“Different types of groin hernia operations and Dr. Desarda repair”

Hernia is a common disease that can affect any body from his childhood to old age. Operation is the only remedy to get relief from this disease. Patient will not mind to get operated if he is sure that he is going to be hernia free after surgery. But this does not happen in many patients because rate of relapse or reappearance of hernia at the same place is also quite high and unacceptable. Different surgeons recommend different operations to repair the hernia. Therefore, there is confusion in the mind of patients as to which operation they should prefer for their hernia surgery. This article gives details of different types of groin hernia operations done worldwide for knowledge of those patients.

Groin anatomy in hernia patients: All the vessels, lymphatics, vas, nerves along with their covers, together called as spermatic cord pass from abdomen to scrotum through inguinal canal. A protrusion of peritoneum called as hernia sac appears in this canal along with the cord and goes on increasing in size if this hernia sac is kept untreated. This canal and cord is normally protected by cover of two muscles behind and one muscle in front. The reason why hernia sac formation takes place is the weakness in those two muscles behind. This weakened spot in the posterior wall is called as weak spot or hernia hole. All traditionally done operations are designed to repair this hernia hole so that there is no recurrence of hernia after surgery.

There are two parts of hernia operations. First part is to separate the hernia sac and excise it. Second part is to repair this weak spot or hernia hole so as to prevent any recurrence in future.

Bassini Shouldice operation: In this operation patient is kept in the hospital for 2-4 days.

General or spinal anaesthesia is given. Hernia sac is excised. Then for repair of hernia hole, back two muscles are pulled down and sutured to the groin ligament. Surgeon takes several stitches so as to keep these pulled down muscles in place. There is tension on those stitches so patient has to take care for life time to avoid disruption of sutures. Unfortunately, this tension on muscles cause pain in groin area and prolonged rest needs to be taken to get relief and then only he can go to his routine work. There is more than 10% recurrence rate in this operation and increases with time because of contraction of the scar tissue adding more tension on the sutures. This results in more incidences of recurrences and groin pain. Repeat operation for recurrence or pain is difficult and bigger and the results are also far from satisfaction.

            Some surgeons use another modification of this technique to reduce tension on the stitches. They suture back muscles and fascia in 4 layers. This reduces the tension on the muscles and sutures but for that many more complicated sutures are needed to be taken. Therefore, this operation can be done only by expert and specially trained hernia surgeons. This has brought down the recurrence rate but it has not totally disappeared. This operation is grouped under ‘tension repairs’ because there is tension on the stitches and muscles.

Mesh repair: In this operation no muscles are pulled down to cover the hernia hole. Instead, mesh is sutured on the weak spot to cover the hernia hole. This mesh is a piece of synthetic cloth just like a mosquito net and it is in no way some thing special. There is no tension on the stitches so this operation grouped under ‘tension free repair’. This has reduced the recurrence rate to a great extent (7-8% in USA) but it did not disappear completely. Reduced recurrences and simplicity of operation made it popular immediately all over the world. The mesh per se does not give any protection because it is delicate. But because it is a foreign body stitched inside, foreign body reaction starts and a tissue curtain is formed just like a corn following the thorn prick. This takes 4-6 months to form the curtain. It takes another 2-3 years to gain strength in this curtain. So, practically patient remains without protection for 2-3 years after surgery and if patient gets an attack of cough or sneezing during this period then there are increased chances of recurrence.

Contraction of this scar tissue adds more to the chances of recurrence. Involvement of nerves, vas or other structures in this scar formation results in to groin pain in 28 to 42% of operated patients. Tearing of sutures, disintegration of mesh, infection, migration are all noted complications. The mesh used by many surgeons is of low quality to save on the cost. Such meshes contract more than 50-60% naturally causing more recurrences. All above complications following mesh repair requires repeat surgery and this surgery is quite difficult and commanding even in the hands of hernia expert surgeons and the results are also poor.

Laparoscopic repair: This operation is done by inserting endoscopes inside by making 4 holes on the abdomen. General anaesthesia is given. Co2 gas is pumped in side the abdomen to inflate it. A much larger size of mesh is required to be stitched to cover the hernia hole from inside the abdomen. It is claimed that there is less pain following this surgery and patient can go to his work earlier. This operation can be done by inserting endoscopes to hernia site through abdominal wall instead of entering the abdominal cavity. This operation can be done only by experts in doing such surgery. More recurrences are seen if done by a novice surgeon. There are more risks involved in this surgery like general anaesthesia, pumping Co2, or trauma to intestines etc. Costly equipments, bigger mesh and expertise required to do this risky operation increase the cost of surgery.

Dr. Desarda repair: This operation is done by taking a cut on the skin. It is simple and does not 

require any foreign body like mesh or any complicated instruments like endoscopes. A strip of a nearby muscle is separated and stitched on the weak spot to cover the hernia hole. There is no foreign body like mesh or no endoscopes are required therefore, this operation is free from all complications and risks that are associated with the mesh or laparoscopic repair. There is no tension on the stitches or muscles as seen in Bassini-Shouldice operation. Therefore, there are no complications and risks that are associated with the Bassini- Shouldice operation. Hernia hole is covered by a strong muscle. Therefore, protection starts on the operation table itself. Patient is admitted in the morning and immediately taken for surgery after preparation. Operation is done under local or spinal anaesthesia. No general anaesthesia is required. Operation is completed in 30 minutes and patient is back on his feet as soon as anaesthesia effect is gone. Patient goes to bathroom on his own within couple of hours and moves freely in the wards afterwards and is ready to get discharged same day night or next day morning. Patients are allowed to drive car and go to office, bend, squat, climb up the staircase or carry luggage and travel. All foreign patients coming to Indian Hernia Institute go back to their country on third day carrying their luggage and a journey of 20-22 hours without any difficulty. The most important quality of this operation is that there is virtually no recurrence or pain. This operation is spreading quite rapidly all around the globe and today it is being followed in many countries. CONTACT: desarda@gmail.com  WEBSITE: http://www.desarda.com