Pinto -our Kang expert….

[NFG12]

Kang appeared on Herniatalk when he saw all the mesh problems and alot have. Seems like a nice guy but he’s doing something he made up that no one knows years down the road. He used mesh before he learned and made up his own technique. He offered to do open bilateral mesh open then repair the hernia open which is frowned upon as Peterson did before and the dudes in a wheelchair. Never get lap mesh removed open especially bilateral Jesus that would tear you up forever and he didn’t admit that until I said it and Dr. Towfigh said no way that so invasive and damaging! He said that cause he only does open surgery and can’t do lap or robotic! They preach what they know all of them some others can do all open, Robotic, regular lap etc. Fir me to travel to Korea take a chance and hope and maybe he is awesome at an initial repair but for me no way! Like ok I’m 2 months out have to deal with it again now this and that just like everyone though the great Dr. Brown in Washington was so great, a kid I knew had lap mesh he removed it open and hurt him more and now he’s not with us anymore. RIP CHRIS

[pinto]

Please understand my posting intends for me to learn by our discussions. My posts often try to be food for thought. Shouldice obviously is a great approach but we also can wonder about things, can’t we. Unfortunately there is risk in almost any decision we make. As I indicated in my earlier postings, I was so shocked by the growth of my IH that I flew into action without checking off all the boxes. So accident insurance or other to cover such things, I didn’t inquire about. I did have at the time a nifty credit card that automatically covered me for travel insurance. So I was covered somewhat but not to the extent you are wondering about. If you happen to look into it and find insurance that covers the contingencies you are thinking about, please share.

[Wim]

The problem with going abroad to Korea is what if there are complications during or after the surgery? The travel insurance will not cover it most likely. Or did you have special insurance Pinto? Or you just risk it?

[pinto]

MarkT, I apologize for overlooking your point that Shouldice has unlikely changed its method over the intervening years. Some of us here discussed a rather biased (negatively) Canadian surgeon’s view of the Shouldice Hospital. I relooked at the commentary at her blog by some Shouldice patients and I was so shocked about some of the hospital polices (e.g., mandatory wakeup call for all patients at 5:30am). Someone described the polices or venue as like being in the military. Assuming that’s all true, I have to bow to you that the methodology likely has not wavered ever a bit over the past decades. 😀
https://canadianfemalesurgeon.wordpress.com/2015/05/19/the-problem-with-shouldice-or-the-most-dangerous-phrase-in-the-english-language-weve-always-done-it-this-way/

[MarkT]

Surely something as relatively benign as suture material changes are not what you had in mind when you claimed that I “unwittingly equated Shouldice 50 yrs. ago with a recent operation, obviously benefitting by decades of medical advancements” – LOL

Prolene sutures were developed in the late 60’s…not a recent medical advancement…and Shouldice’s decision to use stainless, and in recent decades (and its been decades) is hardly based on that idea either as it has negligible (if any?) impact on the repair itself.

My understanding is that Shouldice has continued to use stainless for two reasons: cost (it’s cheaper – Dr. Towfigh said she was even told this by them when she visited) and to a lesser extent because it is essentially ‘inert’ in the body (whereas an extremely small % of people may react to synthetics).

Perhaps a surgeon could speak to this, but I also imagine that they have long since stopped being trained using stainless sutures in most applications and apparently synthetic is considerably easier to use. Some patients also specifically ask for synthetic for whatever reason. It seems natural that Shouldice would transition to having both at some point.

I have no reason to ‘disagree’ with anyone’s decision to use whichever one they want…both have proven to be highly effective. Some surgeons there switched over 20+ years ago. I believe today it comes down to surgeon and patient preference.

[pinto]

Opinions will differ all long the way about each “advancement” but only time will tell how much they truly were. Although some advancements are more significant than others, medical practice has advanced steadily over time. In hindsight some may have proved false but the totality of medical practice over the past century has surely improved the lives of many lucky enough to access it. In thirty years time surely surgical practice changes in some ways, presumably for beneficial reasons. Someone here reported that Bendavid changed from steel to polyester sutures. You might not agree with him, but he and others of the same mind very likely saw the change as an advancement. Ultimately only time will tell truly, but change occurred nonetheless.

[pinto]

@MarkT:

“I’ve also never brought up my experiences there (30yrs and ~20yrs ago) to ‘equate’ them with recent surgeries, but rather to speak to my experiences at the time, my outcomes (flawless in all respects, to the present day), and what someone might generally expect after a Shouldice repair in terms of a ‘standard’ recovery, to ease their concerns over the unknown.” (MarkT)

In our discussion I granted you that while pointing out that you unwittingly were equating “old” Shouldice with the “new” Kang—that I believe were your two surgeries, the former decades ago and the relatively recent one. Apparently you didn’t realize that your thread came off as comparing Kang with Shouldice—a new with the old.

I well recognized that you wanted to help people with your experiences—-again, I granted that. What you don’t recognize are nuances that are emitted—intentionally or not—in one’s communications. How you couched your thread and presented it appeared to have other purposes. Even if you didn’t intend it, readers could glean it so.

Another point you make rather naively: “keep in mind that “decades of medical advancements” would not seem to apply much to Shouldice Hospital, if you understand their model.”

Right there you conceded Shouldice decades later is not absolutely the same as before (by saying “apply much”). Subtle enhancements can make a great deal of difference for surgery outcomes. Surely there were major personnel changes in the hospital decades hence. What you don’t recognize is the difference between model and application.

Models are one thing; applications, another. That’s just about technique. Then there are materials! At least some Shouldice surgeons changed from steel thread suturing to polyester! You kindly credited me, in that earlier thread, for helping you recognize that the occasional twinge you feel is likely from the steel suturing. On principle alone there is no way you can discount decades of medical advancements. So incredibly shortsighted your argument. Thus it was necessary, as is now, to caution your apples-to-oranges writing—if not your thinking.

• This reply was modified 10 months, 4 weeks ago by  pinto.

[MarkT]

“Was it Mike T who unwittingly equated Shouldice 50 yrs. ago with a recent operation, obviously benefitting by decades of medical advancements”

I don’t know if there is a Mike T here (?) or if that referred to me…but keep in mind that “decades of medical advancements” would not seem to apply much to Shouldice Hospital, if you understand their model. In the lap mesh space, it certainly would though!

I’ve also never brought up my experiences there (30yrs and ~20yrs ago) to ‘equate’ them with recent surgeries, but rather to speak to my experiences at the time, my outcomes (flawless in all respects, to the present day), and what someone might generally expect after a Shouldice repair in terms of a ‘standard’ recovery, to ease their concerns over the unknown.

I think you are quite right to highlight things like cultural differences, which may impact both surgeons and patients, particularly patients’ expectations and reports. Such differences are very important to keep in mind when surveying attitudes, behaviours, experiences, etc. across cultural groups.

Watchful, your experience with your surgeon before and after, and your outcomes thus far, makes me wonder about a few things relating to diagnostic and surgical expertise and practise, the pros/cons of specialists dedicated to one repair type vs. offering multiple options, and how healthcare models (e.g. billing practises) might factor into all of that….I’ll make a separate thread as I ponder it some more, as I think it could be an interesting discussion.

[pinto]

I’m sorry for you too @Jtk2. It’s one of the most awful stories I’ve heard how the surgeon brushed you aside not once but at least twice. Just awful. Surely the work of surgeon is demanding and we patients as well, but there’s no excuse for his behavior. If any doc who would happen to read this and I’m wrong, I’d be happy hearing about it.
I just got an insight—-by this example of Jtk2’s, Yunis needs to cut down the daily high volume of surgeries of his by dint of his apparent lack of patience for his patients. Maybe he’s doing too much, thereby lessening his attention given to patients. But not all ….
Another insight: Kang’s high volume and high attention to patients (in my experience) might be only possible by having mostly East Asian clientele, people maybe less demanding than Westerners. Expectations of doctors differ culturally. For example, Western doctors must answer more questions than their Asian counterparts. Overall the job for Asian surgeons might be less stressful.
So I see now this posting extends my previous post about “lining up your ducks” properly. Asian surgeons may be better positioned to do high volume loads than Western surgeons. You can’t say “all things being equal.” Avoiding apple-orange comparisons is vital. Was it Mike T who unwittingly equated Shouldice 50 yrs. ago with a recent operation, obviously benefitting by decades of medical advancements. As you can’t equate different times as the same neither can you about place: unappreciated cultural differences (or advantages) between surgery in different countries can greatly matter. Jtk2, I hope that somehow you mend well and possibly get better regard from Yunis, and well wishes also to Watchful that your recovery speeds up.

• This reply was modified 10 months, 4 weeks ago by  pinto.

[Watchful]

Jtk2,

Really sorry to hear about what happened to you with your Shouldice repair with Dr. Yunis. My experience with a Shouldice repair has been bad as well, and mine was done at the Shouldice Hospital. My surgery was about 6 months ago, and I also suffer from chronic pain, although I wouldn’t call it debilitating in my case.

The explanation I got upon follow-up wasn’t much more illuminating than what you got: large hernia, deep anatomy, so it was a long and difficult surgery. Well, the fact that it was a large hernia was known in advance during the exam. Not the exact measurements, but it was clearly a large (not giant) hernia with a scrotal component, intestine in the hernia sac, and hard to reduce.

My surgeon said there would be no problem repairing it with Shouldice, and that it would be the best or maybe one of the two best ways to fix it. I really gave him a lot of opportunity to tell me if he thought this wasn’t a good way to proceed, and he didn’t show even a smidgen of doubt. After the surgery, it was a different story, and the size of the hernia suddenly turned from something that wouldn’t be a problem to something that was a problem. Hard to understand, but I guess that’s just the way things are with medicine.

None of the other tissue repair surgeons with whom I consulted said that it might be a difficult surgery either. Maybe it’s just not clear until the surgeon cuts you open, but then they should have the ability to use the right technique for your situation. At the Shouldice Hospital, they almost never use mesh, but Dr. Yunis could certainly do it. I think he checks with patients before surgery if they are ok with him going with mesh if he feels it would be better during surgery. If I remember correctly, he even has some form related to that. Did you give him any guidance on that before surgery?

[roger555]

Stephen told me Dr. Kang did ten surgeries the day I had mine and that he has done as many as twelve in one day. It sounded to me that he averages less than twelve surgeries a day. Stephen said the can do two surgeries an hour.

[pinto]

GOT YOUR DUCKS IN A ROW?
You guys when talking about surgeon daily load might miss an essential element of comparison: Equivalence. Those load numbers come not from a vacuum but a sure context. But you likely assume that these surgeons all have equivalent surgery teams and process that might be untrue. Efficiency of scales might make a big difference for some surgeons. For example what practice does each surgeon follow to prevent surgical gauze mistakenly sewn up in the patient’s gut? Could certain surgeons have better practice than others allowing them to handle more patients? I’m not suggesting the issue is unimportant; only that the numbers are like icebergs, their unseen is as important as the seen. Maybe more so.

[Mike M]

@Chuck In case you or watchful are wondering – Dr. Kang takes as long as necessary regardless and cuts no corners. He took his time for my repair due to the difficulty and thus lasted a bit longer than expected per Stephen.

Circling back to the first few days after surgery – yes painful but a small price to pay for the overall successful results.

There are so many factors involved in a successful repair but as Chuck has mentioned Dr. Kang has seen it all and has successfully tackled many challenging patients others might have turned away.

[Watchful]

Correct. Conze takes his time in the evaluation and follow-up, and he doesn’t cram surgeries. The evaluation appointment (including ultrasound) is scheduled for 3 hours. Very exceptional, particularly in the hernia field which is typically handled as a high-volume assembly line.

[Unknown Member]

Watchful exactly….now consider Kang doing 12 surgeries per day….i would bet that Stephen could squeeze you into the front if we went…they roll out the red carpet for foreighners…but still…if you have to do 12 surgeries per day….maybe you cut some corners? Grishckan is another assembly line guy…peterson same thing…and he is downright nasty…I like some of the reports about Koch and weise that i found online….Koch personally visits all his patients at their hotel the next day…Wiese was noted to tell some folks that he would take his time and do it right…I am guessing you got some warm fuzzy feelings about Conze —this kind of stuff might make the difference. I have often thought of offering these doctors a second full fee…if the can fix me without chronic pain….i dont know how to incentivize them to do their best.

[Watchful]

Conze said he does 4-5 surgeries per day. This is one of the things I like about him. Shouldice Hospital surgeons do 6 per day. Yunis told me he does 6-9, which scared me – I kept imagining being the 9th.

[pinto]

Only my opinion but I think your case needs Kang even more than my own. He has seen it all besides being excellently skilled.

[Unknown Member]

Pinto…thanks so much for your quick response. Just a little hard to distinguish between bad pain moving around and painless surgery but your point is taken. I agree that there is a huge danger of surgeon complacency…I read the report of one guy who was damaged by Yunis. He was just on the assembly line of repairs —yunis wrecked him and couldnt even remember his case. Thats a real issue with Kang who performs 12 surgeries per day —thats a lot –it makes me wonder if he might just take a play off on a surgery or two…its just human nature when faced with a lot of work. Watchful do you have any thoughts? You indicated that Conze might be less volume more attention, I am guessing all these surgeons are doing many surgeries per day…good because of the experience…bad because we the patients just become a commodity….it surprises me that any surgeries every turn out ok

[pinto]

Everything I posted about my experience is as accurate as I could make it. Let me correct your mis-statement (in my view):
“Its a little concerning that you had so much post op surgical pain”

Your statement is wrong—from my perspective. You must be referring to my first surgery. I probably am more tolerant of pain than most others but here are three “pains” to talk about: 1) unavoidable pain, immediately post-op that everyone has; 2) my getting out of bed; 3) the taxi rides. Other than those I had no pain. #1 cannot be eliminated anywhere. #2 only if I was not in a motorized bed. #3 not if I had stayed longer in the hospital.

Given I had a sliding hernia it might have required a longer stay for caution’s sake. Moreover as I posted in the thread “Sliding Hernia,” the hospital staff was a bit unaware even though I had them search locally for a rental hospital bed for my hotel room (= unnoticed red flag). As a matter of fact after a few days in my hotel room going into my shower, I thought “I really didn’t need pain meds” (while excepting the walking + taxi rides). The rest of the 99.9% time it was painless.

I surmise that generally most surgical pain comes from the incision. Stephen says Kang’s incision is the smallest in the world at an inch and a half. I’ve yet seen any smaller for pure tissue repair. My #2 and #3 pain was not due to incision (known by my second surgery); I attribute it to the hospital but I am forgiving because everything else was so fine. Anyway going by other Kang patients, my first surgery was not representative. Nevertheless afterwards I was painless and body fully intact. 😀

You say, “several folks that went to Kang have said they were is such pain they could barely walk…one patient said he had to stay another night. So the Kang repair definitely has some downsides.” Name me a surgeon anywhere in the world who could do better. If you look enough you will find the same for any top surgeon. A million and one variables involved. You will find no perfect scenario.

I cannot answer your technical questions. I think Shouldice’s reputation is great—the gold standard. But too much slicing and dicing in my view. Kang, according to his website, was once vice-president of a Korean national surgical society, a position typically elected based on excellence of reputation. Remarkable because he does pure tissue repair—a minority medical approach! I believe he is a great surgeon. The only downside is that his hospital being specialized and reputable does an immense number of surgeries. The double-edged sword for our most important requirement of a surgeon–experience. A trade-off emerges between skill and personalized attention. For you, you absolutely must have a highly skilled and experienced surgeon.

• This reply was modified 11 months, 1 week ago by  pinto.

[MarkT]

I appreciate your post, Pinto.

They really do seemed to have maintained their regimen over the years. I didn’t find any of it problematic, to be honest. I don’t recall the wakeup being 5:30am, but it’s been a while…they did have scheduled ‘morning exercise (stretching), meal times, walking as much as possible, etc., but much of it was ‘strongly encouraged’ rather than ‘forced’.

I’m also not a 100% staunch defender of the way they have done (and continue to do) things. I don’t think it is ‘necessary’ to have the multi-day stay, for example, and I agree with concerns over not choosing your surgeon (though apparently requests can be accommodated). Overall, I do like their overall ‘specialist centre’ model in comparison to the ‘standard’ within the public healthcare system.

I believe I posted my thoughts on that surgeon’s blog post some time ago. Most importantly, I find that she fails to focus upon what is ultimately most important: the quality of the repair and the patient perspective. I think there is some problematic personal (and irrelevant) bias, undertones of bitterness/jealousy, and some ignorance. In one reply to a comment, she admits she had never heard of the Desarda repair, for example, and she fails to acknowledge that there is research that does suggest ‘repetition’ supports developing expertise.

I wouldn’t be ‘happy’ to go through it in detail again…but I would be willing to do so if anyone wants to discuss it, because I think this blog post is that problematic (despite raising some valid system-related points too).

[Jtk2]

With Yunis, I don’t think it matters whether you are #1 or #9. I was somewhere around #3. During my pre-op, Yunis rushed in and out of the room off balance and harried. Yunis refused to answer my question re anesthesia, even though his nursing staff specifically instructed me that this was the time that question should be asked. As previously reported, I woke up halfway through the surgery and was forced to endure excruciating pain, as Yunis cut and stitched, completing only 3-layers of a 4-layer rt inguinal Shouldice repair. Later, when I questioned his nurse about the 3-layer repair, she stated this is not atypical even at Shouldice, but that Shouldice does not disclose how many layers they perform to their patients. It has now been 8 months, and each and every day since my surgery, I suffer chronic debilitating pain (far worse than the hernia) with no end in sight.

Post Script: 2 months after the “surgery” I had a follow up visit with Yunis, at which time I asked him what went wrong. His highly technical response was, “I had to move the cord and separate a lot of stuff.” I left a comment on Dr Towfigh’s Herniatalk interview with Yunis, and Dr Towfigh responded, that I should contact her office, which I did, but to date have received no response. C’est la vie…

[MarkT]

In our discussion I granted you that while pointing out that you unwittingly were equating “old” Shouldice with the “new” Kang—that I believe were your two surgeries, the former decades ago and the relatively recent one. Apparently you didn’t realize that your thread came off as comparing Kang with Shouldice—a new with the old.

Both of my surgeries were a long time ago…30 years on one side, 20 years on the other. I have no idea why anyone would interpret any of my experience posts as a comparison between Shouldice and Kang in terms of ‘old’ vs. ‘new’…?

I well recognized that you wanted to help people with your experiences—-again, I granted that. What you don’t recognize are nuances that are emitted—intentionally or not—in one’s communications. How you couched your thread and presented it appeared to have other purposes. Even if you didn’t intend it, readers could glean it so.

Please expand on this part…I’m typically very careful about the words I choose when I write, specifically to avoid any confusion or where ‘nuance’ can cloud my intentions. I suspect someone readers might be making assumptions here or reading beyond the words I wrote if such ‘nuance’ is being interpreted. I’d appreciate an example though.

Another point you make rather naively: “keep in mind that “decades of medical advancements” would not seem to apply much to Shouldice Hospital, if you understand their model.”

Right there you conceded Shouldice decades later is not absolutely the same as before (by saying “apply much”). Subtle enhancements can make a great deal of difference for surgery outcomes. Surely there were major personnel changes in the hospital decades hence. What you don’t recognize is the difference between model and application.

“Naively”? Again, I choose my words carefully…”much” is to grant that OF COURSE it would not be the case that EVERYTHING is EXACTLY the same as it was 70 years ago. They have used different sedation medications. They allow for different suture material. There have surely been some subtle changes, but these things are not inherently relevant to the repair itself such that my repairs many years ago are rendered incomparable to someone receiving a repair today.

Models are one thing; applications, another. That’s just about technique. Then there are materials! At least some Shouldice surgeons changed from steel thread suturing to polyester! You kindly credited me, in that earlier thread, for helping you recognize that the occasional twinge you feel is likely from the steel suturing. On principle alone there is no way you can discount decades of medical advancements. So incredibly shortsighted your argument. Thus it was necessary, as is now, to caution your apples-to-oranges writing—if not your thinking.

I think you are confusing me with someone else…? First, I do not feel the occasional twinge from either of my surgeries. I’ve said in many threads that I have no lingering effects from either of my hernias or repairs…ZERO. What I have said is that in the very short term (a few months) afterwards, I recalled getting the occasional twinge (which was a normal part of the healing process).

I think it is a HUGE assumption for anyone to claim that a post-op ‘twinges’ would be due to the stainless sutures. I don’t believe I have ever granted that was the case or even a possibility, but if you have a thread suggesting otherwise, please link it.

I’m still waiting for examples of “decades of medical advancements”. If you think some of the surgeons choosing to use Prolene over stainless steel amounts to that, then I’d say a better choice of words is in order…because that certainly does not have a relevant impact in comparing my surgeries years ago with someone going there today.