Inguinal hernia is the most common type of abdominal wall hernia, accounting for nearly 75% of groin hernias and representing a major workload for general surgeons worldwide [1]. The lifetime risk of developing an inguinal hernia is estimated at 27% in men and 3% in women [2]. Despite its frequency, the exact incidence and prevalence remain imprecisely defined due to regional variability and underreporting [3]. The success of surgical repair depends on adequate closure of the hernia defect and reinforcement of the posterior wall to minimize recurrence and postoperative complications [4]. Over time, numerous surgical techniques have been developed, including tissue-based methods such as Bassini, Shouldice, McVay, and nylon darn, as well as mesh-based techniques like the Lichtenstein repair [5]. Currently, Lichtenstein’s tension-free mesh hernioplasty remains the most widely practiced and evaluated procedure due to its low recurrence rates and standardized approach [6]. However, the use of prosthetic mesh is not without limitations. Complications such as chronic groin pain, foreign body sensation, mesh infection, rejection, and, rarely, migration have been reported [7]. In particular, in contaminated fields or complicated hernias (obstructed, strangulated), mesh placement is often contraindicated. To address these challenges, Mohan P. Desarda in 2001 described a novel, tissue-based, tension-free repair that utilizes a strip of the external oblique aponeurosis (EOA) to reinforce the posterior wall of the inguinal canal [8]. This “dynamic repair” avoids foreign material, has a shorter learning curve, and is cost-effective—making it especially suitable for resource-limited settings [9]. Desarda’s technique has shown promising outcomes in terms of reduced postoperative pain, early ambulation, and negligible recurrence rates in both short- and long-term studies [10]. Given these potential advantages, this study evaluates the outcomes of Desarda’s repair for complicated inguinal hernias where mesh repair is not feasible or contraindicated.

Study Design and Setting This was a prospective observational study conducted in the Department of General Surgery, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India. The study period extended from March 2021 to June 2022, and included consecutive patients presenting with complicated inguinal hernias or those in whom mesh repair was contraindicated. Study Population A total of 32 patients were screened for eligibility. Of these, one was excluded intraoperatively due to a weak external oblique aponeurosis, and one patient was lost to follow-up due to death. Thus, 30 patients were finally included and analyzed. Inclusion Criteria • Patients aged >18 years diagnosed with inguinal hernia. • Patients with comorbid conditions such as immunocompromised states, malignancy, long-term steroid use, or those on chemotherapy. • Patients with complicated hernias (obstructed, strangulated, or irreducible) where mesh repair was contraindicated. Exclusion Criteria • Patients unfit for surgery. • Patients who refused consent. • Patients with recurrent hernia. • Patients with thin, weak, or divided external oblique aponeurosis, as identified intraoperatively. Ethical Considerations The study protocol was approved by the Institutional Thesis Protocol Approval Committee (TPAC No. 617) and the Institutional Ethics Committee (IEC No. 1148) of SVIMS, Tirupati. Written informed consent was obtained from all participants prior to inclusion. Surgical Technique All patients underwent Desarda’s repair under aseptic precautions and appropriate anesthesia. A standard oblique groin incision was made to expose the external oblique aponeurosis (EOA). The superior leaf of the EOA was sutured to the inguinal ligament using monofilament absorbable sutures. A strip of the EOA (1.5–2 cm wide) was created and sutured to the internal oblique muscle, thereby reinforcing the posterior wall of the inguinal canal. The spermatic cord was medialized, and the lower leaf of the EOA was approximated to complete the repair. Data Collection Demographic details (age, sex, occupation, residence), clinical presentation, comorbidities, and hernia characteristics were recorded. Perioperative findings, operative time, and postoperative course were documented in structured case proformas. Outcome Measures The primary outcomes assessed were: • Postoperative pain scores: measured using the Visual Analogue Scale (VAS) on postoperative day (POD) 1, 3, 7, 30, and 90. • Return to normal activity: time taken to resume non-strenuous daily activities. • Postoperative complications: including wound infection, seroma, hematoma, orchitis, and recurrence. Secondary outcomes included operative duration and length of hospital stay. Statistical Analysis Data were entered in Microsoft Excel (Microsoft Corp, Redmond, WA) and analyzed using SPSS Statistics Version 26 (IBM Corp, Somers, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) and categorical variables as frequencies and percentages. The normality of quantitative data was tested, and comparisons were made using appropriate statistical tests. A p-value <0.05 was considered statistically significant.

Demographic and Clinical Profile The study included 30 male patients with a mean age of 55.2 ± 16.2 years (range: 18–82 years). Nearly half of the patients (48.3%) were between 41 and 60 years, followed by 38.7% who were above 60 years, and only 12.9% were younger than 40 years. Right-sided inguinal hernia was predominant (66.6%), while the remaining 33.3% had left-sided hernia; no bilateral cases were recorded (Table 1, Figure 1). Operative and Hospitalization Details The mean operative duration was 96.3 ± 22.5 minutes, ranging from 60 to 140 minutes. Surgeries requiring additional dissection in complicated hernias accounted for the longer duration. The average hospital stay was 4.5 ± 3.2 days, with the majority of patients (60%) discharged within three days, while 40% required prolonged hospitalization due to postoperative complications (Table 2). Postoperative Pain Pain intensity showed a progressive decline over time. The mean VAS score was 4.8 on POD 1, dropping to 1.5 on POD 3 and 0.3 on POD 7. By POD 30 and POD 90, all patients reported no pain. Notably, 23.3% were pain-free by POD 3, and 70% by POD 7, with complete resolution in all by one month (Table 3, Figure 2). This decline in pain was statistically significant (p < 0.001). Postoperative Complications Overall, 23.3% of patients experienced complications, all of which were minor and managed conservatively. Seroma formation was the most common (13.3%), followed by wound infection (6.6%) and hematoma (3.3%). Importantly, there were no recurrences, mesh-related complications, or chronic pain during the follow-up period (Table 3, Figure 3). Return to Normal Activity Most patients resumed routine non-strenuous activities within two weeks of surgery. Specifically, 33.3% returned within 7 days, 60% between 8–15 days, and only 6.6% required more than 15 days (Table 3). This reflects the early recovery advantage of Desarda’s repair technique. Nearly half of the patients (43.3%) did not have comorbid illnesses. Among those affected, diabetes (20%) and hypertension (16.6%) were the most common, followed by chronic respiratory and renal conditions. This reflects the typical comorbidity profile of elderly patients with hernia. Table 4 A majority of patients (60%) resumed routine activities between 8 and 15 days after surgery, while 33.3% could return within a week. Only 6.6% required more than two weeks, usually due to postoperative complications. This finding supports the early recovery profile associated with Desarda’s repair. Table 5 Table 1. Demographic and Clinical Characteristics of the Study Population (N=30) Variable Category Frequency (n) Percentage (%) Age (years) 18–40 4 12.9 41–60 15 48.3 >60 12 38.7 Sex Male 30 100 Female 0 0 Hernia Location Right-sided 20 66.6 Left-sided 10 33.3 Bilateral 0 0 Table 2. Operative Parameters and Hospital Stay Variable Mean ± SD Range Distribution (%) Operative time (minutes) 96.3 ± 22.5 60–140 – Hospital stay (days) 4.5 ± 3.2 2–20 <3 days: 60% >3 days: 40% Table 3. Postoperative Pain and Complications Outcome Finding Mean VAS score POD 1: 4.8 POD 3: 1.5 POD 7: 0.3 POD 30 & 90: 0 Pain-free patients (%) POD 3: 23.3% POD 7: 70% POD 30–90: 100% Complications (n=30) Seroma: 4 (13.3%) Wound infection: 2 (6.6%) Hematoma: 1 (3.3%) Recurrence: 0 Return to activity ≤7 days: 33.3% 8–15 days: 60% >15 days: 6.6% Table 4. Baseline Comorbidities in Study Population (N=30) Comorbidity Frequency (n) Percentage (%) Diabetes mellitus 6 20.0 Hypertension 5 16.6 Chronic obstructive airway disease (COAD) 3 10.0 Chronic kidney disease 1 3.3 Immunocompromised (e.g., malignancy, steroid use, chemotherapy) 2 6.6 No comorbidity 13 43.3 Table 5. Return to Normal Activity After Surgery Time to Return to Activity Number of Patients (n) Percentage (%) ≤ 7 days 10 33.3 8–15 days 18 60.0 > 15 days 2 6.6

Inguinal hernia repair continues to be one of the most commonly performed general surgical procedures worldwide, with millions of operations carried out annually [11]. The principle objective of hernia surgery is to provide a durable repair with minimal postoperative complications, rapid return to normal activity, and reduced recurrence rates. In the present study, Desarda’s tissue-based technique demonstrated favorable outcomes in terms of operative feasibility, postoperative pain reduction, early recovery, and negligible recurrence during the follow-up period. Demographic Characteristics The study population was exclusively male, with a mean age of 55 years, aligning with global data that show a higher incidence of inguinal hernia in men compared to women [12]. Most patients were in the 41–60-year age group, similar to observations in large epidemiological series where hernias peak in middle-aged and elderly males [13]. Right-sided hernia predominated, which is consistent with previously published studies attributing this to delayed testicular descent and anatomical differences on the right side [14]. Operative Parameters and Hospital Stay The average operative time in this study was approximately 96 minutes, which is longer compared to standard mesh hernioplasty but acceptable given that most cases were complicated hernias. Similar results were reported by Gedam et al., who observed a mean operative time of 90 minutes for Desarda’s technique in complicated cases [15]. The mean hospital stay in our series was 4.5 days, with 60% of patients discharged within 3 days. This is comparable with reports from Desarda and colleagues, who documented short hospital stays and early mobilization in their trials [16]. Postoperative Pain One of the most notable findings was the significant reduction in pain scores over the first postoperative week, with no patient reporting pain by POD 30. Chronic groin pain, a well-recognized complication of mesh repair due to foreign body reaction and nerve entrapment, was absent in our series. These results are consistent with randomized controlled trials by Szopinski et al., which demonstrated that Desarda’s repair was associated with significantly less chronic pain than Lichtenstein mesh repair [17]. This advantage makes Desarda’s technique particularly suitable in younger, active patients and in regions where mesh availability or affordability is limited. Postoperative Complications The overall complication rate was 23.3%, mostly minor (seroma, wound infection, and hematoma), all of which were managed conservatively. Importantly, no recurrences were recorded during the short-term follow-up. The absence of recurrence in our cohort supports previous findings by Desarda and others, who reported recurrence rates as low as 0–1% at long-term follow-up [18]. By avoiding the use of synthetic mesh, the risk of mesh infection, rejection, and migration is also eliminated. This is particularly beneficial in contaminated or complicated hernias, where mesh placement may be contraindicated. Return to Normal Activity Early ambulation and return to routine activities are critical determinants of surgical success, especially in working-age populations. In this study, 93% of patients resumed normal activities within 15 days, which is similar to outcomes reported in Indian and international trials comparing Desarda with Lichtenstein repair [15,19]. The shorter rehabilitation period reflects the dynamic support provided by the external oblique aponeurotic strip, which acts as a physiologic posterior wall, reducing strain and enabling early mobilization. Comparative Advantages of Desarda’s Repair Mesh repair, while globally accepted as the standard of care, carries long-term risks such as chronic groin pain, foreign body sensation, and higher costs [16]. Desarda’s technique addresses these concerns by offering a cost-effective, tension-free, and biological repair. Furthermore, it does not require specialized prosthetic material, making it ideal for low-resource settings [20]. The procedure is also relatively simple to learn and reproducible, contributing to its growing acceptance. Limitations The limitations of this study include the relatively small sample size and short duration of follow-up. Larger multicentric randomized controlled trials with long-term outcomes are necessary to validate these findings. Additionally, direct head-to-head comparisons with other tissue-based techniques, such as Shouldice repair, were not performed in this study. Clinical Implications Despite its limitations, the present study highlights the utility of Desarda’s repair as a safe and effective alternative in complicated inguinal hernias where mesh use is contraindicated. The absence of recurrence, minimal postoperative pain, and early return to activity observed in this study reinforce its role in both resource-limited and specialized surgical practices.

Desarda’s tissue-based repair offers a safe, effective, and biologically sound alternative to mesh hernioplasty in the management of inguinal hernias, particularly in complicated cases where prosthetic mesh use is contraindicated. In this study, the technique was associated with minimal postoperative pain, early return to daily activities, and an absence of recurrence during short-term follow-up. The dynamic support provided by the external oblique aponeurotic strip allowed for reinforcement of the posterior wall without tension or foreign material, thereby reducing the risks of chronic groin pain and mesh-related complications. Additionally, the procedure demonstrated cost-effectiveness and ease of reproducibility, making it suitable for both resource-limited settings and general surgical practice. While larger randomized controlled trials with long-term outcomes are warranted, the present findings reaffirm Desarda’s repair as a valuable addition to the surgical armamentarium for inguinal hernia management.

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