Marcy Repair

[pinto]

Given Dr. Towfigh’s point above and elsewhere that Marcy is a surgical method for children and small-framed women, I must think that is a generally held view (for doubtlessly Dr. T is quite abreast of the field). So I am surprised that the article addressed here (“Novel modification of Marcy operation…”) shows no awareness of its potentially great contribution to the field—namely Marcy’s applicability for male adult patients!

@KC, the journal editor let you down; he/she overlooked that 90% of the cases were male with mean age of 64! Both age and gender should have rung bells for them. In their defense, the section of the actual version, “Study Population,” no mention of sex/gender or age is made about the patients. Yet Table 1 does have “baseline characteristics” of such included but unfortunately appears several pages away—-likely an editorial mishap. Reading on though in the Results and Discussion we find no mention of the specialness of male elderly adult patients studied. Instead the authors’ thrust is that their modified-Marcy compares favorably with the alternative mesh approaches. Even still the editor did not play their best game for not foregrounding the article in that way—a potential alternative to the use of mesh. Thus in several ways the journal editor did not do their job for the article.

A bigger question: Is Marcy having wider use in Korea than elsewhere? It may be that Marcy has not been confined to solely children and small-framed women as in North America and so on. But in Korea Marcy is used also for male adults.

[pinto]

@KC thank you for kindly answering and correcting my misunderstanding. If I was more of a camera buff, I would have likely got it right the first time. 🙂 I suppose the metaphor is camera lens shutter.

You are doing quite well, KC, and we appreciate even more how you kindly are working to help us understand in English. Korean and English are so widely divergent languages that mastery for either of us is way beyond that required between West European languages. Thank you for the accommodation.

Interestingly your research paper linked above–actually the condensed version—and likely for that reason—omits the sex and ages of the patients. So your statement above is quite exciting: “I have operated my modification technique not to children but to adult male indirect inguinal hernia.”

Because your condensed version of your paper does not include that, we might not hear the expected shock from the hernia field. It will take more time for that to happen. Maybe like a delayed action shutter. 🙂 I commend you for all what you are doing and am much appreciative.

[KC]

@william I use black silk only at the deep inguinal reconstruction. And this way of reconstruction is almost tensionless.
I use prolene in Shouldice operation.
Black silk has a merit of grasping tissue which is ususally disadvantageous in surgery. But in my operation I need to hold the medial end of spermatic fascia of the deep inguinal ring tightly to pull that back to lateral abdominal wall. In this situation, silk is convenient. My operation picture will help you understand that

[William Bryant]

Silk sutures – KC…

Are these used to minimise risk of allergic or foreign body reaction or is there another reason/s?

Is there a chance they may increase the chance of recurrence?

(I think Dr Kang during a discussion on types of sutures suggested silk could increase the chance of a recurrence.)

[Watchful]

Very interesting. Thanks, KC. Indeed, my hernia was a life-long indirect hernia since birth. I didn’t know that this could be displacement of the inner ring (which is not worn out in this case), and that it can be repositioned in surgery. Instead, an unusually difficult and long Shouldice procedure was performed which caused a bunch of issues.

Your level of understanding of the groin anatomy and how to repair it with minimal surgery tailored for the particular problem is extremely rare, unfortunately. I don’t know what it is about the groin anatomy that makes it so hard for surgeons to master. Mesh made things a lot worse because surgeons just learn enough to place the mesh, so they now know even less.

[KC]

thanks to Jack2021 for kind comment.
my operation time is 72 +- 15 minutes.
now a days, i use only two Black silk 1-0 sutures.
my incision is about 5 cm +- 0.5
I changed my operation technique very recently, so My cases need a long term follow up data and need more cases to convince the effectiveness. my report confirms only that there is no early recurrence and Post-herniorrhaphy pain is fair. actually my individual experience says much better.

[KC]

@ watchful : it is about 4 cm distance from the medial margin of the deep inguinal ring to the pubic tubercle. so 6cm size and 4 finger wide deep inguinal ring means that it is very large that the medial margin of the deep inguinal ring is almost approached to the pubic tubercle. In my case usually very long duration hernia with omentum packed case was like that. and also usually hernia presented from earlier life. in these cases I suffered no problem to close the defect, because the deep inguinal ring is only displaced. it is not worned out. my job is repositioning the medial margin to it’s original position.

[KC]

@ pinto ; I am very sorry that I cannot explain well in metaphor cause my English is very poor. but please imagin that the shutter is open a little for a passage of spermatic cord when there is no hernia. and when hernia develops the shutter is open in one direction due to the protrusion of the hernia sac. usually the two lateral pillar is not move much. In human anatomy one lateral pillar is inguinal ligament and another is thick musculofascial tissues. Bassini and Marcy operation is approximating these two pillars together closing the door itself. My modification is pull up close the opening after reduction of the hernia sac.
above explain is for the indirect inguinal hernia. direct hernia is protruding out from the weakened shutter door it self.

[Jack2021]

Hi @kuyongchung (KC),

Many thanks for joining the forum recently to talk openly and candidly about your modified Marcy repair, it’s very much appreciated.

It’s extremely important for innovative surgeons such as yourself to be openly sharing their techniques within their field and to explain and publish all the details of their work, as you’ve begun to do, for which I applaud you, thank-you.

The sooner this happens, the sooner it can be peer reviewed and validated/learnt by other specialists around the world if justifiable to do so and here’s hoping!

@drkang has apparently operated on thousands of patients with his modified Marcy ‘Kang’ repair and claims excellent low recurrence and long term chronic pain numbers, but he still doesn’t appear to be ready to explain and share exactly what his technique is.

As @drkang’s repair apparently takes around 20 minutes to complete, which is less than half the time of other open tissue repairs, one would imagine that the modification/s he’s devised have made his repair relatively straightforward for a skilled surgeon to complete and ergo easier to teach to other surgeons than say the Shouldice repair.

This in itself is or could be a groundbreaking leap forward in many ways, but it needs to be shared and peer reviewed, which @drkang doesn’t appear open to currently, leaving question marks against his claimed results and the method itself, regardless of whether it may be the biggest innovation in hernia repairs for a generation or two of hernia repair specialists, or not.

Perhaps yours may prove to be a long awaited groundbreaking repair KC and your openness makes that a greater possibility.

KC, how long does your modified Marcy ‘KC’ repair take you to complete and do you use permanent Prolene sutures?

What is the size of your incision too please?

Also, it’s interesting that both yourself and @drkang are based in Seoul and you’ve both devised your own modified Marcy repairs with apparent great success which is evidenced in your case, but not @drkang’s yet, although hopefully it will be soon.

Is the Marcy repair very prevalent in South Korea, thereby increasing the likelihood of surgeons such as yourself and @drkang making their own modifications, as seems to be more common with the Shouldice repair internationally, or have there been conventions or similar in South Korea focussing on modifying and simplifying hernia tissue repairs to streamline the repair so more surgeries can be completed in less time, with better long term outcomes and an improved patient experience overall? I guess what I’m getting at is what was the inspiration behind your ‘KC’ repair and the ‘Kang’ repair; is it just a major coincidence that two surgeons in the same city have devised successful modified Marcy repairs, or is there something in common that has inspired you both to create your own modified Marcy repair and could they even be very similar or exactly the same repair?

@drkang, we really need and would very much welcome your input and explanation of your ‘Kang’ repair here too please?

As Watchful mentioned, Dr Ralph Lorenz, who already has some interest and apparent knowledge of the ‘Kang’ repair and no doubt @drtowfigh and all other open-minded hernia specialists will (and should) be interested to learn more about and discuss your repair KC and the findings from your research paper, especially as you appear open to this.

Like you’ve done, we also need @drkang to be open to explaining and publishing the details of his repair, as Professor Desarda did (there are now numerous studies and many in Europe, including 15-year follow up study in Poland which evidenced excellent long-term results) and the sooner the better so it can be peer reviewed, validated and hopefully improve patient outcomes in this common, yet complicated area of surgery.

It would be good to hear your initial thoughts after reading the above posted study and posts too @drtowfigh please?

Many thanks,

Jack

[pinto]

Just when discussion about Marcy became a little gloomy, we have this bolt of sunshine of possibly not one but two modified Marcys (made applicable for adult male patients also). William, it seems Kang Repair, if classifiable as a Marcy, was developed earlier. If my understanding of @KC‘s method correct as I posted above, then it is not surprising that we have these two possibly similar approaches. Marcy was ripe for modification. Given Dr. Lorenz’s related commentary, then @KC‘s method gives added credence to Kang Repair (and vice-versa). As far as their coincidentally coming from Korea, great, but not surprising given the country is a hotbed of medical services, as the “medical tourism” corner for visitors at the Seoul international airport typifies.

[William Bryant]

KC, Pinto and Watchful etc…

Is this modification similar to Dr. Kangs? In that it’s different direction stitching? This was mentioned by Dr. Ralph Lorenz on the interview I believe and made clearer by Jack2021.

If it is similar it’s remarkable that two surgeons have discovered it and it gives (further) credence to Dr. Kangs repair surely?

Of course, like many things, I could have it wrong!

[Watchful]

Thanks, Dr. KC for providing further details. Most of us on this forum are patients, not surgeons, so it’s hard for us to understand much of it, but we get some idea.

It’s excellent (and I guess surprising) that your technique works without a problem on large hernias. Again, understanding that is beyond my ability with my limited knowledge of the groin anatomy.

I had an indirect hernia with a large defect of 6cm. This is large-enough for inserting four fingers, and larger even than some meshes used in open repairs. Are you saying that you can repair such an indirect hernia without a problem with your method? It was a difficult and long operation even with the Shouldice technique.

[pinto]

@KC, excuse me, I must correct myself for my lapse not realizing you besides being a practicing surgeon, might also be a professor if one of the senior co-authors. Nevertheless your paper contributes importantly to the field particularly tissue repair.

[pinto]

Thank you @KC for being for so forthright. I’m happy for you that you likely are part of a medical department that is supportive of innovation. Congratulations on your recent publication something particularly impressive by a practitioner (non-academic, I take it) and should be noted by Members here as well, being a major scientific journal, presumably it was peer-reviewed. So it adds credence to the notion that Marcy, albeit modified, could be effective for adult male patients.

Let me ask some clarification about the shutter window metaphor you used, contrasting two vertical columns to close them by classic Marcy (I recommend you use “classic” rather than “old”) versus the modified one using one horizontal column to close the “window.” (1) Is the great merit of modification that the horizontal removes the potentially weak central area between the vertical columns? (2) How many rows of vertical stitching is made?
(3) Is the hernia “shutters” only gapped centrally or like real shutters there are gaps/crevices around them not only centrally?

Given the most ideal situation for horizontal stitching/Modified Marcy, did you ever wonder why the originator Marcy chose to do it vertically? Your shutter metaphor is so compelling that is seems commonsensical. Indeed I cannot think of any shutter windows or double doors not closed horizontally. Thus classic Marcy begs to be modified.

[KC]

@ pinto, From 2003 to 2017 i performed PHS herniorraphy in about 50% and 3D patch herniorrhaphy in about 30% and TEEP about 20%, and annual inguinal herniorrhaphy number is about 70-80 cases. From 2019 I use mesh only in TEEP cases when patients wanted that or in femoral or obturator hernia cases, annually under 7 cases. all other cases with indirect inguinal hernia, I perform with the Modified Marcy operation. and in direct inguinal hernia cases, I perform Shouldice operation with two layers suture only or TEEP. In direct hernia, I scrutinize the deep inguinal ring. and if i find out small peritoneal sac popping out a little like a tongue at the deep inguinal ring, I perform deep inguinal ring modification simultaneously. 2018 is a transitional period of above.

[pinto]

@KC, thank you for so kindly writing in a considered way. It gives us a deeper appreciation and understanding of your method and that of Marcy. Among your IH surgeries, what proportion do you do tissue repair and what proportion, mesh?

[KC]

And to drtowfigh, i want to comment that I have operated my modification technique not to children but to adult male indirect inguinal hernia. the size of the deep inguinal ring is not a matter, but the definite weakening or defect is important to scrutinize the posterior wall.

[KC]

Dear watchful and Pinto. I am very glad and welcome to talk about this subject with anyone, but I do not know how Dr Kang do his practice and have no information of his data. I respect Dr Marcy as a surgeon who first emphasized deep inguinal ring modification. and my key Idea added to him is that moving medial margin of the deep inguinal ring to the lateral direction. In large indirect hernia you can easily find that the medial margin of the deep inguinal ring with inferior epigastric vessels is encroached medially making the inguinal canal shortened. in this situation, Marcy operation is not so different from Bassini operation.
my technique is not so tricky compared to Marcy operation, If you are to do Marcy operation you should detach the internal spermatic fascia from the vas and testicular vessels. If you do not do this, it’s not true Marcy operation. I think this procedure is most important and my modification is only small but “much different” modification that suturing this medial margin to the upper lateral abdominal wall horizontally. My modification has an effect of pulling the medial margin of deep inguinal ring more laterally, which makes the deep inguinal ring repositioned under the thick internal oblique abdominal muscle and lengthening the inguinal cannal increasing the obliquity of the inguinal cord structure. So there can be possible chance of damaging the spermatic cord during the procedure detaching the internal spermatic fascia from the spermatic cord, but not during the suture of medial margin to the lateral abdominal wall.

[pinto]

Dear @KC,

Previously you mentioned that your method is quite different from Marcy [ “actually it’s detail is much different from old Marcy operation.] Is it your stitching that does that or are there other ways your method differs?

[Watchful]

KC, Dr. Lorenz in Germany may be interested in studying this further, so you may want to contact him. When I talked to him, he was interested in researching the Kang technique for indirect hernia which sounds similar to yours. He seemed to know the details of that technique.

I’m guessing that the tricky aspect of this technique is performing this more elaborate stitching inside the inner ring so close to the spermatic cord without injuring it.