PROF. DR. DESARDA M. P. (MS;FICS;FICA) Present DesignatioN: 1] Professor of general surgery & chief of hernia centre, POONA HOSPITAL 2] Chairman, Indian Hernia Institute, Pune Affiliation: Poona hospital & research centre, A MULTI SPECIALITY HOSPITAL IN PUNE Major Achievements: (Honours) (Awards) (Publications) (OTHERS) Website: Desarda.com Email: desarda@ Invented a new mesh free technique for groin hernias Revolutionized basic concepts of groin hernias Invited guest speech IN world hernia conference, 2015 INVITED GUEST SPEECHES IN POLAND, GERMANY, ITALY, SRILANKA & INDIA “DESARDA HERNIA CENTER-USA” IN FLORIDA, USA TECHNIQUE published in INTERNATIONAL text books More than 150 articles presented or published by surgeons world wide including a dozen of RCT & COMPARATIVE STUDIES NATIONAL SCHOLAR, GOLD MEDAL IN ANATOMY HONOUR OF HIGHEST ORDER 2009, IMPHAL CHAPTER DOCTOR OF THE YEAR AWARD 2010, PUNE DIST. CONGRES DOCTOR OF THE YEAR AWARD 2005, MEDI JAIN BEST ALL ROUND COLLEGE STUDENT AWARD GAURAV PATR AWARD FOR WORK IN FAMILY PLANNING HONOUR OF HIGHEST ORDER 2010, HERNIACON,SELSICON, ASIMANICON AWARD & GOLD MEDAL, WORLD CONGRESS OF MEDICINA ALTERNATIVA SCROLL OF HONOUR FOR EXEMPLARY WORK AT INTERNATIONAL LEVEL AND CONTRIBUTION IN THE FIELD OF SURGERY, 2006, PUNE SURG SOCIETY PRESIDENT OF FEW CHRITABLE TRUSTS AND EDUCATIONAL INSTITUTIONS PHOTO (Passport Format)

“Dr. Desarda’s Repair” For Inguinal Hernia New Millennium Gift We have made a revolution in the BASIC CONCEPTS of INGUINAL CANAL & IT’S OPERATION TECHNIQUE

“WE CLAIM THAT OLD CONCEPTS THAT PREVENT INGUINAL HERNIA FORMATION DESCRIBED IN THE TEXT BOOKS ARE NOT TRUE & PERFECT. THEY NEED TO BE RECONSIDERED” [Based on the anatomical descriptions about the posterior wall & the transversalis fascia given by Codon RE & Nehus LM in the book “Hernia”] OLD CONEPTS Strength of Transversalis fascia Obliquity of inguinal canal Shutter mechanism Chr. Cough, weight lifting, weakness of collagen tissue, old age etc. causes hernia formation OUR CONCEPTS Aponeurotic extensions from the trans. Abd. aponeurotic arch in the post. wall of ing. canal prevents hernia formation in the normal individuals. And if these are absent or deficient then only inguinal hernia formation takes place. And this absent or deficient apo. Ext. is not acquired but genetical.

MISCONCEPTIONS 1] POST. WALL OF INGUINAL CANAL IS FORMED BY THE TRANS. FASCIA :- NO !! IT IS WRONG !!! 2] STRENGTH OF TRANS. FASCIA GIVES PROTECTION NO !! IT IS ALSO WRONG !!! 3] OBLIQUITY OF INGUINAL CANAL, SHUTTER MECHANISM AND MANY OTHER THEORIES ARE DESCRIBED IN BOOKS:-THESE ALL THEORIES ARE NOT TRUE & PREFECT !!! 4] RIGID ANATOMICAL WALL CREATED BY MESH CAN GIVE BEST RESULTS:- NO !! THIS IS NOT TRUE !!!

BASIC CONCEPTS ARE NOT TRUE 1] Transversalis fascia does not have any strength at all. It is paper thin. It is just an extension of the endo-abdominal fascia. 2] Obliquity of the inguinal canal: is not true because the spermatic cord is lying throughout its course on the post. wall alone. It does not pierce 3 muscle as stated in all the text books. 3] Shutter mechanism: is also not true because repeated acts of crying does not increase the incidence of hernia in new born babies in spite of the almost absent "obliquity of inguinal canal" or "shutter mechanism”

So, these are not the real factors that prevent hernia formation 4] Those concepts that are said to prevent herniation are not at all restored in the today’s techniques of inguinal hernia repair and yet 70–98% of pts. are cured. So, these are not the real factors that prevent hernia formation Then what are the real factors? “Aponeurotic Extensions from the Transversus Abdominis Aponeurotic Arch in the posterior wall is the real factor.

WHAT ARE APO. EXTENSIONS ?

CROSS SECTION OF ING. CANAL

NORMAL FULL COVER OF APO. EXT.

Scanty Aponeurotic Extensions seen

DEFICIENT APO. EXTENSIONS

POSTERIOR WALL This posterior wall is not composed of ONE layer of trans. fascia as is described in all the text books but is composed of TWO layers. 1] Trans. fascia behind & 2] Aponeurotic Extensions in front of it The strength of the posterior wall is directly related to the number of Aponeurotic fibers it contains The Aponeurotic extensions give mechanical strength to the posterior wall to resist internal abdominal blows and prevent hernia formation

DYNAMIC POSTERIOR WALL This posterior wall is kept physiologically dynamic due to those Aponeurotic Extensions & muscle contractions. Muscle contraction of the transversus abdominis pulls these Aponeurotic Extensions upward and laterally converting it in to a shield to prevent hernia formation (Physiologically dynamic action of the post. wall)

POSTERIOR WALL IN ACTION AT REST IN ACTION

DYNAMIC POSTERIOR WALL This tension in the posterior wall is created in gradation as per the force of contraction of the muscles. And the force of contraction of the muscles changes as per the force of the internal abdominal blow. This is important physiological phenomenon. The posterior wall plays an important role in the prevention of hernia formation not only because of its anatomical strength but also because of its physiologically dynamic nature “Such a physiologically dynamic & strong posterior wall is needed to be constructed to give 100% cure from the inguinal hernias” And Such post. wall is not at all prepared in any of today's operation techniques

WE NEED TO SHIFT FROM MESH REPAIR TO PURE TISSUE REPAIR BECAUSE We prepare such a new post. wall with Aponeurotic strip in place of absent or deficient apo. extensions It is a pure tissue repair & no mesh or endoscopes. It removes disadvantages of “F.B.” as seen in mesh repair & “tension” as seen in other tissue repairs. It is with the lowest rate of complications. You repair hernia with all continuous abs. sutures It is a very simple & physiological repair, easy to learn, can be done under L.A. and with fast recovery. No staging or typing of hernia required. It can be universally applied in all types of ing hernias irrespective of size, type & age of the patient.

WIKIPEDIA’S NEW CLASSIFICATION PURE TISSUE REPAIRS : A. TENSION REPAIRS–BASSINI, SHOULDICE B. TENSION FREE REPAIR- DESARDA PROSTHETIC REPAIR : A. OPEN OR LAP MESH REPAIRS

Original Bassini Operation Dissection & excision of weak inguinal floor Tightening of int. ring Suturing int. oblique & trans. abdominis muscles to the inguinal ligament Recurrence rate was just 4%

Original Shouldice Operation Excision of weak inguinal floor is done Excision of cribriform fascia is done Cremaster muscle sling is prepared 4 layer suturing with stainless steel wire Lower crux of sup. Ring sutured to ant. rectus sheath to avoid recurrence at medial end Genital nerve, ext. spermatic vessels, & cremasteric muscle are excised Commanding operation-Needs training Danger to iliopubic vein & femoral vessels Shouldice made mess of clean Bassini repair

BASSINI, SHOULDICE, MACVAY 1. All those pure tissue repairs advised extensive excision of the weak tissues of the inguinal floor as its first step 2. And then suturing of the conj. Tendon to inguinal ligament. 3. Results were fairly good, failure rate seen was less than 4% 4. But later results shown were poor because original technique was modified and imp. First step of excision of ing. Floor was omitted

Total excision of weak inguinal floor is a must for this & it is very risky & difficult. Profuse bleeding from ilio pubic vein or danger to femoral vessels may take place.

WHY TENSION REPAIRS HAVE FAILED Surgeons have omitted the first imp. step of excising weak inguinal floor because of highly risky dissection Muscles are pulled down to suture to ing. Ligament . So they are under tension even at rest This tension increases further due to shrinkage of fibrous tissue in later life This tension increases many fold during action Muscles are displaced from its original place so they try to go back to its original place This results in more pain and more recurrences in these tension repairs Surgeons modified operation the way it suits to them

These tension repairs are largely discarded by many surgeons now. But there was no equally good & simple pure tissue repair available for the surgeons in those days So mesh repair became popular in spite of its combined high rate of morbidity

MESH REPAIR Usher & Newman were the real heroes of mesh. But people were reluctant to accept it in those days Later Lichtenstein made it popular with support of mesh companies. BUT Lichtenstein himself warned later in some articles about mesh & its dangers.

Lichtenstein mesh repair Lichtenstein puts a mesh –a mechanical barrier No body uses classical Lichtenstein mesh for repairs. A bi-tailed mesh with knitted borders was used by him Now mesh is cut to suit surgeons choice to reduce the cost. Loose or tight suturing of mesh can’t be standardized Size of the mesh also can’t be standardized Quality of mesh fabric is also not standardized. Why low quality mesh for poor and high quality mesh for rich? Mesh is a F.B. a simple piece of synthetic cloth, naturally associated with all F.B. complications

Does mesh repair qualify as ideal model hernia repair ? NO !!!! Mesh is a foreign body, is known to every one Millions of micro abscesses are formed & dense fibrous tissue is laid down in inguinal canal is also known to every one. 1] That distorts anatomy 2] Atrophies muscles 3] Nerves, vas & vessels get engulfed and affected 4] There are complications like pain, infection, testicular atrophy ETC.

WHY NOT LAPAROSCOPIC REPAIR ? All complications of mesh are present in laparoscopic repairs also. In fact, these complications carry high risk because mesh is stitched in side the abdomen (preperitonial). Additional complications are internal oozing, risk of general anesthesia, nerve damage, trauma to viscera, trocar hernia, recurrence etc You can imagine what would happen to vas & testicular vessels due to fibrosis WHEN MESH IS LAID DOWN DIRECTLY ON THE VAS & TESTICULAR VESSELS IN LAP. REPAIRS?

LAPAROSCOPIC REPAIR

You must bother for your patients. Thus you know that mesh is not 100% safe to body for its routine use in all the cases Lap. repairs carry higher risk & require extreme skills to give excellent results. Many patients life world wide might be getting affected by unscrupulous use of endoscopes by inadequately trained surgeons. Imagine the fate of millions of patients operated in remote places by many surgeons with low quality mesh without any standards. Pharma companies may not bother BUT You must bother for your patients.

Every surgeon wish for 100% safety & cure without complications in every surgery. Then how we have accepted mesh repairs in spite of its morbidity & complications? Because no alternate good tissue repair was available to the general surgeons And also because of the perfect marketing at all levels by the financially giant companies. Product costing few Rs. is being sold at 2000-50000 Rs. making huge profits. So companies will market this product by all means:- ETHICAL or UNETHICAL

WHAT IS THEIR MARKETING MAGIC? Control publishing houses and publish repeatedly similar articles through various doctors claiming mesh repair is the best. Control conferences & make leading doctors to present how mesh repair is the best. Start CME in conferences & make it compulsory to attend to post-graduate students & then hammer on to their mind same thing again how mesh repair is the best. Come out with new products of mesh & again send leading doctors to various seminars to show how mesh repair is the best.

Stop thinking beyond mesh for hernia repairs. Advantage of faith posed by trainee doctors and students in their teachers is exploited. Repeated presentations are made in conferences, repeated publications are made in magazines & the song about mesh goes on & on till junior and budding surgeons mind gets preconditioned to such an extent that they………… Stop thinking beyond mesh for hernia repairs.

WHO IS THE LOOSER The deadliest looser is your own patient. Many patients operated with mesh, open or laparoscopic repair suffer from morbidity & complications. Some patients life gets ruined. Who is responsible for this? But still companies with our help are busy in marketing their product like a soap or hair shampoo, every time coming out with a new variant of the same synthetic cloth like mesh, then mesh & plug, then PHS, then heavy weight, then light weight, then small pores, then large pores etc. etc.

WHO IS THE WINNER And the winner is mesh manufacturing company that silently pocket millions of $ profit every year from all over the world. And what about doctors who are catalytic agents and with whose help companies are making huge profits get? NOTHING Our prestigious organizations have all given our platform to them and made them financially giant. But still, we doctors have to bargain with them about selling stalls or getting advertisements or sponsorships.

Therefore we should invent such a technique that fulfills all criteria of a modern hernia Surgery Ideally, it should replace deficient aponeurotic extensions in the post. Wall with a strong sheet of your own aponeurosis instead of mesh Simple & safe to do & learn Does not use foreign body Does not use weak muscles & fascia Early ambulation Patient goes back to home in a day Pt. is back to his work within a week No major complications Very low rates of minor complications and recurrences

Today’s operation techniques do not satisfy all those criteria completely So, we need to find such a simple hernia operation technique that is mesh free, tension free & even a junior resident can also do it with minimal complications and recurrences

My Operation Technique GIVES SUCH A DYNAMIC, PHYSIOLOGICAL & STRONG POSTERIOR WALL BY REPLACING DEFICIENT APO. EXT. WITH A STRIP OF EOA IN THE POST. WALL OF ING. CANAL

“Physiologically dynamic & elastic Post “Physiologically dynamic & elastic Post. Wall GIVES BETTER PROTECTION than a simple rigid anatomical wall” MESH REPAIR GIVES ANATOMICAL WALL MY REPAIR GIVES PHYSIOLOGICAL WALL AT REST AT REST IN ACTION IN ACTION

PHYSIOLOGICALLY DYNAMIC STRIP

PROTECTION IN LATER PERIOD MESH GIVES MY REPAIR GIVES RIGID WALL ELASTIC WALL

PROTECTION

PROTECTION Entire canal gets compressed between EOA in front & strip behind

STATUS TODAY Today, this operation is being followed in many countries all over the world More than 150 presentations or publications and many more RCTs are conducted on this repair. Results are similar or superior to mesh repairs. Global data of 11170 pts operated by different surgeons was presented by me in the World Hernia conf. in 2015. It showed recurrence 0.2% & complications of 1.8% only. Many text books like Love & Belly, Shwartz etc. have mentioned this operation technique.

WE ARE THE FIRST IN THE WORLD We are the first to put before the world that ing. hernia must be repaired on physiological principle We are the first to scrap century old theories that prevent hernia formation and publish new theory We are the first to give you a very simple hernia repair that does not use mesh or foreign body We are the first to use all absorbable sutures inside We are the first to give you almost complete cure Wikipedia was the first to describe it in a separate section as “Tension free pure tissue repair”

NOW YOU DECIDE Whether to continue with open or laparoscopic mesh repair or to shift to this mesh free “Desarda Repair” MY ANSWER IS “There is no place for mesh prostheses now in hernia repairs because no mesh technique of “Desarda Repair” is available with superior results.”

WARNING !!! 1] Ethicon, Boston Scientific Corp and C.R. Bard are among seven companies facing more than 70,000 mesh injury lawsuits in federal court and thousands of additional cases in state courts of USA. 2] Here companies are playing safe by using doctors’ card in the court litigations. Ethicon's lawyers said the product was thoroughly certified by the doctors and that doctors considered the mesh used to be the "gold standard" for treatment. (From internet)

WARNING !!! Therefore, every surgeon should now take an informed consent in writing from the patient to avoid the court litigation in future following mesh complications after MESH REPAIR !!!!! TAKE CONSENT THAT 1] Mesh is a foreign body prepared from synthetic threads  2] It is associated with possible complications of recurrence, pain, infection, testicular damage, hematoma, seroma, migration, rejection, perforations, sinus formations, intestinal adhesions, sterility etc. etc. Patient may file a suit in future against the doctor and the hospital if such informed consent in writing is not taken from the patient before hernia surgery with mesh because you are implanting a foreign material in the body of the patient.

THANK YOU

OPERATION VIDEO

FAST RECOVERY