Slide 1

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 2

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 3

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 4

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 5

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 6

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 7

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 8

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 9

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 10

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 11

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 12

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 13

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 14

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 15

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 16

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 17

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 18

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 19

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 20

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 21

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 22

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 23

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 24

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 25

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 26

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 27

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 28

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 29

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 30

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 31

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 32

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 33

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 34

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 35

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 36

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 37

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 38

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 39

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 40

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 41

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 42

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 43

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 44

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!


Slide 45

ETIOLOGY OF HERNIA & EVOLUTION
OF HERNIA SURGERY

Dr Sanjay De Bakshi
MS;FRCS.
Consultant Surgeon
Examiner and Surgical Tutor;
Royal College of Surgeons; Edinburgh.
Tutor for DNB Genl. Surgery and G.I. Surgery;
Calcutta Medical Research Institute.

THE ABDOMINAL WALLCOMES IN VARIOUS SHAPES AND SIZES
SERVE VARIOUS FUNCTIONS

THE ABDOMINAL WALLHATE IT-LOVE IT

YOU SIMPLY
CANNOT –

IGNORE IT!!!!

“HERNIA”
But What is a Hernia?

THE HISTORY OF HERNIA SURGERY IS ALMOST AS
OLD AS TIME ITSELF.
Hippocrates used the
Greek term – “hernios”
for
bud or bulge to describe
abdominal hernias.

CLOSEST ANALOGY IS
TO THE STATE OF AN
MUCH USED
OLD-STYLE FOOTBALL!!

Definition
An abnormal
protrusion of the
contents of a closed
cavity through a
potential or an
abnormal opening.

Famous hernia patient
Galileo Galilei
(1564-1642) was
incapacitated by
an irreducible
inguinal hernia in
his later life.

First forays
An illustration from
Caspar Stromayr's

Practica Copiosa

(1559). The
manuscript covered
repair of hernias and
hydroceles

Types of Abdominal Hernias
• Inguinal.
•
•
•
•
•

Umbilical
Incisional
Epigastric
Femoral
Hiatus hernia

INCIDENCE OF DIFFERENT TYPES OF
HERNIAS

CAUSE OF THE HIGH
INCIDENCE OF
INGUINAL HERNIA

MOTION PATH OF THE
GONADS:FROM
CONCEPTION TO BIRTH.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL
RIDGE” OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY
WHILE RUNNING.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

PROBLEM OF EVOLUTION
Born from a need to “Run” food down on
the plains of Africa

-THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT
ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED-

“THE MYOPECTINEAL ORIFICE”

First forays

TRUSS
• PROBLEM OF BEING DANGEROUS AS
IT SOMETIMES CAUSES PRESSURE
AT THE NECK OF THE HERNIA
CUTTING OFF THE BLOOD SUPPLY.

So I Have a Hernia.
Why Should I Have Surgery?
Operation
?
• There is pressure at
the neck of the sac
which can cut off the
blood supply causing
strangulation.

Causes Of Increased Pressure
IN C R E A S E D
PRESSURE

F at

F a e ce s & F la tus

F lu id

F o etus

P U T T IN G O N
W E IG H T

S E V E RE
C O N S T IP A T IO N

D IF IC U L T Y IN
U R IN A T IO N &
F L U ID IN A B D O M E N

PREGNANCY

F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS

Causes of Weakness in the Covering Layers
W E A K N E SS

AGE

O P E R A T IV E
SCARS

MUSCLE
B U LK LO SS
S ta rva tio n e tc.

Tissue Repair – Bassini

Defect
repaired by
stitches

Tension – Pain - Recurrence

PROBLEM OF STITCHING
A STRETCHABLE MATERIAL
LIKE SOCKS IS THAT
IT TEARS UNLESS “DARNED’

Darning with nonabsorbable stitches

Defect repaired
by Darning

• Good but entirely
dependent on the
“yarn” and the
“darner”.
• So, the “yarn” and the
“darn” had to be “darn
good”!!!

TO STANDARDISE “DARNING”

• Lichtenstein devised a mesh made of
polypropelene.
• This effectively was a pre-prepared“darn”.

Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the
hernia with a patch of
mesh, instead of sewing
the edges together
• PAIN FREE repair
• Return to full activities at
the earliest

Lichtenstein Tension Free Single Flat
Mesh

Flat Mesh in a Single Anterior Layer of Protection

Lichtenstein Tension Free Single Flat
Mesh
• Ease of use.
• Tension-free repair.
• Dramatic reduction in the
incidence of recurrence.
• However, the mesh was
situated above the defect.
• Recurrence could occur
between the mesh and the
defect.

It is far more
difficult to break
open a door
against the
direction it is
opened

It is far easier to do this in
the direction the door is
opened

KICKING IN A DOOR!!!

Present Status of Inguinal Hernia
Repair

LICHTENSTEIN
OVERLAY MESH

LAPAROSCOPIC
REPAIR

GILBERT
COMBINATION
MESH

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

Repair by
Laparoscopy

•May be either through the general
abdominal cavity or just outside
the membranous covering.
•Needs general anaesthesia.
•Needs wide dissection and
difficult to do for large irreducible
hernias and where previous
abdominal surgery has been carried
out.

•Needs intensive training.
•Sometime difficult to fix lower
edge of the mesh and this can lead
to reccurence.

•Sometimes complicated by nerve
entrapment pain, bleeding.
Membranous
covering

WIDE DISSECTION

Therefore –
Requires G.A.

DIIFICULT TO TEACH AND DANGEROUS
ANATOMY
TRIANGLE OF
DOOM
TRIANGLE
OF PAIN
CIRCLE OF
DEATH

THEREFORE FIXATION OF THE MESH IS –AT BEST
PARTIAL

THE MESH IS PRONE TO BEING “ROLLED UP”LEADING TO RECC.

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE DIRECT INGUINAL
HERNIA

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS

FOR THE INDIRECT INGUINAL
HERNIA

Tension-Free Repairs
- The PHS

Defect
repaired by
PHS

– Combines the three most common repairs
(overlay, plug, underlay).
– Can be done under local anaesthesia.
– Non-Suture intensive.
– Posterior support. Protects Femoral
Canal from anterior approach.
– Conforms to anatomy in posterior space.
– To date, only few reported cases of
recurrence !!
– Is an open operation, though the incision
is small.
– Mesh is expensive.

ANTERIOR SUPPORT
--------The
mechanical analysis
of a THRUST!!!

THE THRUST MAY CAUSE A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

POSTERIOR SUPPORTEither Laparoscopy or by
PHS Mesh
1) ONLY WAY TO
COVER ENTIRE ILEOPECTINEAL WINDOW
2) BASED ON SOUND
APPLICATION OF
PHYSICS
TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT
BETWEEN THE “MESH” AND THE “HERNIAL GAP”

PHS MESH REPAIR
AN ANIMATION

600+ PATIENTS
IN EASTERN INDIA
HAPPILY SAY

YES!!