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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 !