Mark H – Your decision to use Kang?

[JHawley]

Mark H- I love talking to guys who have taken a hard look at the facts here and have made a decision on how to proceed. Can I ask you why you chose Kang? He is definitely on my shortlist but there are pros and cons

Pros – lots of experience, decent guy, small surgical field, small incision, can do his operation in half the time of shouldice local anesthesia great customer service. He doesnt cut nerves or the cremaster.

Cons – his operation is not time tested -latest version is just 4 years old. Other prominent surgeons have questioned his surgery and said it wont hold longterm. These are honest surgeons like Koch and Lorenz. Well respected and knowledgeable who chose shouldice for their own repairs. His pain statistics are not much better than mesh. With close to 17 percent reporting some level of chronic pain at 1 year. Its difficult to get decent reviews on this surgeon as most of his patients are korean. Several forum members had surgery with Kang and some are still in some level of pain nearly 8 months out. One had a recurrance quickly with kang and confesses to weird sensations now and then but no pain. Kang is also 67 years old and does 10 -12 surgeries per day. Can a 67 year old keep his A game with all those surgeries? Follow-up -if things go south you gotta go back to korea.

Other considerations – you are close to the German surgeons Koch, Conze and Lorenz –all report lower chronic pain rates than Kang – 1-3 percent vs 16 percent all of these surgeons are younger than kang by 10 years and they dont pack as many surgeries into a day. They are doing shouldice or modified shouldice repairs with a lot longer track record than the Kang repair. You are also close to the British Hernia Centre –yes they use open mesh. But they claim zero complications in 30 years. Probably not true but they must have low complication rates. a well done mesh repair does not destroy your anatomy. And open mesh surgery will last a lifetime. If your Kang repair fails you may need mesh anyway. I hope you or others will respond to this post. The decision is near impossible.

[David M]

Chuckles,

I think Dr Kang’s self-reported chronic pain rate was 1.7% rather than 17%. In other words, quite good, though self-reported.

But I do also have reservations about going to Kang, especially with a direct hernia.

[David M]

I should have added that Dr. Kang said on the forum that he was now calling his direct hernia repair the Gibbeum (sp?) repair, while the indirect repair was apparently the only repair under the Kang repair name. So, when he gave his pain statistics, I took those to be only for his Kang (indirect) repair. Don’t know if that was right or wrong.

His direct is a modified Bassini. That sounds like it should have pain statistics in some ways similar to a Shouldice or more, though given the smaller operating space, maybe less due to the smaller space.

Mark H. sounds like he may have already committed, at least to the trip.

[Good intentions]

Isn’t the Shouldice repair a “modified Bassini”? An evolution?

JHawley has a months old indirect hernia on the left and some groin pain on the right. And has never had surgery.

No bulge but pain. – Kang discussion

“Summarizing and catching up your previous posts – you have a confirmed but painless left side indirect hernia, confirmed by two different doctors, but have pain in the right groin where no hernia has been diagnosed. The left side hernia was diagnosed a few months ago. You’ve never had any surgery.”

[William Bryant]

Yes Good Intentions, Shouldice is a variation of Bassini.

[JHawley]

David M- Why concerns about using kang for direct hernia? He is really doing a two layer shouldice no and calling it a gibbeum repair.

Check again on the kang statistics. Pain that was intolerable was 1.7..but total pain…was close to 17 percent. it was lesser pain but pain nonetheless. Which way are you leaning David? I think its a real mistake to continue to watchful wait if you are looking at tissue options. Get that sucker fixed before its too late. Are you in the US anywhere? Would love to pick your brain

[David M]

GI, I’ve looked and looked for a detailed explanation of a Bassini online, but I haven’t found a demo on youtube, nor an explanation on the web that isn’t behind a paywall.

Dr. Kang said the corrupted Bassini practiced in the US left out that the original Bassini repaired the transversalis fascia. So, I’m assuming that something is done there, but all I can get online is that three layers, including the TA are brought over and stitched to the inguinal ligament. That sounds like at least as much tension as the Shouldice, with possibly less repair done on the transversalis fascia. I think they sometimes do that ….what do they call it….relaxing incision?,,, to lessen the tension. Or is that only the McVay that does that? At any rate, on the negative side, I would want to know more. On the positive side, I think Mike M and others may have had his direct repair with success.

• This reply was modified 2 weeks, 4 days ago by David M.

[David M]

On the 1.7% vs 17%, the 1.7% was pain that fell in the 4 category from the Swedish study, meaning pain that had in the previous week somehow interfered with living, which Kang designated as chronic pain.

Yes, my hernia has reached the stage that something needs to be done. It may actually be too late for tissue repair, in which case I will probably get a Lichtenstein. I have a very elderly mother that I would have trouble leaving at the moment. I also have unanswered questions still that I would like to get answered before committing, but, yes, my hernia needs attention.

[JHawley]

Agreed—-nut there was a score of 14% for other pain. Pain is pain…obviously worse if it interferes with daily life. But i am looking for zero pain probably not possible

[David M]

Here’s my overly wordy analogy for pain.

I think it’s really important to exercise, but given my age and circumstances, my exercise of choice is a 2-3 mile walk at somewhere around a 15 minute pace. Even given that relatively mild exercise regimen, I sometimes can feel my knees or shins a little if I overdo it. Most of the time, that just takes a little extra concentration to not overdo the steps in the wrong way. Next time around, if I’m careful enough, things will probably be as good or better. This is just part of living. Sometimes things hurt a little and you just have to pay a little more attention to them.

As long as I’m not making it worse, I doesn’t really change my life in any important way. I may not feel quite as strong at that moment, but I still enjoy and benefit from the exercise. That’s an analogy for those lower levels of pain and those are levels of pain that at some point you just have to not worry about when it comes to getting a hernia fixed.

On the other hand, I’ve also gone out there and walked on a knee that I shouldn’t have. I should have been listening to the pain and altering my life to account for it. That and worse pain, such as the kind that GI complains about where he couldn’t sit for prolonged periods of time is pain that I would certainly try to avoid. I think that’s the kind of pain that fit Dr Kang’s 1.7%. This, thought not perfect, is not a bad result for that type of pain, given that the Swedish study had Open, Tep and Tapp all running around 15% for level 4 and above.

So, I’m not sure it makes sense to avoid all pain, but there is a level of pain that you certainly want to avoid, if possible, when considering your surgery.

• This reply was modified 2 weeks, 4 days ago by David M.

[JHawley]

David M – take a look at Dr. Koch – this guy just gets insane reviews. Just off the phone with a woman who went to him. she emphasized that she did not watchful wait. I think watchful waiting for a small indirect hernia is nuts. its just going to get worse. She went in had it fixed and was back to completely normal in two weeks no pain no nothing. Koch is prob the best hernia surgeon in the world. Outside of his issue with Baris and the fact that he doesnt use local anesthesia…I think guys on this forum way overthink this surgery and make it seem like brain surgery. I am guilty of that too.

[Good intentions]

For a guy that’s only had a hernia for a few months and only been on the forum for three days your opinions are amazingly well-developed. Well-done!

You’re going over old ground and using similar words to Chuck and Joe. “Overthink”, for example.

Did a lot of you ovetthink this?

Hadn’t you already made up your mind that the Desarda repair was the one for you?

[William Bryant]

Dr. Kang is, to my mind, a good choice. Almost every patient review here is very positive. The same cannot be said for any other surgeon I don’t think. The drawback, one of them, us the distance (from the UK).

Good luck Mark H. Please let us know how you get on.
And hope the operation is a success.

[Mark H]

Sorry it took me so long to reply but I’ve been busy with a multitude of mundane stuff.

So, why Dr Kang?

Well first off, apart from PeterC’s horrific experience pretty much ANY of the surgeons would be a good choice. I absolutely don’t want a mesh. So that alone removes around 90% of my initial NHS options. It also removes a huge proportion of the mediocre “journeyman” surgeons that do a hernia op on monday, an appendix removal on Tuesday and cataract surgery on Weds (yes, I KNOW I’m exaggerating).

The fact that we are talking about the advantages and disadvantages of one procedure over another is comforting to me as it indicates we are dealing with World Class surgeons at the top of their game.

The travel is simply not an issue. Whether I go by train to a London clinic, by air to Europe or a little further to Asia, I’ll be where I want to be within 24 hours. I’ve traveled long haul from Manchester to Hong Kong enough times to know it isn’t a problem for me. Wife HATES it though, so I know it can be a major influence for some.

As for the actual procedure, I whittled my options down quite early to going to India for the Desarda repair. Then I saw that Dr Kang did a no mesh repair with very little damage and the more I read from various sources, as well as talking to other hernia sufferers among friends and family, the more I became settled on going to Korea.

Once the decision was made I stopped looking. I didn’t want to fall into the trap of always looking for the “perfect” repair, while the clock is ticking and I lose quality of life. I’m 60 now so over the coming decades I’ll probably be slowing down (a little!) rather than ramping up to Olympic level competition.

Again, there are any number of excellent surgeons I could have chosen and been completely happy with my choice. The fact that Dr Kang has in effect 2 procedures to address two different issues possibly tilted me in his direction. Plus the fact that he’s done so many, he’s seen pretty much everything under the sun! I’m certainly not going to surprise him.

I’m satisfied that I’ve made the right decision for me so now I need to be mindful not to overthink it, as others have said in the past.

[Watchful]

Kang offers a unique repair, so I understand going all the way to Korea if that’s what you really want.

My general advice with tissue repair is to go to surgeons who can do both tissue and mesh well. I know they are rare, but they exist. If it turns out that your case isn’t a good fit for whatever tissue repair method practiced by the surgeon, you want them to be able to fall back on mesh, and not force the tissue repair.

Also, all else being equal, I would prefer going somewhere closer where it’s easier to deal with follow up, complications, and reoperations. Ideally (and most frequently) you don’t need any of that, but it could happen.

If you’re in the UK, I feel that it’s pretty much a no-brainer to go to one of the top German surgeons if you want tissue repair, but I understand the allure of the Kang method for those who are looking for a minimal tissue repair.

[Good intentions]

Watchful, if you’re going to recommend a mesh procedure you should describe the type of procedure and the type of mesh. Lichtenstein with Progrip mesh and TEP with Ovitex mesh are both “mesh” repairs. But are very very different repair methods overall.

It’s so easy to fall in to the simplification of mesh versus no-mesh. I do it myself at times.

TEP, TAPP, Onstep, Lichtenstein, TREPP, plug and patch, and the PHS are all mesh-based. And all very different operations.

[David M]

GI,

What kind of mesh do you recommend for someone getting a lichtenstein?

[Good intentions]

I don’t have one in mind. I’d have to see some long term numbers, which probably don’t exist. The EHS Guidelines have saturated the repair field with the advice that any “large pore” mesh is fine. Dr. Chen follows the Guidelines, and parrots their Guidelines advice, even though he is supposedly an expert in the Lichtenstein procedure. He should be advising the EHS about Lichtenstein repairs, not following their advice.

There are “mesh”es that should probably be avoided since they are so new and relatively untested in the inguinal hernia repair field. Like Ovitex. It was introduced in to the ventral hernia repair field first, then recommended for inguinal hernia repair after a 31 patient study by a single surgeon. Anybody who gets a mesh that has only been validated through 30 day results on 31 patients is essentially the subject of a long-term experiment.

My basic point is the usual one about lumping all things “mesh” in to a single word. Most of any advice I could offer is about avoiding things, not selecting them. Certain types of surgeon to avoid, certain types of mesh design to avoid, certain types of repair method to avoid. Using a process of elimination is the best a person can do with what’s out there today.

But, back to Watchful’s point – if you’re planning on a mesh repair as a fallback if the surgeon decides they can’t do a pure tissue repair, know what the mesh repair will entail. You could choose the best surgeon for the best pure tissue repair and end up with the worst kind of mesh repair.

[JHawley]

Thanks Mark H – I love Kang. Watchful -do you think Kangs repair is time tested? Kangs repair the latest iteration is only 4 years old –and i think he only started doing tissue in 2012. Tissue repairs begin to wither in year 5-10…so my concern would be recurrance at that time. Shouldice repairs at least are well established…Also numerous respected surgeons have questioned the longterm viability of the Kang repair including Towfigh, Lorenz and Koch…who personally laughed about it and said it would not last—just a marcy. Watchful would you agree chronic pain is a wash between Kang and shouldice? Kang keeps insisting that his repair is the least painful of all repairs. But he is relying on his 1.7 percent terrible pain report as the metric- when in fact there is some pain in at least 16 percent of his work. I dont know if that figure matches what conze and lorenz are doing…but certainly they are saying their pain rates are a fraction of that. Mark H I admire your courage in holding to your decision in the face of these facts. I really struggle to lock on to any repair. Another factor would be the postive reviews that conze gets. There are a lot —cant find much on kang…coupled with the fact that conze can tailor repairs…i think he or lorenz is the slame dunk winner here.

[JHawley]

Mark H a quick follow -up —you said once you spoke to family and friends about hernia experiences…you became more set on Kang. Did some family and friends have bad experiences with other tissue repairs like shouldice or desarda? what made you settle on the kang repair?? I love that its a small surgical field. But we had a Kang recurrance on this forum –out of about 8 kang repairs total that would possible suggest a high recurrance rate. In addition two kang patients conceded they are still feeling pain close to a year after their repair. Both express satisfaction however. Whenever i talk to kang and stephen they are very responsive…but their responses are very salesy…Kang is the best –low recurrance—low pain…buy now. With Koch i got a much more professional read. He said no surgeon is perfect but he would do his best to give a good repair.

[Watchful]

JH,

I can’t compare the chronic pain numbers. We have them for Kang, but not Shouldice. Shouldice Hospital chronic pain is at 2% based on a recent statement by them, but we don’t know for what definition of pain, or how they would know without following up. I’m guessing it’s pain severe enough for patients to come back to them complaining about it. Since many of their patients come from far away, I don’t know how this would work. Also, it’s not the kind of place where it’s easy to go back and be seen. In other words, if they studied this like Kang did, my guess is that their numbers would be worse than his, but not sure. Maybe Conze and Lorenz have better results (in terms of chronic pain) with the same procedure because they are more careful. A lot depends on the surgeon.

I didn’t go to Kang mostly because of concern about recurrence as I mentioned before. That’s the risk you take for the minimal repair. I didn’t know quite how large my defect was, but I knew it was large, and didn’t see how it would be fixed with a Marcy-like procedure. Even Dr. Brown (a Marcy fan) wanted to reinforce with a Desarda. Maybe Kang would have been fine, but I didn’t want to take the risk. As it turns out, my case was difficult even for a Shouldice – probably needed mesh.

[JHawley]

Watchful – thanks but you consulted directly with Conze and Lorenz. I believe you said Conze said only 2-3 cases of chronic pain in his career. Lorenz was 1-3 percent. I supposed you didnt go deeper and aske them to define chronic pain. I plan to ask them more detail about this when i talk to them. If kang’s minimal repair was a slam dunk on pain difference it might be worth going to kang. But it doesnt seem to be. Morevoer kang is doing 12 surgeries a day. This is assembly line stuff. I noticed in the reviews that several folks mentioned Conze was definitely not assembly line medicine. I guess you pay for it. But in my mind worth it. Your notes on the shouldice repair continue to trouble me. Rearranging the anatomy in a permanent way. And the healing times are crazy long. Though i spoke to one koch patient who had a shouldice on a monday…went shopping that night and was completely back to normal in two weeks…repair forgotten in two months.

[Mark H]

I remember some years ago that my brother had a hernia and was put on the NHS “conveyor belt” that automatically progressed him to having a mesh repair. Eventually. At the time, he said he could feel it inside and was very uncomfortable.

Over the years he seems to have become used to it as we talked a month ago and he said he hardly knows it’s there. Bear in mind that he’s now in his late 50s and has slowed down an awful lot. He was an electrician working on the building sites but now does mainly inspections and other “softer” pen-pushing jobs. Certainly not the heavy lifting he was used to.

He no longer cycles, but I think that’s more down to lifestyle changes rather than a mesh problem. Would you call his procedure a success? By any measure, a resounding yes. However, if you ask me, he appears to have settled into a much more sedentary lifestyle so many of the issues he may have experienced as a younger man wouldn’t necessarily arise now.

A colleague I used to work with also had a mesh repair and is perfectly happy with it. But again, he’s in his 70s so slowed down considerably and not likely to give the hernia site too much stress.

So if you are happy with a mesh then by all means go for it. For me, I personally prefer not to have one if the option is available. As I alluded to in my earlier post, as I’m now 60 I will take longer to heal fully than I did in my 20s or 30s. So among many other things, the less invasive the surgery (all else being equal!) the sooner and faster I’ll be on the mend.

As I weighed all the options available to me, the Kang repair edged it. With that decided, it was time to pull my finger out and get things done. I didn’t want to get bogged down with “analysis paralysis” where I go round in circles covering old ground over and over. I’ve said in previous posts, someone could take the exact same circumstances and come up with any number of other surgeons or methods and still be completely right for them. But at some stage, a decision needs to be made and stuck to!

[Watchful]

Your experiences in life affect your decisions. My dad recurred years after what we believe was a Marcy-like repair. It turned into a large scrotal hernia which he never fixed – old age, too many other medical issues, etc. This bad experience was a factor in my decision to avoid this type of repair, but maybe Kang does it better.

[Watchful]

JH – Yeah, people are different, so outcomes are different. A young healthy person with excellent tissue quality other than a small indirect hernia is different from an older person with degraded tissue quality and a large hernia. Nerve anatomy can be different, healing capacity can be different, etc. It’s amazing how differently people react to the same thing.

[Author]

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