Reply To: Chronic pain
There are no safe options – chronic pain is a risk with all approaches, and there are other risks as well. You basically have to pick your poison and take your chances if you really need to have surgery done. There are a lot of nerves, and a lot of sensitive tissues and structures in the groin area.
If your case is a good fit for tissue repair, then I think that’s a better bet overall than mesh. Not all cases are a good fit, though, and it’s not necessarily easy to tell in advance.
I don’t know how one should pick among Shouldice, Desarda, and Kang. I think the choice would really depend on the details of your case and anatomy, but there isn’t a way for a patient to get an answer for this. Among these techniques, I think Shouldice is a good fit for the largest variety of cases, but it’s likely “overkill” in some cases.
I don’t think chronic pain is as widespread with Shouldice as you think, at least not severe chronic pain. That wouldn’t be consistent with what I observed while I was at the Shouldice Hospital. Some people were doing the “Shouldice shuffle”, but they were not in severe pain which would require sitting down or lying in bed. Many were walking, exercising, etc. like nothing happened. I wouldn’t have been able to tell that my roommate had surgery. It seemed to have no impact on him whatsoever, and he was in his late 60s. No one left on a wheelchair or with crutches. I don’t think these people that didn’t have severe pain after surgery will develop severe chronic pain. Unlike the case with mesh where the chronic pain issues may hit you later on, I think with tissue repair this starts shortly after surgery. If nothing really bad shows up in the first couple of days after surgery, you’re likely to be fine, although it’s not certain, of course.
Chronic pain, including debilitating chronic pain, definitely happens with this procedure, but it’s not some common thing like you mentioned (not 26%), at least not at the Shouldice Hospital. It’s still a serious problem, though. Even if it’s just very few percent, it’s still too much.
What’s the alternative, though? Mesh (including lap TEP) has chronic pain issues as well. Desarda and Kang are also open repairs, so the increased potential for nerve and tissue injury is still there. There’s less dissection and stitching with Kang than Shouldice, and the incision is smaller (at least if you have only direct or indirect rather than both). However, I don’t know the impact of the extra tension on pain. The benefit you get with Shouldice for all that extra dissection and stitching is that the load and tension are distributed over four layers. Does this mean more pain, or less pain, more recurrence, or less recurrence – who knows really. It is the most studied tissue repair technique, and it has the longest track record, and that should maybe count for something as well.
I think Desarda is actually the most innovative and interesting tissue repair technique of recent times. However, I really don’t know how to assess it.