Marcy repair in adults with Inguinal hernia.
05/21/2018 at 9:14 pm #11309
Ladies and gentlemen in the Hernia Talk comunity, I have held off repair of my right side inguinal hernia in hopes of a less invasive technique and tailored approach.
I recently discovered Dr Kang and William Brown who will perform a Marcy like repair for Indirect Inguinal hernias.
I find this approach very attractive as it limits the dissection but is it enough? Does anyone have any experience or can speak to this technique?
Lastly since this works only for an Indirect hernia, can a scan be done to detect either an Indirect, Direct or both?
Any thoughts greatly appreciated.
05/22/2018 at 1:06 am #16177
Sometimes Ultrasound can differentiate between direct and indirect, and femoral, but sometimes it can erroneously display one or the other, or none, they are not perfect, and I suspect operator and interpreter matters as well.
As far as I know, Marcy repairs are usually done in children and adolescents, I think it basically shrinks the entrance to the inguinal canal so as to make it too small for something to pass through it that does not belong, therefore it would work on indirect but not direct or femoral. I personally know people who had those marcy hernia repairs as children and have never had a recurrence or any other problem.
Interestingly, Dr Todd Ponsky appears to be actively involved in a study on testing this repair done laparoscopically on adult indirect hernias.
Comment from Dr Ponsky found in that YouTube comments says the following:
“We will soon have data from a prospective trial treating all adult in directing a hernia is with this technique and we will have a better understanding on who fails and who succeeds.”
Does your hernia hurt or bother you in another way? Is it large or small?
05/22/2018 at 2:47 pm #16188
Chaunce; Thank you for the reply and the link, I may try to get on board this study.
As far as my hernia, Id say its fairly small to medium, probably mostly fat in there, there have been a few instances where it seems like bowel potentially.
I’d like to avoid surgery if possible, I where a truss and have done exercises to try to strengthen the core and obliques, not sure how much benefit this has had. Im in contact with others that have “almost cured” there hernia so It gave me some hope.
On the other end, I’m so sick of dealing with this thing; Its brought me into a deep depression that has landed me into the hospital twice now.
I’m just so scared of surgery, Nerve damage, chronic pain, reaction to anesthesia or materials, being left worse than I am ect..
05/23/2018 at 11:38 am #16196quote Chaunce1234:
Before performing hernia repair, it is our principle to accurately diagnose what type of inguinal hernia it is. This is because not only is the surgical method different for each indirect inguinal hernia and direct inguinal hernia, the location of skin incision is also different. The subtype of inguinal hernia can be precisely identified by ultrasonography.
Surgical methods for open inguinal hernia on adults is largely divided into two. It is similar to a football match where it is divided into first and second halves. For the sake of convenience, I will refer to “open indirect inguinal hernia repair for adults” as “INDIRECT HERNIA REPAIR”, and “open direct inguinal hernia repair for adults” as “DIRECT HERNIA REPAIR”.
The first half of INDIRECT HERNIA REPAIR is the step when the hernia sac is located then tied off and the stump is placed back into its preperitoneal space. This step is proceeded on every INDIRECT HERNIA REPAIR; whether it is a mesh or non-mesh repair. However, it is different in the second half. In Lichtenstein repair, the inguinal floor is completely covered by mesh sheet, and in mesh plug repair, the mesh plug is placed where the hernia sac is. In the case of tissue repair as well, the inguinal floor is reinforced each in its own method whether Bassini, McVay, Shouldice or Desarda. As such, all INDIRECT HERNIA REPAIR are composed of two sections. In DIRECT HERNIA REPAIR, there are at times when the handling of the hernia sac (first half) is not clearly carried out. But the second half, when the inguinal floor is reinforced, is always carried out.
However, inguinal hernia repair on children is certainly different from that on adults. For children, inguinal hernia is unconditionally the indirect type and surgery is completed by handling the hernia sac and simply placing it back to its preperitoneal space. This is called high ligation. The second step is unnecessary for children because in infantile hernia, the muscle break called the deep inguinal ring is too small for the hernia sac to escape in the first place.
It is unfortunate that many people are confusing high ligation with Marcy repair. Marcy repair consists of both the first and second half mentioned above. This means that in the latter half of Marcy repair, the deep inguinal ring is stitched and closed. In most textbooks, it is written that Marcy repair can only be applied on small indirect inguinal hernia; when the deep inguinal ring is very small. However, I have conducted my repair(Kang repair), which has a similar concept to that of Marcy repair, for the past 5 years on more than 3,500 patients with indirect inguinal hernia continuously with a recurrence rate of merely less than 0.5%. Among these patients, there were many who came to me due to recurred indirect inguinal hernia, and many who needed partial omentectomy during surgery due to an immense amount of omentum being incarcerated. Thus, I have applied my repair on all indirect inguinal hernia patients without exception and have found out that in contrast to existing knowledge, my repair successfully works no matter how severe the indirect inguinal hernia is.
Dr. Todd Ponsky’s laparoscopic repair is a method where the orifice of the hernia sac (peritoneum) is closed and thus, has the same surgical concept as high ligation. This method does not include the procedure of blocking the deep inguinal ring; making it completely different from Marcy repair.
In addition, I’d like to further explain. It is similar to the content of my previous posting.
Most of the existing tissue repairs, as latter parts of the procedure, are surgeries reinforcing the posterior wall of the inguinal canal called the Hesselbach triangle. And according to the difference in the method of reinforcement, they are each called Bassini, McVay, Souldice, Desarda and more. The surgical method for reinforcing the Hesselbach triangle is the ideal surgery for direct inguinal hernia. This is because hernia that is formed as the Hesselbach triangle weakens and widens is direct inguinal hernia.
In contrast, indirect inguinal hernia doesn’t form in the Hesselbach triangle but rather forms slightly above on the lateral where the deep inguinal ring loosens and widens for it to come out. Therefore, INDIRECT HERNIA REPAIR has to block the widened deep inguinal ring. Marcy repair is a method that carries out this concept. However, as there are several surgical methods according to the difference in the method of reinforcement of the Hesselbach triangle, there can be many ways in blocking the deep inguinal ring. Marcy repair is one method, and my repair method is another of them. And my surgical mehod for a direct inguinal hernia is similar to Shouldice repair; except it has been very simplified.
05/23/2018 at 5:57 pm #16197JnomeshParticipant
Thank you Dr. Kang. Your insight is very helpful. And I think a lot of us appreciate the detail you provide Bc there are a lot of us who are interested and probably spend a good amount of time familiarizing ourselves of this complex anatomy to help understand our own particular situations. Most surgeons don’t do this and make a strong line in the sand in surgeon/patient relationship.
toj probably have answered this before somewhere but do you use absorbable sutures for your realized or permanent.
id also like to asks your thoughts on a couple of things
1) classic non mesh hernia repairs and what seems to happen to a lot of people who have laparoscopic mesh repairs and then when they have the mesh removed there are no hernias found as the mesh has promoted scarring and scar tissue that close up the defect. Would this be as strong as a classic non mesh hernia repair? Or weaker because muscle isn’t initially being brought together and stitched. Just curious on your thoughts Bc my self included I’ve come across a good number of people who after lapro mesh is removed don’t hsve any hernias and I’m wonderknf what the prognosis is Fein the line is ther more chance of a recurrence compared to a classic non mesh repair?
2) this leads me to another question regarding this concept that mesh seems to be a process where the defect is closed up upon removal of mesh and a relatively new mesh called absorbable mesh. Could absorbable mesh be a middle ground between mesh and non mesh relairs? For example a lot of people after having mesh removal do not want mesh out back in their bodies but a lot of surgeons rx putting mesh back in because the area may be weakened even if there are no hernias. I’m wondering if absorbable mesh may make sense as a compromise in this situation (and some surgeons are offering this)-the two brands are tiger and phased absorbable mesh that don’t start to break down and absorb/dissolve until 18-24 months and by this time the hernia is repaired through scar tissue formation.
this absorbable mesh could also be a option due to so few surgeons who offer non mesh repairs and the fact that even some that do aren’t experts at it. I’m wondering if the absorbable mesh is a option. Case in point my sisters husband has a hernia ( not sure if direct or indirect ) and wen to see a local surgeon. He expressed concern about permanent mesh and was interested in a non mesh repair. The surgeon told him she doesn’t do non mesh relairs but offered him a absorbable mesh as a compromise. He doesn’t have a lot of money to travel to Canada to the shouldice Hospital and pay out of pocket so he is considering this option.
Woukd be very interested to hear your thoughts on the above questions-and again thanks so much for providing a much needed service as a alternative to mesh and taking the time to answer questions on this forum.
05/24/2018 at 2:54 am #16200quote drkang:
Dr Kang, I want to thank you directly for your detailed explanations and posts here, your knowledge is extensive and you are doing a great service to share this information with the public.
Out of curiosity, how common is it for patients to have BOTH the indirect and direct hernia? Does that make the repair more difficult? Do you ever unexpectedly find the other hernia type once you have already begun the operation? Finally, does the procedure work with a femoral hernia?
05/25/2018 at 12:06 am #16208quote Jnomesh:
In my opinion, for hernia repair to be successful (which ever type of hernia it is), both ends of the muscle margin of the abdominal wall opening, where the hernia comes out, must be made to have direct contact with each other. Thus, the tissue on both ends of the hernia opening need to be attached to heal the tissue in the margin. Even for large incisional hernia repair, which requires mesh, mainly has its focus on the approximation of the own tissues(make contact). Mesh plays a role in supporting the prevention of re-widening of the sewn defect on each margins for the tissues to heal.
The problem is that this is not being followed in mesh inguinal hernia repair. This means that the hernia opening is covered with mesh without it being closed. Fortunately, the opening is most times not large so it still doesn’t seem to have a not so high recurrence rate but recent theses claim the recurrence rate of mesh inguinal hernia repair to be close to 10%. I believe that the reason for it having a rate of 10% despite using mesh is because the opening hadn’t been closed. I believe the reason for hernia not recurring is because it heals itself and blocks the opening since the latter is not big.
I myself have had 38 cases where I removed the implanted mesh through open repair but there were merely 13 cases where I simultaneously performed hernia repair. Of course even in cases where the self-healing process goes well, it is necessary to further reinforce it if there is severe injury on the abdominal wall while removing the mesh.
Concerning the use of absorbable mesh, it is difficult to give you a responsible reply as I do not have enough experience and knowledge on it. However, as I mentioned above, I do not believe that there is any guarantee that the hernia opening will heal itself before the absorbable mesh dissipates because the opening is not blocked in the majority of mesh repair being carried out.
Personally, I don’t recommend Shouldice Clinic because they do not conduct a specific repair for indirect inguinal hernia. That means that the surgery is nonspecific and makes the scale of the surgery very large. I believe Dr. William H. Brown based in California will be of better aid.
05/25/2018 at 2:54 pm #16218quote Chaunce1234:
After receiving your inquiry, I reviewed my record of surgeries that I performed since 2015. During this period, I performed a total of 4,700 inguinal hernia repairs and there were 15 cases(0.32%) where indirect and direct hernia were both present (pantaloon hernia). It is very rare to come across it. In cases of pantaloon hernia, it can simply be treated by operating on both indirect and direct hernia simultaneously.
It is true that there are a few times when the pre-surgery ultrasonographic diagnosis and the actual hernia type found during surgery are different. However, a well-experienced radiologist almost always gets it right.
When treating femoral hernia, I localize the hernia sac below the inguinal ligament (in the thigh) and tie it off. Then I push the sac stump through the femoral canal into the preperitoneal space and close the opening(ligamentous orifice) with a continuous locking suture using 3-0 Prolene. It has the identical concept with indirect inguinal hernia repair. I have performed 25 cases like this since 3 years ago and currently, f/u averages on 19 months with just 1 recurred patient.
05/29/2018 at 9:16 pm #16226
Chaunce1234, Thank you for posting about Dr Todd Ponsky. I talk with him tomorrow morning about entering his trial.
I really hope that I’m a good candidate for the procedure: https://www.youtube.com/watch?v=nsIHTlfhrM4
I just hope that I have an indirect hernia as it seems a less invasive repair can be utilized.
What type is more commonly seen in a fit healthy middle aged male? Direct or Indirect hernia?
05/29/2018 at 11:14 pm #16229quote Jeremy B:
[USER=”2329″]Jeremy B[/USER] That’s very interesting and exciting, please keep us updated on your conversation with Dr Ponsky and if you will be a part of that trial! Would you need to travel to see him? Be sure to ask the doctor about what his plan(s) would be if a direct hernia is found instead of an indirect, as that would apparently require a different procedure.
I am not a doctor, but from my understanding the indirect hernia is more common simply because many people are just born with it, yet it often doesn’t become a problem until later in life (if ever). The direct hernia is supposedly acquired through some sort of injury or cause, though I have also read that isn’t always the case. Both can occur to anyone at any age as far as I know. Personally I know athletic people in good physical shape and of all ages who have had both types of hernias, as well as sports hernias, so I am not sure either of the conditions only impact one age group or another.
05/29/2018 at 11:17 pm #16230quote drkang:
[USER=”2019″]drkang[/USER] Thank you again for the detailed responses to inquiries!
05/30/2018 at 3:50 pm #16238
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.
05/30/2018 at 6:19 pm #16239Momof4Participant
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!
05/30/2018 at 7:16 pm #16240
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!
05/31/2018 at 3:54 pm #16245quote Jeremy B:
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.
05/31/2018 at 4:09 pm #16246quote Jeremy B:
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.
06/01/2018 at 3:14 am #16247quote drkang:
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.
06/01/2018 at 3:51 pm #16251
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”
06/01/2018 at 8:23 pm #16255drtowfighKeymaster
[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.
06/01/2018 at 8:51 pm #16256quote Jeremy B:
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?
06/03/2018 at 10:05 am #16272quote 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.
06/04/2018 at 7:08 pm #16278
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.
06/05/2018 at 2:26 am #16280UhOh!Participantquote drkang:
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)?
06/05/2018 at 2:40 am #16282quote Jeremy B:
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.
06/05/2018 at 11:51 pm #16291quote 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.
06/06/2018 at 2:33 am #16292UhOh!Participantquote drkang:
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.
06/08/2018 at 11:07 pm #16313quote UhOh!:
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.
06/10/2018 at 11:14 pm #16320quote drkang:
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.
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.”
06/11/2018 at 1:00 pm #16323
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.
06/12/2018 at 12:44 am #16329quote drkang:
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.
02/15/2019 at 7:00 pm #17851Good intentionsParticipant
Dr. Ponsky presented at the recent SAGES meeting, in the “Perfect Repair” session.Laparoscopic inguinal hernia repair (Based on Patkowski’s technique – YouTube
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…
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