Good resource comparing open (mesh) repair types

Hernia Discussion Forums Hernia Discussion Good resource comparing open (mesh) repair types

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    • #29613

      As I increasingly suspect my hernia is indirect, I am rethinking what type of repair to go for. If high ligation/Marcy aren’t an option for an adult male, then I want to do my diligence on other options as the non-mesh repairs all seem to have a lot of extra cutting/sewing.

      That said, I want to understand how each differs from the other in terms of results, chronic pain risk and recovery. I want to know what to even ask a surgeon about in terms of options, but just am not that familiar and most sources only differentiate between open-tissue, open-mesh and laparoscopic.

      The other question is whether absorbable mesh is an option for indirect repair, and provides enough reinforcement for that type fo defect (vs a true tear). At least one of the studies on the topic suggested that direct hernias often reoccurred if repaired with absorbable mesh, but not indirect. Again, looking into what all the options are and how to evaluate them.

    • #29614

      I wonder, no doctor could diagnose whether the hernia is direct vs indirect? no ultrasound could discern that?

      As for me all the doctors I saw told me they were 100% sure it is direct, except one, who thinks it is indirect. And I also had two US which also reported a direct hernia…

    • #29615
      Good intentions

      Surgeons are taught that mesh will repair, and prevent, all types of groin hernias. They are not taught to distinguish or compare the results of different methods or materials. Finding a surgeon who can confidently tell you what you’re looking for will be impossible, I think. You can find videos from the professional societies where new surgeons say that pure tissue methods are not taught, and the pros and cons of the numerous types of mesh are not taught either. “Mesh” is a vague generalized word that is used to describe all types of sheet-like repair material.

      An indirect hernia is the result of the space that the spermatic cord passes through becoming enlarged or never fully shrinking down to its correct size. Abdominal contents squeeze through the opening alongside the cord. The pure tissue methods typically just pull the material out then use sutures to make the opening smaller. Mesh is a one procedure “fix-all” method that is easier to teach and easier to implement in a professional practice.

      Here is a pretty good video, below, describing the two types, although he kind of confuses things when he talks about the epigastric artery. If it follows the cord then the artery is irrelevant. I think that artery is used to identify, but not define. 6:40 is where he describes the two types. I had a direct hernia and it exerted pressure on the canal and the cord, affecting the testicle, but did not allow contents in to the scrotum. It created a small pyramid shaped bump about an inch inside of the upper crease of the groin when I stood up, that disappeared when I laid down.

      Anyway, good luck. I think that you’re going to find that the surgeons you talk to will tell you that whatever they do is best, of course. Otherwise, why would they do it. You won’t be able to find an objective view. And, most clinics have to follow a billing protocol. 15 minutes for the first exam and discussion, then the patient has to decide if they want the surgery, schedule the surgery, do the surgery, a 15 minute follow-up meeting, interaction is over. Clinics are not designed to educate, they’re designed to perform procedures. In the big scheme of things, that what surgeons do, procedures. Read Dr. Ramshaw’s account of his big mistake.

      Ironically, considering how it annoys doctors, the internet is probably the best place to get your information.

    • #29618
      Good intentions

      Sorry for the long post above. It might help you to make a list of the various types of open mesh repairs. Here are a few. I think that any of the various flat sheet materials can be formed in to the shapes of the devices used. Anything with a plug seems to be bad, by the collected accounts and discussion and tweets, even the “Guidelines” recommend avoiding plugs. But there are still surgeons using it. How can they change now, how would they explain it?

      Lichtenstein seems to have the best track record, although it still has chronic pain problems too, just like all mesh procedures.

      The two layer system is a lot of mesh, connected by a plug.

      Onflex is too new to know much about it, it has already had a redesign due to insufficient testing before market introduction. The first patients were the lab subjects, involuntarily assisting in product development.

      Plug and patch
      Two layer system (PHS, for example)
      Onflex/Modified Onflex

    • #29619

      Most repairs these days are invariant to whether it’s a direct or indirect hernia from my research into this. That said if it helps you at all, a surgeon I spoke with felt it was fairly probable that my hernia is indirect because while it’s small it occasional goes into the scrotum. As an indirect hernia provides a direct path to the scrotum that explains why a small hernia could reach. A direct hernia that’s dipping into the scrotum would usually be quite large. I hope this information can be of some use to you. Remember that even if you find a surgeon that can do a specific repair you’d like for an indirect/direct hernia they will have to work with what they see when they open you up so keep can open mind.

    • #29624


      There is a way to distinguish between a direct hernia and an indirect hernia without ultrasound.
      More than 95% accurate.

      Be sure to lie down in bed.
      Cough hard.
      If the hernia area is clearly bulging on coughing, it is very likely that it is a direct type hernia.
      Conversely, if there is no change in the hernia area or only slight bulging when coughing, it is most likely an indirect inguinal hernia.

      If you try to raise your head to check the changes while coughing, it may affect the result, so I think it would be better to check in a mirror or have someone else check.

      However, in the case of recurrent inguinal hernia, bulging occurs easily when coughing while lying down even in the indirect type.

      Thank you!

    • #29625


      “However, in the case of recurrent inguinal hernia, bulging may occur easily when coughing while lying down even in the indirect type.”

      • #29759

        Here’s something I’ve wondered about for some time: Do the behaviors of different hernia types (direct and indirect) differ depending on whether they contain fat or intestine? I ask because I’ve experienced the following:

        1. My hernia is reducible, but immediately comes back out when not holding in (either with my finger, or by flexing the surrounding muscles).

        2. It goes back in when lying down, and immediately protrudes upon coughing.

        Both suggest direct, but…

        3. The end of it protrudes into the top of the scrotum (suggesting indirect).

        The ultrasound from a few years ago said mine is fat-containing.

        I’m wondering whether fat, given its consistency, will behave differently and either come out more easily (in the case of indirect) or drop down into the scrotum (in the case of direct) even though atypical. Unfortunately, that ultrasound didn’t specify type.

    • #29631

      @drkang Thanks for the info! Does this method work also for small hernias?

      I did as you suggested and I could hardly notice any bulging (in a mirror), but then again even when standing the bulge can only be seen when stretching the skin (and no, I am not fat, I am quite in shape:).

      All the exams I did ie two ultrasounds and a CT scan, said I have a direct one. All doctors agreed, except one, who instead said she thought it was definitely indirect (but she did not see the CT scan result)…

      • #29633



        I said about 95% accuracy.
        So I can’t say that you obviously have an indirect type.

        However, according to my experience so far, I have seen occasional cases where the indirect type bulges out when coughing while lying down, but I have few memories of seeing no bulging in the direct type.

        However, if it is a very small direct hernia, the bulging may not come out clearly.

        Thank you!

      • #29634

        And for the sake of communication, the hernia surgery team at our hospital calls this test method the lying down cough test or Kang test.

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