic cord, even reaching into the scrotum -- and is adherent to normal tissues along this path; or an inguinal hernia can have a sac that starts protruding elsewhere, entering the inguinal canal between the between the internal ring and external ring, and possibly protrude through the external ring along with the spermatic cord, alongside the spermatic cord (outside the spermatic cord), and it will be adherent to tissues in different ways. This "direct" hernia is outside the spermatic cord. In females, there is no multi-layered spermatic cord, but rather a "round ligament" extending from labium majora to uterus that passes thru the internal and external inguinal rings, instead of a spermatic cord. But, basically, an indirect inguinal hernia passes thru the internal ring; a direct hernia enters the inguinal canal between the internal ring and external ring (which define the 2 ends of the canal, the tunnel thru the muscle layers). Finally, a hernia can be a combination of these "indirect" and "direct" hernia configurations, or it may be a somewhat novel presentation. There may be plenty of original thinking for the surgeon to do after he/she opens up the external oblique aponeurosis to see what is going on underneath. The presentation, and places where the sac is adherent, may be unique, and dealing with the adherent sac may be a unique challenge.

PART TWO: Of anterior methods in common use, there are of 2 basic ways of fixing up the patient, after the contents of the sac are reduced and the sac is pushed back into the abdominal space, so that a hernia will not pop out again: pure tissue repairs and repairs using a prosthesis made out of a synthetic mesh (A piece of cloth made out of Polypropylene, Prolene, Marceline or similar synthetic fibers).

Pure Tissue Repairs (all are via anterior approach)

Some background of Inguinal Anatomy.

A primary landmark in the inguinal region is the inguinal ligament. A ligament is a strong tissue that connects bone to bone. It is flexible, but it does not contract and relax like muscle tissue. The traditional incision for an anterior inguinal hernia repair is an incision parallel to the inguinal ligament, and just a bit higher up, maybe a centimeter. There are three layers of muscle-dash-aponeuroses that make up the "abdominal wall" in the area where the incision is made. These are the external oblique muscle with attached aponeurosis, the internal oblique, and the transverses abdominis. An aponeurosis is tendon, an extension of a muscle that also acts like a fascia. Muscle tissue is contractile. Tendon tissue is non-contractile and very strong. It neither contracts nor relaxes, and stays about the same size. In the abdomen, these muscles not only serve to move our skeletons, but they also form a strong, flexible, 3-layered wall that holds our internal organs inside against the intra-abdominal water pressure of these organs. In the area of the incision, the external oblique presents its aponeurotic portion, rather than its muscular portion. The internal oblique and transversus abdominis each have an "arching edge," a few centimeters away from the incision and toward the body's midline, and can be seen after the aponeurosis of the external oblique is cut through, and the cut flaps of the external oblique, are pulled apart. The transversus abdominis is underneath the internal oblique, that is, between the internal oblique and the peritoneum. It's most posterior layer is the transversalis fascia. The spermatic cord has various layers inside of which are blood vessels and the vas deferens. The internal oblique is muscle here, at the spermatic cord -- and this portion of the internal oblique that contributes to the structure of the spermatic cord is called the cremasteric muscle. The cremasteric muscle is an extension of the internal oblique muscle.

Bassini Repair: The transversalis fascia is incised from internal ring to pubic tubercle. Then the naturally existing lateral edge of the internal oblique muscle, the transversus abdominis muscle, and the lateral edge of the surgically created medial flap of transversalis fascia, are all sutured to the inguinal ligament, with interrupted sutures. They have to be stretched a bit to reach. Then the 2 flaps of external oblique are sutured back together, above the spermatic cord, that is, the spermatic cord is left in its normal anatomical position between the layer of internal oblique and the layer of external oblique. What happens, is that in being stretched toward the inguinal ligament, the layers of tissue cover the dilated internal ring (indirect hernia), or the stretched and thinned transversalis fascia (direct hernia), that allowed the hernia to occur. This stretching is now often blamed for a rather large amount of post-operative pain, and long recuperation period, maybe 6 weeks. It involves a 8-10 centimeter incision, parallel to the inguinal ligament (oblique incision). It is also blamed for thinning the tissues and making them susceptible to allowing another hernia. A further problem of this technique of hernia repair is that a significant number of cases (estimated at up to 10 percent or more of all cases) will recur by virtue of the internal scar tissue becoming pulled out at some time in the patient's life. The repair of this recurrent hernia is therefore a larger operation than the first and the results proportionately more uncomfortable.

Shouldice Repair: This is said to be a modification of the Bassini repair that involves less stretching. There is a specific, complex protocol of overlapping one tissue with another, and making 4 sutured-together, overlapped with excision of cremaster muscle and the genitor femoral nerve. In order to reduce the tension of the stitching, surgeons developed methods of stitching the tissue in layers, one above the other. This technique reduced a little of the pressure, but resulted - by definition - in more stitching through the patient's tissue. Because the patient depends upon this stitching for the rest of his life to hold the abdominal wall closed, the surgeon will normally have to place several stitches, under a degree of tension in the deep tissue, repeating the process until he is satisfied that the join will hold. Unfortunately, this stitching distorts sensitive tissue. This will cause tension and subsequent pain with all movements (including coughing and sneezing). The patient can expect to feel the results of the stitching long after he leaves hospital. He is therefore restricted in physical activity for some weeks.

Desarda Repair:

This is pure tissue repair that resembles the Lichtenstein mesh repair in its simplicity. The author claims results that are superior or equal to Shouldice and Lichtenstein repairs in low frequency of complications and most importantly no recurrences. The repair is remarkable in its simplicity and any body’s first thought upon understanding the basics of the operation will be: why didn't someone think of this before?

The external oblique is incised similarly to the way it is done in the other anterior approach repairs. The spermatic cord is dissected free the same way it is done in all the other anterior approach repairs. The sac are dissected free as usual and generally cut away. The herniated organs are returned to the abdomen as usual.

The upper flap of the external oblique aponeurosis is sutured to the inguinal ligament, behind the spermatic cord. Then the external oblique is incised again, 1-2 centimeters above the inguinal ligament, simultaneously creating (1) a new lower edge to the upper flap, and (2) a "strip," or in my words a patch, made out of a strip of external oblique that is several centimeters wide. The upper edge of this "patch" is sutured to the internal oblique. The result is that a "patch" of external oblique aponeuroses is in place behind the spermatic cord, similarly to the way a Lichtenstein patch would be in place behind the spermatic cord. The difference is, that (1) this is a patch of living tissue and (2) the strip of external oblique aponeurosis is still attached normally to external oblique muscle and contractions of the external oblique muscle have a dynamic affect on countering intra-abdominal pressure, rather than merely static effect that the non-living patch used in a Lichtenstein repair, would have.

The new lower edge of the upper flap is sutured to the original upper edge of the lower flap, above the spermatic cord -- that is, the external oblique is closed similarly to the way it is closed in Bassini, McVay, and Shouldice repairs. However it is the newly created lower edge of the upper flap that is being used, instead of its original upper edge; the original lower edge of the upper flap has previously been sutured to the inguinal ligament. Thus, when the operation is completed, there are 2 layers of external oblique: one under the cord and one above it, instead of only one layer, below the cord, as in normal anatomy, and as in Bassini, McVay, and Shouldice repairs.

Mesh Repairs, Anterior Approach

Lichtenstein, Rutkow Plug&Patch, Prolene Hernia System, Moran repair

Lichtenstein

Uses a 7 or 8 centimeter incision. Dr. Amid, the main living proponent of the Lichtenstein repair, is meticulous about identifying nerves and preserving them. After the hernia sac is taken freed and the herniated organs reduced, a piece of flat polypropylene mesh, about 10 centimeters long by about 4.5 centimeters wide, is placed between the external oblique and internal oblique. A slit is made in the mesh to create two tails, which are wrapped around the spermatic cord where it emerges through the internal inguinal ring. The tails are overlapped. The mesh is held in place with about 8 sutures. This seems to be sufficient to hold the hernia back.

The mesh is monofilament polypropylene. It is a loose knit. The body's natural reaction to polypropylene is to sequester it by forming a layer of non-vascular scar tissue around it.

The hypothesis frequently presented, to account for how the mesh holds back the hernia, is a little puzzling. The scar tissue is said to be desirable, because it strengthens the area and prevents herniation of organs. The kind of knit has a specific size of its spaces, or pores, between the filaments. These pores, are said to be "just the right size" to maximize tissue ingrowths, which is said to be necessary to hold back the hernia. At the same time, the mesh is said to be strong enough to hold back the hernia, even without the ingrowths of scar tissue. They can't seem to make up their mind what holds back the hernia, the mesh, or the tissue ingrowths.

Either way, these tissue ingrowths make removing the mesh a much bigger operation than putting it in. I see this as a major disadvantage. Also, a 20-year old person may live 90 years after having such mesh implanted. What will happen to the mesh 90 years from now? There is no data from 90 years ago, to inform us. There is little or no data from 18 years ago or longer. No-one can tell us for sure what will happen 20 years down the road, much less 90 years. This, combined with the fact that removing mesh is difficult, and removing broken down, disintegrating mesh is would likely be even more difficult, makes me wary of having mesh placed in me.

Prolene Hernia System & Rutkow Plug and Patch (or sometimes just plug) or Moran repair: These are just the modifications of mesh repair and they also work on the same principle of tissue ingrowth.

Posterior approaches; pulling and pushing

For inguinal hernias, the posterior approaches in common use are: Kugel Patch method, and laparoscopic methods. Of the laparoscopic methods, the 2 methods in common use are totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP). Once the "pre-peritoneal space" is accessed, from an incision that may not be directly over the hernia, and may be rather far away, the adherent sac is separated, and the herniated organs are either "pulled" back into the abdomen, or coaxed back into the abdomen by a combination of pulling from inside, and, non-surgically pushing, with a hand, from outside the abdomen, over the area where the protrusion is, much the way the patient would reduce the hernia himself. The "pre-peritoneal space," by the way, is the space between the inner surface of the 3-layered abdominal "wall" and the outer surface of the peritoneum.

Don’t you think now that Desarda Repair is real answer for hernia problem? It takes away the complications of a foreign body seen in mesh repair and there is no tension on suture line as seen in other pure tissue repairs. This operation is based on the new theories that are said to prevent hernia formation in the normal individuals.

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1] No mesh, no foreign body

2] No chronic groin pain

3] Full recovery in one week

4] No risky dissection

5] No recurrence

6] No endoscopes

CONTACT:

desarda@hotmail.com

MOBILE:

+91(0)9373322178

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