Experience with Shouldice , Kang or Desarda repair .

[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.

[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]

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]

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 2 years, 2 months ago by  drkang.

[Monika]

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

[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.

[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?

[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.

[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]

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]

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]

“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. ”

https://herniatalk.com/forums/topic/acknowledgement-that-chronic-pain-is-real-by-the-editor-in-chief-of-hernia/

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

[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.

[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.

[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,

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).

[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.

[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]

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).

[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.