Experience with Shouldice , Kang or Desarda repair .

[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]

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

[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]

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]

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]

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

[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.

[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?

[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 2 years, 9 months ago by  Watchful.

[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.

[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.

[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.