ANZ J. Surg.

(2001)

71

, 680–682

LETTERS TO THE EDITOR

Dear Editor,

Comparison of three methods in surgical treatment of pilonidal disease

I support the conclusions of Aydede

et al

. in the June issue of thisJournal

1

in that excision with primary closure gives better resultsin surgery for post-anal pilonidal sinus than excision with mar-supialization (or second intention healing). Excision with primaryclosure is associated with shorter hospital stay, more rapidhealing and return to work, and, although infections are morecommon, the recurrence rate is similar. I also agree with the useof dye (methylene blue) to outline the track and ensure its com-plete excision, with the need to avoid a dead space, with closedsuction drainage and the use of prophylactic antibiotics.

None of these methods, however, address the two main factorsresponsible for early recurrence due to hair penetration: namely,the depth of the cleft and the presence of a portal of entry for hairsin the midline (the wound). Also, a midline wound is bound byfibrosis to the underlying bone and subject to stretching forcesthat occur with sitting, and this is a cause of delayed healing insome cases. Buttock flaps and Z-plasty flatten the cleft and facili-tate a low recurrence rate but the wound crosses the midline. TheKarydakis procedure is an ‘elliptical’ excision wound centred toone side, and involves undercutting the midline to create a shortthick flap to advance across the midline. It not only reduces thedepth of the cleft (so hairs are less likely to gather) but it alsotakes the whole wound off the midline, providing no entry pointfor new hairs, and provides a supple wound based on muscle notbone. Karydakis reported a 1% recurrence rate in a very largeseries

2

and others have also found his method to be simple,elegant, easy to teach and to have excellent long-term results.

3,4

REFERENCES

1. Aydede H, Erhan Y, Sakarya A, Kumkumoglu Y. Comparison ofthree methods in surgical treatment of pilonidal disease.

ANZ J.Surg.

2001;

71

: 362–4.2. Karydakis GE. Easy and successful treatment of pilonidal sinus

after explanation of its causative process.

Aust. N.Z. J. Surg.

1992;

62

: 385–9.3. Kitchen PRB. Pilonidal sinus: Experience with the Karydakis

operation.

Br. J. Surg.

1996;

83

: 1452–5.4. Anyanwu AC, Williams A, Hossain S, Montgomery ACV. Kary-

dakis operation for saccrococcygeal sinus disease: Experience ina district general hospital.

Ann. R. Coll. Surg. Engl.

1998;

80

:197–9.

P

AUL

K

ITCHEN

Department of Surgery,St Vincent’s Hospital, Fitzroy, Victoria, Australia

Dear Editor,

LETTER TO THE EDITOR

New method of inguinal hernia repair: A new solution

We read with interest Desarda’s recent article describing a newmethod of inguinal hernia repair.

1

Dr Desarda discusses the use ofa medially based longitudinal strip of the external oblique apone-

urosis (EOA) to reinforce the inguinal floor. The strip is suturedlaterally to the inguinal ligament and medially to the internaloblique arch, preserving the spermatic cord subcutaneously. Thetechnique was used in 400 patients, 40% of whom were followedup at 5 years and 27% at 10 or more years after surgery. Desardaconcludes that his results are comparable to those achieved withprosthetic mesh hernioplasties, and constitute a good alternativeto mesh or other open or laparoscopic repairs.

1

Fifty per cent of inguinal hernia recurrences first appear5 years after surgery.

2

Many patients are lost to follow up, partic-ularly those who seek care from other surgeons when theirhernias recur. Ten-year follow up provides a reliable measure ofa repair’s durability.

2

Nearly 75% of Desarda’s patients were lostto follow up, precluding comparison to reports of recent largeseries describing superior follow-up results after both open

3

andlaparoscopic

4

prosthetic mesh inguinal hernioplasty. We findlittle evidence to support Dr Desarda’s conclusion that complica-tions associated with mesh prosthesis, including shrinkage andgroin sepsis,

1

contraindicate its use. Modern monofilamentedprosthetic materials resist infection.

5

Recent literature describesnegligible suppuration rates and excellent mesh incorporationwith preperitoneal

4

and intermuscular

6

prosthetic grafts. DrDesarda claims superiority of the EOA repair over mesh tech-niques but does not mention disorders of collagen metabolism inpatients with hernia, a lifelong risk factor.

7,8

Desarda notes two techniques utilizing the EOA for inguinalfloor reinforcement. Many, many others described in Iason’sclassic 1941 text are similar to Desarda’s.

9

The ‘Johns Hopkinsrepair’ utilizes a relaxing incision of the anterior rectus abdominissheath, suturing it to the inguinal ligament supported by an imbri-cation of the EOA.

10

Koontz, Calman, and Halsted (quoted byMadden) all describe further variants of inguinal floor repair uti-lizing the EOA.

11–13

A large body of literature suggests that theprinciples Dr Desarda proposes are not new.

Desarda’s follow-up results and current literature data

2–8

donot support a conclusion that using the EOA for inguinal floorreinforcement eliminates recurrence risk. Although this methodmight be an alternative in parts of the world where mesh isunavailable, it should not be seen as a front-line therapy in theWestern hemisphere.

REFERENCES

1. Desarda MP. New method of inguinal hernia repair: A new solu-tion.

ANZ J. Surg.

2001;

71

: 241–4.2. Lichtenstein I.

Hernia Repair Without Disability

, 2nd edn. StLouis, MO: Ishiyaku EuroAmerica, 1987.

3. Amid PK, Lichtenstein IL. Long-term result and current status ofthe Lichtenstein open tension-free hernioplasty.

Hernia

1998;

2

:89–94.

4. Leibl BJ, Daubler P, Schmedt CG, Kraft K, Bittner R. Long-termresults of a randomized clinical trial between laparoscopic herni-oplasty and Shouldice repair.

Br. J. Surg.

2000;

87

: 780–3.5. Amid PK, Shulman AG, Lichtenstein IL. Biomaterials for

abdominal wall hernia surgery and principles of their applica-tions.

Langenbecks Arch. Chir.

1994;

379

: 168–71.6. Shulman AG, Amid PK, Lichtenstein IL. Mesh between the

oblique muscles is simple and effective in open hernioplasty.

Am. Surg.

1995;

61

: 326–7.

LETTERS TO THE EDITOR 681

7. Klinge U, Zheng H, Si ZY, Bhardwaj R, Klosterhalfen B,Schumpelick V. Altered collagen synthesis in fascia transversalisof patients with inguinal hernia.

Hernia

1999;

4

: 181–7.8. Klinge U, Zheng H, Schumpelick V, Bhardwaj RS, Kloster-

halfen B. Abnormal collagen I to III distribution in the skin ofpatients with incisional hernia.

Eur. Surg. Res.

2000;

32

: 43–8.9. Iason AH.

Hernia.

Philadelphia, PA: Blackiston Co., 1941.10. Ravitch MM, Hitzrot II JM.

The Operations for Inguinal Hernia.

St Louis, MO: CV Mosby Co., 1960.11. Koontz AR.

Hernia.

New York, NY: Appleton-Century-Crofts,1963.

12. Calman CH.

Atlas of Hernia Repair.

St Louis, MO: CV MosbyCo., 1966.

13. Madden JL.

Abdominal Wall Hernias: An Atlas of Anatomy andRepair.

Philadelphia, PA: WB Saunders Co., 1989.

J

ULIAN

E. L

OSANOFF

, J

AMES

W. J

ONES

AND

B

RUCE

W. R

ICHMAN

Department of Surgery,University of Missouri–Columbia School of Medicine,

Columbia, Missouri, USA

Dear Editor,

LETTER TO THE EDITOR

New method of inguinal hernia repair: A new solution: Reply

I am thankful to Jones

et al

. for reading with interest my recentarticle.

1

I have gone through their comments carefully.Contrary to the comment made by Jones

et al.

, the spermaticcord is not preserved subcutaneously but goes behind the externaloblique aponeurosis (EOA).

1

I have made a mention in the Methods section of my articlethat ‘The author is aware that a 10-year follow up of 26.6% is notenough, but this is not a sufficient reason for ignoring the resultsof the present series. Publication of these data may encourageothers to conduct more trials to prove or disprove these results.’In spite of the best efforts, poor follow up is seen in all the under-developed countries because the cost and transportation act asdeterrents. But all the patients do come for examination to theoperating surgeon even after 10years of operation if there is anyproblem. This is because medical practice in India is more per-sonalized to doctors in the absence of health insurance schemes.As yet no such patients have come to me with recurrence or anyother complaint.

Shrinkage of mesh

in vivo

, as one of the causes of failure ofmesh repair, was recently reported by Lichtenstein, the originalauthor of the mesh repair, in 1997.

2

I have given evidence in my article that the chronic groinsepsis following mesh repair is more frequent than reported pre-viously.

3

An editorial in

Annals of Surgery

, January 2001, raised thequestion of whether the changed techniques of hernia repair inrecent years, mainly implanted mesh, have caused a rise in theincidence of chronic groin pain from 1% to 28.7% after herniarepairs.

Several authors have suggested that alterations in collagen syn-thesis may be responsible for the development of inguinal hernia-tion.

4,5

This is true in the hernia repairs such as the Bassini and theShouldice, which use weakened internal oblique and transverseabdominis muscles for repair. Supporters of mesh prosthesesclaim that the mesh repair is superior to other operations in this

aspect. The theory of mesh repair is based on fibroblast prolifera-tion in the mesh; the degree and magnitude of fibroblast prolifer-ation are also affected by the ageing process. This ageing processhas less effect on the tendons and aponeurosis so a strip of theexternal oblique, which is aponeurotic, is the best alternative tothe mesh. Pure tissue is preferred to a mesh for repair if it givesthe desired results.

The Johns Hopkins, Halsted or any other repairs referred to byJones

et al.

in their comments are in no way similar to my opera-tion. None of them have ever used the strip of EOA as describedin my article, and no operation described to date has ever used theconcept of giving additional muscle strength to the weakenedmuscles of the inguinal canal. The sutured strip of EOA, in myoperation, becomes an independent entity as the posterior wall ofthe inguinal canal. This posterior wall is strong because of thenature of the tissue and it is also kept physiologically dynamic bythe additional muscle strength of the strong external obliquemuscle. Interestingly, in many cases the internal oblique muscle,which did not show any movements when the patient was askedto cough while on the operating table before the strip of EOA wassutured behind the cord, showed improved or good movementsafter the strip was sutured. This may be because of the newanchorage received by the internal oblique muscle arch to theupper border of this strip. Providing a strong and physiologicallydynamic posterior inguinal wall should be the principle of anyinguinal hernia repair. This principle is observed in my operationtechnique and because of this it gives a recurrence rate of almostzero. Pure tissue repair and simplicity of operation are otherimportant features of this operation. The cost involved in pur-chasing and maintaining sophisticated equipment is avoided andthe expertise in hernia surgery required to carry out complicateddissection or handling of such equipment is also not required.

I am in agreement with Jones

et al.

that the preperitoneal orintermuscular prosthetic grafts give good results and are front-line therapy in the Western hemisphere. Twenty per cent of theworld population lives in the Western hemisphere. I am thankfulto Jones

et al.

and others for accepting my operation of inguinalhernia repair as an alternative to a mesh repair for the rest of theworld, which has the remaining 80% of the world population.

Nicholson, in his leading article on inguinal hernia repair in

British Journal of Surgery

(1999) states that:

With over 80000 groin hernia operations carried out in the UKalone each year, and a deepening crisis in surgical manpowerresulting from increased surgical subspecialization and greaterpublic and political demands for quality in surgical practice,inguinal hernia repair will remain for the foreseeable future a pro-cedure likely to be delegated to non-consultant staff. It is essentialtherefore that we design safe and simple pathways for managingthese patients.

[6]

I designed this safe and simple pathway of groin herniarepair, as expressed by Nicholson, not only for the underdevel-oped countries but also for the people of the UK or the Westernhemisphere.

REFERENCES

1. Desarda MP. New method of inguinal hernia repair: A new solu-tion.

ANZ J. Surg.

2001;

71

: 241–4.2. Amid PK, Lichtenstein IL. Lichtenstein open tension free

hernioplasty. In: Maddern GJ, Hiatt JR, Philips EH (eds)

682 LETTERS TO THE EDITOR

Hernia Repair (Open Vs Laparoscopic Approaches)

. Edinburgh:Churchill Livingston, 1997;117–22.

3. Taylor SG, O’Dwyer PJ. Chronic groin sepsis following tension-free inguinal hernioplasty.

Br. J. Surg.

1999;

86

: 562–5.4. Friedman DW, Boyd CD, Narton P

et al.

Increases in type IIIcollagen gene expression and protein synthesis in patients withinguinal hernias.

Ann. Surg.

1993;

218

: 754–60.5. Read RC. A review: The role of protease–antiprotease imbalance

in the pathogenesis of herniation and abdominal aortic aneurysmin certain smokers.

Postgrad. Gen. Surg.

1992;

4

: 161–5. 6. Nicholson S. Inguinal hernia repair.

Br. J. Surg.

1999;

86

: 577–8.

M

OHAN

P. D

ESARDA

Bharati Vidyapith Medical College,Poona Hospital and Research Centre, and Kamala Nehru General Hospital, India