Mike M’s troubling response…question for pinto cpk and others?

[pinto]

Thanks, Watchful, you are a gem of a member here. I appreciate you staying with me on this. HT being an information exchange, hopefully we can learn from one another. I’m just speaking aloud right now, but I feel something amiss about your hospital situation. Surely it’s recognized as the gold standard for pure tissue repair and you made a good choice. But if your descriptions are on the mark, then I see a red flag. Not that it means something untoward. Maybe you can’t answer this but I would have been left uneasy by his statements.

I just wonder if he is restricted somehow by hospital policies. As a surgeon at Hospital X using the “X-approach,” it’s pretty foregone that x-approaches will be used. There may be times an “independent” surgeon might think Y or Z approaches might even be better but unable to be performed there. Thus x-approach might be applied more often than a surgeon would if outside Hospital X. BTW, I think he is really candid the way we would like. That’s a big plus for him. He might be practicing at other hospitals or even his own clinic.

• This reply was modified 12 months ago by  pinto.

[Watchful]

Pinto,

I think my surgeon was honest when saying Shouldice would be good for my case before the surgery. I didn’t get the impression he favors mesh at all, just that he doesn’t favor Shouldice either. He viewed both as good options in general, and in my particular case as well. I expected surgeons there to be biased toward Shouldice (viewing it as a superior approach), but he wasn’t, so that surprised me a bit.

The fallback in case of bad tissue quality is mesh. At Shouldice, they reinforce with posterior mesh in these rare cases. Some of the Germans do the same thing, and some do Lichtenstein in such cases. At Shouldice, they apply Shouldice even in some cases where the Germans would use mesh. Tissue quality isn’t the only criterion used by the Germans. They look at hernia size and anatomy as well when making the decision.

[pinto]

A problem with hernia is it’s so individualized that matching up with other people is not always straightforward. I think size and comfort level will determine how much to wait. Surely if pure tissue repair, then you don’t want to go beyond M size. If your daily living is impacted very little and without pain, then watchful waiting might be just fine. If somehow a very safe mesh came along, then that would buy you a lot more time. Anything short of that, I recommend surgery; the sooner, the better.

[William Bryant]

I remember reading that about pain prior being precursor for pain after Pinto, thanks for reminding me. That puts me in a greater dilemma as my hernia is relatively trouble free. For Mike to go from 7 pain to near enough zero after repair has to be a good result of have thought.

I think Mikes being as honest as he can and I find his posts about Dr Kang and his repair very insightful.

The main thing holding me back from Korea is distance but that has to be weighed up against the results you, Mike and the others have had who posted about it here.

[pinto]

@Watchful, thank you for your thoughtful and gracious reply. You obviously did all you could as a patient to make the best choice and arrangements. Let me see, I think, you once wrote about your surgeon as a surgeon seemingly favors mesh though we would expect pure tissue repair.

Do you think that his view of mesh might differ a bit by the hospital policy; if he had his own hospital, he might have been more in favor of his mesh method?

You write about the surgeon: “He said yes, it would be a good and maybe one of the top two ways to fix it.” The maybe there sticks out. He seems tentative about Shouldice being the best way for your case. My sense (and maybe wrong 😀 ) is that he practices a mesh method unavailable for him to do at your hospital. I believe you wrote somewhere that you now think mesh might have been more favorable for you.

If he thought your tissue was less strong would he have automatically done mesh–or abort for later consultation? I’m glad for you he found your tissue quite adequate but if it wasn’t, what do surgeons do in such a case? Go ahead even though recurrence is likely? Or have a B-plan in place for such time?

[Watchful]

Pinto,

Yes, we discussed mesh before surgery. After the exam, I asked my surgeon if Shouldice would be a good technique for my particular case. He said yes, it would be a good and maybe one of the top two ways to fix it. I then asked about mesh, and he said they do it only if the tissue quality is very bad. I then asked about the details of the mesh procedure, and he said they were doing posterior mesh (similar to Kugel, I guess), not Lichtenstein. He mentioned something about a Shouldice still being part of it, and the posterior mesh is used as reinforcement.

My tissue quality was adequate, so he didn’t use the mesh reinforcement. It was a long and difficult surgery, but he claimed he was still able to repair the hernia well. So far, I don’t have a recurrence, so that seems correct as things stand now. However, this was achieved at the price of extensive work that caused persistent issues (I hope these still improve.) I did ask after surgery if Lichtenstein would have also been difficult, and he said no. As I mentioned, this is not the mesh procedure they do anyway.

Their philosophy there as far as I can tell is to do whatever it takes to repair inguinal hernias with Shouldice, possibly with posterior mesh reinforcement in rare cases where there’s no choice. The goal is to repair in a way that avoids recurrence, and do it with Shouldice. Minimizing the invasiveness and scope of the repair, and reducing the length and complexity of the procedure aren’t goals there.

[Mike M]

One other quick note is you can really feel all the swelling and scarring tone down after the first week. I moved around a lot on the 5th day, like crazy, walking flights of stairs at the lotte tower. By the time my 2nd ultrasound a week or so later all the swelling was gone.

You do sweat some bullets wondering if the surgery “took”, if you over did it, it is easy to see, etc. But mine was perfect knock on wood!

[Mike M]

In regards to “scar tissue” – Moles, calcium deposits, etc. Things in the human body that you can “feel” but cause no pain. I have had scar tissue in other spots from playing sports and it’s really nothing.

One spot is the outside and inside of my left hand. I caught a football, hit the turf, kept moving except for that part of my hand thus the injury. After a few weeks no impact at all. I was in my early twenties and now Im in my late forties.

We’re really pulling at strings here guys. The key point is I was at a 7 in pain prior to surgery and I am at a 0.0 now.

Thanks guys and I hope this helps.

[Good intentions]

Replying to watchful – I wonder what the Munich Hernia Center would have recommended. Linked below, I posted it in William Bryant’s Topic.

I see people on the forum doing what is done across the hernia repair industry, in over-simplifying, and suffering from the “recency” effect. The last thing they read or their strongest memory becomes their personal “status quo”. If you don’t look at the statistics you’ll end up with a different conclusion every week. The shameful thing is that we, the patients, should not have to do all of this work. The pros should have the answers for us. They don’t. Businesses are focused on getting the customers (the patients) in and out and paid up.

https://www.hernia-centre.com/hernia.html

I don’t know if they actually follow this path (every hernia repair center ad looks about the same), but they do lay out what looks like a logical approach.

“INGUINAL HERNIA SURGERY REQUIRES AN ACCURATE DIAGNOSIS TO BE MADE FIRST
Your doctor will only be able to determine which option is best for treating your inguinal hernia after a detailed examination.
Only once an accurate diagnosis has been made will your doctor draw up a meticulous plan for surgery with you and explain to you in detail what happens next.
Given that there are a great number of techniques and surgical methods available, your physical condition and past medical history will also be taken into consideration.”

[pinto]

@Watchful, considering your IH was “very large, life-long hernia” and your openness to mesh use, then wouldn’t we suppose you discussed with your surgeon prior to surgery the option of using mesh? What if the surgeon judged condition warranted mesh during surgery? Did you have a prior agreement about it?

[Watchful]

GI,

There was nothing wrong with my diagnosis – a very large, life-long hernia. It was correct and known from the beginning, even if the exact measurements and anatomy weren’t known until I was opened up. The only wrong thing was the type of repair. Mesh (either open or lap) should have been used rather than Shouldice.

You are correct that the problem here was that I went to a place that doesn’t tailor the type of repair, and forces Shouldice even in cases where the surgery would be difficult and with questionable outcomes. Mine didn’t even remotely qualify for Shouldice based on the European guidelines as followed by the German surgeons, so I’m pretty sure they would have used mesh.

Chuck,

You are confusing risk with certainty. They do regularly get chronic pain outcomes at Shouldice, but those are still the exception, not the rule (at least by whatever definition they use for chronic pain, which may not include very minor pain and discomfort).

[pinto]

@Chuck and all: An important factor overlooked here when talking about post-op pain is pain prior to surgery. I understand that this is a determinant of post-op pain: prior pain tends beget post-op pain. You also may have overlooked what Mike M said about his pre-surgery condition:

“Keep in mind prior to surgery I was to the point (pain wise) where I wasn’t even sure if I would be able to make it on the plane to South Korea.” [Mike M]

Evidently he is saying he had considerable pain enough that could prevent his travel. Thus it is remarkable Mike M appears to have no or little pain post-op.

The mystery however is how a human being can distinguish scar tissue within the deep recesses of their own human body. (Surely “pain” concerns internal tissues not the exterior incision, right?) Mike M says, “I can feel maybe a slight bit of scar tissue.” Is that by finger touch or by mental sensation? If sensation, how is it you are able to pinpoint it to scar tissue and nothing else? You heard this about scar tissue, so you assume it is the case with you?

[Good intentions]

Here is the sequence of statements Mike M. Watchful must have been feeling down, he interpreted your words in the worst way and added his own. Sorry watchful, I know you’re disappointed about your results but your path to Shouldice was correct, based on the hernia that you thought you had. Your real problem is the poor diagnosis in the beginning, and the fact that surgeons, generally, lock in on a technique instead of having a broad skill set that allows them to choose the best option. That is, I think, a more general failing of the medical profession. Another example of surgeons doing what they do, so the diagnosis doesn’t really matter. Shouldice surgeons do Shouldice, lap TEP surgeons do lap TEP, robotic equipment surgeons do robotic lap TAPP.

https://herniatalk.com/forums/topic/excellent-discussion-with-hernia-genius-jf-watchful-bryant-pinto-mike-m/#post-34631

Post #34620 Mike M: Pain was only bad that first week. Some tension the weeks that followed and then it fades into nothing. I can still feel something in that area but nothing of mention. You can only really feel the scar tissue the first few months maybe. The nerves seem settle down and accept the repair after a while. I am starting to “forget” I even had hernia surgery now which was the end goal.

Post #34621 watchful: This doesn’t sound so great. Having symptoms for months after surgery, and still feeling something there after a year (even if minor) isn’t great. Not bad, but not the most desired result. We need to remember that you didn’t even have a large hernia.

Excellent discussion with hernia genius JF–Watchful bryant pinto..mike m

[Unknown Member]

thanks mike…but when you say you feel scar tissue–how does that manifest if not pain.? stiffness…or pain so slight you dont think of it as pain…i am trying to science my way out of a hernia nightmare…I dont want to make any more mistakes…Got the plastic crap out of me now trying to ensure a perfect fix for a recurrance. I don’t understand our friend Wastchfuls fascination with Lap mesh surgery…even if it worked perfectly from a pain standpoint initially–you are never out of the woods….that plastic can move around degrade get stuck on nerves and organs…dr towfigh says well it doesnt “typically” move…well what the heck does that mean. One thing it does for certain is create massive local inflammation…does it become systemic no one knows for sure. I was a dope –I listened to doctors for some reason i trusted them…I saw studies…not fully understanding how currupt big pharma studies can be. I feel like a real dunce for putting that junk in me.

[Mike M]

Just to clarify a third time I never said anything whatsoever about pain after 1 year.

Not sure where they came from other than I can feel maybe a slight bit of scar tissue, maybe, but no pain.

What I did say is that I was told prior to surgery some cases could take longer than others (even a year+) but that was coming from multiple sources including Shouldice doctors that I went to in the U.S. I also read that on here from previous Shouldice patients.

AGAIN – NO PAIN after 1 year.

The only time I really had “pain” was the 1st week then it was mostly tension after that that went away and faded after a few months.

[Unknown Member]

While i appreciate the honestly of Watchfuls surgeon…it just really surprises me that the clinic is seeing regular cases of debilitating pain. I can see now why our Friend bryant is reluctant to fix his hernia…he has a near guarantee of some kind of chronic pain. hernia repair is a very sad state of affairs…