External Oblique Aponeurosis Research Articles

Congenital inguinal hernia repair with and without opening the inguinal canal

Abstract Background Elective repair of congenital inguinal hernia is the most common surgery performed by pediatric surgeons and is considered the treatment of choice. The exact technique and steps involved in the repair differs widely among pediatric surgeons, many surgeons open the roof of inguinal canal while preserving the external ring or opening it, this is called the modified Ferguson, s technique. In infants, the inguinal canal is short and virtually the internal and external rings lie over each other so many surgeons also like to perform the whole operation without opening the external oblique aponeurosis distal to the external ring, this technique is called the Mitchell Banks technique. Objective To compare both techniques regarding intraoperative time, incidence of intraoperative and postoperative complications to pass our experience in a trial to reach an ideal surgical technique for congenital inguinal hernia repair. Patients and Methods In this study, 60 cases of congenital inguinal hernia were randomly selected and divided into two equal groups where group A underwent the repair with opening the external oblique aponeurosis and group B underwent the repair without opening the external oblique aponeurosis. Results As regard the postoperative complications, the patients who underwent the Ferguson’s technique experienced more postoperative pain with statistically significant more incidence of postoperative hydrocele than the Mitchell banks technique, no complications occurred postoperatively other than hydrocele in our study. Conclusion Our study results, we can approve that Mitchell Banks technique is easier, consumes less time than Ferguson’s technique with less incidence of postoperative complications and pain which can make this technique better for congenital inguinal hernia repair in children aging 2 years or less.

Desarda technique versus Lichtenstein repair for inguinal hernia in tertiary care centre: a prospective study

Background: Various techniques for treatment of inguinal hernia have been studied. The use of a mesh is costly and has its own complications. In Desarda’s technique- external oblique muscle aponeurosis is placed in the form of an undetached strip for inguinal hernia repair. The objective of this study is to compare the outcomes of Lichtenstein’s repair versus Desarda’s technique.Methods: In this prospective study, 50 patients with inguinal hernia were enrolled at A. J. Institute of Medical Sciences and Research centre. 25 patients each were divided into two groups by randomization and were operated using Lichtenstein’s hernioplasty and Desarda’s technique. Patients were assessed for cost effectiveness, operation time, postoperative pain, hospital stay, foreign body sensation, return to non-strenuous activity, complications and recurrence rate in the postoperative period on day 1, 3, 5, 1 month and 6 months.Results: With regards to pain, foreign body sensation and duration of surgery Desarda’s repair was better than Lichtenstein’s repair (p<0.05). Mean hospital stay in Desarda’s group was comparable to the Lichtenstein group (p=0.16). Return to normal non-strenuous activity after 7-15 days in Desarda was 80% and 64% in Lichtenstein. No case of recurrence or chronic groin pain in either group was found.Conclusions: Based on the result, reduced cost of treatment, lesser post-operative pain and no mesh related complications authors can conclude that Desarda’s technique is equally effective as Lichtenstein’s repair for inguinal hernia and can consider it as the method of choice in treating inguinal hernia.

Microsurgical subinguinal varicocelectomy with spermatic cord double traction and vein stripping.

We retrospectively reviewed data for 286 patients with varicocele who underwent microsurgical subinguinal varicocelectomy from March 2015 to May 2017 in Shanghai General Hospital (Shanghai, China). In this surgical approach, the testis was delivered, and the gubernacular and external cremasteric veins were stripped. In addition, the spermatic cord was delivered downward with continuous double traction away from the external ring. The remaining procedure was similar to the conventional approach. We followed patients for at least 3 months and evaluated postoperative semen parameters, pain symptoms, and complications. We excluded data for 32 men due to inadequate follow-up (<3 months). Of the remaining 254 patients, 73 had oligoasthenospermia, 121 had nonobstructive azoospermia, and 60 had symptomatic varicoceles. Total progressive sperm counts increased in the oligoasthenospermic patients from a median preoperative value of 9.15 × 106 ml−1 to 25.33 × 106 ml−1 (n = 34), and 35.6% (26/73) initially oligoasthenospermic men contributed to unassisted pregnancies. Sperm returned to the ejaculate in 12.4% (15/121) azoospermia patients. In patients with scrotal pain (n = 60), 43 (71.7%) reported complete resolution of pain, 16 (26.7%) reported partial resolution, and 1 (1.7%) reported no change. No patients experienced varicocele recurrence. This double-traction strategy avoids opening the external oblique aponeurosis, and results in less damage and faster recovery. In addition, the stripping strategy eliminates potential damage to the testis caused by the varicose veins. Our results showed that microsurgical subinguinal varicocelectomy using spermatic cord double traction in conjunction with testicular delivery for vein stripping is a safe and effective approach for varicocele repair.

Nigam’s inverted curtain hernioplasty: a modified lichtenstein tension free hernioplasty for inguinal hernia

Background: It is an open tension-free hernioplasty for primary inguinal hernias using minimal dissection and only 3 sutures to fix the mesh.Methods: A description of operative technique and patient’s demographics are presented.Results: 362 repairs were done with this technique over a period 18 years (March 2000 to March 2018). All were primary uncomplicated inguinal hernias.Conclusions: NICH tackles the both known aetiological factors for recurrence i.e., weakness in inguinal floor and tension at the suture line. It involves minimal tissue dissection and least number of sutures. Two sutures are used to fix the mesh with inguinal ligament. Third suture is used to make an artificial deep inguinal ring in the mesh as well as used to narrow the natural deep inguinal ring to further avoid recurrence. No suture is applied in main body of mesh which remains free like an inverted curtain covering the whole hernia susceptible region of groin. Prolene mesh is used which completely covers the potentially weak area on the floor of inguinal region irrespective of the size of the area in small or big frame persons. Semi double breasting of external oblique aponeurosis avoids displacement of mesh. NICH is associated with least recurrence, less post-operative pain, less post-operative complications and short learning curve.

To Evaluate the Efficacy of Bi Pedicled Strip of External Oblique Aponeurosis for Augmentation of Posterior Wall of Inguinal Canal in Inguinal Hernia Repair

To Evaluate the Efficacy of Bi Pedicled Strip of External Oblique Aponeurosis for Augmentation of Posterior Wall of Inguinal Canal in Inguinal Hernia Repair

Study of non-mesh technique of Desarda for inguinal hernia

Background: The tissue based techniques are still acceptable for primary inguinal hernia repair according to the European Hernia Society guidelines. Desarda’s no mesh technique, introduced in 2001, is a hernia repair method using an undetached strip of external oblique aponeurosis. This study compares the results with the studies done worldwide on Desarda’s technique.Methods: A total 120 cases were studied for 2 years (2015-2017), the primary outcomes measured were postoperative pain scores on day 1,7,30 using visual analogue scale, time taken to return to basic activities, time measured from skin incision to skin closer. Complications like cord oedema, seroma, fever, surgical site infection, chronic groin pain and recurrence were evaluated.Results: After a 15-month mean follow up period, 01 (0.83%) case had a recurrence among 120 patients. Mean operative time is 60 min; mean pain score on day-1, 7, 30 are 3.35, 0.9 and 0.008 respectively. Mean time taken to return back to work is 24 hours; complications like chronic groin pain, foreign bodysensation are not seen in single cases. These results are comparable with the studies done worldwide.Conclusions: In Desarda’s technique of inguinal hernia repair does not use mesh, so no complication related with the foreign body are seen and postoperative pain is less, early return to basic activities and Postoperative complications are less.

Venous Thromboembolism after Abdominal Wall Reconstruction: A Prospective Analysis and Review of the Literature

Ventral hernias are a common problem after exploratory laparotomy, and plastic surgeons often become involved for hernia repair in complex situations. Plastic surgeons can achieve fascial closure through primary repair, an external oblique aponeurosis release, or a transversus abdominis release. Currently, there is scant literature evaluating venous thromboembolism rates after these procedures. The authors sought to evaluate their own experience with complex abdominal wall reconstruction and venous thromboembolism events. The authors retrospectively reviewed their prospectively collected database of all patients who have undergone complex abdominal wall reconstruction performed by a single surgeon at their institution from September of 2013 to February of 2018. Demographic data, anticoagulant use, Caprini score, operative time, and postoperative venous thromboembolism events were recorded. A literature search was also performed, identifying all published articles evaluating venous thromboembolism events after abdominal wall reconstruction. The authors identified 175 patients for analysis. Four patients were found to have postoperative venous thromboembolism events, for a total venous thromboembolism rate of 2.3 percent. The average Caprini score for these patients was 8.5, compared to 5.26 for those without a venous thromboembolism event, and no deaths were reported from these complications. On literature review, three articles were identified in the literature discussing venous thromboembolism after abdominal wall reconstruction, all based on the American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing complex abdominal wall reconstruction are at high risk for venous thromboembolism events. There is scant literature published on this topic, but surgeons should be aware of the risk for venous thromboembolism after complex abdominal wall reconstruction and work to minimize this risk as much as possible. Therapeutic, IV.

Giant cell tumor tendon sheath at inguinal region masquerading as enlarged lymph node

Giant cell tumor of the tendon sheath (GCTTS) is a benign tumor and is the second most common tumor of the hand after ganglion cysts. It is a slow-growing benign lesion of the soft tissues. The etiology of GCTTS is not clear. Although GCTTS most commonly presents in a digit of the hand, it may also present in the palm, wrist, foot, knee, ankle, elbow, or hip. Here, we present a rare case of GCTTS originating at the inguinal region, which has not been previously reported. A 52-year-old male presented with a 2 cm × 1 cm swelling at the right inguinal region. The clinical impression was inguinal lymph node enlargement. Ultrasonography (USG) showed the presence of large inguinal lymph node. Fine-needle aspiration cytology (FNAC) showed the features suggestive of giant cell lesion, possibly GCTTS. Repeat ultrasound revealed a large oblong-shaped hypoechoic lesion with mild internal vascularity in the right inguinal region above the external oblique aponeurosis, suggestive of aponeurotic giant cell tumor. Histopathology was confirmatory. Here, we report this case to highlight the role of FNAC in diagnosing GCTTS at a rare site, i.e., inguinal region. Due to its location at inguinal region, along with clinical suspicion of tubercular lymphadenitis and USG findings showing large inguinal lymph node in the right inguinal area, it needs to be differentiated from other causes of lymph node enlargement. It would be prudent to state that FNAC along with radiology can help reach the final diagnosis.

A Case of Extension Function Reconstruction of Ruptured Extensor Pollicis Longus Tendon by External Oblique Aponeurosis with PAT Transplantation

A Case of Extension Function Reconstruction of Ruptured Extensor Pollicis Longus Tendon by External Oblique Aponeurosis with PAT Transplantation

Desarda versus Lichtenstein repair for inguinal hernia: a randomized, multi-center controlled trial with promising results

Background: The techniques for treatment of an inguinal hernia range from the tissue-repairs to the tension-free hernioplasty. The use of a mesh for repair not free of complications and had higher costs. The Desarda technique for inguinal hernia repair is a new tissue-based method application of the external oblique muscle aponeurosis in the form of an undetached strip has been introduced as a new concept in tissue based hernia repair. The aim of the present stusy was to compare the standard mesh-based Lichtenstein technique with the tissue-based Desarda technique.Methods: In this prospective study, patients with an Inguinal hernia who were referred and enrolled in the study for elective Desarda or Lichtenstein repair between May 2012 and November 2016 at Sohag and Assiut university hospitals, Egypt; Operation, anaesthesia, rescue analgesia and postoperative care were standardized. Patients were assessed for operation time, postoperative pain, hospital stay, foreign body sensation, complications and recurrence rate in the postoperative period on day 1, 1 week, 1, 12 and 24 months, postoperatively.Results: Of 130 patients were included in the study, 65 underwent Desarda (D) versus 65 underwent Lichtenstein repair (L) between May 2012 and November 2016 at Sohag and Assiut university hospital in Egypt. In Desserda group (D) 64 OF 65 patients were male and in Lichtenstein repair group (L) 65 of 65 were male. The patient's age for (L) Group was 40±11.69 and for (D) group was 38±11.55. As regards operative time, hospital stay, return to activity and work for or post-operative pain 24 hours and 7 days after the operation. D group was significantly lower than (L). No difference between groups regarding intraoperative, postoperative complication, mortality rate, recurrence rate, or post-operative pain six months after operation.Conclusions: Desarda repair had lower operative time, early return to basic and work activity, shorter hospital stay and less post-operative pain than Lichtenstein repair. The result of our study supports the use of Desarda repair in our hospitals as the method of choice for most of the patients due to low cost, low recurrence rate, and simplicity of repair.

Testicular transposition in children undergoing brachytherapy for bladder and/or prostate rhabdomyosarcoma

Background/PurposeFertility preservation is a major goal in treatment of children with cancer. We describe a new technique of testicular transposition (TT) in patients treated with pulse-dose-rate (PDR) brachytherapy as part of the multimodal conservative treatment of bladder neck and/or prostate rhabdomyosarcoma (BP RMS). MethodsMedical records of consecutive patients treated between September 2016 and August 2017 were studied. These patients underwent a TT performed during BP RMS surgery by the same suprapubic incision. The external oblique aponeurosis was not incised. The spermatic cord was mobilized up to the external inguinal ring, and the gubernaculum attachments were severed from the scrotum. The testis was then flipped over with care taken to avoid injury of the vessels or the vas, wrapped in a silicone material and sutured under the abdominal skin with a transfixing stitch facing the anterior superior iliac spine. At the end of brachytherapy, the testis was relocated in the scrotum and during the same general anesthesia, plastic tubes and stents were removed. Surgical outcome and dosimetric parameters were examined. ResultsEight patients were identified. Median age was 24 months (range 11–80 months). All had embryonal BP RMS and received chemotherapy according to RMS 2005 protocol prior to local treatment. All patients underwent conservative surgery followed by brachytherapy (60 Gy) and had testicular transposition of one testis. None had surgical complications. After converting doses to biologically equivalent doses in 2-Gy fractions (EQD2), the dose delivered to 75% of the transposed testis was 1.5 GyEQD2 (1–3 GyEQD2), versus 5.4 GyEQD2 (3.9–9.4 Gy EQD2) for the untransposed testis (p < 0.001). ConclusionTesticular transposition is feasible in order to potentially preserve fertility and future quality of life in children undergoing brachytherapy for BP RMS. Type of StudyLevel IV Treatment Study: Case Study with no Comparison Group.

Endometriosis-associated hydrocele of the canal of Nuck with immunohistochemical confirmation: a case report

BackgroundThe canal of Nuck is an embryological vestige of the processus vaginalis, and presents a potential site for endometriosis seeding. Hydroceles in this region are a rare cause of inguinal swelling in females. In addition, endometriosis localized to the canal of Nuck is exceedingly rare.Case presentationA 44-year-old Japanese woman presented with a painful mass overlying her right pubis. She underwent surgery to completely excise the mass. During surgery, division of the external oblique aponeurosis revealed a cyst that occupied the inguinal canal and it adhered to the transverse fascia, inguinal ligament, and pubic bone. The cyst was dissected from the round ligament, and the defect in the internal inguinal ring was repaired and reinforced with mesh. On macroscopic examination, the cyst had a heterogeneous fibrous aspect with dark brown inclusions. Microscopic examination revealed that the cyst was tortuous, lined by mesothelial-like cells, and accompanied by partial subcapsular hemorrhage. Endometrium-like tissue was observed in the cystic wall. Immunohistochemical staining for podoplanin confirmed the mesothelial origin of the cyst-lining cells. The epithelial cells and stromal cells were positive for estrogen receptors.ConclusionsIn this case of an endometriosis-associated hydrocele of the canal of Nuck, the mesothelial origin of the cyst-lining cells and endometriosis were confirmed by positive immunohistochemical staining for podoplanin and estrogen receptors, respectively. We determined that hydrocele resection and reinforcement of the anterior inguinal canal wall (if necessary) are appropriate treatments for this condition.

Evolution of Endoscopic Anterior Component Separation to a Precostal Access with a New Cylindrical Balloon Trocar.

Endoscopic anterior component separation (ECS) techniques facilitate tension-free midline closure of wide ventral hernia defects. We describe a novel approach with a precostal incision and a new cylindrical ballon trocar. A single-center analysis of 19 patients undergoing ECS between January 1, 2014 and August 2, 2017 was performed with regard to improvement of technique. We currently start with a lateral precostal incision. This access in a low-fat and stable area allows for easy identification of the external oblique muscle with the ribs functioning as dorsal abutment for entering the correct plane between external and internal oblique muscles. Then a trocar is inserted with a cylindrical ballon, thus providing sufficient pneumatic widening of the dissection plane. A second 5-mm port is inserted under direct vision below the 12th rib. From there a unidirectional incision of the external oblique aponeurosis is performed from subcostal to the inguinal ligament. If necessary, the cephalad muscular parts of the external oblique can be transected over several centimeters in both directions starting from the precostal incision. We documented no procedure-related complications apart from two hematomas that required no interventions. Four procedures were carried out on one side and the remaining ones bilaterally. In one case, a conversion to conventional open component separation was required due to extensive scarring after open cholecystectomy. There were no notable abdominal bulgings or lateral hernias during a structured postoperative follow-up period of 1 year postoperatively. The technique described offers advantages in terms of determination of the correct entry point for ECS, regardless of abdominal wall conditions and the precostal access allows for unidirectional dissection toward the inguinal ligament with only two trocars in total. The cylindrical shape of the ballon trocar provides adequate widening of the working space and ensures good overview for safe dissection.

A study of open inguinal hernioplasy with horizontal incision at tertiary care hospital

Background: Transverse incision may be truly horizontal or may curve to varying degrees. Transverse incisions mostly follow LANGER lines and give better cosmetic results. The present study was planned with an objective to study open inguinal hernioplasty with transverse crease (Langer’s line) incisions.Methods: The present cross-sectional study was conducted on patients operated for inguinal hernia in single surgical unit between March 2013 to October 2015. After admission in a surgical ward, thorough history and clinical examination of all patients done. A transverse skin incision was used (follow the Langer’s line) in all cases.Results: The mean age of the cases in the present study was 45.21±14.2 years. It was noted that among Indirect inguinal hernias (IIH), 85% of the cases were below 50 years of age while among direct inguinal hernias (DIH), 66% cases were above 50 years of age. It was seen that 42.6% of the direct hernia was right-sided while 70.0% of the indirect hernias were right sided. All the patient had a very good cosmetic outcome.Conclusions: It was concluded from the present study that right sided indirect inguinal hernia was the most common type of Hernia. The use of transverse incision through Langer lines is aesthetical, no folding of scar is seen, all the layers are not on same level so preventing ridge effect, repair become sounder, bigger lower flap of external oblique aponeurosis and even wound is infected, no scar widening.

Efficacy and safety of 0.75% ropivacaine instillation into subinguinal wound in patients after bilateral microsurgical varicocelectomy: a bi-center, randomized, double-blind, placebo-controlled trial.

ObjectiveTo evaluate the efficacy and safety of 0.75% ropivacaine instillation into inguinal wound in patients who have undergone bilateral microsurgical varicocelectomy.Patients and methodsEighty-five men who were screened for bilateral varicoceles from March 2015 to July 2016 were randomized for the treatment. All patients underwent inguinal varicocelectomy by general anesthesia. After ligation of the internal spermatic veins from the spermatic cord, additional delivery of testis through inguinal incision site was done to ligate external spermatic veins and gubernacular veins. Before repairing external oblique aponeurosis, 6 mL of 0.75% ropivacaine and 6 mL of normal saline were instilled under the fascia and around the funiculus (spermatic cord) by a randomized and double-blind method. Visual analog scale (VAS) pain score and Prince Henry Pain Score (PHPS) were used for evaluating operative sites at 1, 2, 4, and 8 hours and 7 days after surgery. Safety and tolerability were evaluated throughout the course of this study by assessing adverse events.ResultsA total of 55 men completed the study. Of these 55 men, 31 received instillation of ropivacaine on the left operative site, while 24 received instillation of ropivacaine on the right operative site. VAS pain scores and PHPS in the ropivacaine-instilled operative site were significantly lower compared to those obtained with placebo at 2, 4, and 8 hours after surgery. In general, instillation of ropivacaine was safe and well tolerated in patients.ConclusionRopivacaine instillation into inguinal surgical site wound significantly reduced postoperative pain after microsurgical varicocelectomy.

The application of free superficial circumflex iliac artery perforator flap in the coverage of upper extremity wounds

Objective To investigate the clinical efficacy of using the free superficial iliac circumflex artery perforator flap to repair skin and soft tissue defects of the upper extremity. Methods Twenty-two cases of skin and soft tissue defects of the upper extremity treated between January 2008 and November 2015 were involved in this study. Among them 6 cases had forearm skin defects combined with tendon or bone exposure, 3 had skin defects around the wrist combined with tendon exposure, 10 had skin defects on the dorsum of the hand with exposure of extensor tendons, and 3 had dorsal finger skin defects with extensor tendon exposure. The size of the skin defects ranged from 3 cm×5 cm to 7 cm×15 cm. Vascularized free iliac circumflex artery perforator flap measuring 4 cm×6 cm to 8 cm×16 cm was used to repair these defects. The external oblique aponeurosis was included in the flap to reconstruct the extensor tendon defect in the finger in 3 cases, who had splint immobilization for 3 weeks before rehabilitation began. Results Intractable vascular spasm due to small caliber of the anastomosed superficial iliac circumflex artery occurred in one case that caused insufficient perfusion and flap necrosis. The wound was covered with local flap transposition. The rest 21 flaps survived uneventfully. The 21 patients were follow-up for 6 to 24 months. Flaps that covered the arm, wrist and dorsum of the hand had good appearance and texture. There was no need for flap debulking surgery. The results were satisfactory. The fingers that had flap transfer and extensor tendon reconstruct were slightly bulky, affecting finger extension and flexion. Conclusion The superficial circumflex iliac artery perforator flap is located in a hidden area of the body. Its blood supply is constant. The flap can be fully utilized. It is one of the ideal flaps for repairing soft tissue defects of the forearm, wrist and dorsum of the hand. Key words: Surgical flaps; Upper extremity; Superficial circumflex iliac artery perforator flap; Repair

English

BACKGROUND Inguinal hernia repair is the most frequently performed operation in any general surgical unit. The Bassini’s, Shouldice and other tissue-based techniques are still being acceptable for primary inguinal hernia repair. Desarda’s technique is originally a tissue based hernia repair using an undetached strip of external oblique aponeurosis to strengthen the posterior wall of the inguinal canal. The aim of the present study was to compare Lichtenstein hernia repair and Desarda herniorrhaphy. METHODS A total of 40 patients with primary unilateral inguinal hernia were subjected either to Desarda herniorrhaphy or Lichtenstein hernioplasty. The patients were followed in terms of recurrence rate, post-operative complications, convalescence, chronic pain and cost effectiveness. RESULTS During the followup all patients had either mild or moderate pain, but the pain intensity was more in Lichtenstein repair compared to Desarda repair in the immediate postoperative period. In Lichenstein repair patients had chronic groin pain even at the end of one year, but none of the patients in Desarda repair had chronic groin pain. Complications such as seroma and wound infection were less in Desarda repair. Time taken to resume normal activities was significantly less in case of Desarda herniorrhaphy; however, there was no recurrence observed in both the groups during the followup period. Average cost incurred for Desarda repair was significantly less than Lichtenstein repair. CONCLUSION Lichtenstein method of hernia repair is simple and safe. But the mesh prosthesis has its drawbacks. Desarda hernia repair is based on physiological principles and the results are good with less convalescence period and fewer recurrences and no chroni c groin pain. It is more cost effective.

The Oblique Rectus Abdominis Musculocutaneous Flap for Reconstruction after Resection of a Spermatic Cord Liposarcoma.

The Oblique Rectus Abdominis Musculocutaneous Flap for Reconstruction after Resection of a Spermatic Cord Liposarcoma.

Randomized clinical trial of Desarda versus Lichtenstein repair for treatment of primary inguinal hernia

BackgroundThe ideal operation to treat inguinal hernia is still far to define. We analyzed the outcomes of the Desarda tissue-based repair in comparison with the standard Lichtenstein procedure in treatment of primary inguinal hernia. MethodsA total of 168 patients were randomly allocated into two groups to undergo one of two repairs: Desarda (group I) or Lichtenstein (group II) (85 vs. 83, respectively). The primary outcome measures were recurrence of inguinal hernia and chronic groin pain. Secondary outcome measures included operating time, postoperative pain scores, time to return to normal gait and to work, foreign body sensation in the groin, and postoperative complications. ResultsDuring 2-year follow up, one recurrence was detected in each group (P = 0.99). Chronic groin pain was experienced by 5.6% and 4.2% of patients from Desarda and Lichtenstein groups respectively (P = 0.68). There was no significant statistical difference in mean postoperative VAS scores for pain at the five time points between the two study groups. There was significantly shorter operating time and earlier return to normal gait in favor of Desarda repair. Foreign body sensation was not different between the two groups. ConclusionSuccessful inguinal hernia treatment without mesh implantation can be achieved using Desarda repair, as it is effective as the standard Lichtenstein procedure. Shorter operating time, early return to normal gait and lower cost (no mesh) are potential benefits of Desarda repair. The suitability of Desarda repair for patients found to have thin, weak or divided external oblique aponeurosis intraoperatively needs further evaluation.

Reply to comment to article: Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation. Bruce Tulloh, Andrew Charles de Beaux, DOI 10.1007/s10029-015-1391-4.

Thank you for these comments. To clarify, in this manuscript, we do not promote anterior component separation (ACS) as the preferred method of closure for large abdominal wall defects for several of the reasons you have outlined; a high wound infection and seroma rate, a high recurrence rate, concerns for skin flap necrosis, as well as inapplicability to non-midline defects [1, 2]. For the management of large defects, we prefer posterior component separation with transversus abdominis release (PCS/TAR) due to a low recurrence rate, and applicability to hernias in every location in the abdominal wall [2–4]. But, having said that, there is little doubt that the popularization of ACS has made it a heavily utilized technique for definitive abdominal wall reconstruction [2]. While component separation methods are presumed to be destructive to the abdominal wall, there is excellent data that division of the external oblique aponeurosis in ACS and the division of the transversus abdominis muscle in PCS/TAR do not result in abdominal wall instability. Rather, the reapproximation of the linea alba afforded with these techniques results in improved abdominal wall function and quality of life [5]. The procedure you have described in 21 patients is a bridged repair covered with hernia sac, with no recreation of the linea alba [6]. While this procedure is an acceptable procedure for patients with no need for a functional abdominal wall (the elderly, those with limited life expectancy) it would not be the procedure of choice for definitive, functional reconstruction of the abdominal wall. Patients with bridged repairs of any type typically complain of persistent midline bulging where the mesh is unsupported and are at higher risk of hernia recurrences and central mesh fracture (depending on the type of mesh used) [7, 8]. We respectfully disagree with your assertion that PCS/ TAR is a salvage procedure. We believe that it is a reconstructive (not destructive) operation that should be considered the first-line procedure for the definitive closure of large abdominal wall defects as it permits wide defect overlap, with the mesh in the preferred sublay position and permits primary fascial closure in 95 % of cases [2, 4]. Bridged repair clearly has a role, but should be reserved for only the largest of hernias with massive loss of domain (in whom primary fascial closure is not feasible) or in patients who are not candidates for a definitive closure due to underlining comorbid conditions.