Letter
to Editor by Losanoff et al- Reply
(Physiological
repair of inguinal hernia-A new technique)
Author:
Prof. Dr. Desarda M. P. (M.S.)
Hernia. (2006) 10:200-201
Affiliations: Professor and head of the Department of surgery,
KEY WORDS: Hernia; Physiological Repair; External oblique
aponurosis, Open repair;
CORRESPONDENCE: 18,
Vishwalaxmi housing society, Kothrud, Pune-411029 India
Email: desarda@hotmail.com
To the Editor,
I
am thankful to J. E. Losanoff M.D. and J. Michael Millis, M.D. for reading my
article with interest. I have gone through their comments carefully.
Their
statement that "The overlap in follow-up time among the series is
confusing and demands an explanation…." is probably because they have
overlooked my explanation given about this in the ‘Introduction’ section itself.
The drawback of poor long term follow up in previously published series is
removed in this series. So it will be nice if we concentrate on results of this
series.
The
statement that "We find no evidence …. his results are superior to that of
previously published series of mesh repair." is also probably because they
have overlooked the zero% recurrence rate observed in the median follow up
period of 7.8 years of this series. I have mentioned in the article about my
personal communications with many other surgeons from other countries and given
their email addresses for verification. The results observed by them also show
zero% recurrence in their locally published series. Secondly, a pure tissue
hernia repair does not need any justification like "Modern monofilament
prosthetic materials resist infection, have a negligible suppuration rates, and
excellent tissue incorporation", as it does not use any foreign body. My
operation technique gains on this count also. I do agree with the above statement
about the quality of modern mesh. But, if given a technique of inguinal hernia
repair having comparable, if not superior results, what will anybody choose for
himself -a pure tissue repair or a mesh (foreign body) repair?
The statement that-"The recent literature
…. pathological changes in collagen, …. that sets the stage for the development
of a hernia" is not relevant to this article because it is a description
of a new technique of hernia repair and not its etiological factors. However, I
agree with their further statement that-"Numerous … trials ….superiority
of the tension-free mesh repair over the traditional tissue approximation
method". This is true because the traditional tissue approximation methods
use transversus abdominis and internal oblique muscles for repair even if they
are weak. Therefore, I have stated in my article that "The aging process
is minimum in tendons and aponurosis and therefore it is the best alternative
to mesh" (Instead of Shouldice or other pure tissue repairs).
"A number of such repairs described in
Lason's classic 1941 text are similar……. Madden [16], Koontz [17], Calman [18],
and Halsted [16] all describe variants of inguinal floor repair similar to the
one described in the Desarda articles". I do not agree with those statements
because Shouldice operation is similar to or a variant of Bassini operation;
various mesh repairs like PHS are variants of the original Lichtenstein mesh
repair but still they are not only accepted but are promoted. I still maintain
that my operation technique is neither similar to or a variant of all
above-mentioned operations, because none of them have ever used the strip of
external oblique aponurosis (EOA) as described in my technique. No operation
described to date has ever used the concept of giving additional muscle
strength to the weakened muscles of the inguinal canal. The sutured strip of
EOA in my operation becomes an independent entity as the posterior wall of the
inguinal canal, which is kept physiologically dynamic as per the force of contraction
of the muscles. This posterior wall is strong because of the nature of the
strip and it is also kept physiologically dynamic by the additional muscle
strength of the strong external oblique muscle. Interestingly, in many cases
the internal oblique muscle, which did not show any movements when the patient
was asked to cough while on the operating table before the strip of EOA was
sutured behind the cord, showed improved or good movements after the strip was
sutured. This may be because of the new anchorage received by the internal
oblique muscle arch to the upper border of this strip. Providing a strong and
physiologically dynamic posterior inguinal wall should be the principle of any
inguinal hernia repair. This principle is observed in my operation technique
and it gives a zero% recurrence rate because of this. Pure tissue repair and
simplicity of operation are other important features of this operation. The
cost involved in purchasing and maintaining sophisticated equipment like
laparoscope is avoided and the expertise required doing complicated dissection
or handling of such equipment is also not required.
I am in agreement with Losanoff et al that
the prosthetic grafts give good results and are frontline therapy in the
Western hemisphere. Twenty per cent of the world population lives in the
Western hemisphere. I am thankful to Losanoff et al for accepting my operation
of inguinal hernia repair as an alternative to a mesh repair for the rest of
the world, which has the remaining 80%of the world population.
On
the basis of afore said discussion, I have strong objection about the title
"Aponurosis instead of prosthetic mesh for inguinal hernia repair: neither
physiological nor new" given by Losanoff et al to their letter. I request
the editors to kindly delete this misleading title.
The
type of title and repeated mention of mesh repair as ‘gold standard’ or the
statements like "Although many of the endogenous repair methods might be
used alternatively to mesh in parts of the world where prosthetic materials are
not available, they cannot become standard in the Western world" points
towards a biased attitude. I conclude with an appeal to all the highly learned
members of the surgical community to come forward with an unbiased mind and
think for themselves what is best for their patients.
Lastly,
I have never criticized the Lichtenstein mesh repair. There is no reason for me
doing so when amid and Lichtenstein themselves have written "In mobile
areas such as the groin there is a tendency for the prosthesis to fold, wrinkle
or curl around the cord. More importantly, in vivo, mesh prosthesis loose
approximately 20% of their size through shrinkage. The slightest movement of
the mesh from the pubic tubercle, the inguinal ligament and the area of the
internal ring, due to the above factors, is a leading cause of failure of mesh
repair of inguinal hernias." (1) Also an editorial in Annals
of Surgery, January 2001, raised the question of whether the changed
techniques of hernia repair in recent years, mainly implanted mesh, have caused
a rise in the incidence of chronic groin pain from 1%to 28.7%after hernia
repairs. Bay-Nielsen et al (2004) reported an incidence of 33.1% at 6-12 months
and 23.1% at 25-36 months of chronic groin pain following Lichtenstein repair.(2)
Nienhuijs SW et al (2005) reported that the "chronic groin pain is
also a very common problem" in their randomized clinical trial comparing
PHS, mesh plug repair and Lichtenstein repair. (3)
Considering all the above points, I think,
this new method of hernia repair will stand the test of time and will prove its
superiority in any controlled trial.
References:
1. Amid PK,
2. Bay-Nielsen M, Nilsson E, Nordin P,
Kehlet H.( 2004) Chronic pain after mesh & sutured repair of indirect
inguinal hernia in young males. Br J Surgery. 91 (10): 1372-76.
3. Nienhuijs SW, van Oort I, Keemers-Gels
ME, Strobbe LJA, Rosman C. (2005) Randomized clinical trial comparing PHS, mesh
plug repair and Lichtenstein repair for open inguinal hernia repair. Br J Surg.
Vol 92:33-38
