Had my surgery done finally – Shouldice

[SN]

sensei_305, do you know if Dr. Billing does non-mesh or tissue-based repairs for hernias? When looking up his information, I see that he specializes in weight loss specialties, so it was kind of odd seeing that he does hernia mesh removal as well.

[sensei_305]

Just had my hernia mesh removed on left side Dr.Peter Billings here in Kirkland,WA. Same surgeon who did it for @good-intentions . We was supposed to remove both sides but looks like my left was very complex and had moved down to Testicle so no time to do right side. I plan on coming back and remove it within 6 months. I must say, great experience and highly recommend Dr.billings and the Evergreen Hospital.

[Stephen]

Hi Chuck, I require one correction from your statement Reply#33277 made on 12/24/2022 at 4:08pm. You wrote, “Stephen told me direct hernias don’t have to bulge…”
It was my mistake to explain so simply.
To get rid of any misunderstanding, I want to say, “There always is bulging in hernia, but in the biggining stage because it is so small it may not be noticeable. Therefore, to find out whether there is hernia or not, it must be diagnosed through dynamic sono/ ultrasound.”
I always thank you for precious contribution.
Happy New year!

[MarkT]

Chuck, I agree 100% with Watchful…don’t put the cart before the horse…diagnosis is the priority.

A hernia can still be palpable if there is no visible bulge…so a physical exam is the first step. If you already had a physical exam that did not find anything, then imaging is the way to go.

Get a dynamic MRI done. It is likely your best option to nail down a diagnosis (whether it is a hernia or something else) which will then inform a course of action.

Ruminating about the past, talking to someone on the phone, contemplating which surgeon to see if you have a hernia recurrence…none of that gives you good information about what you should do next. Get a diagnosis, then go from there.

[Watchful]

You can look up reviews for the Germans on jameda, and there are some on Google as well. The problem with jameda is that they make it hard to post bad reviews, so keep in mind that you’re probably not seeing the whole picture. However, their top hernia surgeons do have many excellent and detailed reviews, and they are pleasant people. I talked to a few of them, and almost went there.

Dr. Kang may be a good choice. There’s less information available out there from patients since he’s in Korea.

How did Carvajal diagnose your direct hernia before surgery? Was he able to palpate it?

[Watchful]

Merry Christmas, Chuck.

It’s true that most don’t have significant issues after inguinal hernia repair, but many do based on the studies that I’ve seen. Looks like well over 10% have at least some long-term pain, discomfort, numbness, paresthesias, etc.

I agree that a hernia that’s too bothersome or that’s increasing in size should be treated, but at this point you don’t even know for sure that you have a hernia, and you have no bulge. I also get pain after certain activities which feels like hernia pain after my Shouldice procedure, but I don’t suspect a recurrence. The same type of pain can be caused by a hernia and by groin surgery.

You have to focus on what you have now, not what you had before. You can’t go back in time and change how you treated it. Also, you don’t know how alternative approaches would have turned out – there’s really no point in torturing yourself about your past decision.

If your current pain is bothering you too much, my advice would be to try to get it diagnosed by the best specialist you can find as mentioned above. Don’t put the cart before the horse. What’s your alternative? Would you really want another hernia surgery done without even knowing that you have a hernia? You may end up with the same pain plus complications from another surgery. See what you learn from diagnosis, and then decide on next steps.

[Watchful]

Hi Chuck,

My case was very different from yours. I had a large indirect hernia with a large defect, and a large hernia sack reaching down into the scrotum. In your case currently, you may or may not have a small direct hernia recurrence.

Like I said before, you need a diagnosis first. I don’t know for sure, but I get the impression that Dr. Towfigh is good at diagnosing non-obvious hernias, and other causes of groin pain. Not sure who else in the US. Maybe Dr. Krpata, and Dr. Chen. In Germany, there are a number of surgeons who are very skilled with ultrasound (such as Dr. Conze), but I think there are occult hernias that even that can’t show, and maybe other types of imaging help with those.

As to how to fix the hernia if it’s there, maybe put off that decision until you find out what’s going on exactly.

I don’t know how frequent and how bad your pain is. If it’s not something that bothers you too much, I personally wouldn’t do anything about it quite frankly. Hernia surgery can cause a lot of trouble as you well know. Also, watch out for shooting-in-the-dark type surgeries (exploratory, random nurectomies) which can be harmful.

[Watchful]

Chuck,

I don’t know what weights you were lifting, but I agree that lifting heavy weights should be avoided. Hernia probably isn’t actually the most common damage this causes. I think spine damage is the big one to worry about with lifting.

My understanding is that most inguinal hernias are unavoidable. Indirect hernias are almost always caused by a congenital defect, and direct hernias are caused by tissue weakness.

In retrospect, my parents should have taken me to surgery as an infant because my hernia would have been trivial to fix back then. As an adult, surgery becomes a lot more questionable because the repair isn’t trivial, it can easily be worse than the disease, and the earlier you have the surgery done, the larger the chunk of your life that may be impacted by bad outcomes such as chronic pain. The caveat here is that if you want tissue repair, you may want to pull the trigger on surgery as soon as you notice that the hernia is progressing and becoming worse.

You don’t know how bilateral tissue repair would have turned out in your case. Also, there was no way for you to know that you would end up being one of the few percent with issues after TEP. You made a rational and informed choice about the procedure, and you took your time with the decision. You could have ended up being one of the few percent with issues after tissue repair, and regretted not getting mesh.

I prefer tissue repair to mesh, but I’m not an absolutist about it, and I know that bad outcomes are possible with both. Also, in some cases tissue repair may be a better fit, and in others mesh may be better. One thing I realized late is that hernia repair really should be tailored. For example, it turned out that I was not a good fit for a Shouldice repair, but it was done anyway because of where I went to have it done. That’s not good.

My advice to those who want tissue repair is to first figure out if they have an “easy” case or not. If it’s a large, long-lasting hernia, be careful. Go to one of the few surgeons who do both tissue repair and mesh, and let them decide what is best either before or during surgery. Such surgeons include Dr. Yunis, Dr. Towfigh, and a few German surgeons. Possibly also Dr. Reinhorn.

[Watchful]

Watchnwaitin,

You can pick based on names you see in reviews. Tell the patient coordinator that you want a specific surgeon.

There is no vaccine requirement. By the way, visitors are still not allowed.

[Watchnwaitin]

@Watchful,

1) How did you go about picking your surgeon? I don’t see any info on the surgeons at Shouldice Hospital on the website.

2) Is there still a c19 vacs policy there for a patient or their spouse or is that gone now?

Hope your post op recovery is going well.

• This reply was modified 2 years ago by  Watchnwaitin.

[Watchful]

Chuck,

Like I mentioned, I would think about it in two steps. The first is getting an accurate diagnosis, and the second is potential surgery. If you’re pretty sure it’s a hernia, I think it’s reasonable to go to Dr. Kang to be diagnosed and possibly treated. You have to decide based on what’s actually going on in there, and you don’t really know yet. Maybe you can have it looked at in the US first (Dr. Krpata, Dr. Towfigh) before going all the way to Korea. If nothing else, it will give you another opinion about what you have and how to treat it.

What does Dr. B. think? How bad is your pain, and when does it happen?

After extensive digging on the Internet and asking a bunch of people, I also found a surprising number of reports of short term as well as chronic pain after Shouldice Hospital repairs. The thing is that you can also find such reports after Lichtenstein as well as TEP. The conventional wisdom is that TEP is the least problematic in this regard.

Who knows what the real numbers are, though. Shouldice sometimes claims 1%, sometimes 2%, and there was even a mention of 5% on that interview with Dr. Towfigh. It’s definitely an issue. They are doing a multi-year study on that, but I don’t know how many patients bother with it because the questionnaires are lengthy and time consuming to fill out. German surgeons sometimes say 0% chronic pain with Shouldice, and sometimes they say 1%-3%. Basically, who the heck knows, but the numbers I’ve seen for mesh are worse. I really don’t think there are reliable numbers for any of these.

There’s also the question of how to treat chronic pain. There are some methods to treat it on mesh repairs (including removal). Not sure about Shouldice.

I know what you’re saying regarding the success of the local general surgeons. I observed the same thing. I have a couple in my area who have many stellar reviews. I actually consulted with one of them. He told me that he always cuts the ilioinguinal nerve, and that pretty much turned me off. However, he has many great reviews. He suffered from chronic pain himself after a Lichtenstein procedure, and required a nurectomy.

Honestly, much of it is luck. You need to pick the best surgeon you can, but it’s still a Russian roulette. Different people react differently to the same exact things, there are anatomical variations (such as with nerve locations), surgeons can be tired and pressed for time, etc.

I think you just got unlucky, and you shouldn’t be hard on yourself. You actually made the rational choice. I’m the one who went out on a limb more by going to Shouldice, and we’ll see how that turns out in the long run, but so far it has not been so good as I mentioned above.

[Stephen]

Hi guys, Chuck said, “Stephen kwon says Dr Kang can get to the bottom of it…with hands on diagnosis…ultrasound and mri if needed…though he says its never needed.”
I just simply want to make it clear. Dr. Kang diagnoses always with his ‘dynamic sono (ultra-sound).’ He says MRI is not necessary. That’s it. I really thank Chuck for his precious statement all the time.

[Watchful]

Chuck,

Would I do it differently? I can’t answer that yet. I really have to wait for further recovery. If I absolutely had to answer that question now, then my answer would be that I would pick a different way of fixing it because of the nature of my particular case. This wasn’t known all that well at the time I made the decision, though.

If I were in your situation, I would first try to get the best diagnosis, and then decide if and how to do surgery. Maybe go to Dr. Krpata or Dr. Towfigh for diagnosis. Dr. Kang might be good for that too, but if he doesn’t find a hernia, where does that leave you? Maybe others could diagnose what’s causing the pain even in that case.

I don’t think you really made a mistake with your choice of procedure. Maybe the choice of surgeon – I don’t know. The vast majority do fine with lap mesh and even open mesh as you mentioned.

Dr. Kang is a reasonable choice if your case is a good fit for his procedure, and it may very well be. Also, he’s a very experienced surgeon. The part I don’t quite see is why you put what he does in a different category than other tissue repairs. His technique for direct hernias is a variation on Shouldice/Bassini as I understand it. Not quite as extensive, but similar in principle. It’s not exempt from recurrence or from pain. Have you read Alan’s account of his recent surgery with him? Very similar to what happened to me at Shouldice in terms of the pain.

[Watchful]

Chuck,

I’m too close to the surgery to know if I’ll be dealing with any lingering issues or not. I need to see where I am when a reasonable healing period is done. I’m not where I expected to be in terms of recovery at this point, but healing is still going on, and things should get better.

The observation that my case was a fairly poor fit for a Shouldice procedure isn’t coming from me or from my research. It came from my surgeon. This doesn’t mean that I won’t have a good outcome, but it resulted in a challenging surgery which is something that one should really try to avoid.

There’s a problem with going to places that use a single procedure such as the Shouldice Hospital, Dr. Kang, and Dr. Tomas. The problem is that you act as your own doctor in the sense that you pick the treatment, and you may pick wrong for your particular case. I think for non-trivial cases, it’s best to go to someone who is good with a number of procedures (tissue repair as well as mesh), and can make an informed decision before or during surgery. Too bad there are only very few such surgeons.

[pinto]

Congratulations on taking the plunge. You knew you were at the endpoint and you had to jump out of the plane. You survived the jump. Any surgery is risky. At this point the important thing is to realize you did your very best. All along the way decision points were calculations. Sometimes though by hindsight either way fails if without a win. In the recent WS game, a baseball manager gambled that his mainstay pitcher should be relieved out the trouble he was in. Unfortunately they lost and the manager roasted ever since. If they won, however, he would be the toast of the town. I marvel how even the most experienced sports casters haven’t fully understood this metric.

In the moment, outsiders cannot grasp the full measure what that manager had to process–and indeed processed–in weighing the best step to take. You are that manager but fortunately the game result is yet written. You made a decision that best fits as you saw it; others go on with less data. What many of us have yet fully grasped is the incredible healing power of the human body. I still ponder the exquisite libido: The moment of complete bliss brings wonder if it ever can return–if indeed the need would even come again. Ah, but it does, again and again. Amazing life force.

However the darkest moment invites doubt about the dawn return. Many stories at HT illustrate that but many also show hope, resolve and healing. It may take time but the life force will see you through, maybe even in record time with your particular case. The return of pain is scary but maybe a sign the life force is healing. Not all pain is bad. Some pain is necessary to send us on our way to health. I hope your pain subsides in due time and you can go well on your way. I myself would take solace in the fact that I were not the poor fellow in the Russian prison snubbed by Biden who must now be in immense despair after four years of imprisonment. You have some medical heavyweights who I’m sure will see you through. Good luck my friend.

[Watchful]

GI,

Most indirect hernias are a result of a congenital defect (persistent processus vaginalis), and long-standing indirect hernias are common. They see large long-standing indirect hernias at Shouldice regularly – I was told they operate on such hernias every week.

I don’t think the different environment in the inguinal canal is an issue. Yes, there was a hernia sac there for a long time, and now there isn’t, but that’s par for the course with indirect hernia repair. None of the experts I talked to considered that to be a potential issue.

One problematic aspect was just the way my anatomy was laid out which made doing a Shouldice repair more difficult, but still possible. On top of that, the hernia defect was large, and the tissue quality was decent, but not great. I was pretty far from an ideal candidate for Shouldice, but this is not something that I could tell in advance. The ultrasound that I had gave an incorrect picture. The skill for doing it correctly for an inguinal hernia doesn’t seem to exist in the US (or Canada), and that’s the reason hernia surgeons find it to be useless. I hear they do a much better job of that in Germany, but we’re talking about hernia surgeons who do it themselves after developing specialized expertise.

Anyway, that’s the reason I mentioned that tailoring the repair is important. I think surgeons who do both Shouldice and mesh would have made the intraoperative (or maybe even preoperative) decision to use mesh in my case. I’m not saying that the fact that it was a more challenging repair explains my pain, but it might. On the other hand, I could have ended up with mesh-related trouble, so who knows.

Having said all that, look at Alan’s case of pain after his Kang repair. Different case, different tissue repair procedure, similar issues after surgery.

We’ll see what happens. Things may settle down, and I may end up being a happy camper with no pain, no recurrence, and no mesh. If anyone is curious about how I would do it with the benefit of hindsight, ask me in a few months.

[Good intentions]

I don’t want to minimize your concerns or the problems you’re having. But from a scientific perspective you are an outlier, and pretty far out, I think. This would be important for the surgeon to consider, before surgery and especially after surgery, if he/she is planning a second operation. Ideally, they would consult with a more experienced surgeon who has seen similar cases. Might be hard to find though.

It’s reasonable to assume that your body had completely adapted to living with the hernia. Growing up from a baby, through puberty, and in to adulthood. It follows, I think, that it will take quite a while to adapt to removal of the hernia. The inguinal canal and the internal ring are in a completely new environment. Tissue that used to be in contact with intestine is now in contact with tissue it’s never seen before. The spermatic cord is especially sensitive, as I understand things. My mesh implant surgeon joked about an “angry spermatic cord” when I presented with problems. It wasn’t funny, of course.

Just offering a more cautious view. The normal decisions for pain after a Shouldice repair might not apply to you. Most surgeons will start from what works for the bulk of Shouldice patients. But your case is unique.

“I had my hernia since birth, and it got worse over the years. The right time to fix it was when I was a baby.”

“Also, my hernia was not run-of-the-mill. It was a large indirect with a scrotal component.”

[Watchful]

I just read Alan’s thread about his surgery with Dr. Kang. Very similar positional-dependent pain symptoms after surgery to what I experienced at Shouldice.

One difference in the experience is that Dr. Kang told Alan that it’s normal, while my surgeon thought it wasn’t, and that something bad happened.

Threads like these are very important because surgeons don’t provide enough information about the true range of “normal” symptoms that can be experienced after surgery, and what helps with those symptoms. Maybe they don’t want to scare people, or maybe they don’t even know.

I’ll keep posting about how this develops, and I hope Alan does as well. A natural question is what the healing process looks like in such relatively bad cases of post-surgery pain, and whether (heaven forbid) chronic pain becomes an issue.

[Watchful]

Thanks for your thoughts, ajm222. I definitely agree with your points about the importance of positive thinking and optimism in healing. Good luck with your procedure if you decide to go ahead with it.

[ajm222]

Very interesting. Thanks for sharing.

My initial thoughts, for whatever they are worth:

I have noticed recently that when I am focused on my issues, the pain and discomfort goes up significantly, to the point of sometimes being debilitating. When I relax about it, it almost vanishes. I will often get stressed about lingering issues and they will get worse and worse, and then I will make an appt with my surgeon and talk over surgical options, and my hope for the future increases with a game plan, and then the pain ‘magically’ goes down to almost nothing.

Point being, I do tend to believe in many cases there is a very cerebral component to the pain and discomfort. Recent science suggests this isn’t at all a new or fringe idea. Anyway, I am wondering if anticipatory anxiety, and being in a situation where you know almost TOO much, has had an impact on your level of pain. Some surgeons even suggest cognitive therapy or medication prior to surgery to improve outcomes.

I had an experience when younger where I had two surgeries. Didn’t feel like I healed from the first one. Then the second didn’t seem like it was healing either. Lots of issues. Freaked out, had a breakdown, got on an SSRI, and finally fully healed within a month. The meds were the difference maker. My brain just needed a break from the obsession. My mind had gotten stuck and physically I was healing but mentally I was not.

So I would recommend trying your best to do some positive visualization and relaxation tricks just to keep your spirits up, and just tell yourself daily you are going to heal up perfectly fine. Unless something bad happens that clearly needs medical intervention, give yourself lots of time to get better and try not to stress too much about it. It also just takes a long time for some folks to heal from surgery. As long as there are regular improvements from week to week, you should be good. The body is amazing with it’s ability to heal. But we can hamper this by focusing too much on it and thinking about the pain. That keeps the body from trimming those neurons and delays it from turning off the pain signals as you heal by reinforcing those pain pathways that really aren’t serving a purpose any longer.

Lastly, I wonder, physically, if having a hernia for that long may just mean it’s going to take you a bit longer to heal and feel back to normal. Most people get a hernia and have it repaired fairly quickly and don’t wait years or decades. And they don’t have a hernia while crossing from child to adult. No reason to think that would prevent you from healing, but it may explain some of the extra pain and healing time needed in your particular case. Usually after about a year most people find the vast majority of twinges and discomforts have finally stopped being noticeable. Ultimately sounds like you’re going to be just fine.

Just some thoughts. Thanks again for sharing this experience. Very interesting.

I am possibly having a procedure myself in February to remove a lipoma and tighten up the inguinal area because I have a small bulge after removal that is apparently technically not a full hernia but probably is some extra fatty tissue pressing on some weak areas that exist possibly because of the mesh removal. I think it may be the source of some lingering pains and discomfort and the plan is to do a more minor repair with some stitches (not a full Shouldice-type repair). Hoping it goes well. But I also have some concerns as I am obsessive and a hypochondriac and I know I am my own worst enemy when it comes to healing. I’d leave it alone but I feel it’s an issue and I am finally ready to deal with it after my last surgery two years ago.

• This reply was modified 2 years ago by  ajm222.