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Marcy repair in adults with Inguinal hernia.
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quote drkang:Hi 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.[USER=”2019″]drkang[/USER] Thank you again for the detailed responses to inquiries!
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quote Jeremy B: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?
[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.
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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?
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quote Chaunce1234: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?
Hi 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. -
quote Jnomesh: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.Hi 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.
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quote drkang:Hi 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.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?
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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. -
quote Chaunce1234: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.
https://www.youtube.com/watch?v=nsIHTlfhrM4
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?
Hi 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. -
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.. -
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.
https://www.youtube.com/watch?v=nsIHTlfhrM4
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?
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You suggest core based excersises can relief symptoms for inguinal hernias..does that apy to both direct and indirect types? I’ve been doing no core exercises in fear the twisting and movement will “spread” the hernia making it worse. Is that true?
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