Decisional process does this make sense?

[MeshorNot]

I think a good algorithm for making a hernia surgery decision is this:

1. Pursue treatment immediately after discovering the hernia. In the US visit Dr. Twofigh or Dr. Yunis to ensure that your hernia can be treated with a tissue repair. Mesh should be avoided at all costs unless needed.

2. If a tissue repair is acceptable -pursue it immediately -watchful waiting may be appropriate but I think you have to pull the trigger quickly. If you don’t you may get stuck with a mesh repair. Every surgeon I talked to said fix it sooner than later.

3. choice of Tissue repairs -Kang, Shouldice, Desarda — Kang repair falls out because its too new…and because numerous prominent surgeons – Towfigh Lorenz Koch question its durability.

4. That leaves Desarda and Shouldice. Desarda sounds better –shorter operation -less risk for chronic pain. Recurrance is possibly higher. There have been people destroyed by desarda and by shouldice. But as a general rule Shouldice has a longer track record and seems to have a lower recurrance rate. The kicker for me is that Dr, Lorenz does both repairs —but decided on a shouldice for his own repair. When I talk to him I plan to try to confirm that it was Koch who did the repair. But if a knowlegable doctor familiar with both repairs elects shouldice –doesnt that close the case? Then its a matter of picking the absolute best shouldice surgeon –I want one that preserves the cremaster and the nerves. That leaves Yunis, Lorenz and Conze….yunis doesnt have enough volume…so that leaves conze and lorenz….Lorenz gets mentioned by nearly every surgeon as someone they would go to…Conze does not get mentioned. But contends he has had only 2-3 cases of chronic pain in his career. He also charges 3 x what lorenz charges….There must be a reason for this. So coinflip Lorenz vs Conze…but Conze does fewer surgeries per day –hopefully that means he is more focused. Pick Conze for shouldice. And pray hard. Rebuttals welcome. Particularly interested in Desarda voters….

[MeshorNot]

Caveat —Watchful says Conze and Lorenz are likely to retire soon. Koch told me he will work ten more years. So even though he uses general anesthesia –i think he moves into the default position…downside is he does a custom repair…some unsubstantiated allegations of fraud. Very good bedside manner….nice guy…very hard to find in the hernia surgeon realm. But given the possible retirements –who is the next best shouldice surgeon. I read all the reviews for Shouldice clinic…Simmons and Slater mentioned. Netto positively mentioned but only there short time. Hall mixed reviews. I trust all these doctors follow the shouldice standard which is to cut the nerves and take the cremaster. Though i read Netto agreed not to for one patient. If there are other good shouldice surgeons i am missing i would love to hear about them.

[Watchful]

What I said is that there’s a high likelihood that they will have retired by the time you recur and actually have a hernia to repair (which may not even happen at all).

Who knows what the options will be if and when that happens. My prediction is that there will be even fewer options for tissue repair in the future than there are now, and eventually (say, in 20 years) there will be practicality none left.

[William Bryant]

That hernias are easier to repair early on had to be weighed up against the risk of chronic pain that could occur.

One thing that many people say is that they didn’t even really need the surgery and another is if they’d have known they wouldn’t have had surgery.

If symptom free, or relatively, then rushing to surgery may not be the best move.

In my case for example, although I had quite a few symptoms early on, I didn’t have surgery straight away as they were not that bad and I was considering which repair and who to go to. Fortunately after about a year rather than get worse my symptoms have got less and less, very fortunately. Would it be prudent to risk that?

I’ve no idea why symptom should subside, btw, any suggestions why?

I accept they will and are likely to worsen though. And surgery will become necessary.

• This reply was modified 1 week ago by William Bryant.

[Good intentions]

Hasn’t somebody said in the past that Dr. Belyansky had a hernia but was waiting on surgery? And didn’t Dr. Belyansky remove Chuck’s mesh? He seems like a good person to talk to. He should know a lot and have a reason for waiting, and also should have a repair method in mind. Plus he would know the anatomy of where the mesh was recently removed. I haven’t seen his opinion shown in any of the threads.

[Good intentions]

Actually, I think it might have been Dr. Brian Jacob. He also removes mesh, but, if I recall correctly, also from a past post on the forum, he gets defensive when people question the use of mesh.

I posted one of his mesh removal videos recently where he questioned why the woman wanted the mesh removed even after she told him it was causing pain. So, he might have some internal mental conflicts.

[MeshorNot]

Thanks for the input. Bryant is there anyway to know when to repair a hernia? By the time you are getting symptoms it could be more difficult to repair. I hear you on the chronic pain but every surgeon i spoke to said fix it early. Grishkan said its like running your car without oil. Its a difficult decision because there is no clear data on chronic pain. If chronic pain is as rare as these surgeons tell us it would make sense to fix it. Who knows? Belyansky is a nice guy great with the robot but not known for tissue repairs. He said the Desarda –that florida thing was an inferior repair in his view to robotic surgery with mesh, I dont know what he was basing this on. All these docs are just pulling things out of their butts. I am curious if anyone thinks Desarda is the better way to go due to simplicity speed of operation and lower chronic pain rate.

[Good intentions]

I found the thread about Dr. Jacob and waiting. Wish we could know his thought process.

Dr. J’s Own Hernia

Put “jacob wait hernia” in the search box if the link does not work.

[herniacomps]

I personally spoke with Dr. Jacob about his hernia. He said it’s small, about the size of a quarter and causes him minimal discomfort, sometimes none at all. With no pain, and an occupation/lifestyle that runs minimal risk of having it worsen, there’s really no reason for him to have it repaired. This approach is inline with a more cautious approach some surgeons often advise. He knows the risk and simply decided that it’s not worth repairing at the moment.

[William Bryant]

Thanks very much for that about Dr Jacob, its very interesting that a surgeon would do Watchful waiting, I wonder if he advises it for patients.

He isn’t the only surgeon as there was a post from another saying he was living with 2 hernias and would carry on doing until a time they were too troublesome. This was on quora and I read it when I first had the hernia..I’ve looked and looked for it but cannot find it again.

[Raymond]

Hi MeshOrNot, Can you please tell me what you mean when you said that there have been people “destroyed by desarda and by shouldice”? Please, Please explain.
I would like to think that there is a backup plan of being able to get a mesh operation if the open desarda or shouldice method fails/Destroys. Thanks for your help as I am quite fearfully trying to figure out the road to take when it comes to getting my Inguinal hernia fixed. Thanks in advance.

[Watchful]

William – Watchful waiting is a pretty standard recommendation for people with hernias that don’t bother them too much. The risk of incarceration is very low. Most of the waiters will probably have to get the surgery done at some point, but waiting those extra years means fewer years of potentially suffering from post-surgery complications such as chronic pain. Some may be able to avoid surgery altogether.

The tricky aspect is how waiting affects the possibility of tissue repair. I don’t think it’s a good idea to wait if that’s what you really want. Some tissue repair surgeons say that the size of the hernia isn’t an issue – Shouldice Hospital, Dr. Kang, Dr. Tomas. I don’t buy that, and that hasn’t been my experience.

Before surgery (at the Shouldice Hospital), I was told by my surgeon that the large size of my hernia wouldn’t be an issue for a Shouldice repair, and after the surgery he said it was one of a couple of issues that led to a difficult surgery. I don’t understand how they can make one statement before surgery, and then the total opposite after. To be fair, the correct size of the defect wasn’t known before surgery, but it was clearly large since my hernia was large.

• This reply was modified 1 week ago by Watchful.

[Mike M]

#1. I like your idea of checking out reputable doctors that are accessible (if you live in the US) who have experience in all Mesh and Open Tissue. I still think there might be a bias towards one or the other regardless and same with doctors who only do no-mesh repairs.

#2. I would add to visit a no-mesh repair expert and see what they advise regardless based on #1 if Mesh is the recommend option (for a second opinion).

#3. Desarda – Nope. Too risky. No tension but most likely to fail out of all three choices, long heal time compared to others, patient must have “perfect” outlying variables with little margin for error.

Shouldice – Maybe depending on the doctor and facility. Definitely a sound choice but choose your doctor wisely.

Dr. Kang – Yep – based on results, transparency, access, and patient feedback experience. Dr. Kang has extensive experience not only with Hernia repair but with everything related to that internal area of the anatomy. Decades of hernia repair experience even if the final version of the “Kang repair” is only 5+ years old. Decades of experience with Mesh before deciding there was a better option for patients going down the no mesh route. Most likely the least invasive out of all options. All experiences have ended up being very positive even with the 1 recurrence on the forum.

Good luck out there. No doctor or procedure is going to bat 1000.

[William Bryant]

In most cases Raymond a tissue repair will be fine and if it should recur or be problematic a revision surgery or mesh could be used. But as with any medical procedure there are possibility for complications and side effects. I think this is what is meant. In short no surgery is risk free I think is what is meant. So I’m with you, fearful of which way to turn.

[William Bryant]

Thanks Watchful. I understand the longer one waits the bigger the defect can become and or the weaker the tissue can get plus aging doesn’t help operations with the anaesthetic etc but I do think at this moment with relatively few symptoms it would be a big gamble. Early on I had far more symptoms and avoided carrying as it aggravated things. It hurt if I bent forward and ached driving or after a long day.

Now I can do all those, I’ve even gone back to carrying things. Not wardrobes but reasonable weights albeit tentatively and carefully. So I’m not sure why I’m improved.

It’s given me a bit of leeway and I do think I will go to Germany or Dr Kang at some point.

[Watchful]

Makes sense, but if you notice that your hernia is growing and you want tissue repair, have the surgery done. Still waiting beyond that point is more reasonable if you’ll ultimately go for mesh, not tissue repair.

[William Bryant]

When you say growing, do you mean size of bulge outwards? As that seems to have got a bit smaller too.

Could it be its larger internally?

[Jack2021]

I just ran a search for Bassini repairs vs Desarda repairs to see if there were any studies and came across this, which I may actually have posted a while ago.

It’s a 10-year Randomised Controlled Clinical Trial of 1313 patients (602 patients with a Modified Desarda technique (modification of Desarda’s technique by adding Modified Bassini’s technique [Darn with continuous suturing with non-absorbable polypropylenesuture]) and 640 patients with Lichtenstein procedure.’

http://www.heraldopenaccess.us/openaccess/a-randomized-trial-comparing-herniorrafia-modified-desarda-repair-and-hernioplastia-lichtenstein-repair-for-inguinal-hernia-study-of-1242-patients

This study appears to evidence even better results than the 10-year Polish study that’s been posted on here numerous times now.

I’m not clear how the modification varies from the original Desarda repair, other than Prof. Desarda advocates long-term absorbable sutures, so if anyone’s able to clarify if the darning with continuous suturing is also a modification, that would be interesting to know.

[MeshorNot]

Jack2021 thanks. Do you favor the Desarda repair that Mike M disparages? Its very hard to get a good grip on the proper fix when there are so many modified repairs floating around. Tomas appears to do more Desarda repairs than anyone. He says he hasnt seen a recurrance in years and if he does he just fixes them…how i do not know

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