Operation Technique

INGUINAL HERNIA REPAIR-NO MESH REPAIR TECHNIQUE

It is possible that some surgeons may use old tension repairs like Bassini or Shouldice under the pretext of mesh free surgery. So always insist for mesh free repair by "DESARDA TECHNIQUE" only

Mesh, a piece of synthetic cloth, never gives protection by itself as believed by many. Body forms a curtain around the scaffold of mesh and then it takes another 2-3 years to gain strength in it to give protection. Till then you are not 100% protected !!!

We advise not to get inguinal hernia repair done through laparoscope because the mesh is inserted inside the abdomen and may cause more serious complications.

Separate informed consent in writing is required before mesh repair to avoid future legal suits

OPERATION TECHNIQUE (For Non-Medical persons)

Be careful about mesh used in hernia surgery. It is a simple piece of synthetic cloth !!!

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SEPARATE INFORMED CONSENT IN WRITING IS REQUIRED IN MESH HERNIA REPAIRS TO AVOID LEGAL SUITS IN FUTURE !!!

Every surgeon should take a separate informed consent in writing from the patient to avoid court litigation in future following mesh complications after MESH REPAIR because it is a foreign body being implanted !!!

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 recurrences. The repair is remarkable in its simplicity and any body’s first thought upon understanding the basics would be: why didn't someone think of this before for last almost 100 years?

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

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 other 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 aponeurosis 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 effect on countering intra-abdominal pressure, rather than merely static effect that the Lichtenstein repair, would have.

The new lower edge of the upper flap is sutured to the original upper edge of the lower flap, above in front of 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 lower 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. This will result in closure effects of both these flaps when the external oblique muscle contracts during cough. Due to this closure effect the entire canal and the spermatic cord will get compressed giving protection against the recurrence of hernia again.

Principle: We were the first to emphasize that inguinal hernia repair should be based on physiological principle and not on anatomical principle to give the best results. We also proved that the coughing or straining or similar concepts postulated for last 100 years as the cause of hernia formation are not true. We also proved that the posterior wall of inguinal canal through which herniation takes place is not formed by transversalis fascia but is formed by the transversus abdominis aponeurosis, an aponeurotic sheet. If this sheet is absent or deficient then only hernia formation takes place. We replace this absent or deficient aponeurotic sheet with a strip from the adjacent external oblique aponeurosis to give long lasting cure from the inguinal hernia.

OPERATION TECHNIQUE (For Medical persons)

Be careful about mesh used in hernia surgery. It is a simple piece of synthetic cloth !!!

READ OUR BOOK RECENTLY PUBLISHED ON AMAZON.COM

1] Title: A Short Handbook of Desarda Repair for Inguinal Hernia at $ 9.99 only.

2] Title: New Technique of no mesh Inguinal Hernia Repair-Desarda Repair at $ 9.99 only.

3] Title: Desarda Repair for midline abdominal wall hernias at $ 2.99 only

CLICK HERE: https://www.amazon.com/s?k=mohan+desarda+book&ref=nb_sb_noss

SEPARATE INFORMED CONSENT IN WRITING IS REQUIRED IN MESH HERNIA REPAIRS !!!

Anaesthesia: Surgery can be done under local or spinal anesthesia. Anesthetist should add Buprigesic (Buprenorphine) drug of dose 60-90 micrograms in the anesthetic agent while giving spinal anesthesia. This reduces post-operative pain dramatically to a great extent.

Surgery: Skin and fascia are incised through a regular oblique inguinal incision to expose the external oblique aponeurosis. The thin, filmy fascial layer covering it (innominate fascia) 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. Upper and lower leaves are cleared from surrounding tissue by proper undermining. 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 direct hernias where it is inverted. Protect the ilioinguinal nerve running in front and the genital branch of the genitofemoral nerve running behind the cord. Surgeon may scrub the posterior wall with a gauze piece to find out the present or absent aponeurotic extensions in the posterior wall. The upper leaf of the external oblique aponeurosis (EOA) is sutured to the inguinal ligament from the pubic tubercle to the internal ring using PDSII no.1 or ‘0’ (Monofilament Polydioxanone violet, Ethicon) continuous sutures. The first suture is taken in the anterior rectus sheath part of the external oblique aponeurosis upper leaf above and the medial most part of the inguinal ligament below near the pubic tubercle. The last suture is taken so as to sufficiently narrow the new internal ring without constricting the spermatic cord by pushing the cord against the arching muscle fibers to its maximum extent (Fig. 44). Here, we are creating a new internal ring in the EOA with the help of the strip while suturing strip's lower border to the inguinal ligament. And the original internal ring becomes defunct. Lateral pushing of spermatic cord against the arching muscle fibers to maximum extent is necessary while this suturing is done. Each suture is passed first through the inguinal ligament and then the external oblique upper leaf. Needle bites are taken as close to the border of the EOA as possible (about 1-2 mm). The index finger of the left hand is used to protect the iliac vessels and retract the cord structures laterally while taking lateral sutures.

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= Newly formed internal ring; 5=Spermatic cord; and 6= Lateral (Lower) leaf.

A splitting incision is made in this sutured upper leaf, partially separating a strip OF 1-2 cms. WIDTH but NEVER more than 2 cms. Normally 1.5cm wide strip is sufficient for most of the patients. This splitting incision is extended medially up to the pubic symphysis and laterally 2-3 cms beyond the internal 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 or ‘0’ (Monofilament Polydioxanone violet, Ethicon) continuous sutures throughout its length. The aponeurotic portion of the internal oblique muscle is used for suturing to this strip wherever and whenever possible; 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 (Physiological tension) on the strip exerted by the external oblique to support the weakened internal oblique and transversus abdominis is clearly visible. The increased strength given by the external oblique muscle is the essence of this operation. The spermatic cord is placed in the inguinal canal and the lower leaf of the external oblique is sutured to the newly formed upper leaf of the external oblique in front of the cord, as usual, again using PDSII no.1 or ‘0’ (Monofilament Polydioxanone violet, Ethicon) continuous sutures. Undermining of the newly formed upper leaf on both of its surfaces facilitate its approximation to the lower leaf. The first stitch is taken between the lateral corner of the splitting incision and lower leaf of the external oblique. This is followed by closure of the superficial fascia and the skin as usual.

FIG. 45. Undetached strip of external oblique aponeurosis forming the posterior wall of inguinal canal.1=Reflected upper 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= Newly formed internal ring; 7=Spermatic cord; and 8= Lateral (Lower) leaf.

Mechanism of action: Contractions of the abdominal wall muscles pull this strip upwards and laterally against the fixed structures like inguinal ligament and pubic symphysis, creating physiological tension 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 physiological tension in the strip and prevent re-herniation is the essence of this operation. The shielding action of the strip of the external oblique aponeurosis can be elegantly demonstrated on the operating table by asking the patient to cough. This is mechanical as well as physiologically dynamic protection given by the newly prepared posterior wall.

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 in hernia patients. The strip of the external oblique aponeurosis sutured in this operation gives the aponeurotic cover to the posterior wall again and restores this anterior-posterior compression effect during the raised intra-abdominal pressures. The spermatic cord is sandwiched between the strip behind and the external oblique aponeurosis in front. The contraction of the external oblique muscle pulls the anterior aponeurosis and the posterior placed strip also to bring them together in its original plane, naturally compressing the entire inguinal canal and the spermatic cord to give perfect and longer protection against the re-herniation or the recurrence.

Spermatic cord lies comfortably between the posterior strip and the anterior external oblique aponeurosis at rest. Posterior wall is tension free at rest.

Contraction of the external oblique muscle pulls posterior strip and anterior EOA to bring them together compressing the entire canal and the spermatic cord thereby protecting from direct or indirect hernia formation. Posterior wall undergoes in to physiological tension converting the posterior wall in to a shield to give mechanical as well as physiologically dynamic protection against the recurrent hernia formation

Want to see and read operation technique for ventral (umbilical and incisional etc.) hernias then click on this link

http://www.desarda.com/operation-technique-2

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