Marcy repair in adults with Inguinal hernia.

[Good intentions]

Dr. Ponsky presented at the recent SAGES meeting, in the “Perfect Repair” session.

Laparoscopic inguinal hernia repair (Based on Patkowski’s technique – YouTube
https://www.youtube.com
This talk was presented at the 2018 SAGES Meeting/16th World Congress of Endoscopic Surgery by Todd Ponsky during the The Great Video Debate: Perfect Inguina…

[Chaunce1234]

quote drkang:

You have requested for detailed explanation of my Kang repair. But I hope you understand it is almost impossible to accurately and completely explain the surgical process through words. But I will film the process in the near future and inform you once it is posted on our website. A few aspects about my repair is that sedative local anesthesia is used, skin incision is less than 1.5 inches, and that it is a very simple surgery that takes from 15 to 20 minutes only. The outline of the process is to deal with the hernia sac then closing the muscle defect (hernia hole) by suturing.

Dr Kang, would you mind recording a video of repairing all potential hernia types with your technique? Indirect, direct, femoral, even umbilical if applicable? I imagine these would be valuable to add to YouTube for both understanding the repairs and hopefully to help the technique spread in popularity. Something to consider, thanks.

[drkang]

Hi Jimbohen,

It is great news that there is possibility of the development of a new medical device that has no side effects to replace current mesh being used. I thank you for such pleasant information. This is because implanting is essential to prevent recurrence for incisional hernia including port-site hernia. However it will be for the best of our interest to confine our discussion to inguinal hernia repair since it accompanies mesh complications the most.

I personally believe that implantation is not necessary at all for inguinal hernia. I confirm this after more than thousands of non-mesh open inguinal repair that I have performed. Of course there are many doctors who disagree with my opinion. However, before disputing over whether implantation of mesh is necessary or not, I would like to point out that current mesh repair has a fundamental flaw.

As everyone knows, hernia is caused due to an anatomical defect on the abdominal wall muscle. Simply explained, to treat hernia the defect should be closed. Directly closing the defect is what tissue repairing means. However, in current mesh inguinal hernia repair, mesh is covered on top with the defect left open. Therefore, it is a technique that overlooks the fundamental cause. Recent theses state that the recurrence rate of mesh inguinal hernia is near 10% and I believe this is because it has a flaw. So despite being it a tensionless repair having used a large and durable mesh to cover the whole inguinal region, the recurrence rate is higher than expected. And there does not seem to be another reason why.

That is why I believe that despite the possibility of the development of an ideal implant without side-effects in the future, the fundamental treatment of inguinal hernia is through tissue repair to close the anatomical defect. I predict the possible new implant will have limits utility-wise. Therefore the first step is to directly close the anatomical defect (tissue repair) and then implant for support if thought necessary by the operating surgeon. The ¡°IMPLANTABLE and INJECTABLE bandages that will NOT be REJECTED by the HUMAN BODY and will NATURALLY BREAK DOWN after the wound has healed up¡± mentioned would be an ideal device for supporting the tissue repair.

You have requested for detailed explanation of my Kang repair. But I hope you understand it is almost impossible to accurately and completely explain the surgical process through words. But I will film the process in the near future and inform you once it is posted on our website. A few aspects about my repair is that sedative local anesthesia is used, skin incision is less than 1.5 inches, and that it is a very simple surgery that takes from 15 to 20 minutes only. The outline of the process is to deal with the hernia sac then closing the muscle defect (hernia hole) by suturing.

[Jimbohen]

quote drkang:

Looking at the active discussions, I understand that many people have deep interest in minimal laparoscopic repair. I can feel the sense of fear that people have towards existing inguinal hernia repair methods; starting from mesh repair. However, I believe more than necessary fear can result into looking at only the trees instead of the whole forest.

If it succeeds, it is definitely delightful but only 1~2% at most, I believe, of the total number of inguinal hernia patients are subject to so called minimal laparoscopic repair. Most inguinal hernia patients will not be able to undergo this surgery. Therefore it will not be of much needed help looking into this technique excessively.

The real question here is which technique is practical for the majority of inguinal hernia patients. So, in my opinion, we need to concentrate our discussion on mesh repair and non-mesh open repair. I believe there are two directions we can take. The first is developing the ideal mesh with no side effects; though I do not know if it is possible or not. The second is finding or developing a new minimal non-mesh open repair different from existing ones and then educating it. It is an issue that each and one of us have to decide on. Every doctor may have different opinions but I personally believe the second direction is the best way.

Dr. Kang,

Thanks for your advise that the discussion should focus on the ideal non-mesh open repair and hernia mesh rather than laparoscopic non-mesh repair since very few adults will ever be candidates for this. Regarding your belief that there are then two directions we should take rather than three. The first, but not the best, is developing the ideal mesh with no side effects. This recent press release from Purdue University seems to hold some real promise. Korean researchers there and in Korea have engineered a silk hybrid material that can attack bacteria when illuminated with green light could be the basis for this revolutionary new ideal mesh.

https://www.purdue.edu/newsroom/rele…al-remedy.html

Here’s a summary of some of the points from this article and another source. I don’t fully understand it all but it seems like it could lead to “the ideal mesh with no side effects” that’s so desperately needed:

These Korean researchers have found a way to fuse a far-red fluorescent protein into silk. When exposed to green light, the resulting material will release molecules that kill bacteria and other dangerous pathogens.
The new all-natural organic biomaterial offers an alternative way to sterilize pathogens. Whereas current hernia meshes are often toxic to humans.
They claim this silk hybrid has several uses including wound treatment.
Young Kim, an associate professor of biomedical engineering at Purdue, said that silk is one of the oldest and best-understood biomaterials. Harvested from the cocoons of silkworms, the material generally does not cause any ill effects in humans aside from the rare allergy.
Likewise, green light is not dangerous like ultraviolet light. Green is the strongest wavelength of the visible spectrum, but it’s still safe for humans since it’s found in natural sunlight.
To create a material that featured the benefits of these two, the Purdue-NAAS research team fused the “mKate2” gene into a silk host. A fluorescent protein in the far-red spectrum, mKate2 creates reactive oxygen species (ROS) in the presence of green light.
ROS are radical molecules that react to any organic contaminants they encounter. They attack the membrane and genetic information of bacteria and other pathogens.
The researchers tested the new silk using E. coli bacteria. When they shone a weak green light on the light-reactive biomaterial, they determined that the survival rate of bacteria on the silk hybrid plummeted to 45 percent.
In addition, the new material appeared to be very versatile. The hybrid silk could be turned into a bandage, FABRIC, FILM, and SOLUTION. (injectable)
Fluorescent silk is eco-friendly and bio-compatible with humans.
Kim’s fellow researcher Jung Woo Leem explained that they made fluorescent silk so that it could be disinfected or decontaminated with just normal light instead of UV light. Kim added that their team’s product is superior to competing plasmonic photocatalysts in terms of efficiency and ability to be scaled up.
Plasmonic photocatalysts use metal nanoparticles from semiconductor materials. While these nanoparticles can react with normal light, they may have hazardous effects on the environment, humans, and animals.
Kim pointed out that silkworms create the host material for the ROS-generating proteins of their fluorescent biomaterials. The manufacturing process of their silk photocatalysts is very easy and environment-friendly compared to industrial processes that create plasmonic photocatalysts.
He and his team are already considering other uses for the hybrid silk. Kim talked about IMPLANTABLE and INJECTABLE bandages that will NOT be REJECTED by the HUMAN BODY and will NATURALLY BREAK DOWN after the wound has healed up.
The hybrid silk was genetically engineered to accommodate the fluorescent protein, but it is an organic product and technically not a GMO. The silkworms that produced it are normal; the protein is added to the silk after harvesting.

Dr. Kang, of course this new biotechnology may take some time if it ever comes to fruition for hernia mesh. Especially here in the USA where the powers that be will bog down the process largely out of greed. Big Pharma won’t want to risk the billions they rake in for their many severely flawed and deficient patented mesh products. And their the tail that wags the doctor dog! Thus, perhaps you can help expedite the process for this ideal hernia mesh with your fellow countrymen.

Regarding your belief that the discussion should also focus on the second direction of finding or developing a new minimal non-mesh open repair different from existing ones and then educating it. Respectfully, your posts under this topic as well as the information on your website have led me to believe that you have essentially achieved that goal. Correct me if I’m wrong, but isn’t your “Kang non-mesh minimal open repair” for indirect hernias a method that you developed and refined over just the past few years? Do you not consider it the ideal method with little or no room for improvement? Therefore, please describe the specific nuances and the advantages of your method in even greater detail to the extent that this is practical. Informing and educating all of us, who are very interested, is a big step in the right direction towards having other surgeons perform it for the benefit their patients. I’m not a doctor so for what it’s worth, like you I also “personally believe (that this) the second direction is the best way.”

[drkang]

quote UhOh!:

Very interesting. Potential genetic causes of differing tissue strength aside, it would be interesting to know what other lifestyle differences might be contributing factors. Perhaps the way westerners do (or do not…) exercise, or the vastly different diets across cultures…

If statistically validated, it sounds like there could perhaps be some interesting guidelines for lifestyle changes that lead to better health beyond direct hernia occurrence/recurrence in westerners.

You have pointed out an interesting point but a massively sized survey will be needed to clarify the difference in the lifestyle of Koreans and Westerners. As already been known relating to lifestyle, repeated increase in abdominal pressure is very important as a factor in raising the risk of direct or indirect inguinal hernia. Therefore, it is recommended for people prone to inguinal hernia, those who have already had it in one side or have relatives who had it, to avoid activities that increase abdominal pressure. Life habits that increase abdominal pressure include chronic coughing, continuous straining during defecation due to constipation, eating habits resulting to excessive abdominal obesity, and exercises that cause abdominal pressure. Smoking weakens muscular tissue so it also increases the risk of hernia; and recurrence as well.

Looking at the active discussions, I understand that many people have deep interest in minimal laparoscopic repair. I can feel the sense of fear that people have towards existing inguinal hernia repair methods; starting from mesh repair. However, I believe more than necessary fear can result into looking at only the trees instead of the whole forest.

If it succeeds, it is definitely delightful but only 1~2% at most, I believe, of the total number of inguinal hernia patients are subject to so called minimal laparoscopic repair. Most inguinal hernia patients will not be able to undergo this surgery. Therefore it will not be of much needed help looking into this technique excessively.

The real question here is which technique is practical for the majority of inguinal hernia patients. So, in my opinion, we need to concentrate our discussion on mesh repair and non-mesh open repair. I believe there are two directions we can take. The first is developing the ideal mesh with no side effects; though I do not know if it is possible or not. The second is finding or developing a new minimal non-mesh open repair different from existing ones and then educating it. It is an issue that each and one of us have to decide on. Every doctor may have different opinions but I personally believe the second direction is the best way.

[UhOh!]

quote drkang:

Hi UhOh!

That is an intriguing question you made.
As you mentioned, most patients that we treat are a mostly homogenous group. If our numbers are statistically significant, I believe it is possible it may be due to ethnic differences.
But rather than Koreans having genetic tendency of indirect hernia, I believe there is higher possibility that Westerners are more susceptible to direct hernia. Reason is, Koreans have a lower prevalence rate of inguinal hernia than that of you Americans. And from my personal experience of surgeries, I have noticed that tissue of many Westerners are slightly softer than that of Oriental people. While indirect types of inguinal hernia are more affected by hereditary anatomical factors, direct types have more relation to the strength of tissue. Therefore, if my above mentioned observation is correct, there is higher possibility of direct type inguinal hernia for Western people.
Bear in mind that I am not saying this with proper or accurate reference, but it is my personal opinion on your interesting inquiry.

Very interesting. Potential genetic causes of differing tissue strength aside, it would be interesting to know what other lifestyle differences might be contributing factors. Perhaps the way westerners do (or do not…) exercise, or the vastly different diets across cultures…

If statistically validated, it sounds like there could perhaps be some interesting guidelines for lifestyle changes that lead to better health beyond direct hernia occurrence/recurrence in westerners.

[drkang]

quote UhOh!:

I’m guessing you see a more homogeneous patient population than a surgeon here in the US might, right? That makes me wonder: Is the difference racial/ethnic (in that Koreans are more genetically predisposed to an indirect hernia) OR cultural (fewer Koreans spend their lives sedentary only to wake up one day and decide to do something stupid like attempt to lift the refrigerator, meaning a lower rate of direct hernia)?

Hi UhOh!

That is an intriguing question you made.
As you mentioned, most patients that we treat are a mostly homogenous group. If our numbers are statistically significant, I believe it is possible it may be due to ethnic differences.
But rather than Koreans having genetic tendency of indirect hernia, I believe there is higher possibility that Westerners are more susceptible to direct hernia. Reason is, Koreans have a lower prevalence rate of inguinal hernia than that of you Americans. And from my personal experience of surgeries, I have noticed that tissue of many Westerners are slightly softer than that of Oriental people. While indirect types of inguinal hernia are more affected by hereditary anatomical factors, direct types have more relation to the strength of tissue. Therefore, if my above mentioned observation is correct, there is higher possibility of direct type inguinal hernia for Western people.
Bear in mind that I am not saying this with proper or accurate reference, but it is my personal opinion on your interesting inquiry.

[drkang]

quote Jeremy B:

Thanks for the discussion @Dr. Kang @Dr Towfigh [USER=”2533″]Jimbohen[/USER]

Has anyone developed a way to perform the high ligation and put a stitch in to narrow the deep inguinal ring using laparoscopy?

Also, is the sac usually adhered pretty well to the cord?
Is that why healing a hernia naturally is not possible?
My thought was that if you could “get the sock out of the door” the muscles could theoretically tighten back up.

-Jeremy

Hi Jeremy,

I heard that some surgeons are attempting non-mesh laparoscopic inguinal hernia repairs for adult patients but I personally don’t know much about this. So I am very careful in talking about this topic.

However, I believe that although this technique may be possible someday, there are not many inguinal hernias that can undergo non-mesh laparoscopic repair without the risk of recurrence. I guess that it is almost impossible for direct inguinal hernias, and only possible in cases where the deep inguinal ring is very small for indirect inguinal hernia. Furthermore, there are still problems for the few section of inguinal hernia that non-mesh laparoscopic repair can be performed on. This makes pre-surgery evaluation of patients eligible for this technique very important. But there is no evaluation that is 100% accurate and there are many times when borderline indications while examining. According to the evaluation, it may seem that non-mesh repair can be performed but during actual surgery, mesh repair may be required as the condition is found to be worse than expected. Of course non-mesh repair can despite be performed but a very high risk of recurrence will have to be dealt with. Like this, patients may wake up to mesh repair when they were expecting non-mesh repair prior to surgery. This isn’t ideal for both patients and doctors.

Therefore I believe non-mesh inguinal hernia repair should be performed in an open method. Through experience, I have found that in open method, non-mesh repair can be used on whichever condition the inguinal hernia is.

Also, unfortunately the formed hernia sac does not heal on its own because the intraabdominal organ keeps going in and out of the sac incessantly.

[UhOh!]

quote drkang:

Hi Jimbohen,

[SIZE=12px][FONT=arial]In the majority of textbooks on hernia, the ratio of indirect and direct hernia for an adult man is 2:1. From the statistics that I collected for adult males, the ratio is 2006 to 646 men, making it approximately 3:1. Thus, my ratio of direct inguinal hernia is not higher but rather lower than that written in text books. I’’m not sure if my numbers have statistical meaning. But if it does, I think it might be due to racial differences.

I’m guessing you see a more homogeneous patient population than a surgeon here in the US might, right? That makes me wonder: Is the difference racial/ethnic (in that Koreans are more genetically predisposed to an indirect hernia) OR cultural (fewer Koreans spend their lives sedentary only to wake up one day and decide to do something stupid like attempt to lift the refrigerator, meaning a lower rate of direct hernia)?

[Jeremy B]

Thanks for the discussion @Dr. Kang @Dr Towfigh [USER=”2533″]Jimbohen[/USER]

Has anyone developed a way to perform the high ligation and put a stitch in to narrow the deep inguinal ring using laparoscopy?

Also, is the sac usually adhered pretty well to the cord?
Is that why healing a hernia naturally is not possible?
My thought was that if you could “get the sock out of the door” the muscles could theoretically tighten back up.

-Jeremy

[drkang]

quote Jimbohen:

Hi Dr. Kang,

Apparently, based on your patient records direct hernias increase with age. And, apparently more strenuous, activity since the incidence of these decreases around 60 when most become more sedentary. That would be expected since they’re often the direct result of a strain and or injury. However, your percentages seem somewhat higher than I’ve heard before. Could that be due to some other doctors misdiagnosing direct as indirect hernias?

Since the deep inguinal ring normally shrinks and closes rather than remains open. Even when it abnormally does, isn’t it more likely to just remain the size of a child’s since it shouldn’t normally grow as the body grows regardless? If the deep inguinal ring abnormally doesn’t shrink and close the result is a patent process vaginalis defect. Thus, a loop of the intestine may herniate through it and create a gross (visible) bulge in BOTH a child and an adult. Hence, why would only the adult, and not the child, be a bad candidate for laparoscopic high ligation simply on that basis alone?

Of course, I’m not a doctor so I’m certainly not trying to challenge your theory. Rather, I’m just seeking clarification for a better understanding. Thanks for sharing your insightful wealth of knowledge.

Hi Jimbohen,

In the majority of textbooks on hernia, the ratio of indirect and direct hernia for an adult man is 2:1. From the statistics that I collected for adult males, the ratio is 2006 to 646 men, making it approximately 3:1. Thus, my ratio of direct inguinal hernia is not higher but rather lower than that written in text books. I’’m not sure if my numbers have statistical meaning. But if it does, I think it might be due to racial differences.

Deep inguinal ring is a hole made up of muscle. This is where the testicular vessel and lymphatics, vas deferens and genitofemoral nerve travel from their preperitoneal space and come out together to become a spermatic cord. Then it goes down the inguinal canal, and this muscular hole is the deep inguinal ring. Hence, deep inguinal ring is a muscle structure covering the spermatic cord.

Deep inguinal ring doesn’’t shrink or close as we grow. Rather, the diameter of the spermatic cord widens as our body grows to contain the spermatic cord inside. The widened diameter maintains its size after maturing in age. This is how each part of our body grows with balance.

Processus vaginalis is a structure that forms during fetal growth. It usually reduces a lot in size at the time of birth. It is called the patent processus vaginalis(PPV) if it remains as a very narrow pit even after birth. Its diameter is usually 1-2mm and looks like a very thin pocket. At birth, 80-90% of babies have it. Just like a cat tail under the door, PPV looks as though it’s stuck between the deep inguinal ring and spermatic cord. PPV usually shrinks further and obliterates as babies grow but some remain even in adulthood that it can be found in 20-30% of autopsy cases. Some of PPV develop into indirect inguinal hernia later but the majority naturally disappears or remains harmless. As such, PPV and indirect inguinal hernia are different from each other. For hernia, the intraabdominal organ goes through the deep inguinal ring and out to the inguinal canal but for PPV, the size is too small that the intraabdominal organ doesn’’t herniate. Therefore, surgery is not applicable for PPV. We don’’t know the cause of PPV exactly, but it is definitely not because the deep inguinal ring doesn’’t shrink.

An infant’’s spermatic cord is too small in diameter that the deep inguinal ring, which covers around it, is very small as well. In hernia patients, deep inguinal ring widens with it, because the muscle forming the deep inguinal ring is stretched due to the bulk of the herniated organ. However, as an infant’’s hernia sac is small, the deep inguinal ring remains small even if a child has an inguinal hernia. During actual surgery, it can be seen that there’s no space for even a single pencil in the deep inguinal ring after the hernia sac has been tied off and pushed back in, that is called the high ligation. Also, an infant’’s deep inguinal ring is much more elastic and has better recovery than that of an adult’s so a simple high ligation of a hernia sac will almost completely prevent recurrence.

They say the diameter of an adult’’s spermatic cord is 11-27mm. So I think the deep inguinal ring has an inner diameter as large as that. Since an adult’’s hernia is much larger than an infant’’s herniated organ, the former’’s deep inguinal ring is stretched much more than the latter’’s. So the diameter of the deep inguinal ring becomes much larger and muscle fiber of the ring is more damaged. In the case of an adult, there are many times when there is more space than an adult’’s index finger in the deep inguinal ring where the stump of the hernia sac is cut, tied off and pushed back inside. Furthermore, an adult’’s deep inguinal ring lacks elasticity compared to that of an infant’’s, and it is also prone to having more serious stretching injury and lacks in recovery. So for most adult males, it is difficult to avoid recurrence just by high ligation of the sac.

Therefore, after high ligation of the sac for adults, it is absolutely necessary to close or make narrow the extra space in the deep inguinal ring where the hernia sac used to be.

[Jimbohen]

quote Jeremy B:

Dr. Ponsky would like the following communicated:
“I DO NOT yet recommend this to adults because we dont have enough data yet. We are conducting a prospective trial in Norway and have not had a recurrence yet (about 20 patients so far) but I make it very clear to my older patients that they must understand that we dont know yet who this will fail in”

Please relay the following to Dr. Todd Ponsky:

Many doctors highly recommend mesh although they don’t know who it will fail in and this seems to be many. So don’t let that hold you back!

You’re an American doctor but you’re only involved in a trial in Norway? Are the mesh pushing doctors and big pharma opposing an American trial?

Would you agree that the deep inguinal ring isn’t genetically programmed to grow as a child grows into adulthood? But instead it normally shrinks and tightens or closes around the spermatic cord? However, even when it abnormally fails to do that and an open gap remains resulting in a patent process vaginalis defect. Which sets the stage for a loop of the intestine to herniate through it and create a visible palpable bulge. Even when this occurs, isn’t the diameter of the deep inguinal ring quite often small enough for successful high ligation? Assuming this is done early enough before it may have expanded and stretched through decades of movement of the spermatic cord? Doesn’t the fact that you’ve had no recurrence with 20 adult patients bare this out?

[drtowfigh]

[USER=”2329″]Jeremy B[/USER] most young people have indirect inguinal hernias. The same is true among older patients. However, direct inguinal hernias increase in incidence as you age, or if there is a strong genetic predisposition toward hernias, as it is basically a weakness of the fascia.

Many can have releof from symptoms of an inguinal Hernia with a core-based exercise regimen. It will not cure the hernia.

[Jeremy B]

Dr. Ponsky would like the following communicated:
“I DO NOT yet recommend this to adults because we dont have enough data yet. We are conducting a prospective trial in Norway and have not had a recurrence yet (about 20 patients so far) but I make it very clear to my older patients that they must understand that we dont know yet who this will fail in”

[Jimbohen]

quote drkang:

Hi Jeremy B,

I reviewed my inguinal hernia repair cases of the past 2 years, 2016 and 2017.
The percentages of the male direct inguinal hernias are as below;

20s: 0% (0 out of 160 total inguinal hernia repairs)
30s: 8.4% (17 out of 202)
40s: 18.1% (67 out of 370)
50s: 32.8% (183 out of 558)
60s: 30.1% (209 out of 695)
70s and plus: 25.5% (170 out of 667)

It is not common that the indirect inguinal hernias have the concomitant weakness in the Hesselbach triangles(direct area).

I am very sorry, but let me say something. I don’t really want to discourage you and also hope I’m not being misunderstood for trying to disparage and criticize other doctors’ methods. All that I wish is to give the correct advice based on my knowledge to everyone on this forum.

Dr. Todd Ponsky introduces himself as a Pediatric General Surgeon and it is mentioned under his video (link above) that “it is the technique for laparoscopic high ligation of an indirect inguinal hernia”. The open high ligation is the well-known technique that has been used only for the pediatric inguinal hernias for last 120 years. Laparoscopic high ligation and open high ligation share the same concept. And if you search Dr. Patkowski’s repair which this technique was based on, you can see that they performed this technique mainly on pediatric inguinal hernias.

Recently one hospital in Seoul performed the similar non-mesh laparoscopic inguinal hernia repairs on adults for a couple of years. But now they abandoned this procedure and returned to using mesh.

To my knowledge, for this technique to be successful on adults as well, the size of the deep inguinal ring has to be as small as that of a child. It means this technique is seldom applicable for the average adults. As you know, it is not applicable for direct inguinal hernia. and can only be performed for small indirect inguinal hernia. At the end of the video, the Dr says that this will work well in young adults that have a small indirect inguinal hernia that is essentially a patent processus vaginalis. This means that it is not adequate to perform if there is gross inguinal bulging in adult patient.

5 years have passed since this video was uploaded in 2013. So I think you’d better ask him the total number of the repairs on adults so far and the surgical outcome before making a final decision.

Hi Dr. Kang,

Apparently, based on your patient records direct hernias increase with age. And, apparently more strenuous, activity since the incidence of these decreases around 60 when most become more sedentary. That would be expected since they’re often the direct result of a strain and or injury. However, your percentages seem somewhat higher than I’ve heard before. Could that be due to some other doctors misdiagnosing direct as indirect hernias?

Since the deep inguinal ring normally shrinks and closes rather than remains open. Even when it abnormally does, isn’t it more likely to just remain the size of a child’s since it shouldn’t normally grow as the body grows regardless? If the deep inguinal ring abnormally doesn’t shrink and close the result is a patent process vaginalis defect. Thus, a loop of the intestine may herniate through it and create a gross (visible) bulge in BOTH a child and an adult. Hence, why would only the adult, and not the child, be a bad candidate for laparoscopic high ligation simply on that basis alone?

Of course, I’m not a doctor so I’m certainly not trying to challenge your theory. Rather, I’m just seeking clarification for a better understanding. Thanks for sharing your insightful wealth of knowledge.

[drkang]

quote Jeremy B:

Thank you Momof4; Yes, this is exactly what I’m in the process to have done. I will keep you all posted on my journey. Crossing my fingers for an indirect hernia.
Dr. Kang, Dr. Towfigh, what is your estimated incidence of Direct vs Indirect? And if It is Indirect, Is there often a weakness in the Direct area?
Thanks in advance!
-Jeremy

Hi Jeremy B,

I reviewed my inguinal hernia repair cases of the past 2 years, 2016 and 2017.
The percentages of the male direct inguinal hernias are as below;

20s: 0% (0 out of 160 total inguinal hernia repairs)
30s: 8.4% (17 out of 202)
40s: 18.1% (67 out of 370)
50s: 32.8% (183 out of 558)
60s: 30.1% (209 out of 695)
70s and plus: 25.5% (170 out of 667)

It is not common that the indirect inguinal hernias have the concomitant weakness of Hesselbach triangles(direct area).

I am very sorry but let me say something. I don’’t really want to discourage you and also hope I’’m not being misunderstood for trying to disparage and criticize other doctors’ methods. All that I wish is to give the correct advice based on my knowledge to everyone on this forum.

Dr. Todd Ponsky introduces himself as a Pediatric General Surgeon and it is mentioned under his video (link above) that ““it is the technique for laparoscopic high ligation of an indirect inguinal hernia””. The open high ligation is the technique that has been used for the pediatric inguinal hernias for last 120 years. Laparoscopic high ligation and open high ligation share the same concept. If you search Dr. Patkowski’’s repair which this technique was based on, you can see that they performed this technique mainly on pediatric inguinal hernias. Recently, one hospital in Seoul performed the similar non-mesh laparoscopic inguinal hernia repairs on adults for a couple of years. But now they abandoned this procedure and returned to using mesh.

To my knowledge, for this technique to be successful on adults as well, the size of the deep inguinal ring has to be as small as that of a child. It means this technique is seldom applicable for the average adults. As you know, it is not applicable for direct inguinal hernia, and can only be performed for small indirect inguinal hernia. At the end of the video, the Dr says that this will work well in young adults that have a small indirect inguinal hernia that is essentially a patent processus vaginalis. This means that it is not adequate to perform if there is gross inguinal bulging in an adult patient.

5 years have passed since this video was uploaded in 2013. So I think you’’d better ask him the total number of the repairs on adults so far and the surgical outcome before making a final decision.

[drkang]

quote Jeremy B:

Thank you Momof4; Yes, this is exactly what I’m in the process to have done. I will keep you all posted on my journey. Crossing my fingers for an indirect hernia.
Dr. Kang, Dr. Towfigh, what is your estimated incidence of Direct vs Indirect? And if It is Indirect, Is there often a weakness in the Direct area?
Thanks in advance!
-Jeremy

Hi Jeremy B,

I reviewed my inguinal hernia repair cases of the past 2 years, 2016 and 2017.
The percentages of the male direct inguinal hernias are as below;

20s: 0% (0 out of 160 total inguinal hernia repairs)
30s: 8.4% (17 out of 202)
40s: 18.1% (67 out of 370)
50s: 32.8% (183 out of 558)
60s: 30.1% (209 out of 695)
70s and plus: 25.5% (170 out of 667)

It is not common that the indirect inguinal hernias have the concomitant weakness in the Hesselbach triangles(direct area).

I am very sorry, but let me say something. I don’t really want to discourage you and also hope I’m not being misunderstood for trying to disparage and criticize other doctors’ methods. All that I wish is to give the correct advice based on my knowledge to everyone on this forum.

Dr. Todd Ponsky introduces himself as a Pediatric General Surgeon and it is mentioned under his video (link above) that “it is the technique for laparoscopic high ligation of an indirect inguinal hernia”. The open high ligation is the well-known technique that has been used only for the pediatric inguinal hernias for last 120 years. Laparoscopic high ligation and open high ligation share the same concept. And if you search Dr. Patkowski’s repair which this technique was based on, you can see that they performed this technique mainly on pediatric inguinal hernias.

Recently one hospital in Seoul performed the similar non-mesh laparoscopic inguinal hernia repairs on adults for a couple of years. But now they abandoned this procedure and returned to using mesh.

To my knowledge, for this technique to be successful on adults as well, the size of the deep inguinal ring has to be as small as that of a child. It means this technique is seldom applicable for the average adults. As you know, it is not applicable for direct inguinal hernia. and can only be performed for small indirect inguinal hernia. At the end of the video, the Dr says that this will work well in young adults that have a small indirect inguinal hernia that is essentially a patent processus vaginalis. This means that it is not adequate to perform if there is gross inguinal bulging in adult patient.

5 years have passed since this video was uploaded in 2013. So I think you’d better ask him the total number of the repairs on adults so far and the surgical outcome before making a final decision.

[Jeremy B]

Thank you Momof4; Yes, this is exactly what I’m in the process to have done. I will keep you all posted on my journey. Crossing my fingers for an indirect hernia.
Dr. Kang, Dr. Towfigh, what is your estimated incidence of Direct vs Indirect? And if It is Indirect, Is there often a weakness in the Direct area?
Thanks in advance!
-Jeremy

[Momof4]

In my experience, most surgeons want some type of imaging to make the best surgical plan. Would it be possible to have Dr. Ponsky order the imaging and you could send it to him to read. That seems like your best option to me. Dr. Towfigh ordered imaging for me to have done at home and then I sent her the disc for interpretation. Usually an imaging center can perform the right imaging with orders but there seems to be a lot of false negative radiology reports when it comes to hernias. Best wishes for a successful minimally invasive surgery that allows you to get back to life, without complications!

[Jeremy B]

I had my phone meeting this morning with Dr Ponsky, I was very impressed with his knowledge and willingness to explain everything and take the time to answer all of my questions and concerns. Like many surgeons on here, he is thinking outside the box in regards to innovate approaches and ideas for hernia repair. I am very excited to potentially have this very minimally invasive surgery. I just need to determine if I have an indirect or direct hernia. Does anyone here know of someone in the states preferably near Minnesota, who can differentiate between the two via sonography or other non invasive methods. Id like to know beforehand vs exploration with laparoscopy. It seems that Dr. Kang routinely orders this before surgery and that seems like a smart idea.

Thanks!
Jeremy