Researching surgeons – what questions to askPosted by ajm222 on September 28, 2017 at 5:33 pm
Just wondering what sorts of research I should do if and when I need to find a surgeon for a hernia. Have appt tomorrow with someone in Dr. Procter’s department at VCU in Richmond VA and suspecting I have a small direct inguinal hernia that has my health anxiety through the roof. The idea of watching and waiting panics me as does surgery and the seemingly high rate of complications/pain. I just lost a lot of weight last year and have been enjoying running at least 4 days per week for the last year+, and then I seem to be paid off with a potential hernia. Seems finding a great surgeon is critical and I want to do my homework and be prepared.
I don’t want things to progress any further (largely asymptomatic right now) but don’t want to get surgery on something that isn’t currently a huge problem if it means I risk more life-long pain or complications. But I also feel like this is a ticking time bomb and feel uncomfortable even moving now simply from worry about what I might do to that area by exerting myself. Wish I hadn’t even discovered the tiny bulge. My PCP did the cough test and said no hernia. But my understanding is that’s only good for indirect hernias and this looks and feels like direct. Just a big dilemma for me.
So that being said, what’s the best way to learn a surgeon’s skill? Ask for references/stats directly from him? What kind of stats (number of operations and type, success rate, etc.)? Ask my PCP? Are there websites for such things?
Thanks in advance.
MemberFebruary 21, 2018 at 5:21 am
Last one of my old posts
What ?s should surgeons be asking their patients?
Thanks for the reply’s. What concerns me is a multiple of issues in my long hernia journey. My case should have been I think pretty straight forward, if I had been given a Surgeon according to my very specific requests. I was told by the person who set up my initial appointment that he was a highly trained hernia specialist that performed hernia surgeries all of the time. I just found out that he had performed 0 in the 18 months leading up to my presurgical consult and that it was known that this quote world renowned hospital had a known 25 to 30 percent 1 year post surgery pain rate. Here is some background. My hernia occurred during a bad coughing spell at the site of the surgery for aN open appendicitis operation about 30 years ago. I will use this from another post ” It is just right of midline between my belly button and pubic bone”. My GP’s PA did the initial diagnosis and said it was a inguinal hernia. The quote expert hernia GS did two separate inguinal exams on different dates both lying down and standing and could not find anything and asked where is the bulge and I pointed to the spot described above. In his notes there is no mention of this, his findings or diagram of the hernia location. A couple on months later it was getting slightly worse for protruding and pain, plus when driving the top of the lap belt ran across it. So I decided to go ahead and have it fixed. So here is were this leads to in this post.
I was told by every staff member of this Doctor by phone or during consults which there were three, how great of surgeon, his current training and knowledge, that he performs them all the time and excellent outcomes at this clinic at 8% or less total problems and/or complication. So after the surgeon and his staff went thru what to expect and was given the little booklet here are my questions to the doctor which I asked.
When I left the first consult watchful waiting and open surgery.
This is what I asked to his PA and what I was told. second consult for surgery work up
How many has he done – performs them all the time since coming to the hospital about 18 months.
Will he perform the entire surgery – we do not have techs so a resident will only assist. She also stated that the resident would be the only non licensed person in OR. It would only be the surgeons highly trained and experienced team in the OR.
Gave the name of a class mate that is anesthesiologist that I would not be comfortable with doing the gas – Agreed but not noted in notes plus told the that it would be a highly experienced general anesthesiologist doing the gas.
Asked about metal-no metal to be used – absolvable sutures were to be used.
What is there are complications or pain post surgery – we have a world renowned specialist on staff for post pain to resolve the issue.
Surgery changed to Lap.
Second consult with surgeon 3rd total. Changed back to open surgery. When I asked why no reason given. But again this is supposedly one of the best hospitals in the nation and being told constantly how great my surgeon is I except this.
Questions I ask the surgeon.
How many times have you done this type of surgery – well over 1,000
Are you going to perform the entire surgery – yes according to their residents exit survey the residents might perform up to 90% of the surgeries at this hospital.
What about current training – I am up on all current techniques for open hernia surgery
What or how do you deal with the three main nerves – We agreed he would locate and preserve. When asked after the surgery about why no note in post op about two of the nerves were not reported I was told not in the surgical field of vision.
What type of mesh to be used – We agreed on lightweight mesh. Heavyweight(PMII) was used and he could not answer why but another PA stated he performed so few since coming to this hospital that he might not have known approved types available.
Time of recovery – 6-8 weeks to be fully recovered.
Can I travel by plane in 10 day s- no problem
Side effects and complications – listed seroma, hematoma and infection as the three main ones. The writer of a study that found they had a 25% post pain issue was in the consult room at the time and said nothing. Also I had two previous surgeries in the general area and never mentioned a possible loss of testicle. Less than a week after the surgery the doctor stated he inserted the mesh a tight as possible
Pure tissue surgery – no can not be done that way.
I now know that I forgot to ask two important questions-Why are you recommending open over lap and if doing it open why are you recommending a general over local.
I think I asked the right questions and was given the answers they wanted me to hear, that led me to consenting but after my surgery and reviewing my history plus what I have found I believe I was intentional missed informed.
That is why I stated this and Dr. Goodyears forum along with the book unaccountable should be required by consent it obtained.
Doctor Towfigh if you or the other mediators would like to review my history I would be more than happy to forward them to you.
Thanks again for all of your time and help you provide to this group
MemberFebruary 21, 2018 at 5:16 am
Another post I did
What ?s should surgeons be asking their patients?
I hope things are better for you. What you describe sounds very much like my experience. As soon as my condition worsened about 7 weeks post surgery I found out the truth about my quote expert hernia surgeon who supposedly performed a large number of hernia surgeries with less than 8% total side effects and complications prior to mine. Afterward when I got worse, I was told the surgeon had no idea what was wrong since he performed so few hernia sugeries. Six years post surgery I just found out he had done a whopping 2 hernia surgeries(just days before my operation) before mine in the previous 18 months. What is also shocking he is now posting online as a surgeon at a Hernia Clinic. And according to a report I received if accurate he did not perform one hernia surgery between 2011 and 2015.
When my problems started it was me that was the problem and was bounced from different specialist to different specialist but when questioned they had no real expertise in this matter unlike the moderators on this site. I finally got new insurance and paid out of pocket to go to one of the real hernia experts to be fixed. Less than a week after corrective surgery I was without the previous pain, walking normally and even spent 11/2 days spectating at an auto race, meaning I was walking the whole day.
I agree with your “First and most importantly, there needs to be more dialogue and more time spent working with the patient. For lack of a clinical term, don’t leave your patient with “lost cause syndrome.”” statement.
I firmly believe that every hernia patient should be given this website address, Dr Goodyears website address and be given a copy of the book Unaccountable before surgery unless an emergency. This would give the patient a much better understanding and true picture of what is to come.
Next there should be a complete checklist that both the Dr. and patient need to check all of the boxes on all aspects of the surgery before the informed consent.
Than the patient should be given a complete copy of all presurgical visit notes and the agreed upon surgical treatment plan to take home and review to make sure it is accurate and complete. I thought I covered all the bases with my surgeon and his staff prior to my surgery, but when reviewing my medical history post surgery I found they failed to note any of the agreed upon treatment plans and none of my history was accurate and no notes by the doctor on the location of my hernia. Here is one example: The doctor agreed that he would locate all three nerves and preserve them. Post op notes states only the inguinal nerve found and preserved. When asked about why the other two nerves were not noted in the post surgical report it was stated that the other two nerves were not in the surgical field of vision on an open procedure.
Informed consent should be given at the last appointment before surgery to be taken home and read at ones own time frame and reviewed by a lawyer if so desired. Instead of being given seconds before you are being wheeled to the operating room.
Again I hope everything is better.
MemberFebruary 21, 2018 at 5:02 am
I hope I am not too late. I wrote this a long time ago on this forum and I hope this helps
top hernia doctors in georgia or tn
This might be a little long. Sorry
If you can get and read Unaccountable by Martin Makary before your next appointment. This might help you with some questions and what to look for. I think it took me about 4 to 8 hours to read. https://www.amazon.com/Unaccountable-Hospitals-Transparency-Revolutionize-Health/dp/1608198383
I hope I have given some good advice and have been clear and concise. I am the worst writer and it is very hard for me to put my thoughts into a written message. This is about the hardest thing I can do.
Your story and what you have gone through is way above what I had to deal with and I know exactly how and what you are going through. I hope wherever and whoever you decide on gets you back to your presurgery condition.
I am a lay person and I am giving you my personal thoughts. You need to go by what you feel is best and which Dr. you trust the most. Out of all of the General surgeons here in the US, I am guessing that their might be 50 to 200 that specialize in hernia surgery. Remember it is just a hernia, just a simply surgery! The number of the true expert/specialist might be around 20 or so with only 1-10 that have knowledge, experience and skills to truly know when they start a surgery like what you need and to understand what is presented to them and how to fix what is or has been broken. You already saw Dr Chen supposedly one of the best. What was his surgical plan?
I have never been to your state or have any knowledge of VCU or any information on the Dr. I think you are seeing but I have personal experience with member of the GS staff at VCU I could never recommend that surgeon and I would be very leery of a hospital that has this surgeon on its staff. VCU and the Dr. you are seeing could be the best in the world but go slowly.
On robotic surgery. It is fairly new to hernia but has been used in other area’s but it is only as good as the surgeon and their skill using it. My parents have a very good friend who had a bad robotic surgery by quote one of the best in the nation. The person who had to surgery was a research Dr. working on a cure for one major disease, graduated from the same school that did the surgery and had complete trust in them. He is one of the most interesting person and nice guys you would meet that know about every issue you could think of. After the surgery the Dr. dropped him like a hot potato and would not speak with him. Shortly afterword he got an infection that almost killed him. Last time I spoke to him he was a broken man a shadow of himself. Very sad. I also saw this same Dr. and wanted to do a different type of surgery but roboticly. Interesting he recommended this surgery with no imaging and when pressed about if he was going to do the entire cutting edge surgery it was like deer in headlights, he froze and could not answer the question. He finally did state that he would be present in the OR with a resident doing the surgery. Goodbye. I would rather have the best/skilled hernia surgeon in the world with 30 to 50 year old technology without mesh than an average general surgeon with a robot with mesh doing my surgery.
Here are some of the questions I would ask the Dr and every person on his staff that you meet. Go in with your eyes wide open and your radar on.
How many years have you been licensed. Also check with the state for any complaints.
How many hernia surgeries have you done the entire surgery. What types hernia surgery and open or lap.
This is a teaching hospital at the one that I have my surgery I found out up to 90% are done by a resident.
Are you going to perform the entire surgery. If not why, who is and what is their experience.
How many have you done in the last year. Success rate. What were the problems.
How many corrective surgeries. How many cases like mine. Results.
Do you have your own surgical team.
Do you have any research grants or financial connections to any of the products to be used in the surgery.
How many robotic surgeries have you done. How many hernia with robotic. How many corrective hernia robotic. Outcomes. There are many Dr.s who are getting money to use robotic surgery to expand the types of surgeries done and prove the concept.
Can I get a copy of the video of the procedure.
Are you a state employee and do you have extra legal protection against law suits. My state there is such a small amount that a state Dr can be sued for, that no lawyer will even talk to you about a lawsuit. The hospital keeps this very close to the vest and does not disclose this fact.
What is your surgical plan and outcome you expect.
recovery time for this complex surgery.
Who will be performing the Gas. Their years of experience. How many surgeries have you done with them.
Get and read the informed consent before signing and surgery
Who is going to be in the OR. Mine was only to be one resident to assist him. But it was One resident, one fellow, two medical students plus his personal surgical team was listed as floaters and the surgeon could not answer any questions afterword on any part of my surgery. It might have been a ghost surgery.
I am sure there are more questions to ask. Some surgeons are put off by questions, since they think whatever they tell you you should just say yes and agree with them.
Trust your sixth sense. Get a copy of all of your medical records and before going ahead with the surgery get a copy of this upcoming appointment. I found out after my surgery that the surgeon did not have any history or progress notes and any of the agreed treatment plan in my medical history
I hope this makes some sense. I wish you the best and if you have any other questions just ask. Again sorry for being so long.
Get the book Unaccountable.
This took me the last day to think this out and over an hour to write this.
MemberOctober 30, 2017 at 5:26 am
Umbilicus is the point where the strongest tension is applied in the abdominal wall.
So to prevent recurrence, large umbilical hernia repair may need Goretex cloth or other material for reinforcement.
Good news is there would be little problem of using foreign material in umbilical hernia repair, if small size material is used and fixed with a thin suture material.
Sadly I haven’t submitted my result to international surgical Journal yet.
I am preparing for it.
MemberOctober 30, 2017 at 5:17 am
Thanks Jnomesh, I have read many of you posts here at HerniaTalk and thank you for your input, especially from someone who has gone through the difficulties of mesh.
Thank you again Dr Kang for your clear and prompt response. Dr Kang, have you submitted any data on your hernia surgery results internationally?
MemberOctober 30, 2017 at 4:46 amquote Rob:
Yes I sometimes use small piece of Goretex cloth for umbilical hernia
But it depends on the size of the hernia opening.
If the opening diameter is less than 1cm, just tissue repair is done.
For inguinal hernia, I always do no-mesh tissue repair without any exception.
Even if any recurrence after my tissue repair occurs, there would be absolutely no difficulty to do laparoscopic mesh repair or Lichtenstein repair.
Because my procedure is very less invasive and minimal, there would be little postoperative adhesion or derangement at the repair site.
And I actually do the second tissue repair for all my recurrence cases, although rare, without any difficulty.
I even do the tissue repair for the recurrent inguinal hernia after open or laparoscopic mesh operation, although it is quite diffiult to perform because of concommitent postoperative derangement.
In terms of the second tissue repair, Lichtenstein repair is worst and my procedure and laparoscopic mesh repair are similar.
MemberOctober 29, 2017 at 2:42 pm
I’m not a doctor but if you have a small umbilical hernia definitely get it repaired by using a tissue repair. I had both a inguinal hernia and a very small umbilical hernia that were both repaired in the same surgery. Mesh was used for my inguinal hernia which turned into a total nightmare and I had to have it removed. The umbilical hernia was stitched up. I never felt a thing and never have had an issue with it.
no need for mesh for a small hernia.
Also the size of the mesh they use for a small hernia can be quite big.
stay away from mesh if possible and find the best qualified surgeon to do your repair even if it means traveling.
just my two cents
MemberOctober 28, 2017 at 11:53 pm
I have some more questions for you Dr Kang:
Have you submitted your surgical data results to international journals? If not why not? I think this would be one of the most valuable things you could do in promoting Gipum Hospital.
Do you use mesh for very small umbilical/epigastric hernias? I have been diagnosed by 2 surgeons who both can feel a hernia in my belly button. Its small, one surgeon recommends just stiching it, the other surgeon recommends a small piece of mesh.
Although you use tissue repair for inguinal hernias, is there any circumstance where you decide to use mesh instead for the repair of inguinal hernia?
If someone had your surgery to repair inguinal hernia and there was a recurrence later. Would laparoscopic mesh surgery or Lichtenstein open mesh surgery still be possible to treat the recurrence?
Again, if someone was to have a recurrence after your tissue repair, can you perform your method again to repair the recurrence? I take that after a recurrence the tissues would be more compromised and the hernia bigger than it was originally?
Thanks again Dr Kang,
MemberOctober 18, 2017 at 8:43 pm
MemberOctober 18, 2017 at 5:15 am
MemberOctober 18, 2017 at 2:45 am
Gotcha-and this can be done even if say there isn’t a true hernia recurrence? So let’s say indirect hernia recurrs but direct doesn’t- the direct space can still be reinforced separately but in same procedure (even if maybe not recommended)
MemberOctober 18, 2017 at 12:18 am
If you want both area to be fixed or reinforced(although prophylactically in one area), It could be done at the same time in one operative field.
I just meant that not one but two different procedures should be done to cover both area.
MemberOctober 17, 2017 at 11:12 pm
Hi thanks dr. Kang. In my particular situation I had both a indirect and direct hernia repaired with mesh laparoscopically. The mesh folded up and had to be removed. Upon removal my surgeon noted that the direct space had been filled in with scar tissue. Although there was no indirect hernia upon removing the mesh there was weakness in the indirect space. This was repaired while he was in laparoscopically by bringing the internal oblique muscle down to the illiopubic tract and closing with absorbable sutures. He also noticed some/slight weakeness in the femoral area but it was to vascular to reinforce with sutures.
i know this whole area is still weak, especially with the removal of the mesh so I was just tying to plan ahead should I get a recurrence and need surgery without mesh I’d like to get the both areas reinforced/fixed in one operation given my history even though there only might be one recurrence. I’d hate to get a indirect hernia recurrence have surgery to fix it and then later get a indirect hernia and have to be cut open again (I’ve already had three surgeries)
so I was hoping there was a way to fix/reinforce the area in one surgery without mesh.
i guess this might not be as easy I had hoped.
MemberOctober 17, 2017 at 3:24 pmquote Jnomesh:
Shouldice mainly covers direct area.
They also do Shouldice for indirect inguinal hernia, but I don’t think it’s appropriate.
And I don’t perform Shouldice at all.
I do Marcy-like procedure for indirect hernia, and it doesn’t cover direct space.
I don’t think there is any tissue repair that could cover both direct and indirect space exactly at the same time, although they say most posterior wall repair, including Bassini, Shouldice or Desarda and so on, can cover both space.
They are basically designed for direct hernia.
If you have an indirect hernia in the future and you want to cover the direct space too, both space can be fixed seperately by the appropriate tissue repair method respectively.
I don’t think the preventive herniorrhaphy is necessary, but it’s not impossible.
Laparoscopic mesh repair may cover all areas of indirect, direct and femoral hernias.
But it seems to me that this is due to a technical limit of laparoscopic mesh hernia repair rather than for patient’s sake.
If you cover only the indirect or direct hernia area with a smaller mesh, it may not be secure enough to prevent recurrence of original hernia.
For this reason, laparoscopic mesh must be big enough to cover all inguinal area.
It means that the main goal of using a large mesh is not to prevent all groin hernias, but to prevent original hernia recurrence.
Though it’s not bad, if it works.
But everything needs to be paid back.
That is, there is a possibility of an additional side effect by using a larger mesh.
So surgery should be minimized. It’s one of the surgical principle.
If you have indirect inguinal hernia, only indirect hernia repair is enough and safer.
There is no need to worry about the possibility of future direct or femoral hernia, which occurs less likely.
I don’t think that more than 99% of patients should undergo over-extended surgery against less than 1% probability of another new hernia.
If it is necessary to do something against a chance of less than 1%, why not against metachronous opposite hernia with a probability of more than 10%? Why not always do hernia repairs in both sides for every hernia patient?
If you have a flat tire, should all other three tires be replaced in order to prevent the future possibility?
If you are rich enough, it may not be bad.
But I definitely won’t.
Moreover, larger surgeries increase the likelihood of complications at the same time.
Therefore, it is not reasonable to take measures in advance against that very low possibility while taking such risks. So, I think it would be better to repair only indirect if indirect, only direct if direct, and only femoral if femoral hernia you have. I do not think the preventive herniorrhaphy is necessary at all.
Therefore, I think the posterior wall repair, such as Shouldice. Desarda, or Bassini, which is said to cover direct and indirect, could be an excessive operation.
Laparoscopic mesh repair covering indirect, direct and femoral areas might be the most aggressive surgery.
Indirect inguinal hernia is also generally being treated with posterior wall tissue repair such as Shouldice or Desarda.
But it’s like wearing a left glove in your right hand.
It is better than nothing on a cold day, but it is not perfect.
It is normal to wear the right glove on the right hand and the left glove on the left hand.
Similarly, if you do tissue repair, direct inguinal hernia should be operated with one of posterior wall repair which reinforces the floor of Hasselbach triangle where direct hernia occurs, and indirect inguinal hernia should be done with appropriate Marcy-like operation which only closes internal inguinal ring through which indirect sac herniates.
In case of combined direct and indirect hernia, I repair the floor of Hasselbach triangle and the internal inguinal ring seperately at the same time.
MemberOctober 17, 2017 at 2:28 am
Thanks, and I’ll keep you posted
MemberOctober 17, 2017 at 2:01 am
I can’t clarify. I only took one course, 30 years ago, in the use of statistics to assess validity of survey data. Some of the background data and references are more informative…
“Recent evidence indicates that 3% to 6% of patients will have severe pain, and up to 31% will have chronic pain after inguinal hernia repair.15-18”
That paper is from 2008 though. There must be more current information out there. You have the most validity in asking questions, since you are planning for a repair. I hope that you do talk to some of the authors and that they’re willing to share. Actually, I hope that they follow this forum and will jump in with some clarification and new results. That would be fantastic.
I also have been around several other forums and have found that many people start recommending that everyone get surgery, based, apparently, on their surviving the surgery itself, and the fact that the surgery was not as bad as they expected. There are very few people who report anything, good or bad, after more than six months. Most people just talk about the healing from the surgery itself. Which is one of the psychological deceptions of the repair – the surgery itself knocks you down so far that you’re just happy to be able to walk again, and forget about why you did it in the first place.
Anyway, carry on and good luck. This thread started with a great question. One question that a person might ask a potential surgeon is whether or not they have recent survey results from their own patients.
MemberOctober 16, 2017 at 11:53 pmquote Good intentions:
Yeah, I might just do that, because I don’t quite get the data in Figure 1. It doesn’t gel at all with anything else in the paper (which is also apparently mostly discussing the merits of this new survey and not really going into as much detail about outcomes from surgeries themselves). I understand this new survey is supposed to better dig into quality of life after hernia repair, but every single category there shows dissatisfaction. Meanwhile, most patients appear to be satisfied on the whole. I could certainly understand overestimating people’s sense of quality of life a bit, or maybe even much more than a bit. But it’s completly opposite. I also don’t quite understand the numbers in that chart and some of the notes. Further, I’ve taken time to visit a number of web forums not strictly dedicated to hernias (for example runners forums and forums completely unrelated to health and fitness that have ‘lifestyle and leisure’ type sub-forums where people occasionally bring up surgery), and people routinely proclaim without qualification that they had the surgery, it wasn’t bad and they are without any issues whatsoever after 5, 10, 15 years etc. There’s usually one in every ten or so that says they sometimes get a twinge once in a while if they move a certain way, but they are glad they had the surgery. Ultimately I’d just like a better explanation for that Figure 1. Not so much because I don’t believe it, but just because I don’t fully understand it. The numbers aren’t numbers of patients, and I don’t get the p values etc. Perhaps you can clarify.
MemberOctober 16, 2017 at 8:37 pm
If I were in your situation, today, I would contact some of the authors of the 2016 paper. I see that one of them is Dr. Belyansky, who I think has been mentioned as a surgeon who also does explantations. Seems like he and the others would have the very broad view of what’s possible and what works.
MemberOctober 16, 2017 at 8:31 pmquote ajm222:
When I posted that, I “knew” that you would see those parts, but not what might be the most important part. You have the hope goggles on, like I did. If you look at Figure 1, you’ll see Dissatisfaction is 4-5 times as high as Satisfaction, in general, in every category. The figure is not explained as clearly as it could be, there’s probably an assumption of knowledge of statistics, but it looks like most people are not happy with the results of their surgery. That’s the kind of information that the surgeon should be telling you in the consultation. When I was researching getting mine fixed all I heard were details of what would be done, but not a word about how I would probably feel bad with the mesh implanted. At that point in my life it was more important to me to be mentally strong, not physically. I had a hernia, but I would have had a plan to get it fixed at the right time. But it sounded so easy and simple, with an implied “guarantee” of a good outcome. Instead it took over my life.
MemberOctober 16, 2017 at 7:37 pmquote Good intentions:
Awesome, thanks! I’ll go through this carefully later and see if I can understand it. A quick glance does seem to suggest that lap surgery appears to be associated with better outcomes in terms of long term paresthesia and groin pain using the better CCS survey. And it was interesting to see that all of those getting the 3d Max mesh appeared ‘satisfied’ (and that lap surgery and inguinal hernia had better results than open or other hernia types). As for waiting and seeing if technology improves, that’s certainly something to consider. Though I feel like it will still be many years before any major advancements or definitive conclusions will be reached in this area. And for me, being the hypochondriac that I am and suffering at just the idea of knowing I have an opening down there where my internal organs are pushing out and seeing it every day, and changing my behavior for fear that I will quickly make things much worse and then have to wait a while for surgery, it’s just hard to imagine I could let this go for much longer. That said, I will still keep all of this in mind and take it day by day. I certainly don’t want to deal with the possibility of chronic pain, but I also don’t like walking around with a hernia. I’m not currently in any real pain per se, but I’m suffering in other ways (mentally, knowing I have this problem and it will get worse eventually, sooner or later). It’s a tough call trying to decide what to do.
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