Moloney Darn Non Mesh repair method

[drkang]

Hello, all!

I would like to address a more fundamental issue.
Inguinal hernia repair before mesh repair, represented by Modified Bassini repair, had a very high recurrence rate of 10-30%. Hernia surgeons attributed this high recurrence rate to high tension after repair.
Therefore, efforts to lower the recurrence rate have naturally led to efforts to develop surgical methods that lower tension.
Darn repair, mesh repairs that are currently mainstream, and even the Desarda technique, a non-mesh repair introduced around 2000, were all developed to lower the tension.

However, Shouldice repair works as an obstacle to this logic. Shouldice repair is a surgical method that is very similar to the original Bassini repair, so some doctors call it Bassini-Shouldice repair. It reports a relatively low recurrence rate of around 2%, even though it generates high tension after repair. 2% recurrence rate is not higher than that of mesh repairs.

If so, could the underlying cause of recurrence be something other than high tension?
I personally believe that the very high recurrence rate of modified Bassini repair was not due to high tension but due to technical defects.
It can be seen from the fact that Shouldice repair, which is being carried out in a very careful and meticulous manner, has a relatively low recurrence rate despite generating high tension.

But I want to go one step further here.
In order to achieve a low recurrence rate, Shouldice repair has a fairly large incision wound and a wide surgical range and is a 3-layer repair using a steel thread. There are also claims that many centers do not achieve the grades reported by Shouldice Hospital.

I want to find the reason in the one-for-all surgical method.
In other words, the operation is performed in the same way without distinguishing between the two subtypes of inguinal hernia, indirect type and direct type, so that it is not the optimal operation for each subtype.

In summary, the high recurrence rate of tissue repairs in the past is thought to be due to the fact that the specialized surgical method for each of the two subtypes of inguinal hernia was not performed, and the technical defect in not accurately suturing healthy muscles and ligaments during suturing. Tension, I think, is only a secondary consideration.
I am convinced that this idea is correct through more than 11.000 non-mesh repair surgeries that applied this idea.
This type-specific repair has a very small surgical wound and surgical range, the operation time is very short, around 15 minutes, and is sufficiently possible with local anesthesia. Although the surgical method is still being improved, the recurrence rate so far is about 0.8%

And, most importantly, it can eliminate the need to continue to perform mesh repair designed to lower the tension.

[Wim]

Recurrence rate is a word used but never we read how the recurrence occured. I guess once you are operated you check regurlarly if there is one or not. Theer is probably a lot one can do once repaired to avoid recurrence.

[Alephy]

@drtowfigh The definition of success is what I have been wondering about (in fact many others have as well) i.e. does this include follow up for potential problems? Since joining in this forum I am inclined to say that most of the times it does not…I guess this is the question for many who consider hernia surgery i.e. whether they can follow the data or not, or the average medical advice; naively I would personally say no:(

[drtowfigh]

My recommendation typically is to follow the data. Data supporting success of the Shouldice and Lichtenstein repairs far outweigh case reports of other techniques.

[Jack2021]

This study from Turkey in 2008 (including suture images) shows excellent results from a Comparison of Modified Darn Repair and Lichtenstein Repair of Primary Inguinal Hernias, with no recurrences in the darn group over an average follow up time of 56 months, vs 0.6% recurrences in the Lichtenstein group. Post-op complications were 1.9% (darn group) vs 11.7% (mesh group).

What isn’t clear unfortunately, is what the modification is to the darn repair:

https://www.sciencedirect.com/science/article/abs/pii/S0022480407004313?casa_token=3xeOqa-plrgAAAAA:w8tRJejpmV48pZtfvBkdlIcArO2LpVrfS7th3xZ0v-6b7oIDWNcGH3QlH5rN651omlzhchk

[Jack2021]

Many thanks for your reply @drtowfigh, I very much appreciate it.

From the Moloney Darn reports and meta-studies I’ve read, as you say, the majority of more recent studies do tend to be in developing countries, but they do appear to evidence very low recurrence rates and chronic pain rates that are at least on a par with the Shouldice and Lichtenstein repairs.

My understanding from the Moloney Darn repair is that the method specifically aims to minimise tension by not fully tightening the sutures, though it obviously does involve multiple suture points.

I’m finding it very difficult to decide whether to go with ‘watchful waiting’, a Moloney Darn repair in the UK or a Shouldice or Desarda repair in Germany. I appear to be eligible for each option currently according to consultants, as I have a low BMI and am in good shape otherwise. If I went for a non-mesh surgery and each option is available to me, would you recommend one option over the others @drtowfigh and if so, why?

Any thoughts and suggestions from other members would be much appreciated also.

Thanks in advance,

?Jack

[drtowfigh]

The Maloney Darn repair in many ways inspired current mesh repair for inguinal hernias. It’s concept is very very old. They used to use silver filigree initially. It is basically many small back and forth sutures, effectively making a mesh in the body. The downside is there are multiple multiple suture points, plus tension, which may lead to chronic pain and tearing through tissues. It is only done in 3rd world countries who can’t afford mesh. The mesh is basically the darning without the sutures through the tissues, so less tension, less chronic pain.

[Jack2021]

Thanks for your reply Good intentions, it’s a very valid point with big businesses so involved in medical supplies and pharmaceuticals.

Re the Moloney darn and other variants of the darn repair technique, they’re clearly more cost effective than a mesh repair, as long as the recurrence rates are pretty equal. If they are as effective or more so than mesh repairs and also carry less risks than those associated with mesh repairs, then surely some reflection by the health care sector is required here.

As we know, the non-mesh techniques which seem to be most effective still leave permanent sutures behind, so there doesn’t appear to be a long term effective repair which leaves no form of foreign body in the patient. Leading on from this, I read a paper by G.E. Moloney from 1961, which came up among the links from the link you kindly posted for me Good intentions, in which Moloney talks about his findings that nylon suture tensile strength reduces significantly after a short period of time (along with its colour and sheen as well!) after being used for hernia repairs. It’s an interesting and concerning article, but I would hope that this has been addressed by now, as it would surely play a big factor in hernia recurrences over time if sutures eventually break under minimal pressure? https://bjssjournals.onlinelibrary.wiley.com/doi/abs/10.1002/bjs.18004821114

It would be great to hear the thoughts of @drtowfigh, @drbrown, @drkang and any of the other doctors/consultants who are members of this forum, regarding suture strength over time and about the Moloney Darn technique, re whether they know or believe it to be an effective method to repair hernias vs the Shouldice, Desarda and Kang techniques.

Many thanks,

Jack

[Good intentions]

There are powerful financial forces supporting the use of mesh. A good open objective honest debate would probably leave most surgeons wondering why they continue to use mesh. The facts of long-term patient welfare don’t support the breadth of its use across the medical profession. Only financial reasons support it.

• This reply was modified 2 years, 10 months ago by  Good intentions.

[Jack2021]

Hi Good intentions,

Thanks so much for your reply, much appreciated. I looked on the Cochrane library and found very little.

From your link, assuming that Open Darn Repair and Moloney darn repair are the same technique(???), the meta-analysis from this link (https://link.springer.com/article/10.1007%2Fs10029-019-01892-1) titled ‘Open darn repair vs open mesh repair of inguinal hernia: a systematic review and meta-analysis of randomised and non-randomised studies’ which appears to be based on over 3,000 patients concludes: ‘Our results suggest that open darn repair is comparable with open mesh repair for inguinal hernias. Considering that consequences of mesh complications in inguinal hernia repair, albeit rare, can be significant, open darn repair provides an equally credible alternative to open mesh repair for inguinal hernias. Further studies are required to investigate patient-reported outcomes and to elicit a superior non-mesh technique.’

A link to a Lancet article in 1958 (https://www.sciencedirect.com/science/article/abs/pii/S0140673658910274) states that ‘A personal series of 253 inguinal hernias repaired with
a nylon darn and surveyed more than 5 years after the last operation, with a 76% follow-up, revealed 2 recur-
rences (0.8%).’

I haven’t accessed the full article, as have to pay $35 for it, but this sounds promising!

If it was so effective though, I wonder why it seems to have almost entirely disappeared as a regular option for hernia repair, especially as it would appear to be the most cost effective too.

It would be great to have some insight from the esteemed doctors/consultants/surgeons who frequent this forum, to hear your thoughts and knowledge around this please.

Many thanks,
?Jack?

[Good intentions]

Here is a link to Google Scholar, a source for scientific publications.

I saw one that suggested it was used in undeveloped countries because it is cheaper than mesh. There are efforts to get mesh in to the underdeveloped countries though, so the methods might die away as other suture-based methods have.

https://scholar.google.com/scholar?hl=en&as_sdt=0%2C48&q=Moloney+Darn&btnG=