Letters To The Editor
New method of inguinal
hernia repair: A new solution: Reply
ANZ Journal of Surgery
Vol. 71 Issue 11 Page 681 November 2001
Mohan P. Desarda
&
New method of inguinal hernia repair: A new solution
ANZ
Journal of Surgery
Vol. 71 Issue 11 Page 680 November 2001
Julian E. Losanoff, James
W. Jones, Bruce W. Richman
Dear editor,
I am thankful to Jones et al .for reading
with interest my recent article.1 I have gone through their comments
carefully. Contrary to the comment made by Jones et al.,the
spermatic cord is not preserved subcutaneously but goes behind the external
oblique aponeurosis (EOA).
I have made a mention in the Methods section of my
article that ‘The author is aware that a 10-year follow up of 26.6%is not enough,but this is not a sufficient reason for ignoring the
results of the present series.Publication of these
data may encourage others to conduct more trials to prove or disprove these
results.’
In spite of the best efforts, poor follow up is
seen in all the under- developed countries because the cost and transportation
act as deterrents.But all the patients do come for
examination to the operating surgeon even after 10years of operation if there
is any problem.
This is because medical practice in
2 I have given evidence in my article that the
chronic groin sepsis following mesh repair is more frequent than reported
previously.
3 An editorial in Annals of Surgery
,January 2001,raised the
question of whether the changed techniques of hernia repair in recent years,mainly implanted mesh,have
caused a rise in the incidence of chronic groin pain from 1%to 28.7%after
hernia repairs. Several authors have suggested that alterations in collagen
synthesis may be responsible for the development of inguinal herniation.
4,5 This is true in the hernia repairs such as the
Bassini and the Shouldice,which use weakened internal
oblique and transverse abdominis muscles for repair.Supporters
of mesh prostheses claim that the mesh repair is superior to other operations
in this aspect.The theory of mesh repair is based on
fibroblast proliferaion in the mesh;the
degree and magnitude of fibroblast proliferation are also affected by the
ageing process.This ageing process has less effect on
the tendons and aponeurosis so a strip of the external oblique,which
is aponeurotic,is the best alternative to the mesh.Pure tissue is preferred to a mesh for repair if it
gives the desired results.
The Johns Hopkins,Halsted or any other repairs referred to by Jones et
al.in
their comments are in no way similar to my operation.None
of them have ever used the strip of EOA as described in my article,and
no operation described to date has ever used the concept of giving additional
muscle strength to the weakened muscles of the inguinal canal.The
sutured strip of EOA,in my operation,becomes
an independent entity as the posterior wall of the inguinal canal.
This posterior wall is strong because of the nature
of the tissue and it is also kept physiologically dynamic by the additional
muscle strength of the strong external oblique muscle.Interestingly,in many cases the internal oblique muscle, which did
not show any movements when the patient was asked to cough while on the
operating table before the strip of EOA was sutured behind the cord,showed improved or good movements after the strip was
sutured.
This may be because of the new anchorage received
by the internal oblique muscle arch to the upper border of this strip.Providing a strong and physiologically dynamic
posterior inguinal wall should be the principle of any inguinal hernia repair.This principle is observed in my operation technique
and because of this it gives a recurrence rate of almost zero.Pure
tissue repair and simplicity of operation are other important features of this
operation.
The cost involved in purchasing and maintaining
sophisticated equipment is avoided and the expertise in hernia surgery required
to carry out complicated dissection or handling of
such equipment is also not required. I am in agreement with Jones et al.that the preperitoneal or intermuscular
prosthetic grafts give good results and are frontline therapy in the Western hemisphere.Twenty per cent of the world population lives in
the Western hemisphere.
I am thankful to Jones et al.and others for accepting my
operation of inguinal hernia repair as an alternative to a mesh repair for the
rest of the world,which has the remaining 80%of the
world population. Nicholson,in
his leading article on inguinal hernia repair in British Journal of Surgery (1999)states
that: With over 80000 groin hernia operations carried out in the UK alone each year,and a deepening crisis in surgical manpower resulting
from increased surgical subspecialization and greater
public and political demands for quality in surgical practice, inguinal hernia
repair will remain for the foreseeable future a procedure likely to be
delegated to on-consultant staff.
It is essential therefore that we design safe and
simple pathways for managing these patients.
6 I designed this
safe and simple pathway of groin hernia repair,as
expressed by Nicholson,not only for the
underdeveloped countries but also for the people of the
References
1.Desarda MP.New method
of inguinal hernia repair:A new solution.ANZ
J.Surg.2001;71 :241 –4.
2.Amid PK,Lichtenstein
IL.Lichtenstein open tension free hernioplasty.In:Maddern
GJ,Hiatt JR,Philips EH
(eds) Hernia Repair (Open Vs Laparoscopic Approaches).Edinburgh:
Churchill Livingston,1997;117 –22.
4.Friedman DW,Boyd CD,Narton P et al.Increases in type III collagen gene
expression and protein synthesis in patients with inguinal hernias.Ann.Surg.1993;218
:754 –60.
5.Read RC.A review:The
role of protease –antiprotease imbalance in the pathogenesisof herniation and abdominal aortic aneurysm in
certain smokers.Postgrad.Gen.Surg.1992;4 :161 –5.
6.Nicholson S.Inguinal
hernia repair.Br.J.Surg.1999;86 :577 –8.
Address for
correspondence:
email:
[email protected]
Dr. Mohan P.Desarda
18, Vishwalaxmi Housing
Society,
BUY A CD FOR $ 20 (Including
postage)
(Live operation on direct, indirect & recurrent groin hernia
operations)
EMAIL: [email protected] or [email protected]