The Tension-Free Repairs without Mesh: Desarda and Modified Bassini Techniques

*Frederica Jessie Tchoungui Ritz*

#### **Abstract**

Hernia repair has three principal objectives: suppress the hernia, prevent recidivism, and reduce postoperative pain. Many techniques have been developed especially the tension-free repair. The Lichtenstein technique is the gold standard, using a mesh. However, sub-Saharan population is known to be hard laborers leading to the high-risk factor of acquiring hernia by a parietal defect. Most of them need a heterologous hernioplasty but have limited resources. The challenge in these countries is respecting the principal objectives of a hernia repair with inexpensive prosthetic material or without it. During these previous years, two principal techniques have been developed and used with satisfied results: Desarda and Modified Bassini techniques.

**Keywords:** inguinal hernia, Desarda, modified Bassini, Lichtenstein, tension-free repair

#### **1. Introduction**

Inguinal hernia is one of the common surgical pathologies. A better understanding of the anatomy of the inguinal canal improved the surgical techniques and the outcomes for the patients. Developed countries are well organized in scientific societies enhancing these improvements. Instead, the sub-Saharan countries do not have specialized centers which will help by improving the hernia surgery [1] and the general surgeon's training. The problematic of hernia surgery here is double, the improvement of inexpensive safe techniques and training of the general surgeons. This chapter emphasizes on two tension-free repair techniques, Desarda and modified Bassini, which are currently used for their low cost and are easily learned by the surgeons [2].

#### **2. Modified Bassini repair**

Bassini developed his hernia repair in 1887, which was minutely described by his student Catterina in 1930. This technique is the one currently used by general surgeon in secondary and tertiary hospitals in sub-Saharan countries. A modified Bassini was introduced, described as an autologous patch. The intervention can be under general or locoregional anesthesia. The description below is a modified Bassini technique by Atah [3].

#### **2.1 Technique**

#### *2.1.1 Skin incision*

A semi-Pfannenstiel incision is done homolateral to the hernia, for an esthetic scar. The inguinal canal opening is performed parallel to the inguinal ligament and the conjoint tendon through the superficial fascia and deep fascia; the external oblique aponeurosis (EOA) is cut. The EOA cut is extended to the superficial inguinal ring. The spermatic cord is opened layer by layer, and the hernia sac is exposed, dissected, and resected.

#### *2.1.2 Parietal repair*

Through the inguinal canal, the internal oblique tendon and the transverse tendon are united to form the joint tendon or separated. Those muscle fibers are parallel to the external oblique muscle, which is behind them. The conjoint tendon or the internal oblique tendon is easily used to strengthen the inguinal canal.

The herniorrhaphy is made with the inguinal ligament left in its normal position without being dissected and sutured to the conjoint tendon with number 1 or 0 Polyglactin 910 rounded overlock suture. The suture begins at the pubic tubercle to the deep inguinal ring. The free leaf of the conjoint tendon is sutured to the inferior part of the inguinal ligament, behind the spermatic cordon following the retrofunicular Bassini technique.

The diameter of the deep inguinal ring is reduced with a separate point, to admit only the tip of the little finger, enough caring not to strangulate the spermatic cordon in male or the round ligament in female. If the repair is under tension, a discharge incision is done, and the two borders are sutured to the EOA with number 1 or 0 Polyglactin 910 interrupted sutures. The skin closure is done.

#### **3. Desarda repair**

The Desarda hernia repair, eponym name to its author, described in 2001, is an autologous hernioplasty. The technique was developed as a tension-free hernia repair without mesh, to reduce the chronic groin pain, recovery time, and cost [4]. The intervention can be performed under general anesthesia or locoregional anesthesia.

#### **3.1 Technique**

#### *3.1.1 Skin incision*

The skin incision is a 6 cm oblique at the level of the inferior abdominal line or the Malgaigne's line (**Figure 1**). The fascia is incised and the EOA exposed. The EOA is cut in line with the inguinal ligament and the upper crux of the superficial ring, with a medial leaf and lateral leaf (**Figure 2**).

#### *3.1.2 Hernia sac dissection*

A direct or indirect hernia, with or without a sac, can be found. The cremaster muscle is resected, and the hernia sac dissected in the direction of the deep inguinal ring protecting the spermatic cord (**Figure 3**). The sac is ligatured with a resorbable thread USP 2/0 and excised in an indirect hernia and inverted in a direct hernia.

**83**

**Figure 3.**

*Hernia sac dissection.*

**Figure 1.** *Skin incision.*

**Figure 2.**

*External oblique aponeurosis incision.*

*The Tension-Free Repairs without Mesh: Desarda and Modified Bassini Techniques*

*DOI: http://dx.doi.org/10.5772/intechopen.88955*

*The Tension-Free Repairs without Mesh: Desarda and Modified Bassini Techniques DOI: http://dx.doi.org/10.5772/intechopen.88955*

**Figure 1.** *Skin incision.*

*Techniques and Innovation in Hernia Surgery*

A semi-Pfannenstiel incision is done homolateral to the hernia, for an esthetic scar. The inguinal canal opening is performed parallel to the inguinal ligament and the conjoint tendon through the superficial fascia and deep fascia; the external oblique aponeurosis (EOA) is cut. The EOA cut is extended to the superficial inguinal ring. The spermatic cord is opened layer by layer, and the hernia sac is exposed,

Through the inguinal canal, the internal oblique tendon and the transverse tendon are united to form the joint tendon or separated. Those muscle fibers are parallel to the external oblique muscle, which is behind them. The conjoint tendon or the internal oblique tendon is easily used to strengthen the inguinal canal.

without being dissected and sutured to the conjoint tendon with number 1 or 0 Polyglactin 910 rounded overlock suture. The suture begins at the pubic tubercle to the deep inguinal ring. The free leaf of the conjoint tendon is sutured to the inferior part of the inguinal ligament, behind the spermatic cordon following the retro-

The diameter of the deep inguinal ring is reduced with a separate point, to admit only the tip of the little finger, enough caring not to strangulate the spermatic cordon in male or the round ligament in female. If the repair is under tension, a discharge incision is done, and the two borders are sutured to the EOA with number

The Desarda hernia repair, eponym name to its author, described in 2001, is an autologous hernioplasty. The technique was developed as a tension-free hernia repair without mesh, to reduce the chronic groin pain, recovery time, and cost [4]. The intervention can be performed under general anesthesia or locoregional anesthesia.

The skin incision is a 6 cm oblique at the level of the inferior abdominal line or the Malgaigne's line (**Figure 1**). The fascia is incised and the EOA exposed. The EOA is cut in line with the inguinal ligament and the upper crux of the superficial ring,

A direct or indirect hernia, with or without a sac, can be found. The cremaster muscle is resected, and the hernia sac dissected in the direction of the deep inguinal ring protecting the spermatic cord (**Figure 3**). The sac is ligatured with a resorbable thread USP 2/0 and excised in an indirect hernia and inverted in a direct hernia.

1 or 0 Polyglactin 910 interrupted sutures. The skin closure is done.

The herniorrhaphy is made with the inguinal ligament left in its normal position

**2.1 Technique**

*2.1.1 Skin incision*

dissected, and resected.

funicular Bassini technique.

**3. Desarda repair**

**3.1 Technique**

*3.1.1 Skin incision*

*3.1.2 Hernia sac dissection*

with a medial leaf and lateral leaf (**Figure 2**).

*2.1.2 Parietal repair*

**82**

**Figure 2.** *External oblique aponeurosis incision.*

**Figure 3.** *Hernia sac dissection.*

#### *3.1.3 Parietal repair*

The fascial plasty starts with the medial leaf of the EOA which is sutured with the inguinal ligament from the pubic tubercle to the abdominal ring using number 2/0 or 0 Monofilament Polydioxanone continuous sutures (**Figure 4**). The first two sutures were taken through the anterior rectus sheath, and the last suture is taken to narrow the abdominal ring sufficiently, caring not to strangulate the spermatic cord.

An incision is made on the sutured medial leaf to obtain an aponeurosis flap of 1–2 cm (**Figure 5**). This fascial flap is extended medially up to the pubic symphysis and 2 cm beyond the abdominal ring laterally.

The upper free border of the aponeurosis flap is sutured to the internal oblique muscle at the level of the conjoint tendon with a number 2/0 or 0 Monofilament Polydioxanone continuous suture (**Figure 6**). With these sutures of the EOA, a new posterior wall of the inguinal canal is formed behind the spermatic cord. After the suture of the EOA, the patient is asked to cough or strain if it is under locoregional anesthesia, and under general anesthesia the anesthetist is asked to give a deep breath to the patient; this is to verify the solidity of the new posterior wall.

**Figure 4.** *Suture of the medial leaf of the EOA to the inguinal ligament.*

**85**

**Figure 8.** *Closure of the EOA.*

**Figure 6.**

**Figure 7.**

*The Tension-Free Repairs without Mesh: Desarda and Modified Bassini Techniques*

*DOI: http://dx.doi.org/10.5772/intechopen.88955*

*Suture of the upper free border of the aponeurosis flap.*

*Suture of the lateral leaf of the EOA to the new medial leaf of the EOA.*

**Figure 5.** *Incision of the sutured medial leaf of the EOA.*

*The Tension-Free Repairs without Mesh: Desarda and Modified Bassini Techniques DOI: http://dx.doi.org/10.5772/intechopen.88955*

**Figure 6.** *Suture of the upper free border of the aponeurosis flap.*

*Techniques and Innovation in Hernia Surgery*

and 2 cm beyond the abdominal ring laterally.

*Suture of the medial leaf of the EOA to the inguinal ligament.*

The fascial plasty starts with the medial leaf of the EOA which is sutured with the inguinal ligament from the pubic tubercle to the abdominal ring using number 2/0 or 0 Monofilament Polydioxanone continuous sutures (**Figure 4**). The first two sutures were taken through the anterior rectus sheath, and the last suture is taken to narrow the abdominal ring sufficiently, caring not to strangulate the spermatic cord. An incision is made on the sutured medial leaf to obtain an aponeurosis flap of 1–2 cm (**Figure 5**). This fascial flap is extended medially up to the pubic symphysis

The upper free border of the aponeurosis flap is sutured to the internal oblique muscle at the level of the conjoint tendon with a number 2/0 or 0 Monofilament Polydioxanone continuous suture (**Figure 6**). With these sutures of the EOA, a new posterior wall of the inguinal canal is formed behind the spermatic cord. After the suture of the EOA, the patient is asked to cough or strain if it is under locoregional anesthesia, and under general anesthesia the anesthetist is asked to give a deep breath to the patient; this is to verify the solidity of the new posterior wall.

*3.1.3 Parietal repair*

**84**

**Figure 5.**

**Figure 4.**

*Incision of the sutured medial leaf of the EOA.*

**Figure 7.** *Suture of the lateral leaf of the EOA to the new medial leaf of the EOA.*

**Figure 8.** *Closure of the EOA.*

The spermatic cord is replaced in the inguinal canal; the lateral leaf of the EOA is sutured to the new medial leaf of the EOA with a number 2/0 Monofilament Polydioxanone continuous sutures (**Figure 7**).

The EOA is sutured forward the spermatic cord (**Figure 8**), and a classic closure of the superficial fascia and the skin is done.

#### **4. Results**

The recurrence rate after an inguinal hernia repair is difficult to determine because of the high percentage of loss to follow-up. But some studies have shown that the modified Bassini technique is the most commonly used or the inguinal hernia repair [5]. This could be explained by the fact that surgeons in most of the peripheral hospitals are using tissue repair, mainly due to the limited resources of the population [6].

However, some complications occur with the tissue repair. Complications encountered in patient follow-up after a modified Bassini hernia repair are multiple; a prospective study in a rural hospital including 300 male patients highlighted some of them (**Table 1**).

The same complications can be observed with the Desarda technique as shown in a prospective study of 2 years, with 100 patients (**Table 2**) [7].

The two techniques are cost inexpensive, with a low rate of recurrence of the hernia and postoperative pain.

The European Hernia Society (EHS) gold standard regarding open tension-free hernia repair is the Lichtenstein mesh repair. However complications associated


#### **Table 1.**

*Complications encountered with modified Bassini technique [6].*


**87**

*The Tension-Free Repairs without Mesh: Desarda and Modified Bassini Techniques*

related complications, which would be an extra cost for the patient.

low rate of recurrence, postoperative pain, and reduced hospital stay.

research, authorship, and/or publication of this manuscript.

with it includes an important rate of mesh-related infection as wound infection due in some cases to an allergic reaction, mesh migration, and nerve entrapment [8]. These complications can lead to a prolonged hospital stay and a long treatment with antibiotics. Using Desarda or modified Bassini techniques avoid the risk of mesh-

Inguinal hernia treatment depends also on the surgeon training and experiences. There are several tension-free techniques describe with or without mesh. Another goal in the management of hernias is the training of surgeons, depending on the

Inguinal hernia is one of the commonest surgical pathology. In sub-Saharan Africa, it should be considered as a public health disease, to improve its management. The socioeconomic context is important here to consider the choice of the hernia repair technique. The tension-free repairs without mesh, Desarda and modified Bassini, response well to the economic criteria, with the advantages of a

The author declared no potential conflicts of interest with respect to the

Faculty of Medicine, Pharmacy and Odontology, Cheikh Anta Diop University,

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: fredericatchoungui@gmail.com

*DOI: http://dx.doi.org/10.5772/intechopen.88955*

medical and socioeconomic context.

**5. Conclusion**

**Conflict of interest**

**Author details**

Dakar, Senegal

Frederica Jessie Tchoungui Ritz

provided the original work is properly cited.

#### **Table 2.**

*Complications encountered with Desarda technique.*

#### *The Tension-Free Repairs without Mesh: Desarda and Modified Bassini Techniques DOI: http://dx.doi.org/10.5772/intechopen.88955*

with it includes an important rate of mesh-related infection as wound infection due in some cases to an allergic reaction, mesh migration, and nerve entrapment [8]. These complications can lead to a prolonged hospital stay and a long treatment with antibiotics. Using Desarda or modified Bassini techniques avoid the risk of meshrelated complications, which would be an extra cost for the patient.

Inguinal hernia treatment depends also on the surgeon training and experiences. There are several tension-free techniques describe with or without mesh. Another goal in the management of hernias is the training of surgeons, depending on the medical and socioeconomic context.

#### **5. Conclusion**

*Techniques and Innovation in Hernia Surgery*

Polydioxanone continuous sutures (**Figure 7**).

of the superficial fascia and the skin is done.

**4. Results**

of them (**Table 1**).

hernia and postoperative pain.

*Complications encountered with modified Bassini technique [6].*

*Complications encountered with Desarda technique.*

The spermatic cord is replaced in the inguinal canal; the lateral leaf of the EOA is sutured to the new medial leaf of the EOA with a number 2/0 Monofilament

The EOA is sutured forward the spermatic cord (**Figure 8**), and a classic closure

The recurrence rate after an inguinal hernia repair is difficult to determine because of the high percentage of loss to follow-up. But some studies have shown that the modified Bassini technique is the most commonly used or the inguinal hernia repair [5]. This could be explained by the fact that surgeons in most of the peripheral hospitals are using tissue repair, mainly due to the limited resources of the population [6]. However, some complications occur with the tissue repair. Complications encountered in patient follow-up after a modified Bassini hernia repair are multiple; a prospective study in a rural hospital including 300 male patients highlighted some

The same complications can be observed with the Desarda technique as shown

The two techniques are cost inexpensive, with a low rate of recurrence of the

**Complications Incidence (%)** Urine retention 5 (2.07) Hematoma (superficial) 1 (0.41) Wound infection 1 (0.41) Seroma 2 (0.83) Postoperative neuralgia 3 (1.24) Scrotal edema 2 (0.83) Ischemic orchitis 0 (0.00) Recurrence 2 (0.83)

**Complications Incidence (%)** Urine retention 3 (0.03) Wound infection 4 (0.04) Vomiting 2 (0.02) Acute postoperative pain 32 (0.32) Chronic postoperative pain after 3 months 4 (0.01) Scrotal edema 2 (0.02) Recurrence from 3 to 27 months 0 (0.00)

The European Hernia Society (EHS) gold standard regarding open tension-free hernia repair is the Lichtenstein mesh repair. However complications associated

in a prospective study of 2 years, with 100 patients (**Table 2**) [7].

**86**

**Table 2.**

**Table 1.**

Inguinal hernia is one of the commonest surgical pathology. In sub-Saharan Africa, it should be considered as a public health disease, to improve its management. The socioeconomic context is important here to consider the choice of the hernia repair technique. The tension-free repairs without mesh, Desarda and modified Bassini, response well to the economic criteria, with the advantages of a low rate of recurrence, postoperative pain, and reduced hospital stay.

#### **Conflict of interest**

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this manuscript.

#### **Author details**

Frederica Jessie Tchoungui Ritz Faculty of Medicine, Pharmacy and Odontology, Cheikh Anta Diop University, Dakar, Senegal

\*Address all correspondence to: fredericatchoungui@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Ohene-Yeboah M, Abantanga FA. Inguinal hernia disease in Africa: A common but neglected surgical condition. West African Journal of Medicine. 2011;**30**(2):77-83

[2] Kingsnorth AN, Clarke MG, Shillcutt SD. Public Health and Policy Issues of Hernia Surgery in Africa. World Journal of Surgery. 2009;**33**(6):1188. DOI: 10.1007/ s00268-009-9964-y

[3] Mgba JA, Tangnyin CP, Atah TN, Meva'a JB, Sosso MA. Cure des Hernies Inguinales en Tension -Free (Nouvelle technique en Bassini modifiée). Health Sciences and Diseases. 2016;**17**(4):83-87

[4] Desarda MP. No-mesh inguinal hernia repair with continuous absorbable sutures: A dream or reality? (A study of 229 patients). Saudi Journal of Gastroenterology: Official Journal of the Saudi Gastroenterology Association. 2008;**14**(3):122-127

[5] Konate I. Primary unilateral uncomplicated inguinal hernia repair, which is the procedure most frequently, performed in operating theatres the world over? Situation of Africa. Hernia. Jun 2019;**23**(3):623-624. DOI: 10.1007/ s10029-019-01937-5. [Epub 9 May 2019]

[6] Gorad K, Lohar H, Patil S, Tonape T, Gautam R. Modified Bassini's repair: Our experience in a rural hospital setup. Medical Journal of Dr. DY Patil University. 2013;**6**:378. DOI: 10.4103/0975-2870.118276

[7] Dieng M, Cissé M, Seck M, Diallo F, Touré A, Konaté I, et al. Cure des hernies inguinales simples de l'adulte par plastie avec l'aponévrose du grand oblique: Technique de Desarda. e-mémoires de l'Académie Nationale de Chirurgie. 2012;**11**(2):069-074

[8] Zulu HG, Mewa Kinoo S, Singh B. Comparison of Lichtenstein inguinal hernia repair with the tension-free Desarda technique: a clinical audit and review of the literature. Tropical Doctor. 2016;**46**(3):125-129

**89**

**Chapter 7**

**Abstract**

and advantages of their use.

cyanoacrylic glue, tacks, suture

while the integration process occurs.

on local habits and personal beliefs.

**1. Introduction**

Hernia Surgery

*Francesco Gabrielli and Marco Chiarelli*

Mesh Fixation Methods in Groin

*Morena Burati, Alberto Scaini, Luca Andrea Fumagalli,* 

No unanimous consent has been reached by surgeons in terms of a method for mesh fixation in laparoscopic and open surgery for inguinal hernia repair. Many different methods of fixation are available, and the choice of which one to use is still based on surgeons' preferences. At present, tissue glues, sutures, and laparoscopic tacks are the most common fixating methods. In open technique, sutures have been the method of choice for their reduced costs and surgeons' habits. Nevertheless, tissue glues have been demonstrated to be effective and safe. Similarly, tacks can be considered the most common means of fixation in laparoscopic hernia repair, but they are connected to a higher risk of complication and morbidity. In this chapter, we present these types of mesh fixation, their characteristics and potential risks,

**Keywords:** inguinal hernia, mesh, fixation, fixation techniques, fibrin glue,

Inguinal hernia repair is one of the most common procedures in surgical practice. In the surgical repair of groin hernia, prosthetic meshes and their fixation have been subject to debate. In the last decades, synthetic meshes have become crucial in surgical treatment of inguinal hernia. Once positioned, meshes are designed to be integrated in local tissue by a fibrotic reaction that gradually incorporates them. Therefore, a good fixation is essential to secure the mesh in its correct position,

The introduction of synthetic meshes and their proper fixation has reduced recurrence rates to below 5%. As a consequence, the most frequent postoperative morbidities have become mesh migration, chronic pain, infection, and seroma [1, 2]. In surgical practice the main challenge in mesh fixation consists in finding a good balance between the strength of fixation, in order to avoid recurrence and the

At present, various fixation techniques and materials have been developed, but no unanimous consent has been reached on the "best" method of fixation. The choice is still based on surgeon's preferences and experience, and much still depends

risk of tissue trauma and nerve entrapment, leading to chronic pain.

#### **Chapter 7**
