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Comparative Study of Open Mesh Repair and Desarda’s No-Mesh Repair in a District

Authors:
  • Dr. M. P. Desarda Charitable Trust & Research Institution

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Background: The first author has described a new technique of pure tissue hernia repair and published his results previously1,2. This article describes the results of a comparative study of this new technique and the open mesh repair done in a district level general hospital set up in India. Methods: This is a retrospective study of 269 hernias operated by the author’s technique and 225 hernias operated by the mesh repair during a period from April 1998 to December 2003. Data ofhospital stay, intra-operative complications, ambulation, pain, and postoperative early and late complications were recorded and compared using SSPS software. Results: The mean stay in the author’s technique was 1.22+/-0.89 days while it was 3.59+/-1.93 days in the mesh group. The mean time to return to work in the author’s technique was 8.48+/-2.43 days while it was 12.46+/-2.11 days in the mesh group. There were 5 complications in the author’s technique while there were 16 complications in the mesh group. There was no recurrence seen with the author’s technique while there were 4 recurrences in the mesh group (1.97%). In addition there were 3 patients in the mesh group who underwent reoperation for chronic debilitating groin pain (1.47%). At the end of 1 year there were 13 /203 patients (6.49%) who had chronic groin pain while there was no incidence of chronic groin pain in the author’s technique. 234(92.8%) patients in author’s group and 171(84.3%) patients in mesh group were followed up for a median follow up period of 4.1 and 3.9 years respectively (Range 1-5 years). Conclusions: The results of the new repair described by the author look very promising. This repair has minimal complications and no recurrence. This operation is based on the physiological principle and this concept of physiological repair of inguinal hernia needs to be studied worldwide. This new repair has the potential to become the gold standard of hernia repair in years to come.
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East And Central African Journal of Surgery Volume 11 Number 2. December 2006
28
Comparative Study of Open Mesh Repair and Desarda’s No-Mesh Repair in a District
Hospital in India
M. P. Desarda1 M.S, A. Ghosh2 DNB, M.B.B.S
1Professor and Head, 2Resident in surgery, Dept of surgery, Poona Hospital & Research Centre, Pune.
Correspondence to: Prof. M. P Desarda, 18, Vishwalaxmi Housing Society, Kothrud, PUNE – 411 029
(INDIA) Telephone: 91 20 32905343E MAIL: Desarda@Gmail.Com
Background: The first author has described a new technique of pure tissue hernia repair and
published his results previously1,2. This article describes the results of a comparative study of this
new technique and the open mesh repair done in a district level general hospital set up in India.
Methods: This is a retrospective study of 269 hernias operated by the author’s technique and 225
hernias operated by the mesh repair during a period from April 1998 to December 2003. Data of
hospital stay, intra-operative complications, ambulation, pain, and postoperative early and late
complications were recorded and compared using SSPS software.
Results: The mean stay in the author’s technique was 1.22+/-0.89 days while it was 3.59+/-1.93 days
in the mesh group. The mean time to return to work in the author’s technique was 8.48+/-2.43 days
while it was 12.46+/-2.11 days in the mesh group. There were 5 complications in the author’s
technique while there were 16 complications in the mesh group. There was no recurrence seen with
the author’s technique while there were 4 recurrences in the mesh group (1.97%). In addition there
were 3 patients in the mesh group who underwent reoperation for chronic debilitating groin pain
(1.47%). At the end of 1 year there were 13 /203 patients (6.49%) who had chronic groin pain while
there was no incidence of chronic groin pain in the author’s technique. 234(92.8%) patients in
author’s group and 171(84.3%) patients in mesh group were followed up for a median follow up
period of 4.1 and 3.9 years respectively (Range 1-5 years).
Conclusions: The results of the new repair described by the author look very promising. This
repair has minimal complications and no recurrence. This operation is based on the physiological
principle and this concept of physiological repair of inguinal hernia needs to be studied worldwide.
This new repair has the potential to become the gold standard of hernia repair in years to come.
Introduction
Improvements in surgical technique and a better
understanding of the anatomy and physiology
of the inguinal canal have significantly
improved outcomes for many patients. These
improvements have occurred most notably in
centers specializing in hernia surgery, with
some institutions reporting failure rates of less
than 1%3,4.
In contrast, failure rates for general surgeons,
without expertise in hernia surgery, or the non-
consultant staffs, operating in smaller district
level general hospitals remain significantly
higher (up to 10% for primary hernias and 5%
to 35% for recurrent hernias5. This has
important socioeconomic implications, adding
an enormous cost of treating the condition,
which runs into billions of dollars. Success of
groin hernia repair is measured primarily by the
permanence of the operation, fewest
complications, minimal costs, and earliest
return to normal activities. The search for a
method that accomplishes all the above goals in
the hands of non-consultant staff continues.
Publication of the results of the author’s series
of operation prompted many others to adopt this
technique1. Their results, as communicated to
the author, are equally encouraging.
This study is undertaken in a district level
general hospital which is not a specialized
hernia centre to compare the early and late
morbidity as seen with the author’s technique
and the mesh repair done by general surgeons
who are not labeled as expert hernia surgeons
and are not doing only hernia surgery.
Methods
This was a retrospective study of 203 cases with
225 inguinal hernias repaired by open mesh
repair and 252 cases having 269 inguinal
hernias repaired by the author’s technique from
April 1998 to December 2003. All the surgeries
were performed at Poona Hospital and Research
Centre, a district level multidisciplinary general
hospital. Patients admitted in unit1 were
operated by the author’s technique and patients
admitted in unit 2 were operated by mesh
repair. None of those surgeons were specialist
in hernia surgery. Only those patients between
East And Central African Journal of Surgery Volume 11 Number 2. December 2006
29
20 to 80 years of age and those operated under
spinal or local anesthesia were included in this
study.
Exclusion criteria included associated surgical
pathologies where the patient was getting
operated for both conditions at the same time,
laparoscopic repairs or the patients given
general anesthesia for any reason. The data was
collected as regards hospital stay, pain,
ambulation and complications recorded during
operation or the hospital stay. Pain was
measured as mild pain (no analgesics),
moderate pain (oral analgesics) and severe pain
(parenteral analgesic). Ambulation was
measured as limited movements inside the
room, free movements as movements out side
the room and no movements where bed rest was
advised. Follow up record was collected from
the out patient record of the respective units till
December 2005 and the data of pain, infection
or other complications were recorded. 32
patients in mesh group and 18 patients in
authors group, whose follow up was seen to
have been lost in the record were called back to
the clinic for examination by the operating
surgeon or his resident surgeon. But, none of
them have turned up for the follow up. Thus,
234 (92.8%) patients in the author’s group and
171(84.3%) patients in the mesh group were
followed up for a median follow up period of
4.1 and 3.9 years respectively (Range 1-5
years).Appearance of a bulge with cough
impulse was treated as recurrence. Use of short
form 36 was done.
Data was analyzed using the Statistical Program
for Social Sciences (SPSS 7.5.1 for Windows)
package. The statistical methods used to
compare the two data were the chi square test
and the independent sample t test. The operative
technique of this new repair method was
followed as described by Desarda2 and mesh
repair was followed as described by
Lichtenstein and Amid6. The Ethics Committee
of the hospital cleared the study.
Desarda’s Repair Technique.
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 and an assessment made about the
strength of it and its thinned-out portion. 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
interrupted 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 1/0 monofilament
polyamide (Ethilon) or polypropylene (Prolene)
interrupted 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 (Figure 1). 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 symphysis 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 1/0 monofilament polyamide or
polypropylene interrupted sutures throughout its
length (Figure 2). 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.
East And Central African Journal of Surgery Volume 11 Number 2. December 2006
30
Figure 1. The medial leaf of the external oblique aponeurosis is sutured to the inguinal
ligament.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
Figure 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.
East And Central African Journal of Surgery Volume 11 Number 2. December 2006
31
Table 1. Table shows comparison of new method with international studies of open mesh repair
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 1/0 monofilament
polyamide or polypropylene interrupted 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.
Results
In the authors group of 252 patients, 62 were
direct, 104 indirect, 5 pantaloon, 53 recurrent,
11 obstructed and 17 bilateral hernias. In the
mesh group of 203 patients, 62 were direct, 96
indirect, 11 pantaloon, 6 recurrent, 7 obstructed
and 22 bilateral hernias. The mean age of the
patients in the mesh group was 54.29+/-
14.64years while in the author’s technique it
was 51.55+/-16.35 years. 28 patients in the
author’s technique and 26 patients in the mesh
group had a co morbid condition. There was no
significant difference in the age and the co
morbid condition in both the groups (p>0.05).
The mean stay in the author’s technique was
1.22+/-0.89 days while it was 3.59+/-1.93 days
in the mesh group. This difference is highly
significant (p<0.001). The mean time to return
to work in the author’s technique was 8.48+/-
2.43 days while it was 12.46+/-2.11 days in the
mesh group. This difference is also highly
significant (p<0.001). There were 5
complications in the author’s technique while
there were 16 complications in the mesh group.
This difference in complication rates is also
highly significant (p=0.003). There was no
recurrence seen with the author’s technique
while there were 4 recurrences in the mesh
group (1.97%). In addition there were 3 patients
in the mesh group who underwent reoperation
for chronic debilating groin pain (1.47%). Thus
the total reoperation rate in the mesh group was
7/203 (3.44%). No patient had discomfort for
more than 15 days in the author’s technique,
where as, in the mesh group, 4 patients had
moderate pain and 15 patients had mild pain or
discomfort at the end of 1 month; 2 patients had
moderate pain while 14 patients had mild pain/
discomfort at the end of 6 month and 13 patients
continued to have mild pain or discomfort at the
end of 1 year. Thus at the end of 1 year there
were 13 (6.4%) out of 203 patients who had
chronic groin pain in the mesh group while
there was no incidence of chronic groin pain in
the author’s technique.
Discussion
Inguinal hernia is a very common condition
afflicting mankind. Newer techniques are
developed as the complication rate of older ones
become unacceptable. The Lichtenstein
technique and its modifications are widely
practiced in the world but their complication
rates and failures are more in the hands of non-
consultant staff. Mesh repair, plug repair, plug
and mesh repair or recently introduced PHS
have all confused what is best and what to
follow in the minds of such surgeons, who are
not expert in hernia surgery. This necessitates
the introduction of a new technique of hernia
repair with reduced complication rates in the
hands of such general surgeons or the non-
consultant staff operating at smaller or district
Desarda’s repair - Present study, (2006) 0%/ 5 years 9.34 days 1.32
Colak T et al10 2003 15.2 days 2.7
Neumayer L11 et al (2004) 4.9%/ 2 years
Koukourou A et al12 (2001) 4%/ 1 year
Vrijland WW et al13 (2002) 1%/ 3 years
Leim MS et al14 (1997) 6%/ 607 days 10 days
East And Central African Journal of Surgery Volume 11 Number 2. December 2006
32
level general hospitals. In this present study of
455 patients, the new method of hernia repair
described by the first author seems to be
superior to the open mesh (Lichtenstein) method
on many counts. Both the groups are statistically
similar with regards to age, sex, and co morbid
conditions. The post operative stay, time taken
to ambulate the patient and the time taken for
the patient to return to work are all significantly
less in the new method compared to the
Lichtenstein method. Also the postoperative
pain and rate of complications is lesser with the
new method.
In the new group there are no recurrences or re-
surgeries required. There were four recurrences
and three re-explorations due to chronic severe
groin pain in the mesh group making a total of 7
(3.44%) who had re-operation. All the re-
surgeries showed extensive fibrosis reaction in
the inguinal canal due to the foreign body
reaction of the mesh. In both the patients who
were explored for chronic debilitating groin
pain, the spermatic cord was seen to be
enmeshed in the strong fibrous tissue around the
mesh. Careful dissection and release of cord
from the extensive adhesions was required. Thus
it can be inferred that the strong foreign body
fibrous reaction seen with mesh repair is
responsible in spermatic cord and nerve
enmeshment leading to chronic groin pain. The
new technique being a pure tissue repair will not
cause extensive fibrosis as seen in mesh repair.
Some studies reported chronic groin pain
following open mesh repair in 28.7 %( 7) to
43.3%. (8) This study also shows chronic
groin pain in the postoperative period in the
mesh group in 18 % of cases. 1.47 %( 3
patients) had to be re-explored for severe
groin pain. In contrast, there was no
incidence of chronic groin pain in the new
method. Chronic groin pain affects the
quality of life of the patients. Since quality
of life is a very important consideration
after any surgery this new method seems to
score over the Lichtenstein technique on this
count also.
This new technique of inguinal hernia repair is
easy to learn and does not require complicated
dissection. As the steps in this surgery are fixed
there is very less scope for modification by
individual surgeon. Hence even in the hand of
junior surgeons this technique will prove to be
very effective. As against this individual
surgeons bring in a lot of modification in the
Lichtenstein repair (like using a smaller size
mesh or not overlapping the mesh over the
tissues adequately). These modifications add to
the failure rates in the Lichtenstein repair.
Moreover, the new technique of hernia repair
does not need any costly mesh or laparoscopic
instruments. This makes this repair highly cost
effective. A cost effective repair that gives
excellent results will go a long way in reducing
health care cost in those days of cost
ergonomics.
This new method of hernia repair described by
Desarda is based on physiological principle. The
posterior wall of the canal is made up of the
transversalis fascia, which is strengthened
medially by the falx inguinalis or edge of rectus
and more laterally by the aponeurotic extensions
from the transversus abdominis arch that make
the posterior wall strong. But these aponeurotic
extensions are absent or deficient in 53% of the
population9. Strong musculo-aponeurotic
structures around the inguinal canal still give
protection to prevent the herniation in such
individuals. This protection is lost if those
muscles are weak. The weak and
physiologically a-dynamic posterior wall of
inguinal canal in such individuals leads to hernia
formation1, 2.
Bassini/Shouldice or similar open repairs use
those muscles for repair even if they are weak
leading to failures. The strip of external oblique
aponeurosis provides the aponeurotic element to
the transversalis fascia of the posterior wall.
Actions like coughing, crying and straining
cause contraction of the abdominal muscles.
Contraction of the external oblique muscle
creates lateral tension in this strip while
contraction of the internal oblique/conjoined
muscle pulls this strip upwards and laterally,
creating tension above and laterally, making the
strip a shield to prevent any herniation. The strip
provides a new insertion to the weak and flabby
internal oblique and transversus abdominis. This
helps to improve the muscle contractions of the
internal oblique and the transversus abdominis
muscles.
The additional strength given by the external
oblique muscle to the weakened conjoined
muscle to create tension in the strip and prevent
hernia recurrence is the essence of this
operation1,2. Tension created in this strip is
graded as per the force of muscle contractions.
East And Central African Journal of Surgery Volume 11 Number 2. December 2006
33
Stronger intra abdominal blows result in
stronger abdominal muscle contractions and
stronger muscle contractions result in increased
tension in this strip to give graded protection.
The strip or the suture line is without any
tension at rest. Thus, a strong and
physiologically dynamic posterior wall is
prepared in this operation1, 2. As this new
technique of inguinal hernia repair compares
favourably with other methods of hernia repair,
this technique needs to be used more
extensively.
Comparison with International Studies.
The data of the Lichtenstein group in our study
may not match with the data of international
studies. Hence the data of this new technique
was compared with the data of international
studies of open mesh repair (Table 1)
The recurrence rate in our study for the new
method is superior to that of international
studies of open mesh repair.
The mean postoperative stay and return to
work in the new method group in our study
compares well with that of other
internationally published studies.
The complication rate in the new method in
our study is lesser than that of other
internationally published studies.
The results of the new repair described by the
author look very promising. Large-scale long-
term multi-centric trials need to be conducted to
evaluate this repair further and establish this
repair among the general population of
surgeons. This repair is easy to learn with
minimal complications or recurrence. This
operation is based on the physiological
principles and this concept of physiological
repair of inguinal hernia needs to be studied.
Conclusion
The results of the new repair described by the
author look very promising. Large-scale long-
term multi-centric trials need to be conducted to
evaluate this repair further and establish this
repair among the general population of
surgeons. This repair is easy to learn with
minimal complications or recurrence. This
operation is based on the physiological
principles and this concept of physiological
repair of inguinal hernia needs to be studied.
This new repair has the potential to become the
gold standard of hernia repair in years to come.
Acknowledgement.
Since its first publication in 2001, the author has
received communication from the following
surgeons in Poland, Cuba, Korea, Albania,
Libiya, Ukraine, Iran, Brazil and India of
clinical trials being conducted by them that had
shown similar results without recurrence till
date. They are:
1. Collegium Medicum in Bydgoszcz,
Nicolaus Copernicus University
(Department of General and Endocrine
Surgery), ul.M.Sk³odowskiej-Curie 9,
85-096 BYDGOSZCZ, POLAND
Contact: Jacek SZopinski, M.D
(Professor of Surgery); Email:
jacek.szopinski@wp.pl
2. Hospital General Docente Enrique
Cabrera. (Department of General
Surgery) Calle Aldabo No. 11117.
Altahabana. Municipio Boyeros. Ciudad
Habana, Cuba. Contact: Pedro Lopez
(Professor of Surgery); Email:
lopezp@infomed.sld.cu,
3. B.J.Medical College and Sassoon
General Hospital, (Department of
surgery), Pune- 411001, India, Contact:
Sudhir Dube (Professor of surgery);
Email: drdubesb@yahoo.co.in,
4. Seoul Surgery Clinic, 237-1
Haksungdong, Wonju, Kangwondo,
Korea  220-964 Contact: Kishik
Kye, M.D.; Email:
kskye@hanafos.com,
5. Civil Hospital. City of Fier, Department
of General Surgery, Albania. Contact:
Robert Metaj, M.D. (Chief surgeon);
Email: metajrobert@yahoo.com,
6. Surgeons working in different medical
institutions in many cities of India, like
Calcutta, Chennai, Sholapur,
Dhavangiri, Kanpur, Karad, Meerut,
Belgaum, Baroda, Nanded etc. had
conducted trials of this technique for
thesis purposes of their post graduate
students.
7. Dr. B. Mohammadhosseini, General
Surgeon, P.O Box 14515-799 Tehran,
IRAN. Contact: Dr. B.
Mohammadhosseini Email:
bmohammadhosseini@yahoo.com.
8. Dr.Elisanio Cardoso, Rua Dr.Moacir
Rabelo Leite, 84,13de Julho, Clínica
Pulmão Coração, CEP 49020-280.
Aracaju-SE-Brasil. Contact: Elisanio
Cardoso Email: elisanio@uol.com.br.
East And Central African Journal of Surgery Volume 11 Number 2. December 2006
34
Others were who showed interest in procedure
included:
1. J. Olejnik, Chirurgika Klinika, FN Akad.
Derera, Limbova 5; 833 05 Brtislava
(Slovakia),
2. Cornelius Lemke,Friedrich Schiller
University, Institute of Anatomy, D-
07740 Jena, Germany,
3. Dr. Y. Bayon, Sofradim production, 116
Avenue Du Formans , 01600 Trevoux,
France,
4. Peter Bruncak,M.D. District Hospital,
Nam, Republiky 14, 984 39 Lucenec
(Slovakia),
5. Dr. Abel Santana, Gonzalez-Chavez,
EMAIL: abel@ventila.mtz.sld.cu,
6. R.Elamiyal, Al-Arab Medical University,
Benghazi, Libiya, Filipe Delgado,
Hospital Pediatrico Docente "Willium
Soler" Apartado No. 8019, Habana-8,
Cuba,
7. Miller Junny, EMAIL:
MILLERJUNNY@cs.com .
To all of them the principal author is very
grateful
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... Situma et al. [41] presented their short-term results of Desarda versus modified Bassini inguinal hernia repair, concluding that there was no difference between these two techniques in regard to pain and return to normal activity. Other results, published by Desarda and his group, were based on a comparison of his technique and the Lichtenstein technique [42]. They reported no recurrence among the 269 Desarda group patients and 1.97% recurrence among the 225 mesh group patients; 6.49% of patients from the mesh group and no patients in the Desarda group reported chronic pain at 1 year after surgery. ...
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The Shouldice method and other tissue-based techniques are still acknowledged to be acceptable for primary inguinal hernia repair according to the European Hernia Society guidelines. Desarda's technique, presented in 2001, is an original hernia repair method using an undetached strip of external oblique aponeurosis. This randomized trial compared outcomes after hernia repair with Desarda (D) and mesh-based Lichtenstein (L) techniques. A total of 208 male patients were randomly assigned to the D or L group (105 vs. 103, respectively). The primary outcomes measured were recurrence and chronic pain. Additionally, early and late complications, foreign body sensation, and return to everyday activity were examined in hospital and at 7, 30 days, and 6, 12, 24, and 36 months after surgery. During the follow-up, two recurrences were observed in each group (p = 1.000). Chronic pain was experienced by 4.8 and 2.9% of patients from groups D and L, respectively (p = 0.464). Foreign body sensation and return to activity were not different between the groups. There was significantly less seroma production in the D group (p = 0.004). The results of primary inguinal hernia repair with the Desarda and Lichtenstein techniques are comparable at the 3-year follow-up. The technique may potentially increase the number of tissue-based methods available for treating groin hernias.
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Ours was a retrospective chart review of all elective open inguinal hernia repairs performed in a single unit at King Edward VIII Hospital, South Africa over an 18-month period. Comparison was made regarding duration of operation, length of hospital stay and complications such as pain, haematoma formation and recurrence between the Lichtenstein and Desarda techniques. The latter was noted to have a shorter operative time and avoided cost and possible complications of mesh usage, which are significant in resource-deprived settings. A larger comparative study with longer follow-up is needed to evaluate the wider suitability of the Desarda repair.
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This study compared the short-term outcomes of the non-mesh (Desarda) and mesh (Lichtenstein) methods of hernia repair among Black African patients, with regard to acute postoperative pain, day of return to normal gait, operative time and complications. A total of 101 participants (51 in the Lichtenstein arm and 50 in the Desarda arm) were enrolled into this single centre double-blind randomised controlled trial. The outcome measures were evaluated at 1-2 h, 3, 7 and 14 days. The power of the study was set at 80%, CI at 95% and a two-sided P < 0.05 was considered statistically significant. There was no significant difference in the mean pain score (based on Visual Analogue Scale 0-10) between the study arms [3rd postoperative day (POD): 3.33 ± 1.75 for Lichtenstein and 2.73 ± 1.64 for Desarda, Effect size (CI): 0.59 (-0.088-1.272) and the scores on the 7th POD were 1.31 ± 1.19 for Lichtenstein and 1.31 ± 1.34 for Desarda, effect size (CI): 0.00 (-0.509-0.509)]. No difference was observed in regard to mean day of resumption of normal gait [2.44 ± 1.62 for Lichtenstein and 2.06 ± 1.13 for Desarda, effect size (CI): 0.08 (-0.030-0.193)]. A significant difference was recorded in regard to operative time, with the Desarda repair markedly shorter in duration [15.9 ± 3.52 min for Lichtenstein repair and 10.02 ± 2.93 min for Desarda's repair, effect size (CI): 5.92 (4.62-7.20), P = 0.0001]. Complication rates were similar in the two study arms. The results of the study showed that the effectiveness of the Desarda technique with respect to influencing the early clinical outcomes of hernia repair is similar to that of the Lichtenstein method. However, the operator in this study showed that the Desarda repair requires significantly shorter operative time.
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To evaluate the early outcome of Lichtenstein's technique for repair of inguinal hernia using polypropylene mesh. This was a descriptive study conducted over a period of twelve months from 1st July 2007 to 30th June 2008 in Surgical 'B' unit, Lady Reading Hospital, Peshawar. One hundred and twelve patients were received through the out patient department with diagnosis of inguinal hernia. Inclusion criteria was patients above the age of 18 years, reducible hernia, evidence of swelling in groin > 2 months. Exclusion criteria was age less than 18 years, chronic constipation, chronic cough, symptoms of prostatism, irreducible hernia, obstructed hernia, strangulated hernia and patients with diabetes mellitus. All the patients were subjected to inguinal mesh repair using the Lichtenstein technique with polypropylene mesh. Mean age of patients was 48.78 +/- 14.41 years. Sixty patients (53.6%) had right sided inguinal hernia while 46 patients (41.1%) had a left sided hernia and 6 patients (5.4%) had bilateral hernia. Sixty two patients (55.4%) had indirect hernia and 43 (38.4%) cases had direct hernia. Sixteen cases (14.3%) had previous history of surgery for hernia on the same side (recurrent hernia). Mild pain was observed in 53 cases (47.3%), moderate pain in 42 cases (37.5%), and severe pain in 17 cases (15.2%). Four patients (3.6%) in all developed a seroma Two patients (1.8%) developed a haematoma that required drainage. Three patients (2.7%) had a prolonged recovery and presented with abdominal distension. Five cases presented with infected wounds. Lichtenstein's technique of inguinal mesh repair is a safe and effective procedure but emerging trends anticipates the implementation of day case surgery.
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Current inguinal hernia operations are generally based on anatomical considerations. Failures of such operations are due to lack of consideration of physiological aspects. Many patients with inguinal hernia are cured as a result of current techniques of operation, though factors that are said to prevent hernia formation are not restored. Therefore, the surgical physiology of inguinal canal needs to be reconsidered. A retrospective study is describer of 200 patients operated on for inguinal hernia under local anaesthesia by the author's technique of inguinal hernia repair. The posterior wall of the inguinal canal was weak and without dynamic movement in all patients. Strong aponeurotic extensions were absent in the posterior wall. The muscle arch movement was lost or diminished in all patients. The movement of the muscle arch improved after it was sutured to the upper border of a strip of the external oblique aponeurosis (EOA). The newly formed posterior wall was kept physiologically dynamic by the additional muscle strength provided by external oblique muscle to the weakened muscles of the muscle arch. A physiologically dynamic and strong posterior inguinal wall, and the shielding and compression action of the muscles and aponeuroses around the inguinal canal are important factors that prevent hernia formation or hernia recurrence after repair. In addition, the squeezing and plugging action of the cremasteric muscle and binding effect of the strong cremasteric fascia, also play an important role in the prevention of hernia.
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Repair of inguinal hernias in men is a common surgical procedure, but the most effective surgical technique is unknown. We randomly assigned men with inguinal hernias at 14 Veterans Affairs (VA) medical centers to either open mesh or laparoscopic mesh repair. The primary outcome was recurrence of hernias at two years. Secondary outcomes included complications and patient-centered outcomes. Of the 2164 patients who were randomly assigned to one of the two procedures, 1983 underwent an operation; two-year follow-up was completed in 1696 (85.5 percent). Recurrences were more common in the laparoscopic group (87 of 862 patients [10.1 percent]) than in the open group (41 of 834 patients [4.9 percent]; odds ratio, 2.2; 95 percent confidence interval, 1.5 to 3.2). The rate of complications was higher in the laparoscopic-surgery group than in the open-surgery group (39.0 percent vs. 33.4 percent; adjusted odds ratio, 1.3; 95 percent confidence interval, 1.1 to 1.6). The laparoscopic-surgery group had less pain initially than the open-surgery group on the day of surgery (difference in mean score on a visual-analogue scale, 10.2 mm; 95 percent confidence interval, 4.8 to 15.6) and at two weeks (6.1 mm; 95 percent confidence interval, 1.7 to 10.5) and returned to normal activities one day earlier (adjusted hazard ratio for a shorter time to return to normal activities, 1.2; 95 percent confidence interval, 1.1 to 1.3). In prespecified analyses, there was a significant interaction between the surgical approach (open or laparoscopic) and the type of hernia (primary or recurrent) (P=0.012). Recurrence was significantly more common after laparoscopic repair than after open repair of primary hernias (10.1 percent vs. 4.0 percent), but rates of recurrence after repair of recurrent hernias were similar in the two groups (10.0 percent and 14.1 percent, respectively). The open technique is superior to the laparoscopic technique for mesh repair of primary hernias.
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Sutureless repair is successful for all but the largest of indirect inguinal hernias. After reduction of the peritoneal sac, the presenting indirect component of the hernia is immediately resolved by placement of a polypropylene mesh through the internal ring. The posterior wall is reinforced with a second swatch of Prolene mesh to prevent herniation, which often results from future degenerative changes. Both swatches of mesh are held in place in separate tissue planes by the body's internal hydrostatic forces. Being sutureless, no tension is placed on any layer; there is no damage to tissues from an errant suturing technique. This procedure has been used in 412 of the 1,091 inguinal hernia repairs over the past 36 months.
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The main aim of this study was to evaluate outcome in patients undergoing open inguinal hernia repair with either polypropylene mesh or nylon darn. This was a randomized prospective trial of patients who underwent the procedure with follow-up at 1 week, 6 weeks and 1 year. One hundred men underwent 105 repairs by consultant surgeons and registrars; there were 54 mesh and 51 nylon repairs. Demographics in both groups were similar at the start of the trial, as were the types of hernia. The pain scores at 24, 48 and 72 h were similar, as was the duration of analgesia requirement. There were no differences in early or late complications. Return to normal activity in each group was also similar, with a mean time of 5 weeks. The recurrence rate in both groups was comparable: 4 per cent after mesh repair and 4 per cent after darn repair at 1-year review. Open inguinal hernia repair with a nylon darn was equivalent to polypropylene mesh with respect to early measures of postoperative outcome and recurrence at 1 year.
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The optimum method for inguinal hernia repair has not yet been determined. The recurrence rate for non-mesh methods varies between 0.2 and 33 per cent. The value of tension-free repair with prosthetic mesh remains to be confirmed. The aim of this study was to compare mesh and non-mesh suture repair of primary inguinal hernias with respect to clinical outcome, quality of life and cost in a multicentre randomized trial in general hospitals. Between September 1993 and January 1996, all patients scheduled for repair of a unilateral primary inguinal hernia were randomized to non-mesh or mesh repair. The patients were followed up at 1 week and at 1, 6, 12, 18, 24 and 36 months. Clinical outcome, quality of life and costs were registered. Three hundred patients were randomized of whom 11 were excluded. Three-year recurrence rates differed significantly: 7 per cent for non-mesh repair (n = 143) and 1 per cent for mesh repair (n = 146) (P = 0.009). There were no differences in clinical variables, quality of life and costs. Mesh repair of primary inguinal hernia repair is superior to non-mesh repair with regard to hernia recurrence and is cost-effective. Postoperative complications, pain and quality of life did not differ between groups.
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The aim of this study was to compare laparoscopic totally extraperitoneal approach (TEP) repair with tension-free open mesh repair in inguinal hernia. One hundred thirty-four patients were allocated randomly to undergo TEP repair (n = 67) or open mesh repair (n = 67). Operative and postoperative outcomes were determined. The mean of operating time (49.67 +/- 14.11 vs. 56.64 +/- 12.32; P = 0.001), visual analog scale score (2.73 +/- 1.69 vs. 4.61 +/- 1.77; P = 0.001), hospital stay (1.8 +/- 0.7 vs. 2.7 +/- 1.6; P = 0.001), and duration of recovery (10.8 +/- 7.4 vs. 15.2 +/- 8.5; P = 0.001) was significantly less for TEP repair when compared with open mesh repair. The incidence of complications (13.4% vs. 16.4%; P = 0.631) and recurrence (2.9% vs. 5.9%; P = 0.407) was approximately equal in each group. Our results showed that laparoscopic TEP repair is superior to open mesh repair.