k Consultant General Surgeon Poona Hospital & Research Centre ä Kamla Nehru Corporation Hospital k...
Transcript of k Consultant General Surgeon Poona Hospital & Research Centre ä Kamla Nehru Corporation Hospital k...
Consultant General Surgeon
Poona Hospital & Research Centre
Kamla Nehru Corporation Hospital
Associate Professor of surgery Bharati Vidyapeeth Med. College
Gold Medallist in Anatomy
Consultant General Surgeon
Poona Hospital & Research Centre
Kamla Nehru Corporation Hospital
Associate Professor of surgery Bharati Vidyapeeth Med. College
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 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)
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…)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
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 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
UPPER BORDER OF SEPERATED STRIP IS SUTURED TO INTERNAL OBIQUE MUSCLE
FIGURE NO. 2
Clinical MaterialClinical 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
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
Age / SexAge / SexMales : 385 Female : 15 Males : 385 Female : 15
11
48
71 71
56
75
58
100
10
20
30
40
50
60
70
80
Between18-20
21-30 31-40 41-50 51-60 61-70 71-80 81-90
Between 18-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
Age wise Distribution
Types of Inguinal HerniaTypes of Inguinal Hernia
14.34% 10.34%
31.34 %
Recurrent indirect Obstructedindirect
Bilateral indirect Bilateral mixed Pantaloon hernia(left)
4%3.75%
3%
0.75% 0.75%
No
of P
atie
nts
Types of Inguinal Hernia (Cont…)Types of Inguinal Hernia (Cont…)
14.34% 10.34%
31.34 %
Primary indirect Primary direct Bilateral direct Right side hernia Left side hernia
No
of P
atie
nts
63.25%
14.25%10.25%
54%
31.25%
Anaesthesia / Operation TimeAnaesthesia / Operation Time
Now majority of operations are done under L.A. only Now majority of operations are done under L.A. only
Operation Time : 30 min to 60 minOperation Time : 30 min to 60 min1%
9%
90%
Spinal 90%
Local 9%
General 1%
Hospital StayHospital Stay
59%
4%5%
3%4%
25%
3 days 25%
4 days 59%
5 days 4%
6 days 3%
7 days 5%
> 7 days 4%
Hospital stay of patientsHospital stay of patients
ComplicationsComplications
0
1
2
3
4
5
6
Recurrence Haematocoele WoundOdema
Mild skininfection
No
of C
ases
Table shows early and late complications seen in this series
0.25%
1.5%
0.25%
1%
Ambulation & Routine WorkAmbulation & Routine Work
11%
73%
26%
1%
100%
89%
2 days 100%
4 days 89%
7 days 11%
7 days 73%
15 days 26%
> 15 days 1%
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 UpFollow Up
99% 85.60%
61.20%53.50%
40.50%
26.60%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
15 days 3 months 1 year 3 years 5 years 10 years ormore
Aetio - Patho - PhysiologyAetio - 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-- AND
? Shutter mechanism is lost / weak
? No strong post. wall
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-- AND
? Shutter mechanism is lost / weak
? No strong post. wall
ANATOMY OF ING.CANALANATOMY OF ING.CANAL
APONEUROTIC EXTENSNS IN POSTERIOR WALL APONEUROTIC EXTENSNS IN POSTERIOR WALL
Conventional ConceptConventional Concept Obliquity of Inguinal canal
Shutter mechanism
Strength of trans.fascia
My Concept (SCS Action)
Shielding action
Compression action
Squeezing action
(Physiologically active and mobile post.ing.
Wall is a must in both concepts)
Obliquity of Inguinal canal
Shutter mechanism
Strength of trans.fascia
My Concept (SCS Action)
Shielding action
Compression action
Squeezing action
(Physiologically active and mobile post.ing.
Wall is a must in both concepts)
S
C
S
SCS ACTIONInt. Blow to Abdominal Wall
SCS ACTIONInt. 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
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
SQUEEZING ACTION OF CREMASTER MUSCLE
SECTION OF INGUINAL CANAL AT RESTSECTION OF INGUINAL CANAL AT REST
CHANGES DURING RAISED INTRA-ABDOMINAL PRESSURECHANGES DURING RAISED INTRA-ABDOMINAL PRESSURE
SCS Action (Contd…..)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
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
ANSWERANSWER
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
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….)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
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 ActionIn My Operation
Mechanism of ActionIn 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 fibresgiving a natural support to trans. fascia
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 fibresgiving a natural support to trans. fascia
MY OPERATION(? The Final Solution)
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
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 TechniqueStar Points of My Technique
It is a Herniorrhaphy operation / plasty
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
No foreign or special material required
Efficacy can be tested on operation table
Satisfies all the criteria of modern Hernia surgery
It is a Herniorrhaphy operation / plasty
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
No foreign or special material required
Efficacy can be tested on operation table
Satisfies all the criteria of modern Hernia surgery
Choice is YoursChoice is Yours
“ Would you still like to insert a mesh in the
body of your patient of inguinal Hernia ?”
You Decide !
“ Would you still like to insert a mesh in the
body of your patient of inguinal Hernia ?”
You Decide !