Kang Repair question

[UhOh!]

[USER=”2019″]drkang[/USER] ,Thank you. So to make sure I understand what you’re saying (since I don’t have a good base of anatomical knowledge), it sounds as though in authentic Bassini several layers of muscle are joined together into one in order to recreate the cumulative barrier effect that the three previously had as separate entities, while Kang sews together only the actual tear, then uses other tissue structures to create the barrier effect?

[drkang]

quote UhOh!:

Very comprehensive explanation, and very interesting (particularly the part about the ‘two Bassinis’). So is the auxiliary barrier in your repair a four-layer repair as in Shouldice, or more similar to the two-layer Shouldice performed by some surgeons?

This brings up two other questions, partially based on the info here and part on my previous thread (about absorbable mesh):

1. If the original Bassini repair had a 2.7% recurrence rate without an auxiliary barrier, why do an auxiliary barrier at all; is there a true need or is it more about the difference between a 2.7% recurrence and the 0.5% you report? That is, of course, unless the recurrence rate was artificially low compared to today, given how many more people would be eligible for surgery/how many more years they live and need the repair to hold…

2. Is the purpose of the auxiliary barrier to hold the repair in place while the fascia heals, or because the fascia will never be “as good as new” again? If it is the former, what would be the likely result of combining a Kang/Bassini (original) fascia repair with a piece of fully absorbable mesh and no auxiliary barrier?

In Kang repair, the auxiliary barrier is erected much more simply than it is done in Shouldice repair. Although I do not fully understand the two-layer Shouldice repair, I think Kang repair is close to it.

Answer to question 1: The authentic Bassini method repairs the hernia by sewing all three medially located muscle layers (transversalis fascia, transversus abdominis and internal oblique muscle) into the lateral structure (lateral leaf of transversalis fascia and inguinal ligament) as one. This is called 3-layer repair. However, in case of Shouldice repair or Kang repair, the auxiliary barrier is additionally needed, because only the defect in transversalis fascia is sewn first. Transversalis fascia is a relatively thin muscle layer, and when there is a direct inguinal hernia, this muscle layer is significantly weakened by the hernia. Thus, although the transversalis fascia is indeed a normal anatomical barrier, it will not be enough to repair only this muscle layer without building any auxiliary barrier.

Answer to question 2: The auxiliary barrier is required not just during the recovery period of sutured transversalis fascia – we must make it work as the permanent barrier. It is because the transversalis fascia of inguinal hernia patient (especially the one who suffers from direct inguinal hernia) would have been weakened. I have administered some 6,000 consecutive non-mesh inguinal hernia repairs and never once felt that I needed any mesh during the surgeries. Some patients out of the 20 to 30 patients whose hernias recurred might not have suffered from recurrence, had I used the mesh. However, I believe that the number would be negligible. Thus, I think it is inappropriate to indiscriminately use mesh (which is risky) to all 6,000 patients for the benefit of only a few. My understanding is that mesh, whether it is absorbable or not, is not free from complication.

[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!

[UhOh!]

Very comprehensive explanation, and very interesting (particularly the part about the ‘two Bassinis’). So is the auxiliary barrier in your repair a four-layer repair as in Shouldice, or more similar to the two-layer Shouldice performed by some surgeons?

This brings up two other questions, partially based on the info here and part on my previous thread (about absorbable mesh):

1. If the original Bassini repair had a 2.7% recurrence rate without an auxiliary barrier, why do an auxiliary barrier at all; is there a true need or is it more about the difference between a 2.7% recurrence and the 0.5% you report? That is, of course, unless the recurrence rate was artificially low compared to today, given how many more people would be eligible for surgery/how many more years they live and need the repair to hold…

2. Is the purpose of the auxiliary barrier to hold the repair in place while the fascia heals, or because the fascia will never be “as good as new” again? If it is the former, what would be the likely result of combining a Kang/Bassini (original) fascia repair with a piece of fully absorbable mesh and no auxiliary barrier?

[drkang]

Hi UhOh!

It has been a while!

Thank you or your interest in and question about Kang repair. At the same time, please accept my apology – when I think of it now, I think there was something wrong with the contents of table.

As a matter of fact, I am still finding out more about inguinal hernia bit by bit, day by day. I sometimes understand new facts during surgery or organize my thoughts as I read related publications. So, I now have an opinion that is somewhat different from that I had when I created the table. Thus, I believe that the part on ‘new barrier’ in the table you mentioned must be updated.

What I am going to explain hereafter is what I have recently discovered.

Dozens of inguinal hernia surgery methods introduced by many hernia textbooks can be largely classified into the methods which erect the new main barriers (Group 1) and which repair the existing damaged anatomical barrier and reuse it as the main barrier (Group 2).

Group 1

All open and laparoscopic mesh repairs, including Bassini repair (? see below) and Desarda technique, can be regarded as the surgery that erects the new main barrier. In most of the surgeries that erect the new main barrier, the existing damaged anatomical barriers are not repaired. Here, the existing anatomical barrier refers to the transversalis fascia.

Group 2

Meanwhile, Shouldice repair reuses the existing damaged anatomical barrier (i.e. the damaged transversalis fascia) after repairing it. However, most surgeries that belong to this Group additionally install auxiliary new barriers, because just repairing the transversalis fascia (the original anatomical barrier) may not be enough. But what is certain is that the main barrier of surgeries that belong to this Group is the transversalis fascia.

Here, I must address this:

Although I said the Bassini repair belonged to Group 1, the Bassini repair published in 1890 was a surgery that belonged to Group 2. The essence of original Bassini repair was to repair the damaged transversalis fascia barrier. While the recurrence rate of inguinal hernia repair announced by other hospitals exceeded 50%, the same rate announced by Bassini in 1890 was merely 2.7%. Owing to this remarkable performance rate, the Bassini repair quickly became famous and many surgeons adopted it. However, it was unfortunate that the method was ‘corrupted’ in the course of it being widely propagated – the initial (and essential) process of transversalis fascia repair was omitted, and the new main barrier was built by pulling and sewing together the separated muscles and ligaments. Some called so ‘corrupted’ surgery method the ‘corrupt Bassini repair’ and the original Bassini repair the ‘authentic Bassini repair’. Thus, the Bassini repair that was said to belong to Group 1 in the above was actually corrupt Bassini repair. However, the authentic Bassini repair is certainly a method that belongs to Group 2 and should be regarded as the most advanced method in the Group. In fact, the processes of repairing transversalis fascia (the main barrier) under the Shouldice repair and the authentic Bassini repair are almost the same. The only difference would be how to create the auxiliary barrier. Thus, some call Shouldice repair the ‘Bassini-Shouldice repair.
Sadly, the Bassini repair most surgeons learned, knew and practiced was not the authentic type, but the corrupt type.

I believe that correctly and strongly repairing the transversalis fascia, the anatomical barrier, is the most important issue in preventing recurrence of hernia. That is why the recurrence rate of initial authentic Bassini repair was only 2.7%, which is an excellent rate even today.
However, as the corrupt Bassini repair became the golden standard of hernia repair thereafter, the recurrence rate had to show a high level of 10 to 30%.

Mesh repair was a surgery method introduced to respond to such a high level of recurrence rate. Unfortunately, mesh repair is also a surgery method that belongs to Group 1 which builds the new main barrier. The only difference from corrupt Bassini is that it builds the new main barrier using mesh, instead of using muscles and ligaments. The mesh inguinal hernia repair should have almost no recurrence, because it uses tough mesh and generates no tension. However, the recurrence rate of mesh inguinal hernia repair appears to be in between 5 to 10% according to the recently announced data. I think it is because the mesh inguinal hernia repair does not repair the transversalis fascia, the main anatomical barrier.

Kang repair I invented is a surgery method that belongs to Group 2, which repairs damaged transversalis fascia, the main anatomical barrier. The difference between Kang repair and other methods in the same Group, such as Shouldice repair or authentic Bassini repair, is that it administers a type-specific repair.
Both Shouldice repair and authentic Bassini repair incise lengthwise the entire transversalis fascia that covers the Hesselbach triangle, including the deep inguinal ring, regardless of the type of inguinal hernia, and repair the entire transversalis fascia again (one-fits-all repair).

However, Kang repair: closes only the stretched deep inguinal ring to its original status (i.e. restoring the damaged transversalis fascia in this area) in case of indirect inguinal hernia; and repairs only the transversalis fascia that covers the Hesselbach in case of direct inguinal hernia (i.e. type-specific repair). In case of indirect hernia, no auxiliary barrier is additionally created, and in case of direct inguinal hernia, the auxiliary barrier is created, similar to what is done in case of Shouldice repair.
The differences between Kang repair and Shouldice repair (which belong to the same Group) are that Kang repair: has very small area of surgery (skin incision of 1.5 inches); does not divide the cremaster muscle; takes little time (20 minutes); has fast recovery time (same-day discharge); and inflicts very little pain. Chronic pain is negligible, and recurrence rate is less than 1%.

I hope I had explained as briefly as I could. In conclusion, ‘yes’ under ‘new barrier’ in ‘Kang repair for direct inguinal hernia’ in the table posted in the website should be changed to ‘no’. I will make sure that the correct information is posted.

I also hope my explanation made sense to you. If you have any question, please do not hesitate to ask me. My explanation in the above is not quoted from any existing information, but derived from what I have understood by administering surgeries and reading reference publications. Thus, other surgeons may not agree thereto. Thank you.

[dog]

drkang Please let as know! Thank you for good question UhOH