Experience with Shouldice , Kang or Desarda repair .

[Monika]

I have small inguinal hernia that will need to be repaired soon. Has anyone had a good or bad experience with Shouldice repair ? I have read a bit about Dr Kang and really like the idea of a minimally invasive operation however I have seen 2 negative opinions on him after operation on hernia talk . Wondering if anyone has Had genuine positive experiences with the hospital in South Korea. Also I have managed to find a doctor in Sydney who can perform the Desarda technique . Has anyone on here had a negative experience with the Desarda operation? Would greatly appreciate any help .

[William Bryant]

Hello again Monika,

What were the 2 bad results with Dr Kang? As I am thinking of a Kang repair?

As far as Desarda, I have seen some negative comments on another forum, hernia bible, but I made a mess of signing up and it’s difficult to search, well I find it so.

However if you go on to it the forum access is towards botom of menu lh side. You don’t have to join to read.

The number of positives for Desarda on there outweight negatives, but the bad ones did make me reconsider Desarda.

That’s the problem, there isn’t a single system that has nothing but good reviews so I go from Desarda to Shouldice to Dr Kang then back again.

Would recommend asking how many Desarda ops the Australian surgeon has done.

[William Bryant]

Actually Chuck, having revisited they aren’t too bad, the bad ones!

[Monika]

Hi William , I think it was Pinto from this forum . I think he had unfortunate experience with Dr Kang . Someone else had recurrence of the hernia within 7 days post operation . I can’t find any reliable sources for Dr Kang and his technique so I am a bit apprehensive about going all the way to South Korea.
I am going thru all this methods back and forth as well . The Desarda looks appealing as the doctor in Sydney would be able to perform it . However the Shouldice repair might have the best long term outcome . You mentioned before Dr Bailey in Uk . Do you have any experience with him?

[William Bryant]

I’ve not had any surgery Monika. But Simon Bailey was trained by the Jones’s who did tissue repairs in UK. Again it’s very hard to find reviews for Simon Bailey. I’ve not come across any for his shouldice hernia repair but he was spoken highly of on patient info forum for mesh removal.. And through googling I found an article about the dancer James Jordan having had his hernia op with Simon Bailey. (I suspect this was a sports hernia not our type of hernia, although it wasn’t made clear).

If someone else had a repeat at 7 days via Dr Kang that is a worry. Did you find that out on thia forum? I’d love to read about it.

I’m wondering whether Dr Kang’s figures are as accurate in that case as I was hoping they were. I wouldn’t want 12 hour flight and a recurrence. What a dilemma.

Beginning to favour Desarda again. But where to get it done???

[Monika]

Someone on hernia talk had recurrence I went thru all the posts one when I was looking for good surgeon . It’s going to be somewhere in here I’ll try and find it for you . Have you heard of clinic in Munich I think the doctors name is Conze I’ve read on here that apparently he is very good for Shouldice repair . It’s a long flight and I guessed you would want to make sure it’s really worth it . Dr Kangs method dose sound very good just not sure how real it is . It’s all super frustrating to be honest . I don’t think it should be this hard to find a surgeon to do mesh free repair well. It’s feels crazy. I have read that lots of people had a very good experience with Dr Yunis in Florida . I’ll try and contact Dr Bailey .

[William Bryant]

https://www.simonbaileysurgeon.co.uk/

[Stephen]

Hello,
I am Stephen, who is working to respond to non-Korean international patients who are curious about Kang Repair. I’ve been doing this for 13 years now. I am also currently translating the book ‘Kang Repair’ written by Dr. Kang. That’s why I know Kang Repair (hernia surgery) very well.
Many people seem to find it difficult to believe because the known results of Kang Repair are too good to believe. It is true that it is difficult to believe the outstanding results of Kang Repair because most of the hernia surgery methods currently being implemented worldwide have many problems. But I know well that all of these results are true because I watched closely for a long time.
Kang Repair began in 2013 and has undergone several upgrade processes so far, and has been fixed as the current surgical method 27 months ago for ‘indirect’ inguinal hernia and 36 months ago for ‘direct’ inguinal hernia.
With this final surgical method, 812 ‘indirect’ inguinal hernias have been operated so far, and 722 ‘direct’ inguinal hernias have been operated. Among them, there was 0 case of ‘indirect’ recurrence and 6 cases of ‘direct’ recurrence.
It is said that there was no preoperative patient selection at all.
For your information, I attach graphs related to recurrence received from Dr. Kang. Please note this data is internal data that has not been published. I heard that few patients complain of chronic postoperative pain.
There are many testimonials in Korean about Kang Repair. They are not written in English, so foreigners cannot understand them, but we can hardly find a negative testimonial. It can be guessed from the fact that Gibbeum Hospital is performing the most hernia surgeries in Korea.
I was worried that you might misunderstand it as promoting, but I think many people are curious about the truthfulness of Kang Repair’s results, so I post a brief introduction.
*Two graphs will follow

[William Bryant]

Thank you Stephen, could I ask what does the hospital do if there should be a reoccurrence?

It would be very useful to know as I, and some other posters, are considering a repair with Dr Kang but as we are miles overseas it would be good to know what happens if there is a problem?

Also what are covid restrictions from say UK,
USA,
and Australia?

Many thanks.

[Stephen]

Especially for those coming from abroad, we are paying more attention to prevent recurrence, but for those who recur, surgery is provided free of charge for treatment. Kang Repair is relatively easy to reoperation because the adherence is not severe even when recurrence occurs.
COVID-19 is currently required to self-isolate on the 7th day*, and there is a possibility that quarantine policies will be further eased soon.
*As soon as you arrive in Korea, you are sent to a hotel of quarantine for 7 days for now with three meals a day provided for the cost of about 100USD depending on the hotel assigned by immigration/quarantine officer(s).

[Stephen]

Preveously I wrote two graphs will follow, of the recurrence of ‘indrect’ and ‘direct’ inguinal hernias.
You will find them in the following link:
https://blog.naver.com/surgeonkang/222658232228

[Stephen]

Further explanation on quarantine in Korea:
The cost about 100USD including three meals is for a day. So for 7 days the cost will be about 700USD. A couple of months ago it was 14 days. As said the restriction will be eased down as time goes by.

[MarkT]

Hi Monika,

I’ve had two repairs at Shouldice Hospital for inguinal hernias (right side 30yrs ago, left side 18yrs ago). Both were flawless as far as I can tell, with no post-op complications or long-term chronic pain at all.

Shouldice’s recurrence rate is extremely low and they guarantee their repair for life (fees are waived for a confirmed recurrence).

[Monika]

Hi Mark ,
Thanks so much for your help . The Shouldice method looks like a very good technique with very low recurrence rate. Unfortunately no one offer Shouldice repair in Australia so I would need to go maybe to Canada or the states .

[MarkT]

Hi Monika,

Fair point…travel can be an obstacle for many people. I can say that Shouldice does get a lot of international patients. When I was there, there were a few from the U.S., U.K., and S.America.

Regardless of what repair method you choose, surgeon experience/frequency is an important variable, and this is particularly true of the Shouldice repair, which is described as relatively complex. I would be quite reluctant to have that repair performed outside of the Shouldice Hospital unless I was certain that a surgeon had a LOT of experience with that repair and performed it fairly frequently.

[William Bryant]

Hello Mark,
Did the Shouldice cut cremaster muscle and/or any nerves?

I’ve read that you don’t get to choose surgeon so you could have someone who is very experienced, experienced, inexperienced or training.

Glad to hear yours went fine.

[MarkT]

Hi William,

Neither of those have been major concerns for me, to be honest.

Shouldice has a reputation and track record to protect…they aren’t going to allow an unprepared surgeon to ruin that. Per their site, their training includes a surgeon assisting on 50 repairs before they are allowed to perform one themselves (under supervision) and then they perform up to 100 repairs (under supervision) before they are allowed to lead a surgical team.

I am not sure why there is so much discussion/concern regarding the way Shouldice treats the cremaster. While I honestly can’t speak to associated risks, keep in mind that *hundreds of thousands* of repairs have been carried out at the Shouldice Hospital over many decades. If significant risks and negative outcomes are associated with the way the cremaster is treated, we would surely have heard of it by now in the research literature and/or via patient reports. Anecdotally, my cremaster reflex has been unaffected by both surgeries.

Dr. Bendavid, a surgeon and researcher from Shouldicde who has since passed, wrote:

“Resection of the Cremaster
This important step seems to have been entirely forgotten. Few students have seen it performed, and fewer surgeons practice it. This step was clearly described and emphasized by Bassini, repeated by Catterina, and perpetuated by Shouldice. The resection of the cremaster and lateral retraction of the cord bring into view the posterior inguinal wall in a manner that can best be described as a “revelation.” It becomes impossible, then, to overlook a direct or indirect inguinal hernia. The transversus abdominis aponeurosis (i.e., the posterior inguinal wall) is now in full view. Whenever possible, the cremasteric vessels should be doubly ligated separately from the cremasteric muscle.” (https://basicmedicalkey.com/the-shouldice-method-of-inguinal-herniorrhaphy)

I’ve read that patients will sometimes have more than one hernia present…so, in addition to claims of reduced recurrence, perhaps this is also a tool to help ensure than no other hernia or area of weakness is missed? Many surgeons will state whether they touch it or not, but I have yet to read anyone claiming that it “ought not” to be touched or any evidence regarding negative outcomes.

It is ALWAYS good to ask questions…but I would not let those two points deter you from considering Shouldice.

[Watchful]

The Shouldice Hospital is a bit of crapshoot, unfortunately. This can be seen in on-line reviews and some blog posts. Overall, most of the reviews are good, but there are quite a few bad ones, including some seriously bad issues. A few surgeon names appear again and again in bad reviews, and those surgeons are still there.

Regarding cutting the cremaster muscle and its nerve… It is indeed true that thousands of these procedures are done a year, so it can’t be that bad to do this. However, this doesn’t mean that there aren’t occasional complications from this (low-hanging testicle, spasms, pain, etc.) which may not be necessary – is the potential benefit really worth the potential trouble? Hard to say, and surgeons who are not trained at Shouldice don’t like to do this. It does add even more complication and anatomical changes to a procedure that already has a lot of that.

Also, if we apply here the argument of “many procedures are done, and there isn’t a widespread outcry about results”, then we can equally apply it to mesh. Hundreds of thousands of those are done a year in the US, and if this was truly a bad procedure, we would see a lot more bad cases. The reality is that there is a small percentage of issues with both Shouldice and mesh, but the vast majority turn out fine. There don’t seem to be definitive studies on what is better, so there is uncertainty on that aspect, but we have to keep things in proportion when thinking about what to choose, and look at things realistically for both procedures. I personally lean toward Shouldice vs mesh for my case, but I’m not sure that this is the “right” decision. I would in all likelihood be ok either way. Maybe the worst case with mesh is worse than the worst case with Shouldice, so that could be a valid argument even when the risk is very remote.

[Good intentions]

“Also, if we apply here the argument of “many procedures are done, and there isn’t a widespread outcry about results”, then we can equally apply it to mesh. Hundreds of thousands of those are done a year in the US, and if this was truly a bad procedure, we would see a lot more bad cases. ”

Acknowledgement that chronic pain is real by the Editor-in-Chief of Hernia

[Watchful]

Right, but chronic pain is real with Shouldice as well, including at the Shouldice Hospital. Watch Dr. Towfigh’s video with Dr. Netto from the Shouldice Hospital. He said they were surprised by a higher percentage of chronic pain than they thought, and were studying it. He was expecting the study to show about 5%.

[Good intentions]

It’s hard to imagine that Dr. Campanelli would not mention chronic pain from pure tissue repairs if the problem was significant. He has every reason to, as an author of the ordinal recommendations to use mesh as the first choice for hernia repair. Not a hint in his letter that he was even trying to draw an equivalence.

Actually, he even hinted at the possibility that the recurrence argument for mesh might not be what it was claimed to be.

From his letter –

“In the past, the most negative long-term effect was recurrence, the incidence rate of which seems to have fallen significantly since prostheses came on the scene. This latter observation, however, remains to be assessed in light of the doubts we have often expressed about the effectiveness and reliability of reported follow ups.”

[Watchful]

The Shouldice Hospital does the largest number of these procedures. Their surgeon is saying that the incidence of chronic pain that they see is higher than they thought it would be. This prompted them to perform a study, and he estimates it to show about 5%. I would take that seriously. He said that their official number is still 1%, but that’s for debilitating constant pain. For chronic pain in general, the number is higher. Higher than they expected, and they are studying it. He thinks 5%. Please watch the video.

[Good intentions]

I’m just providing information, with sources, for people trying to make decisions. Most of my comments have a link to a professional source behind them.

I often compare the chance of chronic pain from mesh to the game of “Russian Roulette”. One chance in six of getting a bad result. That is what numerous studies have shown, which I have linked to in numerous posts at various times over the years.

But, besides the odds of getting a bad results, people should consider the “weight” of that bad result. A recurrence with a pure tissue repair is most often just like going back to where you started. “My hernia is back”. With a pure tissue repair, even the body is almost back to where it started.

I can’t speak to chronic pain from a pure tissue repair because I don’t recall seeing any descriptions of chronic pain from a pure tissue repair. If you can find some please post them.

With a recurrence from a mesh repair, the apparent solution is more mesh or a different type of mesh. Probably after mesh removal, if I recall past posts from Dr. Towfigh correctly. That is an example of the “weight” of the problem of recurrence from mesh. Mesh removal, then more mesh implanted.

With chronic pain from mesh, the weight is also very heavy. Neurectomy, mesh removal, pain medications, etc.

An analogy might be jumping across two ditches. If one ditch is two feet deep and you don’t make it, you can climb back out and try again (pure tissue). If the other ditch is 30 feet deep and you don’t make it you’re probably going to suffer some damage (mesh implant).

That’s what it boils down to from my way of seeing it – the odds of a problem and the magnitude of the problem if it happens. Most of the surgeons promoting mesh deflect from the magnitude of the problem if it happens. They stop considering the patient’s welfare.

[drkang]

@Good Intentions,

I always appreciate your deep knowledge and accurate analysis of hernia repair. I don’t think there are any doctors out there who probably have more relevant knowledge and standards of judgment than you.
I personally always agree that your assertions are closest to the truth.

A low recurrence rate is the number one priority among surgeons advocating mesh repair. However, in actual clinical practice, it is not uncommon to see patients who recur after mesh repair. So, I personally think it’s likely to be higher than the often claimed relapse rate of mesh repair.

There is a paper where you can estimate the actual recurrence rate of mesh repair.

Murphy BL, Ubl DS, Zhang J, Habermann EB, Farley DR, Paley K.Trends of inguinal hernia repairs performed for recurrence in the United States. Surgery. 2018 Feb;163(2):343-350.

Exerpt-

Results: In the Premier database, of the 317,636 inguinal hernia repairs, the proportion performed for recurrence had a small decrease in males from 11.4% in 2010 to 10.5% in 2015 (P < .0001); however, it remained constant in females (6.5% in 2010 to 6.7% in 2015, P = .46). In the National Surgical Quality Improvement Program database, of the 180,512 inguinal hernia repairs, there was no change for either sex: 10.5% to 11.2% (2005-2014, P = .12) in males and 6.2% to 7.1% (2005-2014, P = .11) in females. Within our institution, in the 9,216 patients identified, there was no change in the proportion of inguinal hernia repairs for recurrence in males: 13.3% to 11.5% (2005-2014, P = .25). In females, the proportion increased from 1.3% to 12.0% during the study period (P = .006).
Conclusion: Based on these larger evaluations of recurrent inguinal hernia surgery, the current literature on inguinal hernia repair recurrence is skewed and overly optimistic.

The above results indicate that at least 10% of new inguinal hernia repairs are due to recurrent hernias.
Considering that most of the inguinal hernia repairs are mesh repair these days, it is thought that most of these recurrent hernias are recurrences after mesh repair.

Moreover, if the following paper is true that the rate of recurrent hernia reflects only a part of the actual recurrence rate, the actual recurrence rate of mesh repair is likely to be much higher than 10%.

Kald A, Nilsson E, Anderberg B, Bragmark M, Engstrom P, Gunnarsson U, et al. Reoperation as surrogate endpoint in hernia surgery. A three year follow-up of 1565 herniorrhaphies. Eur J Surg 1998;164:45-50.

Exerpt-

Results: During 1992, 1565 hernia operations were done. The postoperative complication rate was 8% (125/1565). At 36 months postoperatively 108 recurrences had already been reoperated on, six patients with recurrences were on the waiting list for reoperation and a further 36 recurrences had been detected at follow-up. The interhospital variation in recurrence rate ranged from 3% to 20%. Postoperative complications, recurrent hernia, direct hernia and hospital catchment area over 100000 inhabitants were all factors associated with an increased relative risk of recurrence.
Conclusions: The recurrence rate exceeded the reoperation rate for recurrence by almost 40% which should be taken into account if the reoperation rate is used as the endpoint after repairs of groin hernia. An audit scheme, based on prospective recording, reoperation rate, and (periodic) calculation of the recurrence rate may be used to identify risk factors for recurrence and areas in need of improvement.

[Watchful]

So, where does all this lead? Both mesh and tissue repair cause chronic pain in some cases, and both suffer from recurrence in some cases. Different studies show different results, and there is no clarity on which type of procedure is better in terms of chronic pain and recurrence.

The information I got from doctors that I asked is to expect similar results in the hands of top surgeons. In other words, the surgeon matters more than whether the procedure is mesh or tissue repair. Similarly, even Dr. Netto from the Shouldice Hospital said that the difference in outcomes between Shouldice and mesh is in the statistical noise.

The problem is that it’s much more difficult to find a top tissue repair surgeon than a top mesh surgeon. On the other hand, when mesh goes bad, it can go REALLY bad (requiring complex removal), while with tissue repair bad outcomes don’t quite reach that level.

• This reply was modified 1 year, 7 months ago by Watchful.

[Jack]

This seems like a logical way of looking at it. It does seem like pain can happen though with pure tissue. On Google there are some negative (from a pain perspective, who cares about the food) reviews of Shouldice as well as some of the “modified Shouldice” docs in the USA. I’m not a doc, so just a guess but maybe pain from a tissue repair comes from scar tissue hitting nerves? Or a nerve accidentally sutured? Or the “tension”. I do think the pain, based on a few reviews, can be more than just discomfort. And there’s the issue of there’s so few tissue repairs compared to mesh. If there were 800k tissue repairs every year in the USA there would probably be a lot of people online upset about them too?

[Watchful]

Exactly. Chronic pain happens with tissue repair as well, and there are plenty of ways this can happen with the Shouldice procedure.

A surgeon at Shouldice Hospital (Dr. Netto) who works in the trenches is a good professional source. I would take what he says seriously.

[Monika]

Dose anyone on here has experience with Desarda technique? Any long term pain or any bad side effects ?

[drkang]

The Surgical Clinics of North America (SCNA), published under the title of Hernias in April 1984, three years before mesh repair was introduced, said, “Groin pain after normal convalescence from an inguinal hernioplasty is infrequent, but when it occurs, it invariably precipitates a visit to the surgeon by the patient, who believes that the pain indicates recurrence. Although groin pain may, in fact, herald a recurrence, in most cases it disappears spontaneously without sequelae.”

The author seems to have foreseen the excuses of today’s mesh repair surgeons, saying that there were many chronic pains in the past too and that it is not a problem only with mesh repair.

Also, on page 126 of Daniel B. Jones’ textbook ‘HERNIA’, Figure12.1 shows Google ngram comparison that the number of uses of the word ‘chronic groin pain’ in books listed on Google has increased sharply when compared with ‘inguinal recurrence’ since 1987. 1987 was the year when mesh repair was first introduced and gradually started.

The claim that tissue repair causes chronic pain as much as mesh repair might be a defocus strategy.
I have performed more than 70 mesh removal operations so far for a person who complained of chronic debilitating pain after mesh repair. However, while I’ve done over 10,000 tissue repairs, I can hardly remember anyone who has suffered from chronic debilitating pain yet.

• This reply was modified 1 year, 7 months ago by drkang.

[Watchful]

Thanks for reporting your results, Dr. Kang. No cases of chronic debilitating pain out of 10,000 tissue repair surgeries is amazingly good.

May I ask how many cases of recurrence have you seen out of these 10,000?

[drkang]

Hi Watchful,

After receiving your question and reviewing my surgical record again, I found that 12,363 non-mesh inguinal hernia repairs have been performed since 2013, and 217 patients have had reoperation due to recurrence. 1.8% of the total.
However, since 2013, my surgical method has improved over 50 times. Therefore, these statistics cannot be regarded as representing the recurrence rate of Kang repair in the final method currently being used.

The number of people who have had surgery with the current method so far is 1,528. Of these, 675 patients had more than one year after surgery, and 4 cases required reoperation, accounting for 0.6%.

This is not accurate follow-up data conducted through telephone interviews, etc. But I think people who have relapsed come back to me with few exceptions. This is because they are all people who have received Kang repair with a reluctance to mesh repair. However, I do not want to guarantee that no one will go to another hospital after a recurrence. Please refer to this and evaluate our recurrence rate.
Also, please evaluate the mention of chronic debilitating pain in my previous posting in the same context.
Thank you!

[Watchful]

Hi Dr. Kang,

Thanks for providing the numbers. These are extremely good results – congratulations on such a stellar record.

I think in terms of recurrence, the results claimed by the Shouldice Hospital are in the same ballpark as yours. There is some difference in terms of pain, though. Dr. Netto (from Shouldice) was mentioning 1% chronic debilitating pain, and an estimate of 5% for chronic pain in general. Your results are effectively no chronic debilitating pain, and you didn’t mention the result for chronic pain in general.

Is there something in particular in your procedure (when compared to Shouldice) that makes it better in terms of chronic pain?

[drkang]

No clinical trial has been done for that part. And I think 1% or 5% of Shouldice pain incidence is much lower than that of mesh repair. The incidence of chronic debilitating pain after mesh repair is probably around 5%, I guess.

If Kang repair has a lower incidence of chronic pain than Shouldice, I think it may be because of the difference between the surgical scope and the surgical process. For Shouldice repair, the skin wound is about 3-4 inches, whereas Kang repair is about 1.5 inches. The size of the skin wound refers to the size of the surgical area.

And Kang repair preserves normal tissues as much as possible, whereas Shouldice repair cuts the cremaster muscle and genitofemoral nerve, etc. It means Shouldice is more aggressive. Due to this invasiveness, the chronic pain incidence could rise.

[Author]

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