VIDEOS & SLIDE SHOW
|
1] Watch Mr. Stuart : 2nd day after surgery in 2] Watch Mr. David : 3rd day after surgery in 3] Operation video :
Live operative procedure video |
1] OPERATION TECHNIQUE (For
Non-Medical persons)
This is a pure
tissue repair that resembles the Lichtenstein mesh repair in its simplicity.
The author claims results that are superior or equal to Shouldice and
Lichtenstein repairs in low frequency of complications and most importantly no
recurrences. The repair is remarkable in its simplicity and any body’s first
thought upon understanding the basics of the operation will be: why didn't
someone think of this before?
The external
oblique is incised similarly to the way it is done in the other anterior
approach repairs. The spermatic cord is dissected free the same way it is done
in all the other anterior approach repairs. The sac are dissected free as usual
and generally cut away. The herniated organs are returned to the abdomen as
usual.
The upper flap
of the external oblique aponeurosis is sutured to the inguinal ligament, behind
the spermatic cord. Then the external oblique is incised again, 1-2 centimeters
above the inguinal ligament, simultaneously creating (1) a new lower edge to
the upper flap, and (2) a "strip," or in my words a patch,
made out of a strip of external oblique that is several centimeters wide. The
upper edge of this "patch" is sutured to the internal oblique. The
result is that a "patch" of external oblique aponeuroses is in place
behind the spermatic cord, similarly to the way a Lichtenstein patch would be
in place behind the spermatic cord. The difference is, that (1) this is a patch
of living tissue and (2) the strip of external oblique aponeurosis is still
attached normally to external oblique muscle and contractions of the external
oblique muscle have a dynamic affect on countering intra-abdominal
pressure, rather than merely static effect that the non-living patch used in a
Lichtenstein repair, would have.
The new lower
edge of the upper flap is sutured to the original upper edge of the lower flap,
above the spermatic cord -- that is, the external oblique is closed
similarly to the way it is closed in Bassini, McVay, and Shouldice repairs.
However it is the newly created lower edge of the upper flap that is being
used, instead of its original upper edge; the original lower edge of the upper
flap has previously been sutured to the inguinal ligament. Thus, when the
operation is completed, there are 2 layers of external oblique: one under
the cord and one above it, instead of only one layer, above the cord, as in
normal anatomy, and as in Bassini, McVay, and Shouldice repairs.
2] OPERATION TECHNIQUE (For Medical
persons)
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. 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 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). 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 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). 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.
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 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.
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.
Mechanism of
action:16 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.
2] Different Techniques
of Inguinal Hernia Surgery (For non medical persons)
Pushing or Pulling?
There are two ways for a surgeon to approach the
herniated abdominal organs and the peritoneal sac which they have pushed
through, and by which the organs will be surrounded: anteriorly and
posteriorly. That is, hernia surgery can be performed using an anterior
approach (Open surgery) or
a posterior approach (Laparoscopic surgery). The organs need
to be pushed or pulled back into the abdomen.
Anterior approaches: pushing
1] PART ONE: An anterior approach means making an
incision over, or very near to, the area of the abdomen where the herniating
abdominal organs are escaping from the abdomen. The incision is a 5 to 10
centimeter oblique (parallel to the inguinal ligament) incision, or a 5
centimeter left-right incision. After the skin, underlying fatty tissue, layers
of fascia, and external oblique aponeurosis are cut thru, and then the adherent
peritoneal sac is dissected free from surrounding tissues -- from "above."
It may need to be cut open, and tugged on, stretched up and out, in order to be
detached. After the sac is detached, the herniated organs are
"pushed" back into the abdomen. Then the sac itself is dealt with
also. It is either (1) cut away, and its stump is then ligated in order close
up the space created when part of it was cut away, or (2) the whole sac, or
what is left of it, may be pushed back into the abdomen. It is usually possible
to handle the sac this way. But sometimes it is not. For example if the sac
reaches all the way into the scrotum, it may not always be possible to tug the
far end of the sac out of the scrotum, without causing to much damage, so the
sac may be cut so that a piece of it is left in the scrotum, and the other
portion pushed back into the abdomen, perhaps after being ligated.
Exactly where the sac protrudes can vary, not
only from hernia spot to hernia spot, but, for example, an inguinal hernia can
have a sac that protrudes through the "internal inguinal ring" and
follows the inguinal canal up toward the "external inguinal ring."
Such an "indirect" hernia often finally extends through the external
ring, continues along inside the spermatic cord, even reaching into the scrotum
-- and is adherent to normal tissues alonng this path; or an inguinal hernia can
have a sac that starts protruding elsewhere, entering the inguinal canal
between the between the internal ring and external ring, and possibly protrude
through the external ring along with the spermatic cord, alongside the
spermatic cord (outside the spermatic cord), and it will be adherent to tissues
in different ways. This "direct" hernia is outside the spermatic
cord. In females, there is no multi-layered spermatic cord, but rather a
"round ligament" extending from labium majora to uterus that passes
thru the internal and external inguinal rings, instead of a spermatic cord.
But, basically, an indirect inguinal hernia passes thru the internal ring; a
direct hernia enters the inguinal canal between the internal ring and external
ring (which define the 2 ends of the canal, the tunnel thru the muscle layers).
Finally, a hernia can be a combination of these "indirect" and
"direct" hernia configurations, or it may be a somewhat novel
presentation. There may be plenty of original thinking for the surgeon to do
after he/she opens up the external oblique aponeurosis to see what is going on
underneath. The presentation, and places where the sac is adherent, may be
unique, and dealing with the adherent sac may be a unique challenge.
PART TWO: Of anterior methods in common use,
there are of 2 basic ways of fixing up the patient, after the contents of the
sac are reduced and the sac is pushed back into the abdominal space, so that a
hernia will not pop out again: pure tissue repairs and repairs using a
prosthesis made out of a synthetic mesh (A piece of cloth made out of
Polypropylene, Prolene, Marceline or similar synthetic fibers).
Pure Tissue Repairs (all are via anterior
approach)
Some background of Inguinal Anatomy.
A primary landmark in the inguinal region is the
inguinal ligament. A ligament is a strong tissue that connects bone to bone. It
is flexible, but it does not contract and relax like muscle tissue. The
traditional incision for an anterior inguinal hernia repair is an incision parallel
to the inguinal ligament, and just a bit higher up, maybe a centimeter. There
are three layers of muscle-dash-aponeuroses that make up the "abdominal
wall" in the area where the incision is made. These are the external
oblique muscle with attached aponeurosis, the internal oblique, and the
transverses abdominis. An aponeurosis is tendon, an extension of a muscle that
also acts like a fascia. Muscle tissue is contractile. Tendon tissue is
non-contractile and very strong. It neither contracts nor relaxes, and stays
about the same size. In the abdomen, these muscles not only serve to move our
skeletons, but they also form a strong, flexible, 3-layered wall that holds our
internal organs inside against the intra-abdominal water pressure of these
organs. In the area of the incision, the external oblique presents its
aponeurotic portion, rather than its muscular portion. The internal oblique and
transversus abdominis each have an "arching edge," a few centimeters
away from the incision and toward the body's midline, and can be seen after the
aponeurosis of the external oblique is cut through, and the cut flaps of the
external oblique, are pulled apart. The transversus abdominis is underneath the
internal oblique, that is, between the internal oblique and the peritoneum.
It's most posterior layer is the transversalis fascia. The spermatic cord has
various layers inside of which are blood vessels and the vas deferens. The
internal oblique is muscle here, at the spermatic cord -- and this portion of
the internal oblique that contributes to the structure of the spermatic cord is
called the cremasteric muscle. The cremasteric muscle is an extension of the
internal oblique muscle.
Bassini Repair: The
transversalis fascia is incised from internal ring to pubic tubercle. Then the
naturally existing lateral edge of the internal oblique muscle, the transversus
abdominis muscle, and the lateral edge of the surgically created medial flap of
transversalis fascia, are all sutured to the inguinal ligament, with
interrupted sutures. They have to be stretched a bit to reach. Then the 2 flaps
of external oblique are sutured back together, above the spermatic cord, that
is, the spermatic cord is left in its normal anatomical position between the
layer of internal oblique and the layer of external oblique. What happens, is
that in being stretched toward the inguinal ligament, the layers of tissue
cover the dilated internal ring (indirect hernia), or the stretched and thinned
transversalis fascia (direct hernia), that allowed the hernia to occur. This
stretching is now often blamed for a rather large amount of post-operative
pain, and long recuperation period, maybe 6 weeks. It involves a 8-10
centimeter incision, parallel to the inguinal ligament (oblique incision). It
is also blamed for thinning the tissues and making them susceptible to allowing
another hernia. A further problem of this technique of hernia repair is that a
significant number of cases (estimated at up to 10 percent or more of all
cases) will recur by virtue of the internal scar tissue becoming pulled out at
some time in the patient's life. The repair of this recurrent hernia is
therefore a larger operation than the first and the results proportionately
more uncomfortable.
Shouldice Repair: This is said
to be a modification of the Bassini repair that involves less stretching. There
is a specific, complex protocol of overlapping one tissue with another, and
making 4 sutured-together, overlapped with excision of cremaster muscle and the
genitor femoral nerve. In order to reduce the tension of the stitching,
surgeons developed methods of stitching the tissue in layers, one above the
other. This technique reduced a little of the pressure, but resulted - by
definition - in more stitching through the patient's tissue. Because the
patient depends upon this stitching for the rest of his life to hold the
abdominal wall closed, the surgeon will normally have to place several
stitches, under a degree of tension in the deep tissue, repeating the process
until he is satisfied that the join will hold. Unfortunately, this stitching
distorts sensitive tissue. This will cause tension and subsequent pain with all
movements (including coughing and sneezing). The patient can expect to
feel the results of the stitching long after he leaves hospital. He is
therefore restricted in physical activity for some weeks.
Desarda Repair:
This is
pure tissue repair that resembles the Lichtenstein mesh repair in its
simplicity. The author claims results
that are superior or equal to Shouldice and Lichtenstein repairs in low
frequency of complications and most importantly no recurrences. The repair is
remarkable in its simplicity and any body’s first thought upon understanding
the basics of the operation will be: why didn't someone think of this before?
The
external oblique is incised similarly to the way it is done in the other
anterior approach repairs. The spermatic cord is dissected free the same way it
is done in all the other anterior approach repairs. The sac are dissected free
as usual and generally cut away. The herniated organs are returned to the
abdomen as usual.
The upper
flap of the external oblique aponeurosis is sutured to the inguinal ligament, behind
the spermatic cord. Then the external oblique is incised again, 1-2 centimeters
above the inguinal ligament, simultaneously creating (1) a new lower edge to
the upper flap, and (2) a "strip," or in my words a patch,
made out of a strip of external oblique that is several centimeters wide. The
upper edge of this "patch" is sutured to the internal oblique. The
result is that a "patch" of external oblique aponeuroses is in place
behind the spermatic cord, similarly to the way a Lichtenstein patch would be
in place behind the spermatic cord. The difference is, that (1) this is a patch
of living tissue and (2) the strip of external oblique aponeurosis is still
attached normally to external oblique muscle and contractions of the external
oblique muscle have a dynamic affect on countering intra-abdominal
pressure, rather than merely static effect that the non-living patch used in a
Lichtenstein repair, would have.
The new
lower edge of the upper flap is sutured to the original upper edge of the lower
flap, above the spermatic cord -- that is, the external oblique is
closed similarly to the way it is closed in Bassini, McVay, and Shouldice
repairs. However it is the newly created lower edge of the upper flap that is
being used, instead of its original upper edge; the original lower edge of the
upper flap has previously been sutured to the inguinal ligament. Thus, when the
operation is completed, there are 2 layers of external oblique: one under
the cord and one above it, instead of only one layer, below the cord, as in
normal anatomy, and as in Bassini, McVay, and Shouldice repairs.
Mesh Repairs, Anterior Approach
Lichtenstein, Rutkow Plug&Patch, Prolene
Hernia System, Moran repair
Lichtenstein
Uses a 7 or 8 centimeter incision. Dr. Amid, the
main living proponent of the Lichtenstein repair, is meticulous about
identifying nerves and preserving them. After the hernia sac is taken freed and
the herniated organs reduced, a piece of flat polypropylene
mesh, about 10 centimeters long by about 4.5 centimeters wide, is placed
between the external oblique and internal oblique. A slit is made in the mesh
to create two tails, which are wrapped around the spermatic cord where it
emerges through the internal inguinal ring. The tails are overlapped. The mesh
is held in place with about 8 sutures. This seems to be sufficient to hold the
hernia back.
The mesh is monofilament polypropylene. It is a
loose knit. The body's natural reaction to polypropylene is to sequester it by
forming a layer of non-vascular scar tissue around it.
The hypothesis frequently presented, to account
for how the mesh holds back the hernia, is a little puzzling. The scar tissue
is said to be desirable, because it strengthens the area and prevents
herniation of organs. The kind of knit has a specific size of its spaces, or
pores, between the filaments. These pores, are said to be "just the right
size" to maximize tissue ingrowths, which is said to be necessary to hold
back the hernia. At the same time, the mesh is said to be strong enough to hold
back the hernia, even without the ingrowths of scar tissue. They can't seem to
make up their mind what holds back the hernia, the mesh, or the tissue
ingrowths.
Either way, these tissue ingrowths make removing
the mesh a much bigger operation than putting it in. I see this as a major
disadvantage. Also, a 20-year old person may live 90 years after having such
mesh implanted. What will happen to the mesh 90 years from now? There is no
data from 90 years ago, to
Prolene Hernia System & Rutkow Plug and
Patch (or sometimes just plug) or Moran repair: These
are just the modifications of mesh repair and they also work on the same
principle of tissue ingrowth.
Posterior approaches; pulling and pushing
For inguinal hernias, the posterior approaches in
common use are: Kugel Patch method, and laparoscopic methods. Of the
laparoscopic methods, the 2 methods in common use are totally
extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP).
Once the "pre-peritoneal space" is accessed, from an incision that
may not be directly over the hernia, and may be rather far away, the adherent
sac is separated, and the herniated organs are either "pulled" back
into the abdomen, or coaxed back into the abdomen by a combination of pulling
from inside, and, non-surgically pushing, with a hand, from outside the abdomen,
over the area where the protrusion is, much the way the patient would reduce
the hernia himself. The "pre-peritoneal space," by the way, is the
space between the inner surface of the 3-layered abdominal "wall" and
the outer surface of the peritoneum.
Don’t you
think now that Desarda Repair is real answer for hernia problem? It takes away
the complications of a foreign body seen in mesh repair and there is no tension
on suture line as seen in other pure tissue repairs. This operation is based on
the new theories that are said to prevent hernia formation in the normal
individuals.
(BUY A CD $ 20: Live
operations on direct, indirect & recurrent groin hernia)
EMAIL: desarda@gmail.com or desarda@hotmail.com
Donations to " Dr.M.P.Desarda Charitable Trust & Research Institution " are exempt under 80 G of Income Tax Act