Consultant General Surgeon

Poona Hospital & Research Centre

Kamla Nehru Corporation Hospital

Associate Professor of surgery Bharati Vidyapeeth Med. College

Gold Medallist in Anatomy

Consultant General Surgeon

Poona Hospital & Research Centre

Kamla Nehru Corporation Hospital

Associate Professor of surgery Bharati Vidyapeeth Med. College

Gold Medallist in Anatomy

Dr. Desarda Mohan P. MS. (Gen. Surgery)

PUNE

Dr. Desarda Mohan P. MS. (Gen. Surgery)

PUNE

Criteria of Modern Hernia Surgery Criteria of Modern Hernia Surgery

Simple, safe, easy to learn & perform

No risky / complicated dissection / suturing

No tension on tissues

Avoid using weakened muscles or fascia for repair

No foreign body / special material

Cost effective (in those days of cost ergonomy)

Simple, safe, easy to learn & perform

No risky / complicated dissection / suturing

No tension on tissues

Avoid using weakened muscles or fascia for repair

No foreign body / special material

Cost effective (in those days of cost ergonomy)

Criterias (Contd…)Criterias (Contd…)

Concept of “Come today - Go today”

Comfortable post op. period

Immediate ambulation

Rapid recovery to preoperative works efficiency

(Rapidly evolving concept of managed health care)

Immediate or late complications to be comparable,

if not, better than the established techniques

Concept of “Come today - Go today”

Comfortable post op. period

Immediate ambulation

Rapid recovery to preoperative works efficiency

(Rapidly evolving concept of managed health care)

Immediate or late complications to be comparable,

if not, better than the established techniques

UPPER LEAF OF EOA IS SUTURED TO INGUINAL LIGAMENT FIGURE NO. 1

UPPER LEAF OF EOA IS SUTURED TO INGUINAL LIGAMENT FIGURE NO. 1

UPPER BORDER OF SEPERATED STRIP IS SUTURED TO INTERNAL OBIQUE MUSCLE

FIGURE NO. 2

UPPER BORDER OF SEPERATED STRIP IS SUTURED TO INTERNAL OBIQUE MUSCLE

FIGURE NO. 2

Clinical MaterialClinical Material

This study is of fairly large series of 400 operations

from 1983 - 1999, with a long follow up of more than

15 years

No patients selection

Any type of Inguinal Hernia

Bilateral Hernias operated together

Hydorcoele, piles, BEP - dealt with simultaneously

This study is of fairly large series of 400 operations

from 1983 - 1999, with a long follow up of more than

15 years

No patients selection

Any type of Inguinal Hernia

Bilateral Hernias operated together

Hydorcoele, piles, BEP - dealt with simultaneously

Age / SexAge / SexMales : 385 Female : 15 Males : 385 Female : 15

11

48

71 71

56

75

58

100

10

20

30

40

50

60

70

80

Between18-20

21-30 31-40 41-50 51-60 61-70 71-80 81-90

Between 18-20

21-30

31-40

41-50

51-60

61-70

71-80

81-90

Age wise Distribution

Types of Inguinal HerniaTypes of Inguinal Hernia

14.34% 10.34%

31.34 %

Recurrent indirect Obstructedindirect

Bilateral indirect Bilateral mixed Pantaloon hernia(left)

4%3.75%

3%

0.75% 0.75%

No

of P

atie

nts

Types of Inguinal Hernia (Cont…)Types of Inguinal Hernia (Cont…)

14.34% 10.34%

31.34 %

Primary indirect Primary direct Bilateral direct Right side hernia Left side hernia

No

of P

atie

nts

63.25%

14.25%10.25%

54%

31.25%

Anaesthesia / Operation TimeAnaesthesia / Operation Time

Now majority of operations are done under L.A. only Now majority of operations are done under L.A. only

Operation Time : 30 min to 60 minOperation Time : 30 min to 60 min1%

9%

90%

Spinal 90%

Local 9%

General 1%

Hospital StayHospital Stay

59%

4%5%

3%4%

25%

3 days 25%

4 days 59%

5 days 4%

6 days 3%

7 days 5%

> 7 days 4%

Hospital stay of patientsHospital stay of patients

ComplicationsComplications

0

1

2

3

4

5

6

Recurrence Haematocoele WoundOdema

Mild skininfection

No

of C

ases

Table shows early and late complications seen in this series

0.25%

1.5%

0.25%

1%

Ambulation & Routine WorkAmbulation & Routine Work

11%

73%

26%

1%

100%

89%

2 days 100%

4 days 89%

7 days 11%

7 days 73%

15 days 26%

> 15 days 1%

Table shows ambulation of patients and the period when they go back to their routine work

Table shows ambulation of patients and the period when they go back to their routine work

Ambulation

Routine Work

Follow UpFollow Up

99% 85.60%

61.20%53.50%

40.50%

26.60%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

15 days 3 months 1 year 3 years 5 years 10 years ormore

Aetio - Patho - PhysiologyAetio - Patho - Physiology

Ext. blow Guarding Tone shielding action

Int. blows Coughing, Straining etc

Post ing. Wall (Trans. fascia + Aponeurotic ext.) resist int. blow

Absent apo. Ext. then trans fascia alone can not stand int. blows

Strong muscles - shielding action No Hernia

Weak muscles + absent apo.ext Hernia- because int. ring &

post. wall are not protected-- AND

? Shutter mechanism is lost / weak

? No strong post. wall

Ext. blow Guarding Tone shielding action

Int. blows Coughing, Straining etc

Post ing. Wall (Trans. fascia + Aponeurotic ext.) resist int. blow

Absent apo. Ext. then trans fascia alone can not stand int. blows

Strong muscles - shielding action No Hernia

Weak muscles + absent apo.ext Hernia- because int. ring &

post. wall are not protected-- AND

? Shutter mechanism is lost / weak

? No strong post. wall

ANATOMY OF ING.CANALANATOMY OF ING.CANAL

APONEUROTIC EXTENSNS IN POSTERIOR WALL APONEUROTIC EXTENSNS IN POSTERIOR WALL

Conventional ConceptConventional Concept Obliquity of Inguinal canal

Shutter mechanism

Strength of trans.fascia

My Concept (SCS Action)

Shielding action

Compression action

Squeezing action

(Physiologically active and mobile post.ing.

Wall is a must in both concepts)

Obliquity of Inguinal canal

Shutter mechanism

Strength of trans.fascia

My Concept (SCS Action)

Shielding action

Compression action

Squeezing action

(Physiologically active and mobile post.ing.

Wall is a must in both concepts)

S

C

S

SCS ACTIONInt. Blow to Abdominal Wall

SCS ACTIONInt. Blow to Abdominal Wall

All 3 muscles contract - Tone - Generalized shielding

Contraction of Trans abd. muscles tone in post ing.

Wall - local shielding

contraction of int. obl. muscle tone in curved

part shielding action in front of int. inguinal ring

Contraction of cremasteric muscle squeezes sp.cord

contents & pulls it close to int.ing.ring to plug it

squeezing action

All 3 muscles contract - Tone - Generalized shielding

Contraction of Trans abd. muscles tone in post ing.

Wall - local shielding

contraction of int. obl. muscle tone in curved

part shielding action in front of int. inguinal ring

Contraction of cremasteric muscle squeezes sp.cord

contents & pulls it close to int.ing.ring to plug it

squeezing action

SQUEEZING ACTION OF CREMASTER MUSCLE

SQUEEZING ACTION OF CREMASTER MUSCLE

SECTION OF INGUINAL CANAL AT RESTSECTION OF INGUINAL CANAL AT REST

CHANGES DURING RAISED INTRA-ABDOMINAL PRESSURECHANGES DURING RAISED INTRA-ABDOMINAL PRESSURE

SCS Action (Contd…..)SCS Action (Contd…..)

Int. oblique muscle compresses the canal against ing.

ligament & post.wall

Ext. obl. compresses the canal against post. wall

Weak muscles & absent apo.element in post wall --

? SCS action is lost / weak

? No strong & physiologically active post.wall

? RESULT IS HERNIA FORMATION

Int. oblique muscle compresses the canal against ing.

ligament & post.wall

Ext. obl. compresses the canal against post. wall

Weak muscles & absent apo.element in post wall --

? SCS action is lost / weak

? No strong & physiologically active post.wall

? RESULT IS HERNIA FORMATION

ANSWERANSWER

To give a strong, mobile & physiologically active

post.wall to the ing.canal

WHICH MEANS

New wall should have apo.element to support tra. fascia

Should give additional muscle strength to weak muscles

to increase tone & strength of the post.wall of ing.canal

Post wall should remain mobile even after surgery

To give a strong, mobile & physiologically active

post.wall to the ing.canal

WHICH MEANS

New wall should have apo.element to support tra. fascia

Should give additional muscle strength to weak muscles

to increase tone & strength of the post.wall of ing.canal

Post wall should remain mobile even after surgery

ANSWER (contd….)ANSWER (contd….)

Bassini & Shouldice interpose a muscle curtain. If

muscles are weak - no strength in the post.wall

Lichtenstein puts a mesh –a mechanical barrier- BUT

? Intense fibrosis affects the mobility of post.wall

? No additional muscle strength to weakened muscles to

increase tone & strength of the post.wall

? Post.wall is not physiologically active & dynamic

Bassini & Shouldice interpose a muscle curtain. If

muscles are weak - no strength in the post.wall

Lichtenstein puts a mesh –a mechanical barrier- BUT

? Intense fibrosis affects the mobility of post.wall

? No additional muscle strength to weakened muscles to

increase tone & strength of the post.wall

? Post.wall is not physiologically active & dynamic

MESH REPAIR WORKS ONLY AS MECHANICAL BARRIER

Mechanism of ActionIn My Operation

Mechanism of ActionIn My Operation

Strip is fixed below & medically

All 3 abd muscles exert action above & laterally

Ext. oblique gives additional strength to weakened int. oblique & trans. abd

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 contraction of muscles (physiologically active wall)

Strip replaces the absent aponeurotic fibresgiving a natural support to trans. fascia

Strip is fixed below & medically

All 3 abd muscles exert action above & laterally

Ext. oblique gives additional strength to weakened int. oblique & trans. abd

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 contraction of muscles (physiologically active wall)

Strip replaces the absent aponeurotic fibresgiving a natural support to trans. fascia

MY OPERATION(? The Final Solution)

MY OPERATION(? The Final Solution)

1 Strip of EOA replaces the absent aponurotic element

2 It gives additional strength of muscle to weak muscles

3 Minimal or no fibrosis

? Post wall remains mobile

? It is strong

? It is physiologically active

1 Strip of EOA replaces the absent aponurotic element

2 It gives additional strength of muscle to weak muscles

3 Minimal or no fibrosis

? Post wall remains mobile

? It is strong

? It is physiologically active

Star Points of My TechniqueStar Points of My Technique

It is a Herniorrhaphy operation / plasty

Locally available live & active tissue

EOA is large to get strip easily

You get physiologically active posterior wall

No difficult identification of sling of int. ring or

iliopubic tract required

No foreign or special material required

Efficacy can be tested on operation table

Satisfies all the criteria of modern Hernia surgery

It is a Herniorrhaphy operation / plasty

Locally available live & active tissue

EOA is large to get strip easily

You get physiologically active posterior wall

No difficult identification of sling of int. ring or

iliopubic tract required

No foreign or special material required

Efficacy can be tested on operation table

Satisfies all the criteria of modern Hernia surgery

Choice is YoursChoice is Yours

“ Would you still like to insert a mesh in the

body of your patient of inguinal Hernia ?”

You Decide !

“ Would you still like to insert a mesh in the

body of your patient of inguinal Hernia ?”

You Decide !