Reply To: Researching surgeons – what questions to ask

Hernia Discussion Forums Hernia Discussion Researching surgeons – what questions to ask Reply To: Researching surgeons – what questions to ask

quote Jnomesh:

Thanks dr. Kang for your follow up. I have a few more questions regarding the pure tisuue repairs
for indirect and direct hernias.
1) do you know if the shouldice repair for either a direct or a indirect hernia covers both spaces? In other words if you have an indirect hernia will the shouldice repair also reinforce the direct space?

2) the reason I ask is Bc I have had my laparoscopic mesh removed by the Same method.
when mesh was originally put in it was noted that I had both a direct and indirect hernia. However, when the mesh was removed there were no hernias noted by the removal surgeon. The direct hernia was completely filled in by scar tissue and there was weakeness in the indirect space that the surgeon repaired by bringing the internal oblique muscle down to the illiopubic tract and sutured with absorbable sutures. I’m curious if only one hernia should reoccur in the future is there a pure tissue repair that can reinforce both areas even if only one hernia reoccurs. I guess my question is since I had Both types of hernias (and don’t want mesh again) if i should have say a indirect hernia that reoccurs I’d hate to Just have a pure tissue repair of the indirect space knowing I’m susceptible to having a direct hernia and might need a second repair down the line-I’d definitely prefer if possible a pure tissue repair that can not only repair one hernia but in essence also reinforce the other space as well.
just curios if that is possible. How would you handle a patient like me?
thanks in advance -looking forward to your input.

Hi Jnomesh,

Shouldice mainly covers direct area.
They also do Shouldice for indirect inguinal hernia, but I don’t think it’s appropriate.
And I don’t perform Shouldice at all.
I do Marcy-like procedure for indirect hernia, and it doesn’t cover direct space.
I don’t think there is any tissue repair that could cover both direct and indirect space exactly at the same time, although they say most posterior wall repair, including Bassini, Shouldice or Desarda and so on, can cover both space.
They are basically designed for direct hernia.
If you have an indirect hernia in the future and you want to cover the direct space too, both space can be fixed seperately by the appropriate tissue repair method respectively.
I don’t think the preventive herniorrhaphy is necessary, but it’s not impossible.

Laparoscopic mesh repair may cover all areas of indirect, direct and femoral hernias.
But it seems to me that this is due to a technical limit of laparoscopic mesh hernia repair rather than for patient’s sake.
If you cover only the indirect or direct hernia area with a smaller mesh, it may not be secure enough to prevent recurrence of original hernia.

For this reason, laparoscopic mesh must be big enough to cover all inguinal area.
It means that the main goal of using a large mesh is not to prevent all groin hernias, but to prevent original hernia recurrence.
Though it’s not bad, if it works.

But everything needs to be paid back.
That is, there is a possibility of an additional side effect by using a larger mesh.

So surgery should be minimized. It’s one of the surgical principle.
If you have indirect inguinal hernia, only indirect hernia repair is enough and safer.
There is no need to worry about the possibility of future direct or femoral hernia, which occurs less likely.
I don’t think that more than 99% of patients should undergo over-extended surgery against less than 1% probability of another new hernia.
If it is necessary to do something against a chance of less than 1%, why not against metachronous opposite hernia with a probability of more than 10%? Why not always do hernia repairs in both sides for every hernia patient?

If you have a flat tire, should all other three tires be replaced in order to prevent the future possibility?
If you are rich enough, it may not be bad.
But I definitely won’t.

Moreover, larger surgeries increase the likelihood of complications at the same time.
Therefore, it is not reasonable to take measures in advance against that very low possibility while taking such risks. So, I think it would be better to repair only indirect if indirect, only direct if direct, and only femoral if femoral hernia you have. I do not think the preventive herniorrhaphy is necessary at all.

Therefore, I think the posterior wall repair, such as Shouldice. Desarda, or Bassini, which is said to cover direct and indirect, could be an excessive operation.
Laparoscopic mesh repair covering indirect, direct and femoral areas might be the most aggressive surgery.

Indirect inguinal hernia is also generally being treated with posterior wall tissue repair such as Shouldice or Desarda.
But it’s like wearing a left glove in your right hand.
It is better than nothing on a cold day, but it is not perfect.
It is normal to wear the right glove on the right hand and the left glove on the left hand.
Similarly, if you do tissue repair, direct inguinal hernia should be operated with one of posterior wall repair which reinforces the floor of Hasselbach triangle where direct hernia occurs, and indirect inguinal hernia should be done with appropriate Marcy-like operation which only closes internal inguinal ring through which indirect sac herniates.

In case of combined direct and indirect hernia, I repair the floor of Hasselbach triangle and the internal inguinal ring seperately at the same time.


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