Researching surgeons – what questions to ask

[ajm222]

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.

[mst3k]

Start with PCP, however sometimes I have found if you call and just ask for a surgeon they will give you someone close by to you, but you will want more than just convenience. So make sure you ask for who they recommend themselves and who has your PCP’s other patients have had good results with.
I assume you don’t know anyone who had this surgery, because obviously if you find anyone who had it, ask how it went and get a surgeon’s name if they had good results. I got a name (turned out to be the same doctor) both ways.

I thought this website looked useful: http://www.amino.com
you can find surgeons based on condition, and based on insurance info the site can tell you if the surgeon is very experienced in treating it.

In general for hernia you ideally want a doctor that has been doing this for many years and should have thousands of repairs under his belt.

[ajm222]

Thanks! Very helpful. I know three people now who have had this surgery, two locally. I will ask them how it went and who they used. Though it seems everyone had some complication or another or some minor lingering issues. But they seem satisfied ultimately.

By the way, does mesh need to eventually (over years or decades) be replaced, or is it intended to be permanent? Thanks again.

[mst3k]

the majority of mesh implants will be permanent, and hopefully will never need to be removed.
I didn’t mention mesh vs. non-mesh in my first reply because it is a much bigger issue as you can see from other posts. You will find the overwhelming majority of surgeons will use mesh these days, and it will be polypropylene or polyester which is a permanent implant.

[ajm222]

wonderful that’s great to know thanks

[Good intentions]

quote ajm222:

The idea of watching and waiting panics me

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

I felt similar to you when I found that I had a hernia. But mine was symptomatic and painful and was inhibiting my doing the things I liked to do. If I can be frank – a person would be a fool to get an asymptomatic hernia repaired, by any method, if it’s not getting worse and they are doing all of the things that they like to do.

It’s not a “bomb”. If it gets worse it will be fairly slowly. You’ll know that it;s getting worse. More stuff will push out and you’ll have a sizable bump and various other discomforts.

This is an interesting time for hernia repair. There’s been a very big push to get the new mesh products and techniques out to the masses (25% of the population is massive, marketwise). Everyone involved has been overlooking problems, and/or hoping that all of the change is only for the better. But, as you’ve seen, many of the professionals, from the device suppliers to the insurance companies, and many surgeons, are ignoring the signs that there are major problems. The cost, to the patient, physically, of a problematic hernia repair is huge, but the probability of it happening is smaller. They, the people I mentioned above, are paying for lower recurrence rates with the lives of the few that have problems.

Basically the odds of a successful repair (no recurrence) are better but the cost of complications is huge. It will completely change your entire life. That’s what you should be afraid of.

If I had just discovered a hernia and it was minor and asymptomatic I’d wait and see how things shake out. I don’t think that things can continue as they are, the law firms are lined up out there. When I was researching for mine, in 2014, just three years ago, I barely saw any law firms advertising for hernia mesh lawsuits. All I saw was transvaginal mesh law suits. Now the first search page for “hernia mesh” is almost all about hernia complication law suits. That’s in just three years. I’d wait.

[ajm222]

Thanks! That’s great info. Most friends who’ve had the surgery always say ‘sooner rather than later’ but perhaps they simply weren’t aware of the possibility of ‘watch and wait’ or had very symptomatic hernias. I imagine if I DO get surgery I should find someone that seems aware of all the things you’ve mentioned and have considered them. Must be some knowledgeable and experienced surgeons aware of these problems and care enough about their patients to discuss them. But I’ll be sure to bring this up. And perhaps try and steer clear of any cutting-edge, latest-and-greatest mesh products and ask for something tried and true if possible. Will find out tomorrow hopefully what’s going on and start considering what to do.

[Good intentions]

But. If you do decide to go ahead and have it done, I would ask the surgeon if they have actually talked to patients who’ve had the materials and techniques the surgeon is currently using, after 6 months to a year, and heard the patient say that they were happy with the results. Not results from older methods and materials, because change is being made based on potential benefits not proven benefits. And every surgeon has a different method. So you can’t even compare materials and methods. I’ve only found a few people who will say that they’re happy with the results of their hernia repair. I think that there are probably many many people who aren’t but have just accepted their new diminished life. Because there’s nothing that they feel they can do about it.

There are pretty sizable communication barriers between patient and doctor these days. If I want to talk to mine, I have to call his answering service. They deliver a message. If he wants to he can call me back. Or he can ask me to come in for an appointment. That means waiting one to two weeks, then paying a copay, then getting 15-20 minutes of time.

In short, just ask for proof that what the surgeon is going to do to you actually will make you better. It’s a very reasonable question.

[ajm222]

By the way, did you have a bad experience? Having trouble finding previous posts. Thanks.

[Good intentions]

quote ajm222:

Thanks! That’s great info. Most friends who’ve had the surgery always say ‘sooner rather than later’ but perhaps they simply weren’t aware of the possibility of ‘watch and wait’ or had very symptomatic hernias.

I thought that I had found the perfect person for advice when I had mine. A surgeon who had actually done hernia repairs, and had had a hernia himself, which he had repaired. But after I had the surgery I found that he had his done by the open repair method.

If you have friends that will honestly talk about how they are, including all side effects, you’ll be lucky. The thing about healthy active men (maybe women too) is that we are all raised to suck it up, throw some dirt on it, be tough. And we don’t like to admit that we made a mistake. So I think that many of the problems are being hidden by the patients themselves. And the pros who could extract the information, through an anonymous survey, or discussion, aren’t seeking out the truth.

If you find someone who had success, and has been okay for over a year, and they do similar activities to you, and have your same body type, consider having the exact same surgeon and procedure.

[Good intentions]

quote ajm222:

By the way, did you have a bad experience? Having trouble finding previous posts. Thanks.

I did and I’m seeking solutions. I had bilateral laparoscopic mesh implantation of Bard Soft Mesh, for a direct hernia. It hasn’t been anywhere near the impression that’s fostered by the industry. It’s the worst thing that’s happened to me besides the death of family members.

[ajm222]

Very sorry to hear that. I had one friend who had open for one repair and laparoscopic for another. He said he has no issues now but did mention the open method was actually easier recovery, mainly because the lack of bloat that took a couple of weeks to go away. Another friend has had two surgeries. Said the first wasn’t bad but the second took him a month to leave the house and he had nerve damage in legs, which eventually resolved. He was out of work for two months. He said he’s now recovered. Another friend had three surgeries and he says no problems now but I haven’t really talked to him at length yet for details. And the last said he gets anoccasional twinge or discomfort I guess but feels mostly fine. I don’t know what he had done. But I believe all had mesh repairs.

It’s good to be informed but also scary. Went to a law firm website for worst case scenarios and scaremongering and saw stuff about teeth falling out and bowel obstructions and brain damage. But I also know this is one of the most common surgeries there is and has been done with and without mesh for a century. But that doesn’t really matter I suppose if you’re in the bucket of folks who have complications. I know my grandfather had hernia surgery as a middle aged man and never heard anything about complications later in life (he lived to be 91). But I have no idea what method was used for repair. Sigh. So much information out there and so hard on someone like myself who has trouble making decisions. Will see what surgeon(s) say. Thanks again for all your thoughtful responses.

[Good intentions]

I can’t emphasize enough how important it is to get the details of what worked and the details of what your surgeon is planning. Make sure that they match. Things are changing very fast right now and things are being tried that have not been proven to work. There is a lot of experimenting going on, with no long-term follow-up.

Get on to youtube and search “sages conference hernia” or similar and watch some of the presentations. Many of the talks are about the new things being tried, and if you watch closely you’ll see that many of the presenters aren’t really confident that their methods work. Their patients go away and they never hear from them again.

It’s great that you have friends that have had the surgery. But you’ll probably have to press them to find out how they really feel. As I said in post #10, we don’t want to look weak so we tend to hide our problems. I know I did, and still do. Plus I spent a couple of years trying to believe that I hadn’t screwed up by having the surgery done. Convincing myself that things would get better eventually.

The “find a surgeon with many surgeries under his belt and you’ll be fine” advice that you see is almost a marketing tool, to make people feel comfortable about having it done. My surgeon had about 400 repairs behind him. He was very skilled. But he was still modifying his method. He told me that but I convinced myself that he was fine-tuning to perfection instead of asking him what was wrong with the way he had been doing things. Maybe he had had earlier problems. I still don’t know.

It’s very difficult to challenge an expert about what they are telling you. Some will get angry. But you’ll live with your choice for the rest of your life. Much longer than a few months of healing pain. If they can’t answer your questions then you know that they don’t know for sure that their methods actually work. Make sure that their method is tailored to you, and is not a one-size-fits-all method. It’s been posted here and I heard it from my surgeon, that active people with low body fat tend to have more problems with mesh. He told me this after I went back with problems, not before. Even though he knew that I was very physically active, and am obviously low body fat.

Good luck.

[ajm222]

Thanks. This surgeon said it appears I have it on both sides (indirect inguinal) and suggested a laparoscopic robotic surgery with a mesh they’ve been using for well over 10 or 15 years. He had a colleague in this practice that apparently did it recently. He did say he does the open no mesh surgery method that starts with a D (can’t remember name) as well.

[saro]

Hi, Good Intentions: a question: your prosthesis is made of polypropylene?

[Jnomesh]

Dr. Belyanski is a top hernia surgeon in Annapolis Maryland.
Not to scare you but to inform you about mesh but if something should go wrong with mesh and it needs to come out it is a utter nightmare to remove. And very few surgeons do it. Dr. Belyanski removed my mesh-so if you decide on going with mesh I’d consider getting the surgery with him he is highly skilled and in your area-and even a bigger plus is he does and knows how to remove it-should something gonwromg in the future.
this is my biggest complaint about mesh-it’s not whether something will or won’t go wrong or whether it is good or bad-but if it does go wrong it is a utter disaster and an ordeal to get it removed and even if you do get it removed it’s not a slam dunk that you are better off. This stuff can do a lot of damage.
the D you are talking about is most likely the desarda pure tissue repair. Ask how many he does of these types of repairs.
Do your research and make the best decision you can on which way to go.
there is nothing wrong with waiting however if it is small it is much easier to get a pure tissue repair if it gets bigger over time and you want a pure tissue repair it may be harder.

[ajm222]

Thank for all the advice. And yes, that’’’s it – Desarda. I’’’ll try and find out how many he’’’s done. He quoted an interesting study suggesting at three years that method had same recurrence as mesh. No more, no less.

[Good intentions]

quote saro:

Hi, Good Intentions: a question: your prosthesis is made of polypropylene?

Yes, it’s polypropylene. Bard Soft Mesh.

I just came across an article that shows, in a way, the environment we’re all dealing with. There are people with power and responsibility in these giant medical device organizations that just don’t care about the people they’re affecting. When things change rapidly, these kinds of things happen. Five years after they were sure it was bad, they kept on selling it. After they introduced it with no trial data. Ethicon is one of the big hernia mesh companies. The same people might still be there, pushing hernia repair mesh. How does anyone know?

https://www.theguardian.com/society/2017/sep/29/revealed-johnson-johnsons-irresponsible-actions-over-vaginal-mesh-implant

http://www.ethicon.com/healthcare-professionals/products/hernia-repair-and-fixation

jnomesh makes a good point about fixing a small defect over a large one. But, still, if it’s not changing, it’s not really broken. There’s no need to “fix” it.

[ajm222]

Very quickly I’ve gone from feeling like mine are asymptomatic to noting a significant amount of aching and soreness particularly in the testicle when standing even short periods of time. Not sure why it went that quickly but at this point I feel like I can’t get it done soon enough.

[drkang]

Hi,

I understand why some people prefer to wait and see if they have an asymptomatic hernia. This may be due to fear of complication of mesh repair.
But strictly speaking, asymptomatic hernia cannot exist. Because hernia buldging itself is a symptom (actually a sign).
So it’s just the difference between having or not having pain.
However, the presence or absence of pain and progress of the hernia are not proportional. A large hernia may not have pain at all, and pain in the early hernia may also appear. And a painless hernia can also cause severe pain with sudden incarceration or strangulation at any moment. It’s an emergency.

I think you can wait and see a little when it is a small hernia. But eventually it will grow bigger and require more extensive surgery. So, I think it is better to have surgery as early as possible when considering the hernia itself.

The only obstacle is the risk of mesh repair. But there are actually other options, though not easy to find. Shouldice or Desarda repair is the one that does not use a mesh. These repairs are used for both indirect and direct hernia. However, if you look for these surgical procedures on youtube, most of them show only direct inguinal hernia surgery.
Why not indirect?
This is because these operations, which are known as typical tissue repair, are actually suitable for direct inguinal hernia. Not only these but also other tissue repair methods, such as Bassini, McVay, Ferguson, etc., are the same. It means that indirect hernia, which accounts for 70% of the inguinal hernia, does not have the appropriate tissue repair procedure. I think the limit of existing tissue repair, such as high recurrence rate, is due to this fact.

But in fact, there is an appropriate tissue repair procedure for the indirect inguinal hernia. It is just forgotten and ignored. That’s the Marcy operation.

I am a surgeon who strongly advocates tissue repair. And I am trying to make up for the shortcomings of tissue repair and to get better surgical results than mesh repair in all aspects. As part of that, I have devised and implemented different hernia repair procedures for both indirect and direct hernia. Somewhat similar to Marcy operation and Desarda repair, respectively.

I do not know if there is a doctor in the US doing Marcy operation. (Actually, Marcy is an American surgeon who was active in the early 20th century.)
Anyway, if you have an indirect inguinal hernia, I recommend you to seek a doctor who performs Marcy-like operation, and if you have a direct hernia, find a Desarda repair. I think Shouldice is unnecessarily invasive.

In my experience, I do not think that the choice of surgery should be changed according to the size of the hernia. The patient’s body weight and activity also have no significant effect on outcome.
If you can meet a surgeon familiar with the above tissue repair, you will get the best surgical results without fear of mesh.

Thank you!

[ajm222]

This is very interesting and good to know. The surgeon I initially consulted with does do the Desarda technique, presumably on both direct and indirect hernias. But he says he only does that when patients are very determined not to have mesh because of what they have read on the internet. Perhaps because my hernia(s) are indirect I should likely go ahead and get the mesh. I really don’t want to wait because I am now already more uncomfortable and just cannot distract my mind from the fact that I have this damage to my body that I am worried will quickly get worse and/or cause complications. Most people I have talked to have not had any issues with mesh and consider themselves back to normal and pain free several years after surgery with no recurrence. Some had a longer than expected recovery, and some light twinges and pulls of pain up to a year or two after the surgery. But all seemed to eventually see even that disappear.

I understand that people can have major problems with mesh, and that’s definitely a big concern. But it seems the vast majority are fine. There doesn’t seem to be any way to predict ones reaction. And clearly in the US it is very difficult to find surgeons who do tissue-only repair. And because of the way insurance in the US works, it’s not as easy as just finding someone on the other side of the country and traveling at ones own expense and paying much more money for an out-of-network doctor to do a consultation and then scheduling a procedure.

Dr Kang – do you have any concerns with mesh? Do you do mesh repairs, and if so how often do you see issues and people returning for removal and chronic pain more than a year or two later?

Thanks!

quote drkang:

Hi,

I understand why some people prefer to wait and see if they have an asymptomatic hernia. This may be due to fear of complication of mesh repair.
But strictly speaking, asymptomatic hernia cannot exist. Because hernia buldging itself is a symptom (actually a sign).
So it’s just the difference between having or not having pain.
However, the presence or absence of pain and progress of the hernia are not proportional. A large hernia may not have pain at all, and pain in the early hernia may also appear. And a painless hernia can also cause severe pain with sudden incarceration or strangulation at any moment. It’s an emergency.

I think you can wait and see a little when it is a small hernia. But eventually it will grow bigger and require more extensive surgery. So, I think it is better to have surgery as early as possible when considering the hernia itself.

The only obstacle is the risk of mesh repair. But there are actually other options, though not easy to find. Shouldice or Desarda repair is the one that does not use a mesh. These repairs are used for both indirect and direct hernia. However, if you look for these surgical procedures on youtube, most of them show only direct inguinal hernia surgery.
Why not indirect?
This is because these operations, which are known as typical tissue repair, are actually suitable for direct inguinal hernia. Not only these but also other tissue repair methods, such as Bassini, McVay, Ferguson, etc., are the same. It means that indirect hernia, which accounts for 70% of the inguinal hernia, does not have the appropriate tissue repair procedure. I think the limit of existing tissue repair, such as high recurrence rate, is due to this fact.

But in fact, there is an appropriate tissue repair procedure for the indirect inguinal hernia. It is just forgotten and ignored. That’s the Marcy operation.

I am a surgeon who strongly advocates tissue repair. And I am trying to make up for the shortcomings of tissue repair and to get better surgical results than mesh repair in all aspects. As part of that, I have devised and implemented different hernia repair procedures for both indirect and direct hernia. Somewhat similar to Marcy operation and Desarda repair, respectively.

I do not know if there is a doctor in the US doing Marcy operation. (Actually, Marcy is an American surgeon who was active in the early 20th century.)
Anyway, if you have an indirect inguinal hernia, I recommend you to seek a doctor who performs Marcy-like operation, and if you have a direct hernia, find a Desarda repair. I think Shouldice is unnecessarily invasive.

In my experience, I do not think that the choice of surgery should be changed according to the size of the hernia. The patient’s body weight and activity also have no significant effect on outcome.
If you can meet a surgeon familiar with the above tissue repair, you will get the best surgical results without fear of mesh.

Thank you!

[Good intentions]

quote ajm222:

But he says he only does that when patients are very determined not to have mesh because of what they have read on the internet.

I understand that people can have major problems with mesh, and that’s definitely a big concern. But it seems the vast majority are fine.

Just to add some clarity to past comments – I have “mesh”. I’m not just an internet rumor.

And, the point a few of us have been making is not the part about the majority but the part about how very bad things are if you’re one of the unlucky ones. It’s not the probability of a bad mesh experience. it’s the level of the damage that you’ll experience, and the difficulty you’ll have n getting it fixed if it happens. So, basically, it’s a gamble, where the odds of winning are high but if you lose, you lose a lot.

Also, one of my points was that what you’ll get today is not the same as what you would have got just one year ago. That’s why I said that if you can find someone who had a good experience, get exactly the same procedure. These professionals are assuming that because they had success before that they can make changes and will be successful again. They are venturing to unknown areas, with no data to support their actions. That’s where the danger is. They are being sold new materials and procedures and getting new recommendations, and trusting that the medical device suppliers know that they work.

When your doctor talks about getting the surgery and all of his past successes, just ask him if he’s doing exactly what he did before. If he says no, ask him how he knows the changes work. Ask him why he changed if the old method worked.

“Mesh” is more than one simple thing. There are numerous types and forms of mesh available for hernia repair, and they can all be shaped in to uncountable shapes and placed almost anywhere in the abdomen. The combinations are incredible. Maybe that’s why nobody wants to take on the challenge of determining where the bad results come from. It’s easier to categorize everything in to one simple box, the mesh box, and only talk about the good results, ignoring the bad ones. That is what’s happening when you talk to your surgeon. He is ignoring real problems. Because it’s easier. That alone should concern you, because if you have a problem, it won’t be real to him. And if talks about “mesh” as if it’s just one thing that should concern you also. He should be able to describe the different materials and methods, and why some of them give bad results. If he can’t he’s not keeping up.

Make sure that you get a proven set of materials and methods. An expert surgeon using the wrong combination is no better than a bad surgeon using the right one

Sorry to be so wordy. These conversations always tend to get pushed back to vague unsupported opinions, assumptions based on no data, not even a few good anecdotes. Nobody can say for sure what the best method is, at this point in the development of all of these new materials.

[ajm222]

I do like that this surgeon said he’s been using the same mesh for ages (at least a decade I believe). He gave me the name but I’ve forgotten and plan to ask him specifically what it was. And he also did say he’s happy to do the non-mesh repair if I choose. And he said one study suggested mesh versus non-mesh at three years had the exact same recurrence rate. No better or worse. They just don’t really know beyond that perhaps what the recurrence rate is. He did say it looked great, though, and he seemed confident in that method.

[ajm222]

Interestingly, my aunt had an umbilical hernia repaired that she had left alone for like 25 years. And the surgeon didn’t use any kind of mesh to fix her up. Just spoke with her. Very large umbilical hernia and just stitched up presumably with tissue. If that’s possible, it would seem the same could be done with a smaller inguinal hernia without issue, especially considering the study mentioned above. Sort of surprised mesh is still the gold standard for what sounds like 95% of all inguinal hernia repairs when non-mesh repairs seem to be pretty successful. Maybe it’s just not enough people trained to do it. I should ask this surgeon why he doesn’t do more non-mesh repairs.

[Good intentions]

quote ajm222:

I do like that this surgeon said he’s been using the same mesh for ages (at least a decade I believe). He gave me the name but I’ve forgotten and plan to ask him specifically what it was. And he also did say he’s happy to do the non-mesh repair if I choose. And he said one study suggested mesh versus non-mesh at three years had the exact same recurrence rate. No better or worse. They just don’t really know beyond that perhaps what the recurrence rate is. He did say it looked great, though, and he seemed confident in that method.

It’s good that you asked. But the answers are focused on the same thing – recurrence rate. It’s like old-time brain-washing. Ask a question about chronic pain, get an answer about recurrence rate.

My surgeon was very confident about his number of repairs also.

Good luck with whatever you end up doing. Try to lead the conversation though. The environment is intimidating and it’s difficult to challenge the experts.

Here’s one thing you can think about to maintain your curiosity – if “mesh” is perfected and is the superior method, why is so much research being done on new mesh products? Are all of those researchers deluded, and wasting their time? Why do the medical device suppliers keep introducing new mesh materials, if there’s no problem? What need are they addressing?

Here’s a pretty good article (it leans toward industry a bit) that explains how these things happen. The same people are working in hernia repair products. Replace just a few words and it’s easy to imagine that it was written about hernia repair.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4987386/

[ajm222]

i didn’t really ask specifically about chronic pain which is why he didn’t address it. i asked about recurrence rate. but i’ll see what he says when i bring that topic up.

[Jnomesh]

If I can chime in a little bit. The whole topic of recurrence rate is really quite silly when you put it in context. Since mesh is still relatively new in becoming the gold standard there is no way anyone knows the recurrent rate down the line. Are they really following up with people 10, 15 , 20, 30, 40 years down the line? No way.
So as you can see it’s really quite silly to focus on recurrence rates as the main reason to support the use of mesh. Maybe this doesn’t matter as much if you are in your 70’s or 80’s but if you are in your 20’s-50’s it sure does.
However the more important question in my mind is does anyone really know how well mesh holds up in the human body for 30 or 50 years?
so even if you know people who are doing well with mesh and I know them too, how will they be many many years down the line.
the other problem is if you do get a recurrent hernia with mesh, the common paractice is to repair the hernia with more mesh with the opposite way it was inserted. So if you had it placed openly it would be repaired laparoscopically and vice Versa. What you end up having is a what is called a mesh sand which-which is disasterous if you should ever develop pain and want/need mesh removal Bc both meshes can’t be removed Bc your whole inguinal floor will be shredded. So you have to determine and guess which mesh is giving you problems.
And when you think it about it more it is bery disconcerting that failed mesh is left inside of you.
Hmm the mesh failed and was strong enough or good enough to hold the hernia so let’s just leave it inside you. It’s just bizarre and foolish.
There are plenty of people who develop mesh symptoms down the road i.e. 10 years later. It can happen.
so when you look at the totality of the issue with mesh it is just maddening that it is the gold standard with so few alternatives being offered.
i believe from what I’ve researched that even if you just look at recurrence rates-if you look at the best most experienced surgeons doing mesh repairs and the nest most experienced surgeons doing pure tissue repairs recurrence rates would be very similar (shouldice hospital reports recurrence rates below 1%).
but chronic pain? Way higher with mesh.
ill say it again make your best most informed decision and then once you do please find a surgeon who this all they do-hernia repairs whether with mesh or non mesh. And is throw in find a surgeon that is an expert in removing mesh too if that’s what you decide to do. You have NO idea the ringer you will put through if something should go wrong. You will never hear-it’s the mesh!
And good intention has hit on the head-mesh products are continually being introduced to the market. If they are so great why is this? Why are some discontinued or pulled off the market. And others are litigated against.
i came across a post online where a lady was in so much pain from mesh and she finally found a surgeon after years of complaing of pain and every other test being performed instead of looking at the mesh. Anyways this surgeon finally said it’s the mesh and followed with “we don’t use this type of mesh anymore Bc of its bad results”
so she had to go under another operation jus to remove the mesh Bc they have now learned it is no good. So in affect she was a guinea pig-we all are.
do you hear about the numerous new tissue repairs that come out yearly? No.
again if mesh were similar to a walking boot and a walking boot for foot issues turned out to be bad or faulty OK you change the walking boot by simply taking it off and trying a new one.
if a certain type of mesh turns out to be bad you now have to have a prosecutor inside of you meant to be permanent removed surgically.

[Jnomesh]

Dr. Kang,
im curious if you have done any research or are aware of research regarding hernia formation as a process. I read an interesting article where it is suggested that the actual hernia one see as a bulge is actually the final stage of a three step process. And ongoing this interesting for me Bc I never had the classic bulge and the hernias never showed up on MRI or cat scan or during physical examination. But I felt internal heaviness and pressure in the groin. It went undiagnosed for 13 months until I went to a surgeon to rule out a sports hernia and he said I did have a hernia when he did the physical examination. I should not he did the classical examination the finger in the scrotum and cough test but he also did something other before Him hadn’t and that was with me lying down he put his finger at different spots in the surface of the groin and asked me to cough. Anyways when he operated he found a direc and a indirect hernia. Before him at different intervals I had the MRI, the Cst scan and another surgeon spread out months apart all said or showed no hernia-when I actually had two!!!
Anyways the article suggested that the hernia formation is a three stage process and people could feel pain along any three of the stages: weakness in the muscle, fat being hammered into a wedge and then finally entering the inguinal canal. It says this can explain why people may present with groin pain but show no bulge, no confirmation on physical examination and does not show up on scans Bc it has not gone into the canal-which most radiologists are looking for.
just curious as to your thoughts. Thanks

[drkang]

Hi, Jnomesh.

I am very careful to answer your question, because there is a sensitive point.
I am afraid that I don’t know of the research you mentioned. However, I personally made the same guess as the study mentioned with some patients. Often, the inguinal hernia is not confirmed on the inguinal sonogram among those who complain of inguinal discomfort including pain. In this case, I personally guess it may be the precusor symptom which can appear before the overt hernia(it means buldging) development.
Continuous pressure is applied to the weak point of internal inguinal ring(in case of indirect hernia) or of the floor of Hasselbach triangle(in case of direct hernia), and the resulting minute damage in the process of wedge widening may produce pain or other discomfort. I do not think that this condition can be diagnosed as a hernia yet, even though there may be the possibility of processing to an overt hernia in the near future.

Physical examination is not precise, I think. Although I have performed more than 12,000 inguinal hernia repairs so far, there are still many cases where the results of physical and ultrasound examinations (I do ultrasound exam for inguinal hernia, because it is safe-no radiation, easy and can be done in a standing posture which helps precise diagnosis) are not consistent, especially in borderline cases. So I trust the results of the ultrasound examination rather than trusting my physical examination.

Thank you!

[drkang]

quote ajm222:

Dr Kang – do you have any concerns with mesh? Do you do mesh repairs, and if so how often do you see issues and people returning for removal and chronic pain more than a year or two later?

Hi, ajm222

Yes, I have a lot of concern with the mesh inguinal hernia repair. In fact, I performed more than 6,000 open hernia repairs using a mesh plug until the spring of 2013. Sadly I have no exact my statistics of mesh complication, but I had quite many patients who complained of chronic pain after repair. I agree with the statistics saying that the chronic pain after mesh repairs would be over 10% incidence.
In 2012, I performed the first mesh removal for the patient suffering from very severe chronic pain after receiving a mesh repair at other hospital. His pain was so severe that he couldn’t do even normal daily activity. That operation was terrible experience to me as well. As the mesh was so clumped with the surrounding important structure that the operation was too dangerous. After that operation, I got sick from mesh repair and I began to make a lot of effort to develop a new no mesh repair with low recurrence rate.

I think every surgeon performing mesh hernia repairs should try an experience of removing the mesh which he himself inserted. I am sure if they learn from experience how terrible the state of the inserted mesh is and how dangerous mesh removal is, then many of them would stop doing mesh operation any more. But they do not really try to do that.They always tell the patient suffering from chronic pain that there is no recurrence. They don’t like to take the responsibility to solve the patient’s problem by removing the cause. That’s a pity.

Anyway I have removed more than 50 meshes so far ever since. But I have more patients who are still suffering from quite severe pain after mesh hernia repair.
I totally support Jnomesh’s and Good Intention’s claims. I think their knowledge and assertions are very accurate and are based on facts.
And just one more thing to know. Laparoscopically inserted mesh might hinder the future prostatectomy for prostatic cancer.
Thank you!

[ajm222]

Well that’s a bit concerning (especially considering I feel as though my options are almost exclusively limited to get surgery and getting it done with mesh), but I appreciate your candor and response. My father had prostate cancer so that kind of hits home for me. My potential surgeon does Desarda as well but doesn’t seem to think it’s the best option.

quote drkang:

Hi, ajm222

Yes, I have a lot of concern with the mesh inguinal hernia repair. In fact, I performed more than 6,000 open hernia repairs using a mesh plug until the spring of 2013. Sadly I have no exact my statistics of mesh complication, but I had quite many patients who complained of chronic pain after repair. I agree with the statistics saying that the chronic pain after mesh repairs would be over 10% incidence.
In 2012, I performed the first mesh removal for the patient suffering from very severe chronic pain after receiving a mesh repair at other hospital. His pain was so severe that he couldn’t do even normal daily activity. That operation was terrible experience to me as well. As the mesh was so clumped with the surrounding important structure that the operation was too dangerous. After that operation, I got sick from mesh repair and I began to make a lot of effort to develop a new no mesh repair with low recurrence rate.

I think every surgeon performing mesh hernia repairs should try an experience of removing the mesh which he himself inserted. I am sure if they learn from experience how terrible the state of the inserted mesh is and how dangerous mesh removal is, then many of them would stop doing mesh operation any more. But they do not really try to do that.They always tell the patient suffering from chronic pain that there is no recurrence. They don’t like to take the responsibility to solve the patient’s problem by removing the cause. That’s a pity.

Anyway I have removed more than 50 meshes so far ever since. But I have more patients who are still suffering from quite severe pain after mesh hernia repair.
I totally support Jnomesh’s and Good Intention’s claims. I think their knowledge and assertions are very accurate and are based on facts.
And just one more thing to know. Laparoscopically inserted mesh might hinder the future prostatectomy for prostatic cancer.
Thank you!

[ajm222]

Just got another opinion from my old PCP and he says the same as the first – that it doesn’t appear that things have broken through just yet and though there might be some weakened areas in the abdomen/inguinal canal, he’s not detecting a full hernia yet. Very small weak spot that may or may not eventually become a full hernia. So two opinions from non-surgeons saying leave it alone, and another opinion from surgeon saying repair it (and that i likely have bilateral). Very confused at this point. Made appt with another surgeon at another practice to see what he says and then will decide probably one way or another. Would be a real shame to get surgery while having minor or no symptoms most of the time and not have a full blown hernia.

[Jnomesh]

Yes by all means don’t rush into anything-surgery should be a last resort and you should have a definitive reason for the surgery. I know of at least 3 people who had no symptoms and it was debatable whether small hernias showed up on scans. They were encouraged by their surgeons to have them repaired laparoscopically with mesh. All three suffered serious complications from the mesh (2 had allergic reactions that led to not only pain but other severe auto immune symptoms)
all three ended up having mesh removal and although all three are overall better since having the mesh removed they all still have some issues that mesh originally caused. They all say they wish they just waited Bc they all had small hernias ( or maybe not) and they didn’t have any problems.
again my advice is to skip the aberahebfemeral surgeon or even specialist and get and send your scans to someone who can definitely interpret what’s going on. The only two I know of are dr. Towfigh and dr. Belyanski. There was another thread of someone experience pain and dr. Belyanski diagnosed that it was a lipoma and not a hernia (still needed surgery) but that person was in pain.

[Jnomesh]

Thanks for your reply dr. Kang. I think your real world instincts mirror the article I found. I think they called it herniosis: the three stage formation of a hernia.
Anyways I found it really interesting Bc before having mesh surgery (and eventual removal) I had so much burning and a swelling sensation in my left groin and it felt like it was in two places not one-I even felt a sensation of something pushing through more medially and a swelling- but i cat scan showed nothing, them three months later an MRI showed nothing, then 6 months later a physical by a hernia surgeon showed nothing-but man I was in so much pain.
And 13 months later it was finally diagnosed by the surgeon who would docmy surgery. In the report it said significant weakeness in the Heaschel triangle area with fat in it and fat in the indirect space-2 hernias.
so for 13 months I was dealing with two hernias that couldn’t be diagnosed. So maybe I was one of the few that had a lot of discomfort while the hernia was “forming).
also I wonder why the Marcy repair is no longer used in the US. Of the few dr.’a that do pure tissue repair it is either a Bassinin, or modified bassini, desarda or shouldice.
Again thanks for a your insight and feedback. It is so welcomed.
In America (and I’m guessing a lot of other countries) we need more options to mesh repair. And to piggy back on a point you made earlier about how mesh looks once it has been inside the body for a while-I bet if you opened up people who have mesh and no symptoms you would see that the mesh is messed up inside but for whatever reason it don’t bothering the person and is probably still doing its job of preventing a hernia recurrence.
also how is the Marcy operation performed/Carried out. Is it very different from a bassini approach?

[ajm222]

quote Jnomesh:

Yes by all means don’t rush into anything-surgery should be a last resort and you should have a definitive reason for the surgery. I know of at least 3 people who had no symptoms and it was debatable whether small hernias showed up on scans. They were encouraged by their surgeons to have them repaired laparoscopically with mesh. All three suffered serious complications from the mesh (2 had allergic reactions that led to not only pain but other severe auto immune symptoms)
all three ended up having mesh removal and although all three are overall better since having the mesh removed they all still have some issues that mesh originally caused. They all say they wish they just waited Bc they all had small hernias ( or maybe not) and they didn’t have any problems.
again my advice is to skip the aberahebfemeral surgeon or even specialist and get and send your scans to someone who can definitely interpret what’s going on. The only two I know of are dr. Towfigh and dr. Belyanski. There was another thread of someone experience pain and dr. Belyanski diagnosed that it was a lipoma and not a hernia (still needed surgery) but that person was in pain.

Unfortunately I don’t really have any images at this point. I’ve just been examined physically by all the doctors. Perhaps if I do see this last general surgeon next week I can inquire about possibly getting some imaging, though I suspect he will say it’s unnecessary. I can’t say I have any pain, but just some occasional discomfort, and a small bump that gets a little bigger or smaller depending upon the time of day and activity. PCP thought the bump was related to the weakened area of the abdominal wall, but didn’t feel like anything had broken through yet I guess you would say. And I had read on the California Hernia Specialists website that up to 50% of small hernias may never progress or need surgery. I don’t know if this means they stay at a stage where they don’t fully come through the fascia, or if it means they just don’t get larger. I’m only 41 and I am suspecting that over time if I continue to be normally active, that eventually this is going to need attention. But I don’t really know for sure. I also need to get back to exercising and moving around normally again so that I can really gauge my pain and discomfort. Ever since the diagnosis by the surgeon I’ve been extremely cautious and scared to do anything for fear of making this worse quickly. So I don’t really know, but I think I’ve decided to cancel my 10/18 surgery because it feels premature. All have said that there is no serious danger in waiting. I don’t want to wait too long if I do end up needing it repaired, but another month or three should be fine.

Our of curiousity, are the three people you said you know with complications people that you know personally, or those who you’ve met online at similar forums? Just trying to get a sense of what kind of demographic we’re looking at here. I hear from someone like Dr Kang who almost makes it sound like all mesh hernia repairs may be doing damage inside the body but some just aren’t bothered by it, while most surgeons will suggest the rate of complications and truly chronic pain is probably only around 3% after a year or so from surgery (which is very small). It just makes it so hard for a person to decide what to do (not that there are many options – it’s mostly either live with a steadily worsening hernia or get a mesh repair, which may or may not be a bad thing). And I wonder if the description Dr Kang had about what the mesh is doing inside the body actually explains why the mesh is doing good rather than bad in many cases. You would think the whole point of the mesh is to actually get very incorporated into the surrounding tissue. While that could be bad for some people if it irritates or damages important structures like the bowels or spermatic cord or various nerves, you would certainly expect the mesh to be very much intertwined with things around it to strengthen the area and feel more natural. This of course is the challenge a patient has in making medical decisions – very little intimate knowledge of the anatomy and actually seeing all of these things in person, no medical training, and relying on a variety of different opinions from medical professionals.

The challenge for the average person when researching things online I suppose is that we don’t have the medical training or in most cases the scientific background to examine things critically in the same the way doctors do, and we don’t really have access to a lot of the medical papers and studies that many doctors use. We also mostly have to rely on corners of the internet where people are concentrated into groups that are probably overrepresented by 1. people who have had bad experiences or 2. those like myself who have a tendency to maybe over analyze things. To be fair, the latter category isn’t necessarily always a bad thing, because clearly people like myself will tend to ask important questions and spur discussion that didn’t occur to the average person and could be useful to people contemplating surgery. And those in the first category are certainly not to be dismissed. Anyone who has had complications or some kind of bad experience should be taken very seriously. But the point I guess is that the high concentration of bad experiences you see online gives the perception that MOST people have bad experiences, and this this surgery and the use of mesh is usually a bad idea. While that is DEFINITELY the case with those who have chronic pain, it’s not determinate of anyone else’s result.

Anyway, just rambling at this point I guess. I think at this point my main concern is this notion that Dr Kang mentioned suggesting mesh is often doing harm inside the body. I’d be interested to know if I misinterpreted his words, and maybe more detail about what exactly it’s doing in the body that is so concerning. I get the impression that many surgeons have in fact done emergency mesh removal at one time or another and have seen what mesh does in the body over the course of months or years. Perhaps some of them could chime in.

Sorry to be so wordy. Just had a large coffee.

[Jnomesh]

The people I was referencing were people I communicate with online I do not know them personally.
Again I don’t want to go around in circles but I think the point that most of us are making about mesh isn’t whether it is bad or good or whether it will cause you harm or not (yes I have my personal opinions on many of these matters) but thentake away the big take away is if it does go bad it is a nightmare to deal with on so many levels-you can’t even fathom to imagine it.
on some of your other thoughts-no I don’t think in my opinion many doctors have removed mesh in their careers-maybe if it is infected (easier to remove) and maybe some abdminal meshes but I’d guess most haven’t.
i think dr. Krang’s point is that the mesh is supposed to remain flat and not become hard when it is implanted in you-but when he has gone in the mesh can be and often is folded, squished up, moved or attaching to things it shouldn’t.
Also ask your surgeon to show you the actual size of the mesh he will be using-good ones and ones that do a lot should have some examples handy-I guarantee you will do a double take-average size even for small hernias or about 5″x7″ a huge surface area. It has to be way bigger than necessary mostly Bc it is known without a shadow of a doubt to shrink by 30-50% this is a fact.
anyways when I had my surgery I thought the mesh was probably the size of a bandaid. Nope picture a small plate and hold it over your groin to get a better idea.
anyways I highly rx you get a MRI or a cat scan maybe both if one comes up negative. If they both come up negative I’d send them to the surgeons I already mentioned for review.
if after that they come back negative you can loook into other reasons why you have this pain/ bump
id they come back positive you can decide whether to wait or not
if you decide for surgery you can then decide how you want it repaired and make you own best informed decision.
i brought up the other people I correspond with not as a scare story but to give examples of people who rushed into surgery. It was meant to reinforce your decision not to rush into surgery when you don’t know exactly what is going on.
tou are fortunate that whatever is going on with you isn’t bothering you much so take your time gather as much information as possible (please get something scans) get second and third opinions and then you can make the best informed decision.

[ajm222]

Thanks. Good to know. Great advice. Surprised at the size of the mesh. Very interesting.

[drkang]

quote Jnomesh:

In America (and I’m guessing a lot of other countries) we need more options to mesh repair. And to piggy back on a point you made earlier about how mesh looks once it has been inside the body for a while-I bet if you opened up people who have mesh and no symptoms you would see that the mesh is messed up inside but for whatever reason it don’t bothering the person and is probably still doing its job of preventing a hernia recurrence.
also how is the Marcy operation performed/Carried out. Is it very different from a bassini approach?

Hi Jnomesh,
I was on a bit long holiday, so I couldn’t answer your above question quickly.

Almost all tissue repair, including Bassini operation, are reinforcing the Hasselbach triangle. Shouldice or Desarda repair is also included.
These procedures are suitable for direct inguinal hernia which breaks out through the weakened and torn floor of Hasselbach triangle.
These are called ‘the posterior wall repair’.

However, Marcy operation is just closing the internal inguinal ring. So, it is the most suitable tissue repair for the indirect inguinal hernia which is coming through the widened internal inguinal ring.
The internal inguinal ring, together with the spermatic cord, is located within the bundle of cremaster muscle and has nothing to do with the Hasselbach triangle which is underneath and medial to the cremaster muscle.

Therefore, it is unfortunate for most surgeons to perform the posterior wall repair for indirect inguinal hernia instead of closing the internal inguinal ring as Marcy operation does.
I think the high recurrence rate after tissue repair for inguinal hernia, in the past, is probably due to this mistake.

So, my Kangs repair consists of two surgical methods.
The Kangs repair for indirect inguinal hernia is similar to the Marcy operation and that for direct inguinal hernia is similar to Desarda method.
Since the skin incision is made at a specific position for each type of inguinal hernia, it is possible to operate with a smaller skin wound.
The indirect and the direct inguinal hernia are about 2 cm apart from each other.

Thank you!

[Jnomesh]

Thanks dr. Kang for your follow up. I have a few more questions regarding the pure tisuue repairs
for indirect and direct hernias.
1) do you know if the shouldice repair for either a direct or a indirect hernia covers both spaces? In other words if you have an indirect hernia will the shouldice repair also reinforce the direct space?

2) the reason I ask is Bc I have had my laparoscopic mesh removed by the Same method.
when mesh was originally put in it was noted that I had both a direct and indirect hernia. However, when the mesh was removed there were no hernias noted by the removal surgeon. The direct hernia was completely filled in by scar tissue and there was weakeness in the indirect space that the surgeon repaired by bringing the internal oblique muscle down to the illiopubic tract and sutured with absorbable sutures. I’m curious if only one hernia should reoccur in the future is there a pure tissue repair that can reinforce both areas even if only one hernia reoccurs. I guess my question is since I had Both types of hernias (and don’t want mesh again) if i should have say a indirect hernia that reoccurs I’d hate to Just have a pure tissue repair of the indirect space knowing I’m susceptible to having a direct hernia and might need a second repair down the line-I’d definitely prefer if possible a pure tissue repair that can not only repair one hernia but in essence also reinforce the other space as well.
just curios if that is possible. How would you handle a patient like me?
thanks in advance -looking forward to your input.

[drtowfigh]

The history of hernia recurrence has shown that if you repair an indirect hernia only, then you if you get a recurrence it will most likely be a direct hernia. The opposite has not yet been shown.

For laparoscopic mesh repair with mesh, the indirect, direct and femoral hernias are all covered.

For open inguinal hernia repair with mesh, the direct and indirect inguinal Hernia areas are covered.

For Shouldice and Bassini, both the direct and indirect spaces are involved.

For the Marcy, only the indirect space is repaired, which is why it’s mostly reserved for children and some women.

[Jnomesh]

Very interesting. Any data for people like myself who had both a direct and indirect hernia at the time of repair. If there is a recurrence is it likely to be one or the other or both?

[drtowfigh]

Direct Hernia’s are more likely to recur than indirect.

[Good intentions]

To ajm22 – one more good reason to wait, at least a short while (relative to the rest of your life) is because the tools to understand the effects of all of the new materials, technology, and techniques, are still being developed.

Defocus your research to the more general “quality of life” definition and the state of the hernia repair field becomes more clear. So many new things have been developed, and pushed, and put in to use, that nobody can really say which is better. I’ve struggled myself to call my problems “pain”- related. It’s not really pain, it’s discomfort, some pain with certain activities, the knowledge that you can’t do what you used to do without pain, etc. You become less of a person. You’re able to live without pain if you want to, but you can’t do what you used to do. I’ve thought at times, that it’s much like an amputation of a limb. If you search for chronic pain issues, you’ll get low numbers, just like if you search for recurrence.

This doctor, below, Dr. Todd Heniford, seems to be leading the push for better data collection and the proper usage of it. Read and view some of his work. It’s very informative. The link below is a recent paper, from after I had my surgery, published barely over a year ago. I wish that I had done more research before I had my surgery.

http://journals.lww.com/annalsofsurgery/Abstract/publishahead/Carolinas_Comfort_Scale_as_a_Measure_of_Hernia.96382.aspx

Here’s another, showing how long they’ve been working on it. https://www.carolinashealthcare.org/documents/cmcsurgery/CCSarticle.pdf

He demonstrates how surgeons can be comfortable that what they’re doing works fine, because they don’t really know the long-term outcomes. There’s very little data collected, and what is collected isn’t very useful.

[ajm222]

quote Good intentions:

To ajm22 – one more good reason to wait, at least a short while (relative to the rest of your life) is because the tools to understand the effects of all of the new materials, technology, and techniques, are still being developed.

Defocus your research to the more general “quality of life” definition and the state of the hernia repair field becomes more clear. So many new things have been developed, and pushed, and put in to use, that nobody can really say which is better. I’ve struggled myself to call my problems “pain”- related. It’s not really pain, it’s discomfort, some pain with certain activities, the knowledge that you can’t do what you used to do without pain, etc. You become less of a person. You’re able to live without pain if you want to, but you can’t do what you used to do. I’ve thought at times, that it’s much like an amputation of a limb. If you search for chronic pain issues, you’ll get low numbers, just like if you search for recurrence.

This doctor, below, Dr. Todd Heniford, seems to be leading the push for better data collection and the proper usage of it. Read and view some of his work. It’s very informative. The link below is a recent paper, from after I had my surgery, published barely over a year ago. I wish that I had done more research before I had my surgery.

http://journals.lww.com/annalsofsurgery/Abstract/publishahead/Carolinas_Comfort_Scale_as_a_Measure_of_Hernia.96382.aspx

Here’s another, showing how long they’ve been working on it. https://www.carolinashealthcare.org/documents/cmcsurgery/CCSarticle.pdf

He demonstrates how surgeons can be comfortable that what they’re doing works fine, because they don’t really know the long-term outcomes. There’s very little data collected, and what is collected isn’t very useful.

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.

[Good intentions]

quote ajm222:

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).

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.

[Good intentions]

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.

[ajm222]

quote Good intentions:

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.

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.

[Good intentions]

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.

[ajm222]

Thanks, and I’ll keep you posted

[drkang]

quote Jnomesh:

Thanks dr. Kang for your follow up. I have a few more questions regarding the pure tisuue repairs
for indirect and direct hernias.
1) do you know if the shouldice repair for either a direct or a indirect hernia covers both spaces? In other words if you have an indirect hernia will the shouldice repair also reinforce the direct space?

2) the reason I ask is Bc I have had my laparoscopic mesh removed by the Same method.
when mesh was originally put in it was noted that I had both a direct and indirect hernia. However, when the mesh was removed there were no hernias noted by the removal surgeon. The direct hernia was completely filled in by scar tissue and there was weakeness in the indirect space that the surgeon repaired by bringing the internal oblique muscle down to the illiopubic tract and sutured with absorbable sutures. I’m curious if only one hernia should reoccur in the future is there a pure tissue repair that can reinforce both areas even if only one hernia reoccurs. I guess my question is since I had Both types of hernias (and don’t want mesh again) if i should have say a indirect hernia that reoccurs I’d hate to Just have a pure tissue repair of the indirect space knowing I’m susceptible to having a direct hernia and might need a second repair down the line-I’d definitely prefer if possible a pure tissue repair that can not only repair one hernia but in essence also reinforce the other space as well.
just curios if that is possible. How would you handle a patient like me?
thanks in advance -looking forward to your input.

Hi 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.

Thanks!

[Jnomesh]

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.

[drkang]

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.

[Jnomesh]

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)

[drkang]

Yes, exactly.

[Jnomesh]

Thanks again!

[Rob]

Dr kang,

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,
Rob

[Jnomesh]

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

[drkang]

quote Rob:

Dr kang,

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,
Rob

Hi, 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.

Thank you!

[Rob]

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?

[drkang]

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.

[Beenthere]

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

Hi Momof4,

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.

Good Luck

[Beenthere]

Another post I did

What ?s should surgeons be asking their patients?

HI Groundfaller,

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.

[Beenthere]

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

[Author]

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