k Consultant General Surgeon  Poona Hospital & Research Centre ä Kamla Nehru Corporation Hospital k Associate Professor of surgery  Bharati Vidyapeeth Med. College k Gold Medallist in Anatomy k Consultant General Surgeon  Poona Hospital & Research Centre ä Kamla Nehru Corporation Hospital k Associate Professor of surgery  Bharati Vidyapeeth Med. College k Gold Medallist in Anatomy Dr. Desarda Mohan P. MS. (Gen. Surgery) PUNE Dr. Desarda Mohan P. MS. (Gen. Surgery) PUNE

Criteria of Modern Hernia Surgery 4Simple, safe, easy to learn & perform 4No risky / complicated dissection / suturing 4No tension on tissues 4Avoid using weakened muscles or fascia for repair 4No foreign body / special material 4Cost effective (in those days of cost ergonomy) 4Simple, safe, easy to learn & perform 4No risky / complicated dissection / suturing 4No tension on tissues 4Avoid using weakened muscles or fascia for repair 4No foreign body / special material 4Cost effective (in those days of cost ergonomy)

Criterias (Contd…) 4Concept of “Come today - Go today” 4Comfortable post op. period 4Immediate ambulation 4Rapid recovery to preoperative works efficiency (Rapidly evolving concept of managed health care) 4Immediate or late complications to be comparable, if not, better than the established techniques 4Concept of “Come today - Go today” 4Comfortable post op. period 4Immediate ambulation 4Rapid recovery to preoperative works efficiency (Rapidly evolving concept of managed health care) 4Immediate 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 , with a long follow up of more than 15 years k No patients selection k Any type of Inguinal Hernia k Bilateral Hernias operated together k Hydorcoele, piles, BEP - dealt with simultaneously This study is of fairly large series of 400 operations from , with a long follow up of more than 15 years k No patients selection k Any type of Inguinal Hernia k Bilateral Hernias operated together k Hydorcoele, piles, BEP - dealt with simultaneously

Age / Sex Males : 385 Female : 15 Age wise Distribution

Types of Inguinal Hernia 14.34% 10.34% % 4% 3.75% 3% 0.75% No of Patients

Types of Inguinal Hernia (Cont…) 14.34% 10.34% % No of Patients 63.25% 14.25% 10.25% 54% 31.25%

Anaesthesia / Operation Time Now majority of operations are done under L.A. only Operation Time : 30 min to 60 min

Hospital Stay Hospital stay of patients

Complications No of Cases Table shows early and late complications seen in this series 0.25% 1.5% 0.25% 1%

Ambulation & Routine Work Table shows ambulation of patients and the period when they go back to their routine work Table shows ambulation of patients and the period when they go back to their routine work Ambulation Routine Work

Follow Up

Aetio - Patho - Physiology kExt. blow  Guarding   Tone  shielding action kInt. blows  Coughing, Straining etc kPost ing. Wall (Trans. fascia + Aponeurotic ext.) resist int. blow kAbsent apo. Ext. then trans fascia alone can not stand int. blows kStrong muscles - shielding action  No Hernia kWeak muscles + absent apo.ext  Hernia- because int. ring & post. wall are not protected-- AND ?Shutter mechanism is lost / weak ?No strong post. wall kExt. blow  Guarding   Tone  shielding action kInt. blows  Coughing, Straining etc kPost ing. Wall (Trans. fascia + Aponeurotic ext.) resist int. blow kAbsent apo. Ext. then trans fascia alone can not stand int. blows kStrong muscles - shielding action  No Hernia kWeak muscles + absent apo.ext  Hernia- because int. ring & post. wall are not protected-- AND ?Shutter mechanism is lost / weak ?No strong post. wall

ANATOMY OF ING.CANAL

kAPONEUROTIC EXTENSNS IN POSTERIOR WALL

Conventional Concept k Obliquity of Inguinal canal k Shutter mechanism k Strength of trans.fascia My Concept (SCS Action) k Shielding action k Compression action k Squeezing action (Physiologically active and mobile post.ing. Wall is a must in both concepts) k Obliquity of Inguinal canal k Shutter mechanism k Strength of trans.fascia My Concept (SCS Action) k Shielding action k Compression action k Squeezing action (Physiologically active and mobile post.ing. Wall is a must in both concepts) S C S

SCS ACTION Int. Blow to Abdominal Wall k All 3 muscles contract -  Tone - Generalized shielding k Contraction of Trans abd. muscles   tone in post ing. Wall - local shielding k contraction of int. obl. muscle   tone in curved part  shielding action in front of int. inguinal ring k Contraction of cremasteric muscle squeezes sp.cord contents & pulls it close to int.ing.ring to plug it  squeezing action k All 3 muscles contract -  Tone - Generalized shielding k Contraction of Trans abd. muscles   tone in post ing. Wall - local shielding k contraction of int. obl. muscle   tone in curved part  shielding action in front of int. inguinal ring k 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…..) k Int. oblique muscle compresses the canal against ing. ligament & post.wall k Ext. obl. compresses the canal against post. wall k Weak muscles & absent apo.element in post wall -- ?SCS action is lost / weak ?No strong & physiologically active post.wall ?RESULT IS HERNIA FORMATION k Int. oblique muscle compresses the canal against ing. ligament & post.wall k Ext. obl. compresses the canal against post. wall k Weak muscles & absent apo.element in post wall -- ?SCS action is lost / weak ?No strong & physiologically active post.wall ?RESULT IS HERNIA FORMATION

ANSWER k To give a strong, mobile & physiologically active post.wall to the ing.canal WHICH MEANS k New wall should have apo.element to support tra. fascia k Should give additional muscle strength to weak muscles to increase tone & strength of the post.wall of ing.canal k Post wall should remain mobile even after surgery k To give a strong, mobile & physiologically active post.wall to the ing.canal WHICH MEANS k New wall should have apo.element to support tra. fascia k Should give additional muscle strength to weak muscles to increase tone & strength of the post.wall of ing.canal k Post wall should remain mobile even after surgery

ANSWER (contd….) kBassini & Shouldice interpose a muscle curtain. If muscles are weak - no strength in the post.wall kLichtenstein 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 kBassini & Shouldice interpose a muscle curtain. If muscles are weak - no strength in the post.wall kLichtenstein 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 k Strip is fixed below & medically k All 3 abd muscles exert action above & laterally k Ext. oblique gives additional strength to weakened int. oblique & trans. abd k Contraction of muscle increases tone of the strip converting it into a shield to prevent hernia k Tone of strip is graded as per force of contraction of muscles (physiologically active wall) k Strip replaces the absent aponeurotic fibres giving a natural support to trans. fascia k Strip is fixed below & medically k All 3 abd muscles exert action above & laterally k Ext. oblique gives additional strength to weakened int. oblique & trans. abd k Contraction of muscle increases tone of the strip converting it into a shield to prevent hernia k Tone of strip is graded as per force of contraction of muscles (physiologically active wall) k Strip replaces the absent aponeurotic fibres giving a natural support to trans. fascia

MY OPERATION (? The Final Solution) 1Strip of EOA replaces the absent aponurotic element 2It gives additional strength of muscle to weak muscles 3Minimal or no fibrosis ?Post wall remains mobile ?It is strong ?It is physiologically active 1Strip of EOA replaces the absent aponurotic element 2It gives additional strength of muscle to weak muscles 3Minimal or no fibrosis ?Post wall remains mobile ?It is strong ?It is physiologically active

Star Points of My Technique H It is a Herniorrhaphy operation / plasty H Locally available live & active tissue H EOA is large to get strip easily H You get physiologically active posterior wall H No difficult identification of sling of int. ring or iliopubic tract required H No foreign or special material required H Efficacy can be tested on operation table H Satisfies all the criteria of modern Hernia surgery H It is a Herniorrhaphy operation / plasty H Locally available live & active tissue H EOA is large to get strip easily H You get physiologically active posterior wall H No difficult identification of sling of int. ring or iliopubic tract required H No foreign or special material required H Efficacy can be tested on operation table H 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 !