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Letter
to Editor by Losanoff et al- Reply
(Physiological
repair of inguinal hernia-A new technique)
Author:
Prof. Dr. Desarda M. P. (M.S.)
Hernia. (2006) 10:200-201
Affiliations: Professor and head of the Department of surgery,
KEY WORDS: Hernia; Physiological Repair; External oblique aponurosis, Open repair;
CORRESPONDENCE: 18,
Vishwalaxmi housing society, Kothrud, Pune-411029 India
Email: desarda@hotmail.com
To the Editor,
I
am thankful to J. E. Losanoff M.D. and J. Michael
Millis, M.D. for reading my article with interest. I have gone through their comments carefully.
Their
statement that "The overlap in follow-up time among the series is
confusing and demands an explanation…." is probably because they have
overlooked my explanation given about this in the ‘Introduction’ section
itself. The drawback of poor long term follow up in previously published series
is removed in this series. So it will be nice if we concentrate on results of
this series.
The
statement that "We find no evidence …. his
results are superior to that of previously published series of mesh
repair." is also probably because they have overlooked the zero%
recurrence rate observed in the median follow up period of 7.8 years of this
series. I have mentioned in the article about my personal communications with
many other surgeons from other countries and given their email addresses for
verification. The results observed by them also show zero% recurrence in their
locally published series. Secondly, a pure tissue hernia repair does not need
any justification like "Modern monofilament prosthetic materials resist
infection, have a negligible suppuration rates, and excellent tissue
incorporation", as it does not use any foreign body. My operation technique
gains on this count also. I do agree with the above statement about the quality
of modern mesh. But, if given a technique of inguinal hernia repair having
comparable, if not superior results, what will anybody choose for himself -a
pure tissue repair or a mesh (foreign body) repair?
The statement that-"The recent
literature …. pathological changes in collagen, …. that sets the stage for the development of a hernia" is
not relevant to this article because it is a description of a new technique of
hernia repair and not its etiological factors. However, I agree with their
further statement that-"Numerous … trials ….superiority of the
tension-free mesh repair over the traditional tissue approximation
method". This is true because the traditional tissue approximation methods
use transversus abdominis and internal oblique muscles for repair even if they
are weak. Therefore, I have stated in my article that "The aging process
is minimum in tendons and aponurosis
and therefore it is the best alternative to mesh" (Instead of Shouldice or
other pure tissue repairs).
"A number of such repairs described in Lason's classic 1941 text are similar……. Madden [16],
Koontz [17], Calman [18], and Halsted
[16] all describe variants of inguinal floor repair similar to the one described
in the Desarda articles". I do not agree with those statements because
Shouldice operation is similar to or a variant of Bassini operation; various
mesh repairs like PHS are variants of the original Lichtenstein mesh repair but
still they are not only accepted but are promoted. I still maintain that my
operation technique is neither similar to or a variant of all above-mentioned
operations, because none of them have ever used the strip of external oblique aponurosis (EOA) as described in my technique. 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, which is kept physiologically dynamic as per the force of
contraction of the muscles. This posterior wall is strong because of the nature
of the strip 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 it gives a zero% recurrence rate because of this.
Pure tissue repair and simplicity of operation are other important features of
this operation. The cost involved in purchasing and maintaining sophisticated
equipment like laparoscope is avoided and the expertise required doing
complicated dissection or handling of such equipment is also not required.
I am in agreement with Losanoff
et al that the 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 Losanoff et al
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.
On
the basis of afore said discussion, I have strong objection about the title
"Aponurosis instead of prosthetic mesh for
inguinal hernia repair: neither physiological nor new" given by Losanoff et al to their letter. I request the editors to
kindly delete this misleading title.
The
type of title and repeated mention of mesh repair as ‘gold standard’ or the
statements like "Although many of the endogenous repair methods might be
used alternatively to mesh in parts of the world where prosthetic materials are
not available, they cannot become standard in the Western world" points
towards a biased attitude. I conclude with an appeal to all the highly learned
members of the surgical community to come forward with an unbiased mind and
think for themselves what is best for their patients.
Lastly,
I have never criticized the Lichtenstein mesh repair. There is no reason for me
doing so when amid and Lichtenstein themselves have written "In mobile areas
such as the groin there is a tendency for the prosthesis to fold, wrinkle or
curl around the cord. More importantly, in vivo, mesh prosthesis loose
approximately 20% of their size through shrinkage. The slightest movement of
the mesh from the pubic tubercle, the inguinal ligament and the area of the
internal ring, due to the above factors, is a leading cause of failure of mesh
repair of inguinal hernias." (1) Also 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. Bay-Nielsen et al (2004) reported an incidence of 33.1% at 6-12 months
and 23.1% at 25-36 months of chronic groin pain following Lichtenstein repair.(2)
Nienhuijs SW et al (2005) reported that the "chronic groin pain is
also a very common problem" in their randomized clinical trial comparing
PHS, mesh plug repair and Lichtenstein repair. (3)
Considering all the above points, I think,
this new method of hernia repair will stand the test of time and will prove its
superiority in any controlled trial.
References:
1. Amid PK,
2. Bay-Nielsen M, Nilsson E, Nordin P, Kehlet H.( 2004)
Chronic pain after mesh & sutured repair of indirect inguinal hernia in
young males. Br J Surgery. 91 (10): 1372-76.
3. Nienhuijs SW, van Oort I, Keemers-Gels
ME, Strobbe LJA, Rosman C. (2005) Randomized clinical trial comparing PHS, mesh
plug repair and Lichtenstein repair for open inguinal hernia repair. Br J Surg.
Vol 92:33-38
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