Kang Repair question

[UhOh!]

I think what you say about type-specific vs. one-size-fits-all is even more true with a “pseudo-recurrence” for another important reason: the term “pseudo-recurrence” (hernia of another type discovered later) suggests that the two surgeries would be done at different times (vs. true pantaloon, when they’d supposedly be done simultaneously). That would seem to also imply one would have the chance to recover completely from the first surgery before even discovering the second hernia.

The insurance issue may well be exclusive to the US, and the new emphasis on outcome-based reimbursements. The idea that the provider is reimbursed based on the success of their care (vs. simply the price tag of the services) is good in theory, but leaves many potential problems and misalignments of incentives. If the discovery later of a second hernia (different type) is considered a recurrence (particularly when preoperative imaging isn’t used) then surgeons are incentivized to perform a catch-all repair, instead of the most appropriate repair.

[drkang]

To answer your question “which will inflict less pain and fewer potential complications, receiving type-specific repair twice or one-fits-all repair once?” I will have to consider many variables. However, I would definitely choose the latter – type-specific repair is less problematic.

First of all, receiving type-specific repair twice because of pseudo-recurrence can happen to one out of hundred inguinal hernia patients, according to my statistics.You are making a comparison assuming the worst case that you are the one out of one hundred patients.

First, let us compare the cases of: receiving mesh one-fits-all repair once and non-mesh type-specific repair twice. I would choose to receive two type-specific repairs which is 100% definitely non-mesh repair.I think many postings made to this forum can explain why.
Second, we could compare type-specific repair to non-mesh one-fits-all repair, such as Shouldice repair. Even in this case, I would choose to go with type-specific repair.Because two small pains are better than one big pain, and two minor repairs would pose smaller possibility of complication than one extensive repair would.This is especially so, when considered that most one-fits-all repairs including Shouldice repair sacrifice cremaster muscle and genital branch of genitofemoral nerve.

However, this is a scenario you must worry about if you were that 1%.

If you were not that 1%, but the 99%, the mesh, which was absolutely not necessary, would have been placed onto you, or you would have received a more destructive surgery that was not necessary at all.

Moreover, the possibility of true recurrence was excluded in the above.According to my judgment, the true recurrence rate would definitely be higher in case of one-fits-all repair than in case of type-specific repair. (Here, ‘true recurrence’ includes: any type of hernia, in case of one-fits-all repair; and the type of hernia identical to the type of hernia previously operated on, in case of type-specific repair.)It is because the line to be protected is longer in case of one-fits-all repair.

Shouldice hospital reports a low recurrence rate of about 1%. However, as far as I understand, Shouldice hospital strictly selects the patients who would go through the surgery, by excluding those who experienced recurrence and 1 year has not passed thereafter or who weigh a lot. Also, I understand that they use mesh, although it is uncommon, in case of recurrent hernia or severe direct hernia. After all, the patients who are deemed to have higher risks of recurrence are eliminated from the list of patients who would receive Shouldice repair. Thus, if non-mesh Shouldice repair is administered for all cases without excluding any patients, we can anticipate that the recurrence rate will exceed 1%.
In conclusion, I do not think that the re-operation rate of Shouldice repair (which is thought to be the method with the lowest re-operation rate among non-mesh repairs) would never be lower than the re-operation rate of type-specific repair.

Therefor, under any circumstances, my choice would always be non-mesh type-specific repair. And even in case of the pantaloon hernia, I perform two type-specific repairs once to save the cremaster muscle.

I do not know much about the insurance issue.However, when the opinion that type-specific repair is absolutely advantageous to the patients is widely accepted, excluding the occurrence of second type hernia, i.e. pseudo-recurrence, from true recurrence will not be so difficult.

[UhOh!]

I think an even more practical question regarding “pseudo-recurrence” patients is: What is ultimately going to cause less pain and fewer potential complications, a one-size-fits-all repair that requires excessive cutting and sewing, or two defect-specific surgeries, with very limited scopes, conducted at different times?

Absent an obvious pantaloon, I’d almost certainly opt for the latter.

Then, of course, there is the growing issue of reimbursements: If insurance companies consider the development of a second type of hernia on the same side a “recurrence” then that could put reimbursements in jeopardy. Completely backwards set of incentives for surgeons, but these are the times we live in…

[drkang]

[USER=”2468″]Baris[/USER] You have suggested that when a surgeon administers the type-specific repair, other types of inguinal hernia may occur in the future (direct type hernia after indirect repair or vice versa) and the patient may have to go through another surgery. This is a very important topic that will be an essential issue when discussing about the feasibility of type-specific repair. Thank you for pointing out such an important topic.

This is a great opportunity for me to hear the thoughts of Shouldice surgeon through your great question. In fact, the thoughts of Shouldice surgeons agree with the thoughts of most of the contemporary hernia surgeons (voluntarily or involuntarily).

It is natural for all surgeons who administer Shouldice or one-fits-all repair to ignore preoperative imaging. I would do the same, if I were in their shoes. You are going to make a large wound and visually check the area to conduct the surgery anyway. Why would you make efforts in advance to accurately check the area?
However, making a big incision and checking the area with your own eyes come with a cost. You may cause many injuries to a large area of normal structure and weaken the otherwise normal floor.

I think the Shouldice surgeon said what he/she said (that your second defect was what had been missed from the previous surgery) to protect his/her claim, and it was too conclusive. It is definitely difficult to tell before or during the surgery whether the second defect existed at the time of previous surgery or occurred thereafter.
Indirect hernia and direct hernia existing together is referred to as pantaloon hernia, and I cannot agree with the claim that 13 to 14% of cases are pantaloon hernia. According to the statistical data from my hospital gathered over the last 7 years, the share of cases where pantaloon hernia was identified from the pre-operation imaging test and the two types of hernias being operated was mere 0.27%.

Also, the share of cases where type-specific repair was administered and other type of hernia occurred thereafter (e.g. direct hernia occurring after indirect inguinal hernia surgery was administered, or vice versa) was 0.9% (as a result of follow-up for average 4 years). I mulled over it and named it as ‘pseudo-recurrence’. I wonder if the naming was appropriate. If you can come up with a more suitable name, please do not hesitate to make a recommendation. Anyway, even if all the 0.9% of the cases were the cases where it already existed at the time of previous surgery and was missed (although I personally do not think all of them were ‘missed’), the rate of pantaloon hernia at my hospital was no more than 1.2%. A long-term follow-up may reveal a greater rate of pseudo-recurrence. However, what happened after so long must not be the second hernia that had been missed during the previous surgery. Thus, the rate of pantaloon hernia during the surgery being 13 to 14% is exaggerated.

I guess that there are two reasons why the rate of pantaloon hernia was so exaggerated. One, for a surgeon to check if there were a second direct inguinal hernia, he/she must separate cremaster muscle from the floor of Hasselbach triangle. By the way, transversalis fascia, the floor muscle, often gets damaged during this process. Transversalis fascia might have been weakened during this process, and the surgeon might have deemed it as an early direct hernia. Two, transversalis fascia that forms the floor of Hesselbach triangle is elastic, thus, even when they are in normal condition they often appear bulged a little bit. It is often difficult to visually tell whether it is physiologic bulging or hernia occurred by torn fascia. I think the rate of pantaloon hernia is exaggerated because of the above reasons.

‘Pseudo-recurrence’ (where a second type of hernia that did not exist at the time of type-specific hernia repair occur at some point of time after the surgery) cannot be exactly deemed as a recurrence. When you pulled a decayed wisdom tooth in the upper gum and discovered another decayed wisdom tooth in the lower gum later, you cannot call the second decayed wisdom tooth a recurrence. Nevertheless, I think you can lower the chance of making another surgery because of pseudo-recurrence which includes the second hernia that had been missed at the time of type-specific repair, if you administer one-fits-all repair.

If the rate of administering another surgery after a type-specific repair was too high, there would have been no place for the type-specific repair. Thus the pseudo-recurrence rate after type-specific repair is very important. However, I understand that there is almost no study conducted related to this issue, unfortunately. The surgeons might have had no reason to be interested in the pseudo-recurrence, because most of the surgeries so far have been one-fits-all repair
Fortunately, I can check the pseudo-recurrence rate, because I have been administering type-specific repair since 2012 at my hospital. According to the records kept by my hospital, the pseudo-recurrence rate was 0.9%, as stated in the above. In fact, this is not a number that can be ignored, and the longer the follow-up period, the higher the number can be. But you should remember the fact that the average rate of repeated surgery after one-fits-all repair is usually 5% or above. Of course, the Shouldice hospital shows a very low recurrence rate.

Thus, a patient must choose which surgery method shall be administered, considering: the above statistical information; difference of invasiveness of each surgery method; post-surgery recovery process; difference in aftereffects, etc.
I think Shouldice repair is too invasive and chooses the patients (who would be repaired thereby) under the excessively strict standard. Mesh repair(which also belongs to one-fits-all repairs) also has serious problems, such as chronic pain. I think all these must be fully considered. Based on my experiences, I think there must be a way to bring the pseudo-recurrence rate after type-specific repair below the 0.9% established so far, and I am actually conducting a study in this regard.

‘Determining how prone the muscle is to rupture by imaging technique is almost impossible’ is a correct statement. What we can find out by imaging technique is whether there is a direct hernia or not, or whether there is an indirect hernia or not. Meanwhile, Shouldice repair is administered under the premise that it is 100% sure that the second area is the problem. When reviewed the historical data of my hospital, I think the pseudo-recurrence rate would be no more than 2 to 3%, even if the follow-up period is extended. (And I am studying the ways to reduce this rate.) Then, what we should do is to determine whether we should administer the less invasive type-specific repair, believing the 97 to 98% of possibility, or administer more destructive one-fits-all repair to remove the 2 to 3% possibility of administering a repeated surgery.

[USER=”1391″]UhOh![/USER] I totally agree with your opinion. For the surgeons to be interested in my type-specific repair(which is your defect-specific scope repair), we should make them be assured about the result of surgery. That is, the fact that so called pseudo-recurrence rate is not high must be fully confirmed. I am conducting a study related to this issue.

[UhOh!]

Yes, that’s exactly what I meant when referring to “type-specific repair” and “defect-specific scope.” I do understand that, particularly for direct hernias, the type-specific repair methods are new, but my hypothesis was that the challenge, for most surgeons, is not figuring out how to do such a repair, it is altering how they fundamentally think of hernias.

From your description, it sounds as though very similar principles of defect repair exist in authentic Bassini and McVay to your repair (and a surgeon experienced with the former could learn the latter fairly easily), BUT the main challenge is convincing surgeons to apply those principles to what is, essentially, a new problem: Until now, those principles were applied to creating maximal reinforcement to an anatomical area, instead of applying them to repair of a very specific deficiency. Behavior change is much harder than learning new skills. The patient’s goal of having their hernia repaired is the same, but the surgeon’s goal, in terms of what the final anatomy should look like, is different between the two.

My way of thinking about this also stems from my professional work, in product marketing, which often involves developing different stories around one product/capability intended for different audiences. It’s easy for me to do as a consultant, but notoriously difficult for people to do when they’ve only thought about the product they’re selling in one way. I recognize that how a surgeon interprets any of this will differ than how I do, as each profession comes with its own way of thinking about pretty much everything.

[drkang]

[USER=”1391″]UhOh![/USER] You have used two terms, ‘type-specific repair’ and ‘defect-specific scope of repair.’ I understood as follows and wonder if I understood them correctly: ‘type-specific repair’ means all cases where the indirect and the direct repairs are administered by different methods; and ‘defect-specific scope of repair’ means the case where only the applicable area is operated appropriately for each type. If I understood correctly, the ‘defect-specific scope of repair’ is the type-specific repair that I refer to. However, I think it is not really meaningful to operate on indirect or direct inguinal hernia by selecting different methods among many one-fits-all repair methods (the ‘type-specific repair’ you referred to). Because, you may reduce the recurrence rate by a little by doing so, but there is no other benefit (such as reduced area of, time of or damage from the surgery) to be gained. Thus, I would recommend uniformly using ‘type-specific repair’ to refer to ‘defect-specific scope of repair’ you mentioned, instead of using ‘type-specific repair’ or ‘defect-specific scope of repair’ respectively for different purposes.

To administer the type-specific repair, it is very important for a surgeon to make an accurate diagnosis before the surgery. However, the surgeon cannot immediately administer the type-specific repair just because he/she accurately checked whether the hernia is indirect or direct, because the type-specific repair is a completely new surgery method that a surgeon must learn anew and accustomed to – one may not just slightly modify the one-fits-all repair according to the circumstances when conducting the type-specific repair. You cannot make a child’s dress by just reducing the dimensions of a grown-up’s dress – you need to have a know-how on how to make a child’s dress to properly make one. For your information, it took more than 6,000 surgeries over 6 years or longer for me to accomplish the current Kang repair method after I first realized that a type-specific, non-mesh repair was necessary.

Also, as far as I understand, most hernia surgeons do not feel that type-specific repair is necessary. Thus, even if they understood the type of hernia in advance, they usually proceed the method they prefer among many one-fits-all repair methods almost automatically without wondering about which method to go with. For the mainstream of hernia repair to move from the current one-fits-all repair to the type-specific repair, I think we need a switch of ideas to a degree greater than that came into play when the tissue repair in the past shifted to the mesh repair.

[UhOh!]

quote Baris:

Thats true aswell but if i had an indirect hernia and no defect in the direct area would imaging techniques show how prone the muscle is to rupture? Or would it allow the surgeon to confirm that the area is strong enough to not even need to check the fascia and just repair the ring in case of an indirect hernia? How would an ultrasound intepret this?

Now you’re asking questions I would have to make up answers to 🙂

However, what I will say, and this is a personal opinion/preference ONLY: If the ultrasound didn’t reveal anything, I personally would only want that which was confirmed by imaging to be repaired, and in the least destructive way possible. If something else should rupture at a future date, fine, I’ll deal with it then. But I’m not one to do more extensive surgery over a “maybe” in this type of situation.

[Baris]

quote UhOh!:

But wouldn’t all of those questions be answered in advance if imaging were done by a technician with hernia expertise? Part of the problem is how operator-dependent ultrasound imaging is and how much variance there seems to be in expertise among technicians specific to hernias.

Thats true aswell but if i had an indirect hernia and no defect in the direct area would imaging techniques show how prone the muscle is to rupture? Or would it allow the surgeon to confirm that the area is strong enough to not even need to check the fascia and just repair the ring in case of an indirect hernia? How would an ultrasound intepret this?

[UhOh!]

quote Baris:

Hi dr kang,
in relation to imaging none of my hernias were present on the imaging but felt when touched. How would the surgeon know how big to make the insicion to see the whole inguinal floor? When i asked the surgeon at shouldice he very quicklly dismissed imaging techniques for hernias. In my case for instance i was shocked to find out that the surgeon cuts all the way down to the pubic tubercile. However i was glad it was done that way as on my left side i had both a direct and indirect hernia. My left side had been operated on before twice and it was totally missed. Now coming back to choosing specific types of repairs for the type of hernia, if the surgeon didnt intent to cut the whole muscle and do a one big repair (fit for both direct and indirect) how would he have found the second defect that was present on my left side. I asked about this ( to the surgeon at the shouldice clinic) and was frustrated it had been missed before. He said that they deliberately restructure the whole floor as one of the main reasons being is that in 13-14% of surgeries they perform there is a secondary hernia present which is missed by most other surgeons. I then asked what if there wasnt a secondary hernia and it was just an indirect isnt that pointless that the tissue is cut away? I was then told what if when i arrived i had an indirect but that area (where direct hernias appear) was still intact but very weak? How would i have known? How would the surgeon of known? Wouldnt it increase the likelihood of me having a reoccurence and then more surgery to then correct the direct hernia? Leading to more pain invasion and scarring? In a way thats why i believe in the shouldice technique the idea is to go in once and do the utmost to minimuze the risk to the lowest stage possible by repairing the whole area to a high standard to minimize future issues and strengthen the tissue as a whole, especially incase its still intact but prone to rupture. That is why i think the reoccurence rates are very low as every possibility is assesed and repair is done not just to fix but also to prevent.
So in a way yes its more cutting away and maybe slight more invasion but i do believe it cuts out any possibilities of being a short term resolution and rather being a long term solution, thus why they do a one repair fit for all and have amazing statistics. The only reason i say this is because i had two previous surgeries and i think everyone will agree that youd rather have one ‘supposedly invasive’ surgery rather than many little ones to correct eachother.
This is why i belive the clinic/technique does a repair which addresses both direct and indirect regardless of the type of inguinal hernia you have.

i hope i have made sense :)))
Regards
Baris

But wouldn’t all of those questions be answered in advance if imaging were done by a technician with hernia expertise? Part of the problem is how operator-dependent ultrasound imaging is and how much variance there seems to be in expertise among technicians specific to hernias.

[Baris]

Hi dr kang,
in relation to imaging none of my hernias were present on the imaging but felt when touched. How would the surgeon know how big to make the insicion to see the whole inguinal floor? When i asked the surgeon at shouldice he very quicklly dismissed imaging techniques for hernias. In my case for instance i was shocked to find out that the surgeon cuts all the way down to the pubic tubercile. However i was glad it was done that way as on my left side i had both a direct and indirect hernia. My left side had been operated on before twice and it was totally missed. Now coming back to choosing specific types of repairs for the type of hernia, if the surgeon didnt intent to cut the whole muscle and do a one big repair (fit for both direct and indirect) how would he have found the second defect that was present on my left side. I asked about this ( to the surgeon at the shouldice clinic) and was frustrated it had been missed before. He said that they deliberately restructure the whole floor as one of the main reasons being is that in 13-14% of surgeries they perform there is a secondary hernia present which is missed by most other surgeons. I then asked what if there wasnt a secondary hernia and it was just an indirect isnt that pointless that the tissue is cut away? I was then told what if when i arrived i had an indirect but that area (where direct hernias appear) was still intact but very weak? How would i have known? How would the surgeon of known? Wouldnt it increase the likelihood of me having a reoccurence and then more surgery to then correct the direct hernia? Leading to more pain invasion and scarring? In a way thats why i believe in the shouldice technique the idea is to go in once and do the utmost to minimuze the risk to the lowest stage possible by repairing the whole area to a high standard to minimize future issues and strengthen the tissue as a whole, especially incase its still intact but prone to rupture. That is why i think the reoccurence rates are very low as every possibility is assesed and repair is done not just to fix but also to prevent.
So in a way yes its more cutting away and maybe slight more invasion but i do believe it cuts out any possibilities of being a short term resolution and rather being a long term solution, thus why they do a one repair fit for all and have amazing statistics. The only reason i say this is because i had two previous surgeries and i think everyone will agree that youd rather have one ‘supposedly invasive’ surgery rather than many little ones to correct eachother.
This is why i belive the clinic/technique does a repair which addresses both direct and indirect regardless of the type of inguinal hernia you have.

i hope i have made sense :)))
Regards
Baris

[UhOh!]

[USER=”2019″]drkang[/USER] thanks for that very detailed (yet very understandable!) description of McVay vs. authentic Bassini vs. corrupt Bassini. That at least some some US surgeons seem to recognize the need to use different repair techniques for different hernia types is reassuring, but it tells me something else, too, that’s completely wrong with the way the vast majority of surgeons approach hernia repair.

While your methods sound more effective than what the majority of non-mesh surgeons do, and I don’t want to diminish that in the slightest, it sounds as though your results are attributable in large part to one thing that has nothing to do with surgery itself: the use of preoperative imaging. Like you, it seems that experienced surgeons recognize, on some level, the need for a type-specific repair. What they DO NOT recognize, is the need for a defect-specific scope of repair.

That preoperative imaging means that not only does the surgeon know the type of hernia, they know exactly where the defect is and don’t need to do any extra cutting in order to get a visual on the entire anatomy. While I think I understand the merits of your specific techniques over authentic Bassini, McVay or Marcey, it sounds as though veteran surgeons familiar with these techniques could achieve similar results as you if they used preoperative imaging to not only select a repair suitable to the type of hernia, but also limit the scope of the repair to the actual defect, no?

[Chaunce1234]

This is an incredibly fascinating thread to read, thank you for the detailed explanations and discussion [USER=”2019″]drkang[/USER] .

If possible, please publish more information, specifics, and outcomes about your hernia repair methods so that they can be learned and adopted by other surgeons.

And if you are feeling entrepreneurial, or perhaps one of your students, consider opening a [USER=”2019″]drkang[/USER] clinic in the USA to treat patients, I am sure it would be well received!

[drkang]

McVay repair was devised by McVay, an American surgeon, in 1939. Under this method, cremaster muscle is divided and all transversalis fascia of inguinal canal, including the deep inguinal ring, is cut – which is the same process as that of the authentic Bassini repair. The difference is that the original Bassini repair sews triple layer of medial muscles to inguinal ligament in the lateral, while McVay repair sews triple layer of medial muscles to Cooper’s ligament, which is located deeper than inguinal ligament. Thus, McVay repair belongs to the surgery method that rebuilds the main anatomical barrier, and once administered correctly, recurrence should be minimal.

However, the problem with McVay repair is that it is technically difficult to identify Cooper’s ligament that is located in the deep and sewing triple layer of medial muscles to it. Thus, it is very difficult to correctly administer McVay repair, unless the surgeon is especially well aware of inguinal anatomy.

I remember that my professors, during my resident years, explaining that McVay repair is a very good method that has lower recurrence rate than that of Bassini repair. At the time I did not pay so much attention to such comment, but when I think of it now, the professors were just comparing the performances of corrupt Bassini repair and McVay repair. If my guess is right, it is only natural that the performance of McVay repair is much better.

I think the reason why the doctor you mentioned above told you that he would administer McVay repair for the direct inguinal hernia is that the corrupt Bassini repair shows higher recurrence rate especially in the direct type inguinal hernia. I think that is why the doctor said he would administer McVay repair for the direct type hernia. I do not think that McVay repair would have been required for direct inguinal repair, if the doctor knew about the original Bassini repair. Fortunately in case of indirect inguinal hernia, the corrupt Bassini repair would work better than for direct inguinal hernia.
Anyhow, the corrupt or the authentic Bassini repair or McVay repair are all ‘one-fits-all’ type of repairs.

Sac ligation is a process that must be carried out to cure the indirect hernia, and finishing the surgery by sac ligation is called ‘high ligation’, which is mainly administered to children. Marcy repair is a totally different surgery from high ligation. Marcy repair is a surgery method that narrows the enlarged deep inguinal ring by sewing, after treating the indirect hernia sac. Thus, Marcy repair is also a good surgery method that repairs transversalis fascia, the main anatomical barrier, which can be deemed as a limited version of the original Bassini repair.

Concept of Marcy repair is similar to that of Kang repair administered for the indirect inguinal hernia. However, the big difference between Marcy and Kang ‘indirect’ repairs is that cremaster muscle is always divided in Marcy repair. Also, Marcy repair and Kang ‘indirect’ repair have different areas of sewing the loosened deep inguinal ring.

[drkang]

McVay repair was devised by McVay, an American surgeon, in 1939. Under this method, cremaster muscle is divided and all transversalis fascia of inguinal canal, including the deep inguinal ring, is cut – which is the same process as that of the authentic Bassini repair. The difference is that the original Bassini repair sews triple layer of medial muscles to inguinal ligament in the lateral, while McVay repair sews triple layer of medial muscles to Cooper’s ligament, which is located deeper than inguinal ligament. Thus, McVay repair belongs to the surgery method that rebuilds the main anatomical barrier, and once administered correctly, recurrence should be minimal.

However, the problem with McVay repair is that it is technically difficult to identify Cooper’s ligament that is located in the deep and sewing triple layer of medial muscles to it. Thus, it is very difficult to correctly administer McVay repair, unless the surgeon is especially well aware of inguinal anatomy.

I remember that my professors, during my resident years, explaining that McVay repair is a very good method that has lower recurrence rate than that of Bassini repair. At the time I did not pay so much attention to such comment, but when I think of it now, the professors were just comparing the performances of corrupt Bassini repair and McVay repair. If my guess is right, it is only natural that the performance of McVay repair is much better.

I think the reason why the doctor you mentioned above told you that he would administer McVay repair for the direct inguinal hernia is that the corrupt Bassini repair shows higher recurrence rate especially in the direct type inguinal hernia. I think that is why the doctor said he would administer McVay repair for the direct type hernia. I do not think that McVay repair would have been required for direct inguinal repair, if the doctor knew about the original Bassini repair. Forutnately in case of indirect inguinal hernia, even the corrupt Bassini repair would work better than for direct inguinal hernia.
Anyhow, the corrupt or the authentic Bassini repair or McVay repair are all ‘one-fits-all’ type of repairs.

Sac ligation is a process that must be carried out to cure the indirect hernia, and finishing the surgery by sac ligation is called ‘high ligation’, which is mainly administered to children. Marcy repair is a totally different surgery from high ligation. Marcy repair is a surgery method that narrows the enlarged deep inguinal ring by sewing, after treating the indirect hernia sac. Thus, Marcy repair is also a good surgery method that repairs transversalis fascia, the main anatomical barrier, which can be deemed as a limited version of the original Bassini repair.

Concept of Marcy repair is similar to that of Kang repair administered for the indirect inguinal hernia. However, the big difference between Marcy and Kang ‘indirect’ repairs is that cremaster muscle is always divided in Marcy repair. Also, Marcy repair and Kang ‘indirect’ repair have different areas of sewing the loosened deep inguinal ring.

[UhOh!]

Ah, I now have a better understanding! I didn’t realize that the “authentic” involved cutting that which was not already torn.

This is quite interesting to compare with what a veteran (probably about 70 years old) surgeon told me when I sought a consultation and discussed tissue repairs (since he’s old enough to have actually learned them). I asked which technique he used, and he told me Bassini (assuming the “corrupt” and not “authentic”) for an indirect, and McVay for direct. I’m not sure the reasoning, but at least he seems to recognize that different repairs are somewhat better suited to different types. Though some of what he said conflicts with info I’ve seen elsewhere (notably Dr. Brown’s repair descriptions).

He also said that, in his opinion, the high ligation repair was sufficient for indirect, but that he’s come to do mesh repairs in keeping with the standard of care. I’m assuming he was referring to the Marcey, as I seem to recall you saying that a true high ligation doesn’t involve narrowing the internal ring, and is only applicable to children.

[drkang]

Even though it is not the torn part, there are areas that must be sewn in the indirect inguinal hernia. It is the enlarged deep inguinal ring. The diameter of ring must be decreased to a degree that only spermatic cord can pass through by sewing the loosened area.

The original Bassini repair was not devised exclusively for the repair of direct inguinal hernia, but was devised to be applied to both direct and indirect inguinal hernias. For the sake of briefness, I will skip the process of treating hernia sac and explain only the process of restoring the anatomical barrier.

First, cremaster muscle (that acts as a fence) is cut, so that the surgeon can visually confirm the deep inguinal ring. In the original Bassini repair or Shouldice repair, the surgeon definitely cuts cremaster muscle, to confirm the deep inguinal ring.

After confirming the condition of deep inguinal ring by cutting cremaster muscle, the surgeon starts to cut transversalis fascia from the lower part of the ring to the pubic tubercle – the entire transversalis fascia (which forms the floor of Hesselbach triangle) is cut and made into one big defect. Now, the small hole (i.e. deep inguinal ring) is changed into a hole as large as the entire inguinal canal. Thereafter, all defects in the lower area is sewn together, leaving only a gap in the upper area (the area where the deep inguinal ring used to be) enough for spermatic cord to pass through. Because the transversalis fascia on the entire inguinal canal floor is repaired leaving only the gap for spermatic cord to pass through, this method can be applied regardless of indirect or direct inguinal hernia. So original Bassini was already an ‘one-fits-all’ repair.

Thus, the corrupt version was not modified to allow the ‘one-fits-all’ approach. I do not know the exact cause thereof. I think someone mistakenly administered the surgery omitting this process, without recognizing the importance of transversalis fascia as the anatomical barrier, and the wrong method was handed down to the next generation of surgeons in the course of knowledge transfer. A hernia textbook said that the authentic Bassini repair remained quite much in its original state in Europe, while only the corrupt version became known to America – maybe the persons who transferred the knowledge to America have made a mistake.

Authentic Bassini or Shouldice rebuilds the entire inguinal floor, regardless of the type of inguinal hernia, as seen in the above, and I personally wonder if that is the only solution. So, in Kang repair, only the enlarged deep inguinal ring is narrowed to an appropriate degree, in case of indirect inguinal hernia, and only the transversalis fascia that covers Hesselbach triangle is rebuilt, in case of direct inguinal hernia.

It is because I think there is no reason why even the healthy Hesselbach triangle must be intentionally cut and sewn back again in case of indirect inguinal hernia, or why a portion of healthy (which had not been loosened) deep inguinal ring must be intentionally cut and sewn back again in case of direct inguinal hernia.

By restoring only the damaged areas, as I do with Kang repair, area, time and damage of the surgery can be reduced, which can consequently reduce aftereffect and accelerate recovery. Also, Kang repair can preserve cremaster muscle (in which many people are interested) as is, without any damage.

[UhOh!]

Was the original Bassini repair intended for direct hernias (since indirect wouldn’t have an actual tear to sew together)? I wonder if the corrupt version came about from a desire to develop a one-size-fits-all approach (which would seem rather popular with American teaching institutions).

[drkang]

Scaredtodeath, not yet but I would like to in the near future.

UhOh, You have correctly understood Bassini repair. And the correct title of such procedure is ¡®triple layer repair.¡¯ I would like to correct my reference (¡®3-layer repair¡¯) in my previous answer.

Under Kang repair in case of direct hernia, the parts of torn transversalis fascia which still remain strong are identified and sewn together, so that the sewn transversalis fascia will fully function as a barrier, rather than just sewing together the torn part of transversalis fascia. This is because the transversalis fascia has a very important role as the main barrier. In addition to the above operation, the conjoined muscles (transversus abdominis and internal oblique muscle) are attached to and sewn together with the inguinal ligament to build the auxiliary barrier.

In case of indirect hernia, narrowing the deep inguinal ring (transversalis fascia) by sewing has the same meaning as that of rebuilding the main barrier. However, because it is a very narrow area, it is often difficult to differentiate the layers, and the tissues of other layers are usually sewn together.

[scaredtodeath]

Dr Kang… if I may ask… have you lectured to the American surgeons about your method and results

[drkang]

quote Jnomesh:

Thanks Dr. Kang. Fascinating and kudos to be able to take a complex subject matter and brilliantly conveying it to the readers on this forum.
Some of the surgeons here in the US who do a non mesh repair used what they term a modified Bassini. I wonder if this is the authentic or corrupted version.
Thanks dr. Kang for your contribution!

Hi Jnomesh,

Thank you for your encouragement. According to some hernia textbooks I read, Bassini repair passed onto North America was sadly the corrupt Bassini repair. If it was the authentic Bassini repair that was passed onto North America, Dr. Shouldice would not have created his own surgery method that was very similar to Bassini repair. Because he did not know about the authentic Bassini repair, he had to develop his own surgery method to minimize recurrence. The modified Bassini repair I learned when I was a general surgery resident in the 1980s was actually the corrupt Bassini repair, when I think about it now. I think it was because most of the professors at Korean university medical centers at the time went to the U.S. and learned surgery methods there.

However, if there is a surgery being administered under the name of ‘modified Bassini repair’ in the U.S., I do not know if it is the corrupt Bassini repair or the authentic Bassini repair. A surgeon who is aware of the above particulars may administer the authentic Bassini repair. I cannot rule out the possibility of a surgeon who is not aware of the above particulars administering the corrupt version of Bassini repair.