Desarda Hernia Repair

History of Inguinal Hernia Repair

The reigning heavyweight champion of no-mesh inguinal hernia techniques was the Shouldice operation which was described in the 1940s. Apart from the Shouldice operation, other no-mesh techniques were noted to have significantly higher rates of recurrence, thought likely to be attributed to tissue tension and using already compromised tissue to fashion a repair.

In the 1980s, Dr. Lichtenstein described a tension-free mesh repair. The results from this operation were quite encouraging and showed low recurrence rates and, most importantly, the operation was reproducible (i.e. it was easily learned and reproduced by most surgeons). This operation ended up being the most popular operation for inguinal hernias performed in the United States. The Shouldice operation had not gained widespread adoption in the US because i) it was a technically challenging operation (i.e. it was not easily reproducible), and ii) other studies could not replicate the low recurrence rates published by the Shouldice Clinic (probably due to lack of expertise, and more stringent patient selection at the Shouldice Clinic).

Over the years, multiple different tissue repairs were described, but studies could never achieve comparable results to the Lichtenstein mesh repair. In the 1990s surgeons started doing laparoscopic inguinal hernia operations. After an initial period of learning the new approach (the anatomy was a different view from what most surgeons were used to, they were now looking at things "from behind" as opposed to "from the front"), this approach has now become one of the most popular techniques (now commonly done robotically), and utilizes mesh.

Dr. Desarda's Discovery

In 2001, Dr. Desarda published his first widespread study on his repair which he had developed over the previous decades. The results were surprisingly good and comparable to the standard mesh repairs. Most American surgeons were suspicious of the findings as many other repairs had come and gone over the years. Dr. Cober remembers reading the study as a surgical resident and wondering if it was truly reproducible. In the US, the Desarda repair was not commonly performed, although Dr. Desarda had been training surgeons throughout the world and it was slowly becoming more commonplace in other parts of the world.

Fast forward to the late 2010s, more and more papers started popping up describing good results with the Desarda repair. Dr. Cober remembers reviewing some of these recent studies and getting very interested in the Desarda technique, now that it appeared to be doing well after 20 years of scrutiny by the wider international surgical community. Dr. Cober started learning more about it from Dr. Desarda and Dr. Yunis, one of the US' foremost hernia experts who is located in Sarasota, FL. Dr. Desarda freely teaches the technique to surgeons and did not appear to have a financial incentive but rather appeared to be genuinely interested in improving hernia surgery for patients everywhere. Dr. Cober now believes that the Desarda repair has good data and reproducibility and offers it to patients.

Dr. Cober's favorite aspects of the Desarda repair is that it provides a physiologically dynamic tissue that can contract and brings the conjoint tendon back into functional relationship with the inguinal ligament as opposed to simple anatomic apposition to it -- just as in the anatomy of a normal inguinal canal. In other words, the external oblique strip very closely replicates the function of the normal aponeurotic extensions from the conjoint tendon to the inguinal ligament as seen in healthy inguinal canals.

There are numerous articles in peer-reviewed journals. See the References section here. Also see Dr. Desarda's website here.