Dr. Grischkan Experiences

[Watchful]

Thanks, Dr. Kang – this makes it clearer.

It looks like Dr. Ponsky simplifies even further and just performs high ligation even in adults (same as in children) without repairing the deep inguinal ring. He says recurrence has been only 4% so far. He does this laparoscopically in both adults and children.

If even just that works so well, then if you add repairing the inguinal ring, results should be really good.

I’m still wondering why tissue repair surgeons who know how to do Marcy choose not to do that in most cases of adult indirect inguinal hernias, and prefer Shouldice, Desarda, etc. There must be a reason… Maybe just misguided accepted wisdom?

By the way, what are your thoughts on the Desarda repair?

Thanks again for helping us understand your approach, Dr. Kang.

• This reply was modified 2 years, 9 months ago by  Watchful.

[William Bryant]

Thank you Dr Kang.
Would it be possible to let us know what you do with cremaster and also the gentifemoral, illoinguinal nerves etc, please. If you have time.

And for overseas visitors how long would you suggest they should stay after operation?

[drkang]

Hi all,

I am not sure if I could personally answer the various doubts about Kang repair. Because I am afraid that my intentions may be perverted. However, I think it will be helpful to broaden our understanding by giving answers to the various doubts raised.

Marcy repair was developed around 1870. So it is difficult to say the exact surgical method nowadays.
Kang repair for indirect inguinal hernia is the same as Marcy, only narrowing the deep inguinal ring, but the specific surgery method is completely different.
Marcy was developed as a surgical technique for adult hernias. Therefore, the claim that Marcy is only applicable to child hernias is not correct. In most child hernias, high ligation of the hernia sac is sufficient, so repair of the deep inguinal ring is not required.

Therefore, to say that Marcy is a surgery that can only be used for child hernia is an expression of disrespect for this surgical technique, I think.

Surgeons don’t just do surgery. After surgery, follow-up and management should be done. Therefore, it is difficult to continue the operation if the results are clearly bad. Because many patients will continue to complain. However, I have done over 12,000 surgeries in a similar way so far, and I don’t feel any pressure to continue with this method.
The answer to why Marcy is rarely done if its result is good may be similar to the answer to the question of why mesh repair continues despite mesh complications. Anyway, Kang repair for indirect hernia differs from Marcy.

Most of the tissue repairs as well as the Shouldice focus on repairing the Hesselbach triangle. Therefore, it is difficult to say that these are the proper surgical methods for indirect inguinal hernia. Because most indirect inguinal hernias have a healthy Hesselbach triangle.

[William Bryant]

One further no question Mike M….
How long after surgery do you intend to stay in Korea?

This is something I think about a lot.

[William Bryant]

If Dr Kang repair is a variation on this it sounds good to me.

[William Bryant]

Hurray!!! For once Ive found what I remembered seeing!!!

And of course it was originally posted by Good Intentions!!!

Hernia repair “blasphemy”… High ligation mesh free repair in adults!!! Dr Ponsky I think…

https://youtu.be/VHX62HfVopA

[William Bryant]

Good luck Mike M, hope it goes well. If you think of it and don’t mind. Could you keep us updated afterwards do you think? When you think of it.

It’s really helpful to those of us who ate finding it difficult to decide where to go etc.

[William Bryant]

Is Marcy the high stitching? That is usually done in children? If so there was a post on the forum that was a link to one surgeon who advocates for it’s use in adults due to less pain I think it was and no mesh.

Someone may remember it. It was the surgeon saying he was going against convention.

[Watchful]

Thanks, Mike M. I don’t know how much he modifies Marcy, but if it’s very close to Marcy, and it works so well, then why does anyone do the much more complicated Shouldice on indirect inguinal hernias? Why is Marcy so rarely done in adults?

I consulted with Dr. Brown before he retired. He used to do a bunch of tissue repair techniques, including Marcy. For my indirect inguinal hernia, he was going to do a combination of Shouldice and Desarda. The Desarda was for further reinforcement and for reduced tension. He did not mention Marcy as an option even though it was in his repertoire. Why would he even think of such a complex procedure if the repair could be done successfully with the much simpler Marcy? He knew how to do Marcy. This whole area is quite baffling…

[Mike M]

@Watchful – My take on Dr. Kang cremaster response is two things.

#1. Direct Hernia the cremaster is not directly involved in his repair and will not be modified.

#2. Indirect Hernia he will also work with extreme care however it will need to “manipulated” to an extent as to fix the issues with the indirect hernia with his procedure. The expectation is there could be some damage but it will be “superficial” and not affect the outcome. I don’t know if you could ask for anything more with any type of open tissue non-mesh repair.

In regards to Dr. Kang using a “non standard and not well known procedure”. This is an excellent point. However it is my understanding after posing this question that Dr. Kang uses modified versions of existing well-known procedures. The modifications are his version of improvements.

Indirect – The repair method (at least the ideology) is similar to a Marcy? https://www.sportshernia.com/marcy-technique-nonmesh-hernia-repair/

Direct – It is similar to Bassini / Shouldice repair.

You always have to take into consideration for the law of unintended consequences anytime a standard procedure is “modified” to improve it especially to the extent that it resembles a new procedure rather than the original.

I took questions from people that researched the topic extensively, feedback from other doctors, my own questions and ultimately accepted the responses. I will probably keep asking questions up until the knife starts slicing. lol

Everything I have research so far from Dr. Kang is very conservative in his methodologies, approach, and his appreciation for keeping nerves, muscles, etc. “intact”.

So conservative to the point where I ask myself is it a lot more likely for a recurrence to happen 10-20 years down the road using this method vs. anything else in my 40 something but active age group. I am not sweating a 1% point however which seems to be where the data leads.

Dr. Grischkan and Dr. Kang have been extremely successful in working on a wide range of body types, athletes, body builders, martial artists, people with pre-existing conditions, extreme cases etc. so my case should be a walk in the park. Crossing fingers.

@Good Intentions – 100% Agree. Dr. Grischkan’s “modified” Shouldice is enough of a comprise I could live with with if I had to in a pinch with all of the other checkboxes marked.

I do not have enough data with Dr. Yunis to tell you if he would be able to meet my criteria because I never got a chance to speak to the doctor directly. Based on other patient positives experiences it does seem like he would be able to meet all criteria with the one asterisk you mentioned. Dr. Grischkan proposed a very simple and easy work around which was totally acceptable as did Dr. Kang. I am concluding for now that my experience with Dr. Yunis was more related to a specific staff member / assistant which I found to be appallingly devoid of compassion and totally unprofessional as it relates to male patients. The request was posed in a very polite and benign manner and the response was power trippy, incredibly “weird”, and not something I am comfortable with in quoting verbatim. Not to be dramatic but I mentioned it to my wife just to make sure there wasn’t something I missed or another way I could take it and she was taken back by it. I suspect (although unknown) Dr. Yunis would have been able to make simple and agreeable accommodations if I had spoken with him directly.

[Good intentions]

These lists of important factors to consider are a good example of how people should approach such an important event in their life.

I think that anybody trying to use somebody else’s list should be careful though. Thunder Rose is a woman, with requirements/needs/wants specific to that factor. And Mike M. had a specific demand that no women be involved in preparing him for surgery or being present during surgery.

Sorry Mike M. but you left that important disqualifier out of your list. Dr. Yunis might meet all of your requirements otherwise. I assume that might be why Shouldice is out also.

Good luck to all.

[Watchful]

Thanks for the details, Mike M. I still don’t really know what Dr. Kang does, and it’s hard to understand the English in the quotes you posted from him. It sounds like he does do something to the cremaster, but leaves it mostly intact – it’s hard to understand the description. Also, it sounds like his approach is tailored to the patient, so you aren’t really necessarily getting some standard well-known procedure. Anyway, the results that he quotes speak for themselves, and are wonderful (assuming accuracy).

Not sure how to reconcile what Dr. Grischkan is saying about the cremaster (repair won’t be tight-enough without shaving it) and the fact that a number of other surgeons (including Dr. Yunis) seem to be able to get good results without doing this.

Recurrence isn’t something to be taken lightly, but if you’re still in the single-digit percentage points, then taking the chance is reasonable. Who knows, though… We’re just guessing since this hasn’t been studied much, and the little that’s out there is contradictory (which is not unusual in the medical field, unfortunately).

[Mike M]

I plan on going to Dr. Kang the 1st or 2nd week of April.

If for some reason my condition changes unexpectedly and dramatically then I will go to Dr. Grischkan. There is zero chance I would choose the Shouldice Hospital in Canada over Dr. Grisckhan.

Desarda repair had too many concerns from experienced members including some nightmare stories for me to consider it as an option.

Dr. Conze in Munich sounded good but it is my understanding that the muschaweck repair is very specific and for small hernias exclusively. Not sure what I have at the moment. Also a lot of concerns about the cremaster in their procedures. However it is my understanding that the Munich Hospital is very careful regarding nerves and images nerves route specifically? to avoid long term issues.

Dr. Yunis works around the cremaster muscle and is a vascular surgeon which is a plus in my book. ThunderRose had success in having him agree to perform the procedure with some of her requirements. However Dr. Yunis does not complete as many open tissue repairs as the other experts and I recently read a story of a patient requiring a bag after one of his operations.

Here is my checklist by rank of importance.

#1. Surgeon experience and skill specifically in the procedure performed.

#2. Type of surgery – No-Mesh (or minimal if absolutely required), open tissue repair under local or twilight sedition. I also used the checklist by ThunderRose as a basic guide along with some understanding of the procedure.

#3. Longevity – I will sacrifice a slightly higher chance for reoccurrence if it means avoiding a large piece of mesh. I disagree that this is an Airplane to Cars analogy in terms of risk vs. reward. I do agree that there is a higher chance for reoccurrence especially in large hernias with older patients without some mesh type structure to assist. I will roll the dice on this one and hope for the best.

#4. Bedside manner, ability to meet basic, reasonable, and *respectful* accommodations for a patients needs, ability for staff and the Doctor to communicate in a healthy and respectful manner to patients. Tied for #1 for me for non-emergency situations.

#5. Specialized Outpatient facility for Hernia Repairs – Not huge but has perks.

Choices:

Open non-mesh – #1. Dr. Kang and #2. Dr. Grischkan (mainly because of the cremaster concern)

All other options – #1. Cleveland Clinic expert (there are a few really good ones up there) or Dr. Towfigh possibly. Had I known I had a hernia when I was in Bev Hills for the Superbowl I would have extended my stay to see Dr. Towfigh for another opinion.

[William Bryant]

Thanks Mike, are you any closer to deciding who, where, when you’ll have operation?

I seem to go round in circles. From Germany, Canada, India, USA, Korea.

Dr Kang sounds very good.

[Mike M]

@Watchful – Regarding cremaster shaving – Dr. Grischkan did not give me the option. Dr. Grischkan stated that it would be incredibly difficult to get a tight repair in that area without doing something. “tight repair” as in one he would be comfortable with in long term. I could probably force the issue but I would hate being the first one for him to test it on if that is what he does and has experience in doing without complications.

Dr. Grischkan repairs the entire Inguinal floor regardless of indirect or direct where as Dr. Kang has a tailored approach. Dr. Kang will add more support depending on the circumstances and repair everything if it is needed. Repairing everything regardless of circumstance is definitely more involved but I guess it gives you the added reassurance that you won’t get an indirect hernia later down the road if you had a direct hernia? at least that was the impression I had when it was explained to me.

Dr. Kang does *not* cut any nerves and leaves everything intact.

Regarding Dr. Kang and cremaster this is how it was explained to me by his team whereas the cremaster is the warehouse.

Dr. Kang – “To repair the facilities in the warehouse, you can think of it as if you had to open the warehouse door and enter it, split open the master muscle fiber, operate on the structure inside, and close the warehouse door again.”

Dr. Kang – “I do not remove or damage whatever inside body structure. Only in the type/case of ‘indirect’ hernia, along the fiber plane of cremaster muscle, after I split and I need to deal with the sac in there, I might incur a little bit of damage inevitably but it is almost ignorable. ”

In my opinion that is a lot better than taking or taking up to 50% of the cremaster.

@William Byrant – I did speak with Dr. Yunis’ assistant / gatekeeper in an attempt to setup a consult. However it did not get past the initial stages as I was taken back by the lack of empathy and professionalism by that individual when I made a simple inquiry and request regarding their procedure and accommodations. Dr. Kang, Dr. Grischkan, and all the other doctors I consulted have been incredibly compassionate and understanding throughout the entire process.

Dr. Yunis has an overwhelming amount of positive reviews and is a vascular specialist. That can’t hurt? I also understand he works around the cremaster muscle completely which is great.

Some negatives reading the forums here regarding Dr. Yunis. #1. Someone stated a patient ended up having to have a bag with one of his procedures after nicking a bowel? I suppose when you do thousands of repairs there are bound to be some complications on some of the patients. You just hope that % is incredibly small. #2. His primary preference and specialty? method of repair is not tissue, it is mesh.

Ultimately it is really up to Doctors themselves in regards to how things are going to be setup and handled so my advice is if Yunis is a consideration for you make sure you speak to him directly before you form a final opinion.

[William Bryant]

Thanks for the well written report. Have you considered Dr Yunis, I cannot remember!

I’ve got both Dr Kang and Dr Yunis on possible list

[Mike M]

Just a little follow up – I met with Dr. Grischkan and it was a very positive experience. I found Dr. Grischkan to have an excellent bedside manner and he was very knowledgeable. He showed me examples of some difficult cases he worked on (which mine is not) with very positive outcomes. Additionally he had a lot past and very recent of personal experiences expressed in hand written letters / cards attach to the wall as soon as you walk in making you feel a little more at ease.

He also tailors the procedure depending on the size, scope, and anatomy of the patient. If it is a seriously large hernia his approach is very aggressive with the polybutester suture that has demonstrated to be one of the best inert options available.

Dr. Grischkan also does not cut any nerves but he does trim the Cremaster muscle 30%-50%.

The entire procedure as explained to me checked off all my boxes except for the Cremaster portion. I would rather have someone work around it and risk a little higher reoccurrence then trim it.

Ultimately I think I will try Dr. Kang. There are an overwhelming amount of positive testimonials, he is extremely well respected, and his credentials are impeccable from what I have found.

Most likely I will opt to stay in the hospital for an extra day if needed to make sure the sutures are 100% solid before I go back to the hotel.

I think the pure tissue repair method is an interesting study on whether or not the human body can handle a more “natural” tissue repair in that area without requiring synthetic assistance. I guess time will tell.

I did consider the more “traditional” mesh repair method using a specialist from the Cleveland Clinic but I would rather avoid general and an hour long surgery if possible.

[William Bryant]

If you do find out he goes to USA please let us know.

[Mike M]

@Chuck Thanks. I am requesting more info from Dr. Kang today. Not a bad idea to get a few different options. Everything I read so far is that he is top notch too. I also read on the Facebook Forums that he sometimes comes to the US? I will update what I find out.

[Good intentions]

Good luck with your search. I think that you will find that everybody and anybody who had bad results would run naked through their hometown if the bad results could be undone.

I think that you might also find that surgeons will see a patient with unreasonable expectations and might avoid you. So, your demands might actually end up being a big part of your selection process, limiting your choices.

Good luck.