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Bilateral Inguinal Hernia – Direct or Indirect? VIDEO
43 year-old male with bilateral inguinal hernia. Starting the journey! Trying to determine if this is direct or indirect hernias? I’m looking to have a pure tissue repair.
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This discussion was modified 4 years, 6 months ago by
Mark.
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This discussion was modified 4 years, 6 months ago by
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8 Replies
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I agree with Alephy. It is a theme we have been trying to promote throughout HerniaTalk. There is no one best hernia repair. Or one best hernia surgeon. Everyone has different needs. For example, what would your answer be if you asked someone what car you should buy? Everyone’s needs are different. And every surgeon’s specialty and skill is different.
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Personally I would just go to a doctor that will tailor the surgery to you, even before considering the ultrasound.
At the end of the day, unless you opt out for watchful waiting (this is me at the moment) the surgeon will go in and (unless it is a mesh surgery) he or she should be able to adapt to what is type of hernia is there (I am just reporting what Dr. Brown at one point said, which resonates to me making perfect sense)…my two cents -
Tissue repairs are best for Indirect inguinal hernias. Not as good for directs. But most surgeons would not image an inguinal hernia obvious on examination.
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Physical exam is not perfect for determining direct vs indirect for small inguinal hernias. Imaging can help confirm. In larger hernias, the indirect inguinal hernia will fall into the scrotum area.
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Dear Mark.
Probably indirect hernias on both sides.
Bill Brown MD -
I agree with your comment that pure tissue repairs are best for indirect hernias. But which ones do you suggest so I can read on them?
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Its confusing if they see the hernia on physical examination and don’t want imaging to distinguish between an indirect and direct hernia because there the pure tissue repair options are different based on if you have an indirect vs direct hernia. For instance dr brown, dr kang, dr Szotek are fans if using a marcy repair on a mid to small sized indirect inguinal hernia and going with a shouldice repair for instance with an indirect is “overkill” as you don’t need to reconstruct the floor or tissues that are already healthy. However, shouldice and other non-marcy types are more for direct hernias and not for indirect. I also understand incision size and location is optimal based on what repair type the surgeon plans to use which is important in knowing if it is likely indirect or direct. And last, some surgeons only offer certain types of pure tissue repairs. Dr Brown is the exception there. But for example Dr grischkan offers only 2 layer shouldice, dr yunis only offers shouldice and desarda, most do not offer an indirect repair like the marcy as I believe only Dr brown does. So if a surgeon only does shouldice 4 layer, shouldice 2 layer, desarda, ect… Which are not type specific for an indirect hernia then I’d probably not go there to begin with knowing I had an indirect hernia. My thought process was..confirm if these are indirect vs direct with the highest possible accuracy. If indirect seek treatment with dr brown or someone who can perform a marcy and be “tailored” incase something else is needed like reinforcement in addition to the marcy. If direct hernias then go straight to the shouldice hospital. Thoughts, am I missing something? I reached out to dr. Pauli after watching the recent herniatalk because it sounded like he is the very best at imaging and diagnosing if this is indirect versus direct. Dr pauli said any doctor including a pcp could all perform the inguinal ultrasound because they are easy which conflicts what you and he discussed on the episode…that ultrasounds are great if they are administers in the right hands. I am willing to go anywhere for a physical exam and imaging to accurately confirm if these are indirect, direct and to what degree. My left side is so small and never goes in or out..it always stays out which thinks it will be hard to confirm if this is a hernia or what type. And doctors you feel are great at diagnosis and imaging please advise.
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Thank you docs for the replies! Is it even important or is there even a need a test to help verify if I have a direct or indirect hernia? I ask this because I gather a general consensus that most surgeons do the repair the same way? Meaning of if I was to have a pure tissue shouldice or similar repair…essentially they will cut you open and visually verify what they are dealing with then proceed to repair with that shouldice say for example. So if it were direct or indirect, they are still essentially doing the similar repair. So why incur the added cost and time associated with diagnostics when they are not very reliable and it don’t seem to matter (from a patient novice perspective)?
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