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For Direct Treatment Only
At Dr Kangs website he states that Shouldice and Desarda should be used only for direct hernias.
Since 70% are direct, are we to conclude that 30% of people are getting the wrong treatment if they are not diagnosed before surgery?
That seems like a pretty serious problem? Can a doctor chime in?
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24 Replies
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What about a surgeon that does not do any imaging or ultrasound
Just cuts open does no mesh repair and then decides what type of repair he will do
Either desarda or shouldice once he cuts hernia
That is acceptable protocol
Thanx -
@uhoh This seems to make total sense to me for what it’s worth too. Dr Conze in Germany, who I think is fair to say matters a lot what he thinks, also agrees. They will not do any surgery until the surgeon themself does an ultrasound. Not a passed-off reading done elsewhere even, but their own.
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This, to me, is a great lesson in being careful what behaviors we incentivize, and what the unintended consequences might be. Long ago, it was determined, somehow, somewhere, that the primary determinant for successful hernia surgery was recurrence rate. Therefore, every surgeon’s primary incentive was to prevent recurrence (as that is the primary metric of a “successful” operation).
Unfortunately, an occult hernia on the same side would still appear as a recurrence, even if its origins were entirely different. So, what do you do, in order to prevent such “recurrences”? Check for hidden hernias, or insert enough prosthetic to cover every possible site of another hernia, of course!
That’s why, in my (completely non-medical, non-professional!!!) opinion, Dr. Kang’s greatest innovation is the use of ultrasound imaging preoperatively. Having that information, of what type you’re dealing with, and whether there are others lurking, ensures that only necessary cutting and sewing be done.
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@Casimir I understand English is not your native language (neither mine) and it’s hard for me to fully understand what you really mean. I invite you to please write it in your own language and I’ll try to have it translated by Google so that I can help.
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@kaspa I should have said that by non-reduceable, there is no material at the hernia site that is extended outwards and reduces, none that does so under pressure, non-reducible because it’s not extruded to begin with at the site. If the material migrated a few inches one would have to assume it’s fat. If it were intestine and separated form itself… that would seem to be physically impossible or there would be serious emergency issues.
Anyway, each is different so maybe not useful to talk in generalities. But — seems like a lot of destruction of healthy tissue, for a small indirect hernia as I described. I doubt a doctor would opt for that treatment with a Desarda in that case. If they did anything, at all.
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@Casimir If your’ hernia doesn’t bother you too much maybe it’s better to wait and see. I wouldn’t agree though that a non-reducible hernia cannot incarcerate.
Indirect hernias usually have intestinal contents, not fat…
About 10% of patients from Shouldice Hospital are doctors. So they take the full repair for direct or indirect hernia.
If treating an hernia was quite simple, something like an injection, and costed something like $100 I’d take a specific repair and see. However repairing it may cost a lot of money and you wouldn’t like to repeat that in case you get another hernia on the same side. Further, if you don’t have any complication what’s the problem to have the whole groin repaired?
IMHO Desarda and Shouldice are designed to repair both direct and indirect hernia, whatever type one may have. Why don’t these surgeons have designed a specific repair for indirect hernia is a mystery. Maybe they need to repair the whole Hasselbach triangle to have a robust indirect hernia repair.
Dr. Kang designed a modified Marcy that works in adults. That’s great but you still have a small change you need to have another repair. If you treat all area you only have to worry about the other side if you have no hernia there.
It would be highly desirable that Dr. Kang publish his repairs and results anyway. Not just to offer more confidence, but also to help non-mesh repairs evolve.
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You might have to create an account. It’s easy to do, just an email and a pasword.
The discussion seems to cover all types of hernias, not just inguinal so is a little broader than what most people here expect. Still, the views are interesting. Dr. Voeller especialy, since he is a aprofessor and is well-knonw on the conference circuit.
Even for incisional hernias, the benefits of mesh are undefined. And the experts still talk about all mesh types “as “mesh”. All the same despite all the differences.
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Yes I agree 100%…to the point that I am thinking even the learning of the anatomy of the area might be overlooked these days…
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A big part of today’s hernia repair with mesh uses the idea of “prophylactic” repair, or prevention of future hernias. I had written about this a few years ago and was told that that it doesn’t happen but I just saw a panel discussion where the question was raised and several surgeons said that they do it routinely. I’ll see if I can find it, it was in General Surgery News.
So, I think that your question will only reach a very very small audience. Dr. Kang has realized this and uses the term “type-specific repair”, as you noted. But surgeons today aren’t taught about type-specific repair. They’re only taught about preventing all future recurrences by implanting as much mesh as they can fit over all possible hernia sites. It sounds crazy but I think that it is true. The mesh is seen as a better version of the existing abdominal wall, like something Ironman would develop (so that he can carry the heavy steel suit).
I think that only two surgeons who might respond to your question have already responded in many past posts. Dr. Brown and Dr. Kang. Everyone else is still thinking in terms of recurrence. The training to answer your question well just isn’t there anymore.
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@kaspa Yes, I might ask him. I know I think what he will say though based on what he says on his site.
From what I have learned, a small indirect hernia, that remained small say for 3 or 4 years already, say is fatty, and is non-reducable and therefore the risk is basically nil for strangulation, and is causing minimal pain, zero testicular pain, and has virtually no physical oppressors so you can do what you want without it inducing pain, is about as perfect the instance for at least *suggesting a “watch and wait” approach as an appropriate option to consider as there can be. I can’t image a more appropriate time actually.
I’d be surprised, if given that scenario, a doctor here would subject themselves to a desarda that frankly does considerable damage to tissue that is generally fine in this case, and with the added risk of never fully knowing what the result of surgery will be, as there are obviously risks to be considered.
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I said “incarcerated” but should be “strangulated”.
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Dr. Kang is perhaps the only doctor doing specific repair for indirect hernia. I don’t think non-reducible hernias aren’t able to be treated by any tissue repair (perhaps you mean incarcerated?).
Treating your indirect hernia only means you have a small risk, perhaps 10%, you can have a recurrence because of a missing hernia and you’ll need to be operated again.
A small indirect hernia won’t last forever that size and will likely enlarge.
Information given here is provided between forum users with good faith to anyone requesting it.
You can also e-mail Dr. Kang and I’m sure he’ll gladly provide all personal information you need.
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Edit 2: that also caused minimal pain and didn’t impede physical activity.
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Edit — I meant to type he says ““everyone SHOULD know this”.
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@drtowfigh @drbrown or any other doctor that is willing to weigh in about the post directly above ^ — can a doctor weigh in please? This thread sort of reached a point where there’s an interesting question hanging, and input from those who’s opinions would carry the most weight / respect I am guessing would be appreciated…
The question from above is (and started this thread as I saw on Dr Kangs site that he says “everyone would know this”, by that I assume he means every patient should know it’s not recommended): What would a doctor on this forum do for themselves in the case above, ie,, would you think it appropriate and see a likely case for yourself to have a desarda or shouldice done on yourself, if you understood you had a 1) non-reduceable 2) small 3) indirect inguinal hernia?
Seems to me that would not be a wise choice per Dr Kangs reasoning, but the more opinions the better and appreciated, thank you.
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I think the desarda is indicated for reducible hernias, not indicated for non reducible indirect. I see studies on them and the subjects have reduceable.
Why would anyone allow or propose all the tissue damage and re-arrangement and associated risk for a small indirect non reducible hernia, say, when it’s got nothing to do with that type? Even moving ab muscles can affect reliant structures, like your spine…
Sounds like crazy talk to me. Like getting a CT as part of annual physical — or worse actually, because we know 100 for certain that will never be the same.
Can a doc weigh in? Would you undergo this for yourself under these circumstances?
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According to Shouldice numbers 1991-2001 secondary hernias are not as prevalent as in Obney’s article.
They repaired 72.228 hernias. Of these 60% were indirect and had 8% occult hernias, 38% were direct and had 25% occult, 1.88% femoral and 70% occult. This makes about 15% on average.
If you have no complication after hernia repair, I think having indirect-only repaired or all area repaired doesn’t make a great difference. Perhaps if you have indirect-only repaired and later need a direct repair, that’s more difficult to do (my thoughts). Missing a femoral hernia, even if quite rare, is too bad as these can be really dangerous.
Anyway, these considerations only happen with tissue repairs. For mesh repairs, one is applied blindly and there’s no discussion.
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I think both comments have validity.
What I like about dr. Brown’s approach is that he looks at the tissue and what’s going on inside the patient and then decides on the best approach and he says he is skilled on all of them.
Not sure if he checks for a femoral hernia or not.
I’d imagine say one has a direct hernia but say the direct area tissue is weakened he may do a shouldice type repair to fix the indirect hernia and reinforce the direct space at the same time.
But I do like the bathroom comparison as it appears for many a simple Bassini or modified Bassini for a indirect hernia is appropriate.
Although it seems like the shouldice repair at the shouldice hospital gives you a comprehensive exploration of all 3 types of inguinal hernias as well as a very sturdy repair for a low recurrence rate. -
Shouldice claims that often enough there are occult hernias and these account for a percentage of recurrence. That’s why they explore the whole area, including searching for femoral hernia (here, if present, they apply a mesh almost always). To explore the area completely they must cut a lot of structures and reconstruct them. That’s the rationale. I presume Desarda is more or less the same.
According to literature if you treat indirect hernia only, you’ll get 37% recurrence due to “missed hernias”. See: Obney N, Chan CK. Repair of multiple time recurrent inguinal hernias with reference to common causes of recurrence. Contemporary Surgery 25:25-32(1984).
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My understanding is that when it’s indirect, there is generally no issue with many delicate and important structures the desarda is disruptive to.
And therefore is sort of like asking for a remodeled bathroom, you leave, and come back to a demolished house and a new one not as good cobbled together in it’s place, and the contractor says well you said you wanted a remodeled bathroom — ya got one. Technically you satisfied the request, but with collateral damage that is not appropriate.
This is how I am reading it. I will do more research. For whatever reason, this stuff fascinates me now.
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