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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: desarda@gmail.com
Dr. Mohan P.Desarda
18, Vishwalaxmi Housing
Society,