New Millennium Gift

1. New Millennium Gift “Dr. Desarda’s Repair” For Inguinal Hernia

2. Prof. Dr. Desarda Mohan P. MS. (Gen. Surgery) PUNE (INDIA) PROFESSOR & HEAD OF THE DEPARTMENT OF GENERAL SURGERY Poona Hospital & Research Centre Kamala Nehru Corporation Hospital Ex-Associate Professor of surgery Bharati Vidyapeeth Med. College Gold Medallist in Anatomy

3. Journey • Hippocrates (400 BC)-first described hernia • Celsus (1st cent. AD) - first to advise surgery • Gimbenat, Hasselbach, cooper (1760-1820) careful dissection of ing. canal • Lucas championniere (1881) first opened inguinal canal for surgery • Marcy (1881) - first to describe logical step in reconstructive repair • Bassini (1888-90) - first to provide strong posterior wall

4. Journey(Contd…) High recurrence rate of Bassini’s repair prompted introduction of many other modifications • Halsted • Blood good • McVay • Darning Operation • Tantalum Gauge or Dacron net HernioplastyBut none of those were accepted for equally high failure rates or some other reason. • Andrews • Tanner • Zimmerman

5. Journey (21st Century) Accepted methods of repair today • Shouldice - since 5 decades • Lichtenstein Mesh - since 1-2 decades • Laparoscopic repair - since 1 decade • Bassini’s repair - since one century

6. No Answer ?? • Bassini & Shouldic repair are basically & principally similar operations • Previously described and now rejected Tantalum gauge or Dacron net Hernioplasty is also basically & principally similar to Lichtenstein mesh Hernioplasty • Mechanism of action to prevent recurrence is same but still later operations claim less than 1% recurrence rate & previously described operations are rejected How ?

7. Scenario Today • Lichtenstein & Shouldice supporters are two powerful lobbies - each claiming superior to other • Periodically papers are published criticizing directly / indirectly others technique & showing best results with their technique • Results are better because operating surgeons are experts in Hernia surgery & operation is done in specialized Hernia center Shouldice Lichtenastein

8. Junior / Average Surgeon • Kux, Schemper, Burlinger, Piper, Belanger, Panos, Kingworth & many more surgeons reported that, “In the hands of junior surgeons or that huge mass of general surgeons without expertise in Hernia surgery, the recurrence rate have been reported to be is still very high ”

9. Demand of those Surgeons • Inguinal Hernia is a bread & butter of this mass of the general surgeons • DEMAND - Do not find an operation that converts recurrence rate from 2 % to 1% in the hands of expertsBUT “to find an operation which is simple, safe, easy to learn & perform, does not require special material to repair & also gives recurrence rate less than 2% without any major complications during or after surgery”

10. No doubt thatInguinal hernia repair is still a problem AND This is my humble contribution to solve this problem

11. Problems are • RECURRENCES • COMPLICATIONS • TIME TO RESUME ‘NORMAL’ ACTIVITIES • LOSSES DUE TO WAITING TIME

12. RECURRENCES * The recurrence rate for NHS hospitals in UK in 1995–96 was 7.2%. & approximately 10% of all hernia repairs were done for recurrent hernias in USA. * The low rates from Large specialist centers seen may be due to short periods of follow-up, differences in case mix, and the skill of experienced hernia surgeons. * Prolonged follow-up is desirable when assessing recurrence rates, as over 50% of recurrences occur four or more years after surgery .

13. Age- and sex-specific recurrent hernia repair rates(Source: HES data 1995/96)

14. LOSSES DUE TO RECURRENCE • Private day-case surgery. (Price includes assessment and follow-up) £895 • Private GP consultation £36 • Inpatient groin hernia repair £814 • Day-case groin hernia repair £488 • Outpatient appointment, first visit £73 • Outpatient appointment, follow-up £41 • Loss for every recurrence is £ 900 and loss for each in-patient over day-case surgery is £305.

15. MEDIAN TIME TO RESUME ‘NORMAL’ ACTIVITIES FOLLOWING SURGERY • Varies enormously between studies:1-6 weeks • In the UK, patients are routinely given sick notes for 4 to 6 weeks • In the USA, median time to return to work and period of post-operative pain have been related to the availability of compensation . • Specialist centers undertaking open, tension-free repair recommend early mobilization, and patients return to work after a median of 9 days

16. LOSSES DUE TO WAITING TIME FOR INGUINAL HERNIA SURGERY • People in manual occupations may be on sick leave for prolonged periods of time waiting for a hernia repair, with considerable cost to the individuals, their employers, and the welfare state. If 1% of people waiting for an inguinal hernia repair are unable to work while waiting, with a mean wait of 133 days. • This is equivalent to 295 lost years of productivity per annum.

17. Regional variation in waiting times for primary inguinal hernia repair(Source HES data 95-96)

18. UNITED KINGDOM • 80000 repairs per year with recurrences of 7.2% translates to nearly 6000 operations are required to be re-done • This comes to a huge loss of 6000 X 900 = 5400000 ( 5.4 MILLION ) Pounds & 295 lost yearsof productivity per year in UK “Groin hernia is one of the commonest disease affecting 2-3% of world population every year, so it can not remain a monopoly of a few hernia expert surgeons for better results or complete cure, looking at those losses”

19. What solution? We need an operation technique which is • Simple & safe to do & learn by the non consultant staff also with equal results • Does not use foreign body as mesh • Does not use weak muscles & fascia • Immediate ambulation without much pain • Pt. goes home in a day • Pt. is back to his work within a week • No major complications • NO RECURRENCE

20. INGUINAL CANAL PHYSIOLOGY To achieve this let us understand that:- • Some questions related to the physiology of ing. canal or factors that prevent herniation still exist. • “Obliquity of the inguinal canal" is not a perfect description since the spermatic cord is lying throughout its course on the transversalis fascia. • Repeated acts of crying, do not increase the incidence of hernia in new born babies in spite of the almost absent "obliquity of the inguinal canal" or "shutter mechanism of the canal". • Every individual with a high arch or a patent processus vaginalis does not develop hernia.

21. CONCEPTS OF CANAL PHYSIOLOGY • Concepts that are said to prevent herniation are not restored in the traditional techniques of inguinal hernia repair and yet 70–98% of pts. are cured. • Then what are the additional factors that play a real role in the prevention of hernia in the normal individuals? OR after surgery? • The role played by apo.extensions from the tr.abd.apo.arch in the posterior wall is not much emphasized in the literature

22. ANATOMY OF ING.CANAL

23. APONUROTIC EXTENSIONS

24. POSTERIOR WALL • The posterior inguinal wall is composed of condensed transversalis fascia along with the aponurotic extensions from the transversus abdominis aponurotic arch • The condensed fibro-collagenous tissue and aponurotic extensions both give physio-mechanical strength to the posterior inguinal wall to resist int. abd. blows. And prevent herniation • The strength of the posterior inguinal wall is directly related to the number of aponurotic fibers it contains

25. POSTERIOR WALL AT REST

26. POSTERIOR WALL (cont.) • However, nearly 53 % of individuals have negligible or nil aponurotic extensions. • If aponurotic extensions are absent, then the trans. fascia alone cannot resist the internal blows for a long period and herniation occurs • Secondly, the posterior inguinal wall and accompanying aponurotic extensions are physiologically active and dynamic • Muscular contraction of the transversus abdominis pulls this posterior wall and the aponurotic extensions upward and laterally creating tension in it (Physiologically dynamic) to prevent herniation

27. POSTERIOR WALL IN ACTION

28. POSTERIOR WALL (cont.) • This tension in the posterior wall is created in gradation as per the force of contraction of the muscles. And the force of contraction of the muscle changes as per the force of the internal abdominal blow. This is important physiological phenomenon. The posterior inguinal wall should be described as an independent entity, playing an important role in the prevention of hernia formation, not only because of its mechanical strength but also because of its dynamic nature. • Such a physiologically dynamic posterior wall is needed to be constructed to give 100% cure from the inguinal hernias

29. MUSCULO-APONUROTIC STRUCTURES • Every individual with absent or deficient apo. Ext. do not develop hernia because of the role played by the strong musculo-apo. structures around the inguinal canal • ‘Shielding-Compression-Squeezing’ action of those musculo-apo. structures around the canal prevent herniation in such people with weak post. wall • But if apo. Ext. are absent or deficient and muscles are also weak then herniation is sure to take place • Therefore, any new approach to inguinal hernia repair must consider replacing apo. element in the post. Wall and also giving additional muscle strength to keep it physiologically dynamic

30. ANSWER • To give a strong, mobile & physiologically dynamicpost.wall to the inguinal canalWHICH MEANS NEW POST. WALL • Should have apo. element to support tra. fascia • Should give additional muscle strength to weakmuscles to increase tone of the post.wall • Post. wall should remain mobile after surgery

31. My Operation Technique “DR. DESARDA’S REPAIR”

32. UPPER LEAF OF EOA IS SUTURED TO INGUINAL LIGAMENT

33. UPPER BORDER OF SEPERATED STRIP IS SUTURED TO INT. OBIQUE MUSCLE

34. Mechanism of Action • Strip is fixed below & medially • All abd muscles exert action above & laterally • Ext. oblique gives additional strength to theweakened int. oblique & trans. abdominis • Contraction of muscle increases tone of the strip converting it into a shield to prevent hernia • Tone of strip is graded as per force of muscle contractions (physiologically dynamic wall) • Strip replaces the absent aponurotic fibresgiving a natural support to the trans. fascia

35. Star Points of Technique • It is a Herniorrhaphy operation / plasty • Locally available live & active tissue • EOA is large enough to get strip easily • You get physiologically dynamic posterior wall • No difficult dissection is required • No foreign body or special material required • Satisfies all the criteria of modern Hernia surgery like day surgery, low learning curve, early ambulation, back to work in a week, minimal pain, no major complications and “ ZERO RECURRENCE “

36. Would you still like to insert a mesh in the body of your patient for inguinal hernia repair & give millions of micro abscesses ?? YOU DECIDE ! ! CHOICE IS YOURS ! ! !

37. REFERENCES • Millikan KW, Deziel DJ. The management of hernia. Considerations in cost effectiveness. • Williams M, Frankel S, Nanchahal K, Coast J, Donavon J. Hernia repair. In: Stevens A, Raftery J (eds) Health Care Needs Assessment. (1e). Oxford: Radcliffe Press, 1994. 8 • Anonymous. Activity and recurrent hernia [editorial]. BMJ 1977; 2: 3–4. 10 • Review] [33 refs]. Surgical Clinics of North America 1996; 76(1): 105–116. 11 • Kux M, Fuchsjager N, Schemper M. Shouldice is superior to Bassini inguinal herniorrhaphy. Am. J. Surg. 1994; 168: 15–18. 12 • Kark AE, Kurzer MN, Belsham PA. Three thousand one hundred seventy-five primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia. Journal of the American College of Surgeons 1998; 186(4): 447–455. 22 • Salcedo-Wasicek MC, Thirlby RC. Postoperative course after inguinal herniorrhaphy. A case-controlled comparison of patients receiving workers' compensation vs. patients with commercial insurance. Archives of Surgery 1995; 130: 29–32. 23 • Liem M, van Steensel C, Boelhouwer R, Weidema W, Clevers G, Meijer W et al. The learning curve for totally extraperitoneal laparoscopic inguinal hernia repair. The American Journal of Surgery 1996; 171: 281–285. 29 • Rattner D. Inguinal herniorrhaphy: for surgical specialists only? Lancet 1999; 354. 32 • Webb k, Scott NW, GO PMNYH, Ross S, Grant AM on behalf of the EU Hernia Triallists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair (Cochrane Rebiew) In: The Cochrane Library, Issue 4, 2000, Oxford Update Software. 33

38. THANK YOU