History of Desarda Repair
HISTORY: Mesh repair was introduced in around 1980. But my teacher when I was post graduate student and later me was using a piece of synthetic cloth made from Terene and Terelyne, available in those days of 1970 for inguinal hernia repair. This synthetic cloth was manufactured by Reliance industries for the first time in India. But I was never satisfied about the results, complications and the hardships suffered by some patients following use of such pieces of cloth.
So, I started studying various techniques that were traditionally used in those days like Bassini, Shouldice, Marcy, Bloodgoods, Halstead and many others. I found no satisfaction with those repairs as they were truly called as tension repairs. Basically muscles are pulled down to suture to the inguinal ligament. This results in to 1] Displacement of muscle and 2] Tension on suture line even at rest. In fact, classical Bassini or Shouldice or MacVay are very good repairs with good results but all these classical operations required complex dissection and excision of the inguinal floor. Surgeons generally would love to have a simple operation without any complicated and risky dissection or suturing and so they started omitting this complicated step of the excision of the inguinal floor. That is how all later operations that were described by different surgeons in different institutions were not ideal and classical operations but the modified operations. Naturally, the results delivered were also poor.
I was also using Bassini repair in those days 1970-80 but by omitting this complicated step of the excision of the inguinal floor. I got good results where the gap in the inguinal floor was narrow and patients had relatively less strenuous activities to carry. In others, I started using a piece of synthetic cloth.
The mesh was introduced in 1980 but was costly and was not easily available. Otherwise also, I was against using piece of cloth for repair of hernia. The reason was that similar trials like Dacron net hernioplasty were already tried and adopted in practice but later rejected by many surgeons in the past.
The main deterrent factor found while doing Bassini repair was the weakened muscles of the muscle arch. And repairing with such weak muscles is always bound to fail. So I started thinking as to why not to use nearby external oblique muscle which is always strong.
On this background, I thought of studying the aetiology, pathology, anatomy of the inguinal canal. I wanted our own body tissue to repair the hernia. I read in detail about such techniques described in those days 1970-80 that used a patch of skin or fascia lata or darning with a strip of fascia lata. But these technique did not appeal me because the tissue used for repair get necrosed resulting in more complications. Internal oblique or the conjoint tendon was sutured with external oblique together behind the cord as in Andrew could not give good results because of double damage to the local muscles. Internal oblique or conjoint tendon is weak in hernia patients and that you weaken more by displacing or stretching or by taking relaxing incisions. External oblique which is otherwise strong is also affected by displacing and stretching and suturing to inguinal ligament under tension. Not less than 81 operative techniques for inguinal hernia repair have been described since the work of Bassini. Such proliferation of techniques is the typical result of poor outcome.
I wanted a strong muscle that can be sutured in the gap for the repair of inguinal hernia. AND THEN ONE DAY THAT GREAT IDEA WAS BORN IN MY MIND OF USING A MUSCLE TRANSFER TECHNIQUE IN THE YEAR 1983. The conjoint tendon or internal oblique is weak, so that can’t be used. So I thought of using external oblique muscle to fill up the gap. The procedure was very simple. Herniotomy was done as usual. Then a strip of the upper leaf of EOA was separated from pubic tubercle to internal ring keeping its continuity intact and then this strip was sutured to the inguinal ligament below and the internal oblique muscle above to fill up the gap. This was my first operation. But, I realized the difficulty arising due to curling of strip and causing great difficulty in taking sutures. So, I made my first and the last alteration in my procedure. I started suturing the upper leaf first to the inguinal ligament and then separating a strip. That solved all the difficulties. Some surgeons have wrongly interpreted this as a relaxing incision as is done in some modified Bassinin's operations.
Since then, I did around 200 surgeries by this technique and sent my " NEW OPERATION TECHNIQUE FOR INGUINAL HERNIA" in the Indian Journal of Surgery for publication and it was published in 1998.
Later, I completed study on around 400 patients with followup of more than 10 years and the results were published in international indexed journals. That evoked a great inquisitive response from all over the world. Obviously, this was because majority of unbiased general surgeons were never happy of inserting a piece of synthetic cloth in the body of their patients and every body was aware about the foreign body complications arising out of mesh repair causing irreversible damage to the body tissues.
Every body welcomed this new invention without mesh and no body wrote any thing against this except one surgeon. That was Julian E. Losanoff, M.D., J. Michael Millis, M.D who wrote against this technique in not only this publication but also other publication in a study on more than 860 patients in the "Hernia, The World Journal of abdominal wall surgery". Obviously, he was biased for mesh repair and failed to give independent unbiased thinking on the technique. I replied to his letters to editor that are worth reading.
Simultaneously, I published, how old concepts that prevent inguinal hernia formation in the normal individuals are not true and perfect. This was published in the year 2002 and later in 2018. I revolutionized the entire concepts of inguinal hernia, inguinal floor and its physiology. 1] Posterior wall of inguinal canal is formed by transversalis fascia. THIS IS WRONG !! It is formed by the aponeurotic extensions from the transverses abdominis and the transversalis fascia is behind it. Thus it is 2 layered structure and not a single layer. 2] The strength of the transversalis fascia prevents hernia formation. THIS IS ALSO WRONG !! It is these aponeurotic extensions that prevents hernia formation. The transversalis fascia is paper thin and without any strength. 3] Obliquity of inguinal canal is not true because spermatic cord is lying on these aponeurotic extensions and the transversalis fascia through out its course. 4] I was the first to describe the concept of inguinal hernia repair on physiological principle to give better cure rate instead of doing a mechanical repair by stitching mesh on the weak spot. 5] This is the only revolutionary hernia repair that does not need typing or staging or size of hernia to choose the type of repair for better cure. This technique can be universally applied to all primary hernias with good results irrespective of its type or stage or size.
Then another mile stone was to use all absorbable continuous sutures for this repair, a thing that was never imagined by any body till today. No body dreamt that a day will come where we can use continuous suture instead of interrupted sutures (used out of fear of recurrence) and also to use absorbable sutures instead of non absorbable sutures (used out of fear of recurrence). This article was published in the Saudi Journal of the Gastroenterology. I had to confront with rejection of publication of my articles here and later at every stage, obviously because the pro mesh reviewers did not want to publish my articles.
Today, you will find a crop is erupting every where in all countries of the world to establish hernia societies. WHY? Because hernia is a very common disease and a great money earner for those companies. If their product mesh is used more and more, they will earn more and more. For this purpose they started hiring openly professors as attached with their companies and started sending them to deliver lectures before the medical graduates to market their product. If the readers of this article are interested in getting more knowledge about this, I would advise to read my lecture in Germany delivered in 2013 about the 'MARKETING MAGIC" used by those companies. VISIT: www.desarda.com a power point presentation under the heading "A MESSAGE TO ALL SURGEONS"
BUT, all can not go in favour of mesh simply because they had financial muscle power. There are many surgeons at the top who still believe in patients safety more than the financial support from mesh companies. I was invited to the first world hernia conference in April 2015 as faculty to deliver a guest lecture on my new invention of a pure tissue repair based on the new principles. I presented global data of around 11000 patients with follow up of more than 3-5 years. Recurrences were 0.2% and complications seen were around 1.8% . This was the ultimate proof that my operation technique is much superior in all respects if compared with any other technique. Thanks !!