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Dr. Desarda Mohan P. MS. (Gen. Surgery) PUNE Consultant General Surgeon Poona Hospital & Research Centre Kamla Nehru Corporation Hospital Associate Professor of surgery Bharati Vidyapeeth Med. College Gold Medallist in Anatomy 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) 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 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 Clinical 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 Males : 385 Age / Sex Female : 15 Age wise Distribution 80 71 70 75 71 60 58 56 48 Between 18-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 50 40 30 20 10 11 10 0 Between 18-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 Types of Inguinal Hernia 3.75% 4% No of Patients 3% 31.34 % 14.34% 10.34% 0.75% Recurrent indirect Obstructed indirect Bilateral indirect Bilateral mixed 0.75% Pantaloon hernia (left) Types of Inguinal Hernia (Cont…) 63.25% No of Patients 54% 31.34 % 14.34% 14.25% Primary indirect 31.25% 10.34% Primary direct 10.25% Bilateral direct Right side hernia Left side hernia Anaesthesia / Operation Time Operation Time : 30 min to 60 min 1% 9% Spinal 90% Local 9% General 1% 90% Now majority of operations are done under L.A. only Hospital Stay 5% 4% 3 days 25% 3% 4% 4 days 59% 25% 5 days 4% 6 days 3% 7 days 5% 59% > 7 days 4% Hospital stay of patients Complications 6 1.5% 5 1% 4 3 2 0.25% 0.25% 1 0 Recurrence Haematocoele Wound Odema Mild skin infection Table shows early and late complications seen in this series Ambulation & Routine Work Ambulation 1% 2 days 100% 26% 4 days 89% 100% 73% 7 days 11% 7 days 73% 15 days 26% > 15 days 1% 11% 89% Routine Work Table shows ambulation of patients and the period when they go back to their routine work Follow Up 100% 90% 99% 85.60% 80% 70% 61.20% 60% 53.50% 50% 40.50% 40% 26.60% 30% 20% 10% 0% 15 days 3 months 1 year 3 years 5 years 10 years or more Aetio - 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-? Shutter mechanism is lost / weak ? No strong post. wall AND ANATOMY OF ING.CANAL APONEUROTIC EXTENSNS IN POSTERIOR WALL Conventional Concept Obliquity of Inguinal canal Shutter mechanism Strength of trans.fascia My Concept (SCS Action) S Shielding action C Compression action S Squeezing action (Physiologically active and mobile post.ing. Wall is a must in both concepts) SCS ACTION Int. 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 SQUEEZING ACTION OF CREMASTER MUSCLE SECTION OF INGUINAL CANAL AT REST CHANGES DURING RAISED INTRA-ABDOMINAL PRESSURE 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 ANSWER 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….) 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 Action In 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 fibres giving a natural support to trans. fascia 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 Star Points of My Technique It is a Herniorrhaphy operation / plasty No foreign or special material required 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 Efficacy can be tested on operation table Satisfies all the criteria of modern Hernia surgery Choice is Yours “ Would you still like to insert a mesh in the body of your patient of inguinal Hernia ?” You Decide !