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									                  "Desarda Repair for inguinal hernia without mesh"

Traditionally done operations today are tension repairs like Bassini, Shouldice or
MacVay's repairs and tension free repairs like repairs done with mesh, plug and mesh
or PHS (Prolene Hernia System). All tension repairs have high rate of recurrences and
post-operative pain. Sutures are under tension even at rest and gets aggravated during
contractions and scar shrinkage in healing process. Therefore, these tension repairs are
practically replaced by tension free repairs where mesh prosthesis is used. But then
there are many associated complications of a foreign body. Mesh is prepared from PVC
material and therefore recurrence, pain, infection, migration, rejection, testicular
ischemia or atrophy and perforations are all documented complications. Laparoscopic
hernia surgery reduces pain but then there are dangers of general anaesthesia, gas
filling under pressure and instrumentations in addition to the mesh stitched in side.
Those complications are more risky because mesh is stitched in side the abdomen.

       Desarda repair has removed all drawbacks of both types of repairs. There is no
tension on suture lines as seen in tension repairs and there is no foreign body used like
mesh repairs. This operation is simple without any complicated dissection or does not
require costly equipments like laparoscope or any expertise required to handle those
laparoscopes or to do complex dissections. There is minimal pain, fast recovery and
virtually complete cure from the inguinal hernia.

        Operation technique: Skin and fascia are incised through a regular oblique
inguinal incision to expose the external oblique aponeurosis. The external oblique is cut
in line with the upper crux of the superficial ring. 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).

A splitting incision is made in this sutured medial leaf, partially separating a strip with
a width not more than 1.5-2 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). 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.

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.

                                          Figure 1

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.
                                          Figure 2

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: 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.
                                         Figure 3

                                        Figure 4

RESULTS: This operation is very simple without any complex dissection or without
any foreign body or does not require complex instruments like laparoscope. It gives fast
recovery and complete cure from the inguinal hernias. All patients are admitted in the
morning and taken for surgery under local or spinal anesthesia. Operation takes about
30-40 minutes and patients are freely mobile within couple of hours ready to go home
same day. There are no restrictions to be followed and patient can drive car and go to
office or travel, lift luggage, climb up or down the staircase or take a walk for shopping
within 3-4 days without any fear of recurrence or pain.

As of today, there are 53 centers all around the globe in many countries where desarda
repair is routinely followed in hundreds of patients. There are 3 centers in USA alone.
Nearly 72 research articles are published or presented by different surgeons and out of
that more than a dozen are comparative studies or randomized controlled trials. Dr.
Desarda himself has operated on more than 2000 patients till today without even a
single case of recurrence. Web site published by Dr. Desarda is extremely popular and
is visited by over a million of visitors till today. You can also visit this web site and get
complete knowledge about inguinal hernias including very high quality videos of
operation or recovery or presentation of his various lectures delivered as invited faculty
during national as well as international conferences.

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