Excellent discussion with hernia genius JF–Watchful bryant pinto..mike m

[pinto]

@Watchful, I share your concern for accurate and reliable data, however it seems you sidestepped the issue I raised. I quote you from your original post:

“You’re [Chuck] engaging in selective belief/disbelief based on your particular results with your lap mesh procedure. In the case of Kang, I don’t recall that he even provided any chronic pain and discomfort results. He provided some of his recurrence stats (without counting Pinto which raised the question of who else he may not have counted) – that’s all I remember.” [Watchful]

You appear to be making an example of Kang being “selective” with his data, which if so, would be a serious charge. Later in the same thread, he explained that

“The reason the last statistics were for patients 7 to 32 months after surgery was because there was an important change in our indirect hernia repair method…. [F]rom December 2019, I used permanent 2-0 Prolene in some patients [with untypical hernias] [but still maintained absorbable use for typical cases]. …As a result, there was no recurrence in 401 high risk patients who used Prolene, but among 1405 patients who used Vicryl, recurrence occurred intermittently, and 12 patients have relapsed so far. …My previous statistic of no recurrence with 738 patients 7-32 months after indirect hernia repairs, were only about those with the permanent Prolenes. Pinto, who underwent the first operation in August 2019 for left sliding hernia, was excluded from the previous statistic because he had surgery with Vicryl at the time.” [Kang]

My original surgery was indeed absorbable so he shouldn’t include me as a recurrence because he wanted to show how improved results came by using permanent suturing. Thus you not only misrepresented Kang but make an untoward accusation. You appear by your latest post to justify the latter by saying a Korean colleague of yours found as many as 3 recurrences on the same day at Kang’s hospital. As you said it yourself, such doesn’t prove anything. Moreover it does not justify your misrepresenting Kang’s report.

For me, the most outstanding feature is the apparent irony in that you are being “selective” (=biased) not Kang.

[Watchful]

Pinto,

There was no mention initially that the statistic was just for the latest (post-Pinto) among his 50 (!) versions of the indirect procedure. This came out when I asked how come you weren’t counted. Once my Korean colleague studied the Korean on-line reviews and found the reports of recurrence, I moved on. I was particularly affected by the one reported by my colleague where a patient with a recurrence said that he encountered two other patients with a recurrence at the hospital on his surgery day. All this doesn’t prove that his recurrence rate is or was too high, but it was enough to raise doubt in me, particularly since recurrence is indeed the big concern with a Marcy-type repair in adults.

[Watchful]

GI,

Even my surgeon at Shouldice told me that the technique that’s least likely to cause chronic pain is lap mesh. He said even that procedure can cause it unfortunately, but the incidence is lower than with Shouldice and open mesh. He was pretty direct about the chronic pain issue saying that they encounter new bad cases on a weekly basis among their patients, and it’s sometimes debilitating. He told me all that before the surgery in response to my questions on this topic.

I decided to go ahead with it anyway since this wasn’t a surprise to me. The thing that got me was that I had a pretty huge hernia. There was no mention of that as being a problem before the surgery even though the surgeon examined me, and I asked him if this would be a good procedure for my case. After the surgery, it was mentioned as a reason for the difficult and long surgery. Also, he told me he still managed to fix the hernia well in spite of its large size. I then asked him if mesh would have been difficult as well, and he said no. I have no recurrence so far, so that’s good, but the surgery caused way too much trauma to the area, and persisting issues.

It goes even further than that… I chatted with him quite a bit after surgery about the tissue repair vs mesh choice that I made, coming there for it, etc. There was zero indication that he thought this was a better approach than others, which surprised me. He viewed it as one of the modalities that could be used, and that’s pretty much as far as it went – no particular enthusiasm for it vs others. This wasn’t even just in the context of my case, but part of a general discussion.

When I asked what to do if there was a recurrence, he said that this was unlikely to happen, but lap mesh would likely be the best choice.

I really think they should follow some guidelines on hernia size and maybe other anatomical aspects, just like they do with the weight. They obsess a lot about the weight, and not at all about the hernia size. The Germans do factor the hernia size into their decision, with a hernia defect size limit. The Germans also do a careful ultrasound as part of the process of figuring out the best treatment for the particular anatomy. They can also make the decision that mesh is more appropriate during surgery, which Shouldice does only in extreme cases. You probably don’t want Shouldice to do mesh on you actually because they don’t get much experience with it…

[pinto]

@Watchful, please confirm your claim that Kang was being “selective” (=biased) in his stats for recurrence, citing that he (by self-disclosure) excluded me from the stats. Didn’t he do that in association with reporting a change in surgical procedure, quite reasonable to do? I don’t believe he was referring to his overall, total over his long career as a surgeon. Please correct me if I am wrong but you seem to have mischaracterized Kang’s report, possibly applying a selective view yourself.

[Good intentions]

I should add also say that the one of the major flaws in almost every discussion of hernia repair is the lumping of all materials and techniques in to simple categories. “Mesh”, “lap”, “open”, are about as vague and undefined as can be. Now “robotic” has been introduced, as somehow separate from laparoscopy, but it’s not separate. It is actually robotic laparoscopy. The tools are controlled remotely, and moved by machinery. One of the early problems in robotic lap is that the feedback to the controls in the surgeon’s hands was poor. In other words they couldn’t tell how hard they were pulling or pushing. So, somewhat ironically, the surgeon can see more clearly, and pause to think, but has less ability to manipulate what they are seeing.

Anyway, the situation is so varied and complex that it’s easy to understand why even the pros fall back on vague and undefined descriptions of what they do. Something that people should always be aware of.

[Good intentions]

Watchful, could you provide some references or at least more commentary about your opinions below?

Not to insult you but I’ve noticed that you seem to be trending away from the logical and rigorous approach that led you to Shouldice. Your statements are getting vague and as you say below, “generalized”. “least bad”? What does that even mean?

Again, no offense intended. I just hate to see people slide down that path of falling for the marketing and advertising, or, in your case, doubting that the good research work they did was the right way to do things.

A couple of quotes from your posts above –

“However, if I knew mesh was the way to go in my case, I would seriously consider lap mesh instead of open. You and a couple others here had a bad experience with it, but it seems to have better results overall based on studies.”

“I think that objectively and generally speaking, it has been shown to be the least bad approach all things considered. “

[ajm222]

I’ll also add that I’ve heard that the robot in fact makes visibility of the structures much better. Sort of a 3D enhanced zoomed in view. So I think just because they aren’t right in front of the patient doesn’t mean they have a bad view. I’m 46 and can’t see a damn thing even with my glasses on thanks to astigmatism plus aging eyes. The robotic view would probably make things much easier for someone like me. And the tools allow them to have better maneuverability inside the patient. I hated how I felt after robotic surgery, and I don’t think my stomach has ever quite looked the same. So I have issues with it. But I don’t think they’re sacrificing surgical ability using it. Likely the opposite on some level. But it also comes down to surgeon preference as well.

[Watchful]

Chuck,

Not sure if you’re aware that Kugel is actually more invasive than Lichtenstein. That doesn’t mean that it’s not better, but it’s not obvious. I haven’t encountered much data about it, but I didn’t really focus on it.

You’re engaging in selective belief/disbelief based on your particular results with your lap mesh procedure.

In the case of Kang, I don’t recall that he even provided any chronic pain and discomfort results. He provided some of his recurrence stats (without counting Pinto which raised the question of who else he may not have counted) – that’s all I remember.

As I mentioned before, I think the lap mesh procedure is scary, and I don’t like general anesthesia, so I’m not a fan of it personally, but these are personal biases. I think that objectively and generally speaking, it has been shown to be the least bad approach all things considered. That doesn’t mean that it’s best for every type of case, or that you won’t get bad results in some cases.

[Unknown Member]

Watchful…surprises me to hear you select lap mesh. The studies are mostly garbage…paid for by mesh companies…i Looked into the studies posted by Dr Twofigh which she said showed superiority in terms of recurrance and pain…the studies she posted didnt even say those things. Open mesh is actually safer because the surgeon is looking right at his work insteand of using chopsticks and looking across the room…Boston Hernia seems to have the best open mesh option…Reinhorn claims a chronic pain rate of .0003 —prob a lie but still. Lap is a very destructive surgery…I dont think i will ever recover from it. its sad because i had a great life…about to retire get married…and a small painless hernia will likely put me in the cemetery…I saw that Dr Alexander was still working at shouldice when i first got my hernia…prob should have gone to him straight away…conze looks good too…life isnt worth living in constant chronic pain. And I chose lap because all the studies said it was lowest risk —but the studies are garbage—if you watch lap performed you will never do it

[Watchful]

Chuck,

I’m not sure what is meant by “tightness”. I do get some dull pain and a feeling of pressure in some situations. I guess this feeling of pressure could be called tightness, but it feels more like it’s caused by the injury to the area and scar tissue from all the dissection rather than tightness of the repair.

I’m not sure what to make of the Mike M one year post-Kang update because he mentions a difficult surgery, initial severe pain and discomfort for 48 hours, and then improvement over time. It sounded like he didn’t suffer from severe symptoms after the first 48 hours, but it’s not clear how long he continued to have at least some symptoms of pain and discomfort.

I don’t know what tissue repairs your friends had. My dad also had a no-name tissue repair of an inguinal hernia, and it recurred eventually. He said his scar was small, and his recovery was very fast. As we know, Dr. Felix also recurred after his unknown tissue repairs. Even the Shouldice procedure had pretty high recurrence rates in most places outside the Shouldice Hospital back in the day.

I agree with ajm22 – you are looking for some ideal solution which doesn’t exist in reality. Pick a very experienced surgeon with excellent results as far as you can ascertain, but realize that it’s still a crapshoot.

Yes, Conze would still be my first choice for open repair. I don’t think Shouldice is a problematic procedure if done right, and on the right patients, but these are pretty big “ifs”. Conze seems to do it right, and he tries to avoid doing it on cases where it’s not a good fit (unlike the practice at the Shouldice Hospital). In those cases, he uses open mesh, and he is really good and very experienced at that as well based on my research.

However, if I knew mesh was the way to go in my case, I would seriously consider lap mesh instead of open. You and a couple others here had a bad experience with it, but it seems to have better results overall based on studies.

[ajm222]

I didn’t use cost as a factor, I just mention it as an additional benefit – compared to private doctors who won’t accept insurance at all and charge tens of thousands for a single surgery. it also suggests to me he’s not in it for the money himself. as for only going to the best, I think it’s pretty clear at this point based on your own post that there really kind of is no best, or it’s an unknowable thing. and even the best have stories of folks with less than good outcomes. you’ll spin your wheels forever if you’re trying to find the single best surgeon and procedure. at some point, if you need surgery, you have to make a decision, and it will always have pros and cons with an uncertain outcome. such is life.

• This reply was modified 1 year ago by  ajm222.

[Unknown Member]

AJM di hope Dr B’s repair works out for you…thought I gotta say I simply don’t understand making cost a consideration of this operation. Isnt that what got you into trouble the first time? My advice to anyone here is to see the best…no matter what the cost or the distance. I live on the East coast but flew to see the criminal carvajal because he was doing a single incision lap surgery that i thought would be even less invasive…and he claimed 5000 surgeries…i know know that was a lie…but I did go all out to get the best result. I just got lied to and confused about the risks of tissue repair. i got my hernia in mid 2016—and i wonder if i had gone to Dr Alexander at shouldice before he retired whther i would have gotten a good result. It seems like everyone with a shouldice has some tightness or chronic pain issues.. Two Dc surgeons told me they had had severl patients from the shouldice clinic with chronic pain…could well have been a lie,

[Unknown Member]

Mike—can you elaborate on uncorrupted bassini…did you mean unmodified? No one is doing pure bassini that i know of anyway….did you find a doc who would do it? How long did it take for the pain from you kang repair to resolve? The real criticism of the kang repair is that it is not a strong repair and is likely to recur. Towfigh comparing it to a Marcy. Kang says he has a low recurrance rate for his latest version of his repain….but its only about three years old? his follow up is probably better than most because he is in a small country where everyone can get back to him. It troubles me that some US surgeons flat out said he was lying about his statistics. I used to trust doctors but now i dont trust them at all…still of all the docs…Kang seems like the most trustworthy….Do you know if his son or other docs at Gibbeum have mastered the kang repair? At some point i will be heading to see Kang. Hernia surgery is exceptionally dangerous —its amazing how few people truly understand the risks they are facing from this treacherous procedure. Watchful do you feel the tightness that so many critics of shouldice cite?

[Mike M]

“Uncorrupted” Bassini is the direction I would have gone if I had not visited Dr. Kang. It seems the least evasive open tissue no mesh repair in the U.S. that is still effective.

Desarda – I read some pretty extreme mishaps with that procedure from patients. Also there was mention of being more delicate in the initial years than the other methods by members researching it on these forums as well as Dr. Kang’s concerns.

Mesh – Seems safe and the most reliable until its not. Biggest concern is entanglement near “sensitive” parts or your bowel getting perforated by even the most expert of surgeon (albeit very “low risk”)

Bottom line: We have to commend Hernia Doctors who are continuing to innovate and make all types of Hernia procedures more accessible and safer. Patients are going to rule out types of procedures that are not going to be acceptable to them for varying reasons. This is an area of healthcare where there needs to be real and effective alternatives. Hernia doctors do not always get the same type of acknowledgement and compensation from the mainstream health insurance industrial complex as other procedures even less complicated ones. Hernia surgery is a *major* surgery that involves operating near critical key areas easily damaged and directly responsible for long term quality of life.

[ajm222]

“Is there a way to just sew these hernias closed without opening the inguinal floor and putting a bazillion layers of suturing in???”

This is what Dr. B did for me. Used absorbable sutures and determined that the inguinal floor did not need to be opened, and used a modified Bassini technique to tighten things up. That may largely be because my hernia was indirect. And it remains to be seen what my long-term prospects are, so I can’t say if it worked or not. Two months out and still have some discomfort and no clue if hernia was totally fixed. But I had some pre-existing discomfort since the first mesh surgery and then removal, and it may always be impossible for me to say what the source of any of my issues truly are. I am not currently in much pain per se. It’s more discomfort and mild soreness and weakness. Feeling tightness in the groin and like a heavy knot is just kind of sitting in that spot and tugging and pulling on things. The next few months will probably be instructive. And perhaps even a year or two as the tissue remodels.

At any rate, another reason I chose him (besides the fact that he’s an expert on hernias and abdominal wall reconstruction and knows the anatomy inside and out) is that he took a very conservative approach. His surgical notes carefully detailed his sewing technique to provide a strong repair but one that wouldn’t be too tight, and how he made an effort to avoid all critical nerves and other important structures. He’s no tissue guru, but he’s a bona fide expert, a nice guy, honest and practical and keeps it real, and he’s cheap and close by.

Dr. Kang also commented here how he also wasn’t sure why so many surgeons found it necessary to always open the inguinal floor when in many cases it’s just not needed.

Lastly, I do think with some of the techniques, even with permanent sutures the amount of permanent material is pretty negligible considering how thin the sutures are. Shouldice obviously will have more. I asked Dr. B what he recommended for me and I told him I was open to permanent, but he thought given my history it might be best to go with absorbable so there’s no question down the road about whether or not some permanent material is causing ongoing issues. He may have suggested that partially for his own protection, but he seemed to think a younger healthy person should be able to form enough scar tissue over several months to hold an indirect hernia tightly. And as I mentioned before, he did some extra work to strengthen the direct space.

[Unknown Member]

Watchful…thanks again for weighing in.. I have now studied this for a good 5 years and with the hindsight to know that lap mesh is a disaster. Maybe if i had gone to the Carolina Medical Center I would have gotten a better result who knows. The two surgeons I saw in DC both said thats where they would go for lap surgery. But knowing how you are never out of the woods with mesh…I guess its still best to gamble on tissue. JF is like you thousands of hours of research. Flew all over the country to see the best docs…his experience with shouldice is like mine…many taking a very long to recover from the surgery. Some complaining of issues 4 years later. Also the sensation of tightness and loss of flexibility…even from guys who went to shouldice. Dr Kang says shouldice is too invasive…Twofigh said its alaway too Tight. AS you discovered there is good potential for chronic pain. After speaking with many desarda patients i thought i would go in that direction…but the anti desarda facebook page…JF’s comments and your own have dissuaded me from that repair When i spoke with peterson…he mumbled that he did his own mesh free repair…based on shouldice with modification…he assured me he did not have cases of severe chronic pain…well thats great but what about less severe???? I cant believe after countless hours of research that I don’t have more clarity. The german surgeons look experienced and i spoke to Koch and he was very nice…but they are all doing mostly shoudice–I just think the risk for chronic pain with that repair is too high. What i dont get is this. I have several friends who had tissue repairs in the late 60s and 70s…that are still holding….these tissue repairs were not fancy shouldice repairs….they were just sew jobs from some local yocal…yet they have stood the test of time and neither of these guys has any pain. Is there a way to just sew these hernias closed without opening the inguinal floor and putting a bazillion layers of suturing in??? After reading Mike Ms stofy…are you still sticking with Conze as your top guy? thanks

[Watchful]

Lichtenstein isn’t so great. Remember the hard bacon pictures of removed open mesh with adhered nerves posted by Dr. Brown? He was doing many of these removals, and said that this was the procedure that caused him to lose the most sleep.

As I mentioned a couple of times before, one of the general surgeons with whom I consulted needed a nurectomy after a Lichtenstein procedure he had for his own hernia. Now he normally cuts the ilioinguinal nerve in his patients (just like VA surgeon from the Hernia journal letter).

With inguinal hernia surgery, all you can do is pick your poison, and who will give it to you. It does turn out ok in most cases regardless of the choice of technique, but at least some level of chronic issues is too common for comfort.

Lap mesh does seem scary, but surprisingly it actually has the best results overall in most studies that I’ve seen – faster recovery, lower rates of chronic pain, and similar recurrence rates. The risk of causing nerve issues is higher with open mesh and tissue repairs than lap mesh.

[Unknown Member]

GI you never advised who you will select in the event of a recurrance…its really troubling how there is basically one safe option for hernia repair in the world….but millions of open mesh guys seem to be doing just fine….

[Good intentions]

Never mind, I found it. Overlooked it the first time. Good luck.

“he spent thousands of hours researching hernias…traveled all over visiting surgeons…”

[Good intentions]

Who is JF? If he wants to stay anonymous, what are his qualifications, at least?

[Mike M]

@watchful Just to clarify I have no lingering pain and no real pain after the first few days. Also nothing of what I would consider of consequence after the first few weeks. The outcome to me was as “perfect” as I had hoped.

Keep in mind prior to surgery I was to the point (pain wise) where I wasn’t even sure if I would be able to make it on the plane to South Korea. Size doesn’t always tell the full picture imho.

[Watchful]

This doesn’t sound so great. Having symptoms for months after surgery, and still feeling something there after a year (even if minor) isn’t great. Not bad, but not the most desired result. We need to remember that you didn’t even have a large hernia.

[Mike M]

@chuck

Dr. Kang’s repair that is similar to Marcy is only if you have indirect.

Dr. Kang repair is closest to Bassini for direct hernias.

Pain was only bad that first week. Some tension the weeks that followed and then it fades into nothing. I can still feel something in that area but nothing of mention. You can only really feel the scar tissue the first few months maybe. The nerves seem settle down and accept the repair after a while. I am starting to “forget” I even had hernia surgery now which was the end goal.

I know his son is completing the Kang repair now. I do not have any other information on that but maybe Dr. Kang can comment.

Dr. Kang elaborated on the corrupted vs. uncorrupted Bassini on these forums.
https://herniatalk.com/forums/topic/kang-repair-question/

“Although I said the Bassini repair belonged to Group 1, the Bassini repair published in 1890 was a surgery that belonged to Group 2. The essence of original Bassini repair was to repair the damaged transversalis fascia barrier. While the recurrence rate of inguinal hernia repair announced by other hospitals exceeded 50%, the same rate announced by Bassini in 1890 was merely 2.7%. Owing to this remarkable performance rate, the Bassini repair quickly became famous and many surgeons adopted it. However, it was unfortunate that the method was ‘corrupted’ in the course of it being widely propagated – the initial (and essential) process of transversalis fascia repair was omitted, and the new main barrier was built by pulling and sewing together the separated muscles and ligaments. Some called so ‘corrupted’ surgery method the ‘corrupt Bassini repair’ and the original Bassini repair the ‘authentic Bassini repair’. Thus, the Bassini repair that was said to belong to Group 1 in the above was actually corrupt Bassini repair. However, the authentic Bassini repair is certainly a method that belongs to Group 2 and should be regarded as the most advanced method in the Group. In fact, the processes of repairing transversalis fascia (the main barrier) under the Shouldice repair and the authentic Bassini repair are almost the same. The only difference would be how to create the auxiliary barrier. Thus, some call Shouldice repair the ‘Bassini-Shouldice repair.
Sadly, the Bassini repair most surgeons learned, knew and practiced was not the authentic type, but the corrupt type.

I believe that correctly and strongly repairing the transversalis fascia, the anatomical barrier, is the most important issue in preventing recurrence of hernia. That is why the recurrence rate of initial authentic Bassini repair was only 2.7%, which is an excellent rate even today.
However, as the corrupt Bassini repair became the golden standard of hernia repair thereafter, the recurrence rate had to show a high level of 10 to 30%.”

Kang Repair question