3. NEW CONCEPTS OF PHYSIOLOGY OF ING. CANAL THAT PREVENT INGUINAL HERNIA FORMATION

4. TODAYS TRENDS Mesh repair was introduced 3-4 decades ago and it was accepted world wide in spite of its F.B. complications WHY ? Because we did not have alternative pure tissue repair that was eqally simple & easy to do and still gave equal results with minimum complications

5. INGUINAL CANAL PHYSIOLOGY If you wish to develop such pure tissue repair then you must understand the factors that prevent inguinal hernia formation in the normal individuals

6. RECALL MEMORY ABOUT ING. CANAL PHYSIOLOGY The theory described in text books and taught to students every year is The theory described in text books and taught to students every year is 1] Post. Wall is a single layer structure formed by Trans. Fascia alone & 2] Its strength prevents the ing. hernia formation “In reality this is not true and still this misconception got fixed widely in the minds of every one”

7. WHAT IS A REALITY? IN REALITY The Post. Wall of inguinal canal is composed of 2 layers instead of 1 layer 1] Transversalis Fascia and 2] Aponeurotic extensions from the Trans. Abdominis aponeurotic arch Bendavid stated that the Bendavid stated that the surgeons overlooked this critical observation, and the misconceptions have been carried in many publications & books

8. TWO LAYERED POST WALL

9. ANATOMY OF ING.CANAL -post. view

10. TRANSVERSALIS FASCIA 1] Transversalis fascia is just an extension of the endo-abdominal fascia in inguinal canal 2] It is a sheet of loosely packed areolar tissue between the Aponeurotic Extensions in front and the pre-peritoneal pad of fat behind. 3] Obviously, it does not have any strength to protect the posterior wall of inguinal canal

11. SECTION OF INGUINAL CANAL

12. TRANSVERSALIS FASCIA  Thus you will find that trans. Fascia alone does not form the post wall & it hardly plays any role in the prevention of the hernia formation. IT MEANS THESE THEORIES IT MEANS THESE THEORIES DESCRIBED AND BELIEVED DESCRIBED AND BELIEVED TO BE TRUE FOR ALMOST A TO BE TRUE FOR ALMOST A CENTURY ARE REALLY NOT TRUE AND CORRECT NOT TRUE AND CORRECT

13. NEW CONCEPTS OR THEORIES PUBLISHED BY US A poneurotic Extensions from the Transversus Abdominis Aponeurotic Arch in the posterior wall of the ing. Canal is important real factor that prevents hernia formation in the normal individuals AND Hernia formation takes place only if they are absent or deficient Hernia formation takes place only if they are absent or deficient

14. TOTAL COVER OF APO. EXT. IN NORMAL CANAL WITHOUT HERNIA

15. Transversus Abdo. Apo. Arch sending Aponeurotic Extensions-No full cover

16. Hernia seen through scanty Apo. Ext.

17. Hernia seen through Scanty Apo. Ext.

18. PHYSIOLOGICALLY DYNAMIC POSTERIOR WALL  This post. Inguinal wall is kept physiologically dynamic due to those Aponeurotic Extensions & muscle contractions.  Contraction of the trans. abdominis pulls this posterior wall and the aponeurotic extensions upward and laterally creating increased tone in it to prevent hernia formation (Physiologically dynamic action of the post. wall)

19. HOW PHYSIOLOGICALLY DYNAMIC PROTECTION IS GIVEN TO POSTERIOR WALL AT REST IN ACTION

20. POSTERIOR WALL (cont.) 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 muscle changes as per the force of the internal abdominal blow. 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 muscle changes as per the force of the internal abdominal blow. Such a physiologically dynamic & strong post. wall is needed to be constructed to give 100% cure from the ing. hernias Such a physiologically dynamic & strong post. wall is needed to be constructed to give 100% cure from the ing. hernias

21. NO MESH INGUINAL HERNIA REPAIR WITH CONTNIOUS ABSORBABLE SUTURES BASED ON THOSE NEW CONCEPTS

32. Star Points of Technique  It is a Herniorrhaphy operation / plasty  Locally available live & active tissue  EOA is large enough to get strip easily  You get physio. dynamic post. wall  No difficult dissection is required  No foreign body or special material  Satisfies all criteria of modern Hernia surgery like day surgery, low learning curve, early ambulation, recovery in a week, minimal pain, no major complications and ALMOST ZERO RECURRENCE

33. OUR STUDY  Operated on 2000 pts. during last 20 yrs.  Continuous Absorbable sutures were used in more than 800 pts during last 8 years.  Median follow up period more than 7-8 yr  98% patients went home within 24 hrs.  95% pts started routine work in 3-8 days. Pts. could drive car and go to office.  Pt. can bend, squat, climb up a staircase, carry luggage & travel. Pts from abroad go back to their country on 3 rd day.  Recurrence & minor complications <0.1%

34. STATUS TODAY Today, this operation is being followed in many countries like USA, Poland, Germany, China, Malaysia, Cuba, Russia, Korea etc. Today, this operation is being followed in many countries like USA, Poland, Germany, China, Malaysia, Cuba, Russia, Korea etc. This technique is now added in the famous “Love & Bailey” text book of surgery along with Bassini & Shouldice & has become a part of the curriculum to teach under graduate and postgraduate students. This technique is now added in the famous “Love & Bailey” text book of surgery along with Bassini & Shouldice & has become a part of the curriculum to teach under graduate and postgraduate students. Web site www.desarda.com have been visited by more than 1 million of people till today Web site www.desarda.com have been visited by more than 1 million of people till todayww.desarda.com

35. “ RECURRENCE FREE ING. HERNIA REPAIR WITH CONTINUOUS ABSORBABLE SUTURES LEAVING NO FOREIGN BODY IN SIDE THE PATIENT IS NO LONGER A DREAM BUT A REALITY TODAT THEN WHY SHOULD WE DO A MESH REPAIR ATALL???

37. REFERENCES 1. Millikan KW, Deziel DJ. The management of hernia. Considerations in cost effectiveness. 2. Williams M, Frankel S, Nanchahal K, Coast J, Donavon J. Hernia repair. In: Stevens A, Raftery J (eds) Health Care Needs Assessment. (1e). Oxford: Radcliffe Press, 1994. 8 3. Anonymous. Activity and recurrent hernia [editorial]. BMJ 1977; 2: 3–4. 10 4. Review] [33 refs]. Surgical Clinics of North America 1996; 76(1): 105–116. 11 5. Kux M, Fuchsjager N, Schemper M. Shouldice is superior to Bassini inguinal herniorrhaphy. Am. J. Surg. 1994; 168: 15–18. 12 6. Kark AE, Kurzer MN, Belsham PA. Three thousand one hundred seventy-five primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia. Journal of the American College of Surgeons 1998; 186(4): 447– 455. 22 7. Salcedo-Wasicek MC, Thirlby RC. Postoperative course after inguinal herniorrhaphy. A case-controlled comparison of patients receiving workers' compensation vs. patients with commercial insurance. Archives of Surgery 1995; 130: 29–32. 23 8. Liem M, van Steensel C, Boelhouwer R, Weidema W, Clevers G, Meijer W et al. The learning curve for totally extraperitoneal laparoscopic inguinal hernia repair. The American Journal of Surgery 1996; 171: 281–285. 29 9. Rattner D. Inguinal herniorrhaphy: for surgical specialists only? Lancet 1999; 354. 32 10. Webb k, Scott NW, GO PMNYH, Ross S, Grant AM on behalf of the EU Hernia Triallists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair (Cochrane Rebiew) In: The Cochrane Library, Issue 4, 2000, Oxford Update Software. 33

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