Why Use No-Mesh Hernia Surgery: Desarda Repair

Dear Editor, Thank you for your interest in our article. I read your comments with interest and appreciate the concerns raised. I am glad that you are a proponent of Desarda’s technique, which I, too, hold in high regard as the only true tension-free nonmesh repair. However, I would like to respond to your concerns on the points regarding the critique of Desarda’s technique. 1. “Lack of clarity on feasibility in large direct hernias.” As regards the suitability of Desarda’s technique for giant hernias, I feel that it must be considered in a case-by-case manner rather than as a definite default procedure. The reason for this is, giant hernias are usually chronic, large, and are found in debilitated patients whose tissue strength is suboptimal. Employing a weak tissue to reinforce the inguinal wall is fraught with the possibility of failure. In addition, barring a few case reports, there is a clear lack of high-level evidence in the literature to support your case. 2. “Criteria for unsuitability when the external oblique aponeurosis is weak.” I would beg to differ from your view that aponeurosis does not weaken. They do. We all must have seen at some point a thinned, splayed external oblique aponeurosis that tears during the closure in an open inguinal hernia repair. It is also interesting to see that you shared the same concern in your own paper about this when you wrote, “We agree that the use of an unhealthy, thinned out, weak, or divided effective orifice area tissue for repair may lead to recurrence.”[1] 3. “Paucity of high-quality randomized controlled trials comparing head-to-head with Shouldice.” I agree that there is a significant literature comparing Desarda’s technique with Lichtenstein’s repair. Our point was specifically regarding the lack of evidence with “head-to-head” comparison of Desarda’s technique with the “gold standard” nonmesh technique—Shouldice repair. I agree that this absence of evidence does not necessarily mean evidence of absence. Rather, it highlights the reasons as to why an elegant nonmesh technique like Desarda’s is encaged within the domains of a few centers, when it has the potential to be spread more widely. We also place the responsibility of evaluating and validating that technique on the teachers of surgery and the various hernia societies. Our critique is actually a defence for propagating Desarda’s technique more vigorously rather than denigrating it. With Regards, Dr. Parthasarathy Govindaraju Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.