What is the Desarda repair technique and its indications for an adult patient with a primary inguinal hernia?

Desarda Repair for Primary Inguinal Hernia

What is the Desarda Technique?

The Desarda repair is a tissue-based (non-mesh) inguinal hernia repair technique that uses an undetached strip of the external oblique aponeurosis to reinforce the posterior wall of the inguinal canal. 1 This method was introduced in 2001 as an alternative to mesh-based repairs, specifically designed to avoid foreign material implantation while maintaining structural integrity. 2

Technical Description

• The technique involves creating a strip from the external oblique aponeurosis that remains attached laterally, which is then sutured to the inguinal ligament and conjoint tendon to reinforce the posterior wall of the inguinal canal. 1
• The procedure does not require mesh implantation, making it a pure tissue-based repair method. 2
• Operative time is comparable to Lichtenstein mesh repair (approximately 72-74 minutes), with no significant difference between techniques. 2

Clinical Indications for Adult Primary Inguinal Hernia

Desarda repair should be considered as a viable alternative to mesh-based repair specifically when a tissue-based technique is preferred or required. 3 The following clinical scenarios favor this approach:

Primary Indications:

• Young, active patients where avoiding foreign body implantation is desirable, as the technique demonstrates excellent outcomes without mesh-related complications. 4
• Patients with concerns about mesh-related complications including chronic foreign body sensation, mesh migration, or mesh-related chronic pain. 1
• Resource-limited settings where mesh availability or cost is prohibitive, as Desarda repair eliminates mesh expense without compromising outcomes. 5
• Patients with intact, healthy external oblique aponeurosis suitable for creating the reinforcing strip. 5

Relative Contraindications:

• Patients with thin, weak, or divided external oblique aponeurosis discovered intraoperatively require alternative techniques, as the integrity of this structure is essential for Desarda repair. 5
• Emergency settings with strangulated hernias or bowel compromise where mesh repair remains the standard approach according to current guidelines. 6

Clinical Outcomes Compared to Standard Mesh Repair

Recurrence Rates:

• Recurrence rates are equivalent to Lichtenstein mesh repair at 1-3 year follow-up, with approximately 1-2% recurrence in both techniques. 2, 1, 5
• This challenges the traditional assumption that only mesh repairs provide adequate long-term durability. 1

Pain and Recovery:

• Postoperative pain is significantly lower in the first 7 days following Desarda repair compared to Lichtenstein (P = 0.09). 2
• Return to normal gait and daily activities occurs significantly faster with Desarda repair (approximately 6-7 days earlier). 3, 5
• Chronic pain rates are comparable between techniques (4.8% vs 2.9%, P = 0.464), with no significant difference. 1

Complications:

• Seroma formation is significantly less common with Desarda repair compared to mesh-based techniques (P = 0.004). 1
• Foreign body sensation is eliminated with Desarda repair since no mesh is implanted. 1, 5
• Overall complication rates including infection, hematoma, and hydrocele are similar between techniques. 2, 3

Quality of Life:

• Quality of life at 12 months postoperatively is equivalent to laparoscopic TAPP repair and significantly higher than reference populations. 4
• Patients demonstrate excellent functional outcomes without mesh-related concerns. 4

Comparison to Other Tissue-Based Techniques

Desarda repair demonstrates superior operative efficiency compared to Shouldice technique, requiring 12.9 minutes less operative time (95% CI: -20.6 to -5.2) and 6.6 days faster recovery (95% CI: -11.7 to -1.4). 3 Recurrence rates, chronic pain, and complication profiles are equivalent between these tissue-based methods. 3

Critical Limitations and Caveats

• The technique requires intact external oblique aponeurosis for creating the reinforcing strip; intraoperative findings of weak or divided fascia necessitate alternative repair methods. 5
• Current guidelines still recommend mesh repair as the standard approach for primary inguinal hernias due to lower recurrence rates in large-scale studies, though Desarda shows comparable results in selected populations. 7, 8
• Long-term data beyond 3 years remains limited, whereas mesh repairs have decades of follow-up data supporting their durability. 1
• The technique is not appropriate for emergency/complicated hernias where guidelines recommend mesh repair in clean fields or biological mesh in contaminated fields. 6

Practical Application Algorithm

For adult patients with primary, uncomplicated inguinal hernia:

1. Assess patient preference regarding mesh vs. tissue-based repair after discussing risks/benefits of both approaches. 2, 5

2. If tissue-based repair is chosen, Desarda should be considered the preferred technique over Shouldice due to shorter operative time and faster recovery. 3

3. Intraoperatively verify the external oblique aponeurosis is healthy and suitable for creating the reinforcing strip. 5

4. If aponeurosis is inadequate, convert to mesh-based repair (Lichtenstein or laparoscopic approach) as per standard guidelines. 7, 8, 5

5. For bilateral hernias, recurrent hernias, or patient preference for minimal invasiveness, laparoscopic mesh repair (TAPP/TEP) remains the guideline-recommended approach. 7, 8