High rates of pain with pure tissue repair?

[Chuck]

It seems like nearly everyone that has a pure tissue repair has some level of chronic pain. It may be nothing to mention as Mike m says. Or periodic like thunder rose says. Pinto is your kang repair always completely painless? Am my friends with pure tissue have some issue. Dead spots. Nerve twinges. Desarda is reported to be lowest risk of chronic pain per Tomas. Shouldice seems to cause it at a pretty high rate bSed on my detailed study. 27 percent in some studies. It’s why I went lap mesh. Seems like the forum is in agreement. Shouldice for a lasting repair. Kang for lowest risk of chronic pain.

[Watchful]

I don’t think we know the chronic pain rates with Kang. Has he provided them? They may be lower than Shouldice since his procedures are less extensive. On the other hand, if his techniques result in more tension, then there may actually be more pain and discomfort. One of the reasons for the 4-layer Shouldice repair is the reduction of tension.

[Chuck]

Thx watchful. Hoping some kang patients can weigh in. Our friend pinto said he had little pain. Of course his hernia recurred. Kang himself says he sees little chronic pain. Of course Tomas says no pain for desarda. My issue is that I have seen lots of reports of pain with shouldice. From my doctors in DC. From a few studies. From reviews at the shouldice clinic. And from patient reports on Facebook kang says the repair is very invasive that would suggest it’s likley more painful. This is such a nightmare. There really are no good answers. Any input appreciated.

[Chuck]

I am going to follow up with the good doctor kang. Dr kang is a committed Christian – hopefully he can be trusted to give an honest answer.

[Oceanic]

Freeman recently had a tissue repair and said he feels fine, I think its still a minority that have chronic pain not the majority of people.

[William Bryant]

I don’t think Mike had major pain issues following his Dr Kang repair. He mentioned in passing some sporadic discomfort maybe at times. He went on to clarify before Dr Kang repair pain was 7 and after 0.0 or near enough I seem to remember.

The ideal would be nothing of course but i also remember a poster saying or asking is anyone’s groin the same after hernia surgery. It may have been your good self Chuck or Watchful.

[Watchful]

William,

It was a Canadian hernia (mesh) surgeon who wrote in her blog that no groin feels the same (as a normal groin) after surgery.

[Good intentions]

When you guys are researching pain and chronic pain and discomfort you should try to differentiate static pain from dynamic pain. My discomfort from mesh was mostly static. Sitting in a chair, like a person would do to work on a computer, was not tolerable. I actually progressed from an office chair, to a straight-backed dining table chair, to standing up while trying to work on a computer. So that I could focus on what I was trying to do for more than a few minutes. I built a stand for my monitor and keyboard to raise them up so that I could stand. I tried kneeling on the dining table chair so that I wouldn’t have to stand for so long. None of it worked well.

On the other hand, movement made the surgery area feel better. Exercise, running, bike riding all felt good while in motion. But the effects of the movement made the static discomfort worse. I found that I could get about a half-day’s worth of feeling “normal” the day after exercise. But the discomfort always came back. I ended up in a cycle of 2-3 days trying to find some balance that would make life bearable. While this was going on other family members who could have used my presence did not get it. I was almost completely preoccupied with trying to learn how to live with the mesh in my body.

I have often thought that implanting mesh would be a good torture technique. Implant two large pieces of mesh, make the victim exercise then lock them in a cell where they have no freedom to move. Promise to remove the mesh if they tell their secrets.

[MarkT]

“It seems like nearly everyone that has a pure tissue repair has some level of chronic pain…”

That is undeniably false, Chuck. Why are you still making irresponsible claims like this? You are doing a disservice to this community.

[Chuck]

Mark T i have looked at this extensively…there is a study where shouldice repairs led to 25 percent chronic pain…check the FB groups….tons of people there complaining about shouldice pain…my lying mesh docs told me they had seen a bunch of patients with chronic pain from “that clinic” ie shouldice….those that don’t have chronic pain nearly all confess to periodic pain…a dog pulling hard…lifting a baby…lifting weights….the chronic pain rates are way way higher than the surgeons are telling us

[MarkT]

No, you have not. You’ve been in echo chambers on social media groups looking at non-respresentative problem cases.

The 27% study is NOT from Shouldice Hospital, the Germans, or anyone else who is an ‘expert’ with that repair, is it? Then that would be non-representative too.

Even if we granted a 27% pain rate, how does 27% = the “nearly everyone” claim from your irresponsible opening post?

[Chuck]

Good intentions…has your pain resolved with removal?

[Watchful]

Here’s a German paper from 2004 that I looked at a while back, and it kind of shocked me:

Chronic pain after hernia repair

After 52 months, they had 36% of patients reporting chronic pain after Shouldice, 31% after Lichtenstein, and 15% after lap TAPP. Pain causing limitations to daily life: 14% of Shouldice patients, 13% Lichtenstein, 2.4% TAPP.

[Good intentions]

Was it modified Shouldice or the Shouldice Hospital method of Shouldice? Polypropylene or SS or absorbable sutures? What type of hernias were repaired? How many recurrences were there?

The 2nd to last statement in the summary is odd. Lichtenstein is a mesh procedure. They changed the verbiage to postoperative complaints. Not clear why.

” The presence of the prosthetic mesh was not associated with significant postoperative complaints.”

It is an odd effort compared to the main author’s other work. I did find a different paper in which he was a co-author, from three years later, which seems to use the same 280 patients. I linked it below the excerpt below. Just seems strange.

“Results: Chronic pain was present in 36% of patients after Shouldice repair, in 31% after Lichtenstein repair and in 15% after TAPP repair. Pain correlated with physical strain in 25% of patients after Shouldice, in 20% after Lichtenstein and in 11% after TAPP repair. Limitations to daily life, leisure activities and sports occurred in 14% of patients after Shouldice, 13% after Lichtenstein and 2.4% after TAPP repair.

Conclusion: Chronic pain after hernia surgery is significantly more common with the open approach to the groin by Shouldice and Lichtenstein methods. The presence of the prosthetic mesh was not associated with significant postoperative complaints. The TAPP repair represents the most effective approach of the three techniques in the hands of an experienced surgeon.”

https://academic.oup.com/bjs/article/94/5/562/6142702

[Good intentions]

Here is the 2007 paper again. It has more detail, and a different author line-up.

https://academic.oup.com/bjs/article/94/5/562/6142702

Long-term results of a randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs
M Butters, J Redecke, J Köninger
British Journal of Surgery, Volume 94, Issue 5, May 2007, Pages 562–565, https://doi.org/10.1002/bjs.5733
Published: 19 April 2007

“Results
Hernia recurrence occurred in six patients after Shouldice repair, and in one patient each after Lichtenstein and TAPP repairs. All recurrences after tension-free repairs were diagnosed within the first year after surgery. Nerve injuries were significantly more frequent after open Shouldice and Lichtenstein repairs. Patient satisfaction was greatest after laparoscopic TAPP repair.”

[Good intentions]

For what it’s worth, Dr. Billing uses the TAPP mesh implantation procedure for his hernia repairs. At least he did when I talked to him. I can’t remember the type of mesh but I think he used the procedure taught at the Mayo Clinic when he was there as a resident. Smaller well-placed pieces of mesh, only covering the defect. Not the large “cover everything” method used today. Probably similar to the procedure used in the study above. He seemed confident in his results and he stays in touch with his patients. I can’t imagine that one of his former patients would not contact him first if they had pain. He mentioned one person that had pain but I did not get the details, and I don’t know how many hernia repairs he does per year.

[Watchful]

Not sure what is strange or odd. They are saying that open causes more chronic pain than lap TAPP. With open, mesh doesn’t cause more complaints than non-mesh (namely Shouldice).

What shocked me wasn’t the relative results. I just found the absolute numbers to be surprisingly high. The relative results are consistent with the mainstream thinking (virtual consensus) in hernia repair. Same as what Dr. Towfigh has been saying, and the same as even what my surgeon at the Shouldice Hospital told me.

[Good intentions]

Without reading the full paper and seeing how they performed the surgeries, and defined pain, and queried the patients, there’s not much value in the summary. The summary is not clear, and for some odd reason, a different primary author led the effort to rewrite and republish the study results. The link to the 2007 paper contains the full publication, with data.

You can find presentations by experts in each method describing ways to go wrong. Dr. Chen produced a video about the Lichtenstein method and potential problems.

Shocking numbers can be found pretty easily on the internet.

https://www.tandfonline.com/doi/abs/10.1080/00325481.2016.1121090

[pinto]

The paper by the German research group

• This reply was modified 1 week, 5 days ago by pinto.

[pinto]

The paper by the German research group struck me because it is categorized as a “clinical trial” not merely a survey or review. A question is who performed the surgeries. Without the original paper and having to guess, I’d say the surgeons are general surgeons based on the fact their affiliation is a general surgery department and the lead author is known not for hernia surgery but abdominal surgery as indicated by Medifind.

In other words, these two “German” papers concern surgery by non-specialist surgeons (generalists), probably the most likely performed surgery for hernia. The results for chronic pain must be cautioned as they most likely concern hernia surgery at general hospitals, something many HT members would avoid.

[Chuck]

Watchful –thanks for finding that paper…given all your research —why did you still select shouldice? Whether its 26 percent or 31 percent…or 5 percent or greater at the shouldice clinic as quoted by Dr. Netto…the shouldice surgery sure looks like it presents a ton of risk. Very troubling that there really is no way to get a safe surgery.

Pinto —you mentioned you really didnt have any pain with the kang surgery? the initial or the recurrant? I plan to reach out to Stephen on this…

[Watchful]

Fair question. These are the options I had:

1) Laparoscopic. As I mentioned before, the best lap mesh surgeon in my area wasn’t sure he could do it in my case. He said there was an 20% chance that he would need to convert to open. I definitely didn’t want something like that to happen. Dr. Towfigh recommended Lichtenstein in my case, although she was willing to do lap mesh. Beyond all that, I was biased against this procedure. I wanted to avoid general anesthesia because my mother suffered delirium and cognitive dysfunction from surgery with general anesthesia. Also, I simply didn’t like the invasiveness of TEP/TAPP and the large amount of mesh.

2) Open. Here I converged on two options. Lichtenstein or Shouldice. There was a third option of posterior mesh, but I didn’t have anyone who could do that – Reinhorn wasn’t taking patients from outside New England.

There were the options of other tissue repairs. I didn’t have a good gut feeling about Tomas, and the Germans recommended Shouldice over Desarda, so I dismissed Desarda. With Kang, I was concerned about recurrence for reasons I described in other threads. My dad had a recurrence from tissue repair, and I believe it was a Marcy-like repair based on what he described. He never had the recurrence repaired, and his hernia is really bad now. It would be a huge mess to fix at this point. Anyway, he has plenty of bigger problems, and surgery is not a good idea at his age.

Between Shouldice and Lichtenstein, I felt that Shouldice would be the better choice. Some studies show pretty similar chronic pain numbers for these, and some show more chronic pain with Lichtenstein. My thinking was why take any chance with mesh complications if I don’t have to, and if Lichtenstein doesn’t really offer an advantage. On the recurrence front, I felt that the Shouldice Hospital numbers are low-enough.

You know the rest of the story. In my particular case, Lichtenstein would have probably been a better choice because of the size of the hernia and my anatomy. My Shouldice surgery ended up being long and difficult, and it led to some chronic pain and discomfort (although not too awful at this point). Of course, I didn’t know all this when making the decision, and I had incorrect information about the size of my hernia because of a grossly inaccurate ultrasound.

With hindsight, I think I regret not going with Lichtenstein. However, if my chronic pain and discomfort resolve mostly over time, and there’s no recurrence, it may turn out that I’ll feel like I made the right choice. I don’t regret not going to Kang. If my hernia was challenging for a Shouldice repair in the hands of one of the top experts, I don’t see how it would have worked with a Kang repair – I don’t see how he would have stitched the huge defect that I had with his Marcy-like repair.

• This reply was modified 1 week, 5 days ago by Watchful.

[Chuck]

Thanks Watchful for that excellent summation…you really were in a difficult situation. I fear i will be in the same situation if my hernia recurs. Its hard to know how large it was but it was descending into the testicle…it makes me wonder how anyone will be able to fix a recurrance without mesh. Its really difficult to make decisions here because every doctor will tell you then can fix you —whether they can or not…and once you have terrible chronic pain…they just wont return your calls. I keep going back and forth —Kang says he has repaired hernia as large as a babies head. Tomas has a video online of him repairing and enormous hernia that looks like a basketball. The shouldice procedure scares me —even when it works –it takes a year or more to feel better…and I found a blog from a guy that was still hurting three years later. How did hernias become so problematic??? Maybe Mark T is right and hanging around the forums just exposes you to lots of problem cases…I really have no clue what to do if my hernia comes back. And i am still suffering with pain from the removal. Its amazing that a small painless hernia can ruin your whole life. Sadly your great research has convinced me that nothing can be trusted…one percent recurrance rates all these surgeons cite and one percent chronic pain…its all just noise.

[Chuck]

Also—watchful…you never named your shouldice surgeon? Slater? Simmons Hall ? I believe you said those were the top three. if i had gone right when my hernia occured…Alexander was still operating. But that clinic is such a cluster i couldnt tell if i would be able to get him. Plus i didnt want the stainless steel and didnt realize it was optional. I guess you have convinced me that the best option for further sugery is Dr Conze–thought that likely means a feared shouldice repair.

[pinto]

@Chuck, you raise some issues but you are smart enough to know the answers already:
1 Biased sampling: complaints at FB etc. must be taken with a grain of salt. Most people happy are not as motivated to post as people having pain. The complaints could possibly be a very small proportion of all cases pro or con.

2 HT Hangers-on: Have you noticed that a lot of members here once they have a surgery and report never come back again? Apparently they had a satisfactory surgery and feel no reason to continue the topic. Some though like Good intentions is on a life-mission to destroy the mesh industry. Pinto’s reason is academic: he wants to learn more about hernia because once a hernia then always the chance (i.e., member Dog).

3 Bias against Dr. K. One or two members have an unfortunate bias in this regard. They made their minds up and so not easily changed. Their reasoning seems sound but if you at it more closely, you will see the weakness.

4 Surgeon religion. Should it matter? If so, how much?

[MarkT]

I pulled a copy of the 2007 British study
https://academic.oup.com/bjs/article/94/5/562/6142702

Results (median 52 months follow-up)

Shouldice (74 repairs): six recurrences, eight cases of suprapubic numbness, and one of scrotal numbness.
Lichtenstein (76 repairs): one recurrence, one case of suprapubic numbness, and 10 cases of scrotal numbness.
TAPP (81 repairs): one recurrence and one case of lateral cutaneous nerve damage.

We’re talking about rather small sample sizes here.

“The increased rate of recurrence after Shouldice hernia repair during long-term follow-up has been reported in several studies 15–17.”

The first of those citations is a study whose purpose was “to investigate whether an alteration in type I and type III collagen synthesis, amounts of MMP-1 and MMP-13 and the expression of fibronectin were associated with the development of inguinal hernia”. They looked at the hernia sacs of 23 patients. No full article…but this is not a primary source discussing recurrences after Shouldice repairs.

The second citation is a study concerning short- and long-term absorbable meshes, and I was able to pull a full copy. The word ‘Shouldice’ is not found in the entire article and their experiment involved comparing short- and long-term absorbable mesh in rats…?

The purpose of the third was “to investigate the collagen matrix in recurrent inguinal hernias”. I pulled a full copy of this one too. Again, the word “Shouldice” does not appear in the entire article. They do refer to six studies that discuss repairs and recurrences, but I’m just not willing to pull all six of those to get details.

The authors should be citing the primary sources and then noting the secondary ones citing those sources. It is extremely lazy to send the reader on a chase to verify those claims, especially when there cited studies in turn (allegedly) point to other studies that supposedly state what they are claiming.

“A recent 10-year follow-up study showed a recurrence rate of 7·7 per cent after primary hernia and 22 per cent after recurrent hernia repair 18”.

I pulled that citation too, since those figures seem high. It was a retrospective study that looked at 229 patients who had 293 inguinal hernias repaired in 1992 by the Shouldice technique in University Hospital Aachen, Germany, with a 10yr follow-up period.

Only 31 patients had a recurrent hernia repair…so the 22% figure cited is based on 7 out of 31 people experiencing a recurrence. This does not seem like a terribly representational study from which a recurrence rate should be attached to the Shouldice technique…but there seems to be more.

The authors of that study state their repair details were described in a previous paper…so I pulled that one too. Unfortunately, the full text was in German, but the English abstract included: “For all primary hernias and indirect or small recurrent hernias a modified two-layer Shouldice repair of the transversalis fascia using a monofilament running suture (Polypropylene 0) is recommended.”

So they use a modified two-layer repair? Is that is what the originally stated recurrence rates for ‘Shouldice’ are based on?

[pinto]

That study was not “British” but German because it was done by German surgeons in Germany I believe. That’s just a side note. I would call the results of the study biased in that it is applicable to general hospitals not specialist ones. Moreover I am unsure that the Shouldice method was done such that it truly could called that. I was glad Mike T you offered this study because it answers the question, who did the surgeries. By the authors of the paper, right? So that supports my concern made elsewhere as well about the research by these same authors. (It’s not necessarily bad but is really limited to general hospital situations not to specialist ones.)

@Chuck, I have reported various places that both my surgeries and post were painless.

[MarkT]

Yes, you are correct…I had meant to edit that to say the 2007 British Journal of Surgery study (not 2007 British Study)

The problem goes much deeper than the setting, though that is a big deal on its own. The total # of patients getting a ‘Shouldice repair’ (modified repair, it seems) at that hopsital is about one third of what ONE full-time Shouldice Hospital surgeon would do in a year. To be fair, they are not mere ‘generalists’ doing very few repairs, but they aren’t doing as many as the high-volume specialists either.

IMHO, a bigger problem though is that the results perpetuate in future papers with ZERO context…and then readers come along and fail to evaluate the quality of that ‘evidence’.

It is extremely problematic to say “A recent 10-year follow-up study showed a recurrence rate of 7·7 per cent after primary hernia and 22 per cent after recurrent hernia repair” with no further context…and when digging deeper you find out those percentages are based on an extremely small sample size and (apparently) a modified repair.

[Watchful]

I don’t know anything about these particular surgeons, but there are hernia specialists in German general surgery departments in hospitals. The famous German hernia specialist Volker Schumplick was in general surgery at Aachen (where he was even the head of general surgery.) His protege Joachim Conze was practicing there for many years as well before going into private practice.

• This reply was modified 1 week, 5 days ago by Watchful.

[pinto]

Watchful, I don’t doubt that general hospitals have specialists. Indeed from my experience they do. Only certain staff do the hernias for example—but they also do a lot more different surgeries. Thus they likely to be much much less experienced with hernias than the specialists talked about at HT. Moreover because these are general hospitals, the hernia surgeon will likely have less latitude about approach and material. Many likely are pushed to do mesh and mesh chosen for them. Some do mesh and non-mesh true, but here again they can’t match up with the experience of the specialist surgeons we speak of here at HT.

[Author]

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