robotic pure-tissue, Kang repair, long-term mesh studies, exercising w/hernia

[William Bryant]

Sorry for butting in… Does Dr Kang cut any nerves?

[Spartan]

I would say that Dr. Kang also has access to more advanced medical equipment than typical American Surgeons at a regular US Surgical Clinic vs Gibbeum, a Hospital dedicated to hernias. At least, that is what I got from watching the videos at that website. Correct me if I am wrong, but I remember him being able glue certain incisions vs suturing them, and look thru a machine to be better able to see what the surgeon was doing during surgery.

I hope Dr. Kang will eventually share and train some US, Canadian and European doctors on his technique someday when the Covid Restrictions come completely off. I believe there are quite a number of things, these other doctors could learn that would make their approaches better, even if they stick with their same tried & true methods.

[dave11]

Dr. Kang, thanks for your various clarifications. I do feel that your mentioned mesh hernia surgery becoming even more entrenched has become a reality here since none of the surgeons I have contacted locally will agree to do no mesh surgery. I think they have been trained to do mesh AND there is a greater profit margin in mesh surgery. I do totally understand this because our medical service industry is one of the most expensive in the world. I was amazed at the vastly lower prices I saw for surgical procedures in Korea versus the USA. Further, given the unpublished and unshared exact nature of your Kang repair, it is understandable why our surgeons are reluctant to offer it

Your knowledge of the historical evolution of hernia surgery is amazing. It seems like the journey of someone who is looking for the ultimate best ways to perform hernia surgery today, especially in light of some tragic painful mesh surgeries. I sincerely hope your journey’s end will result in the most beneficial surgical procedures for all hernia patients. My journey as a hernia patient is made difficult by an Internet that decades ago was actually mostly informative, but now it is mostly commercially geared for marketing and sales. The problem with this is the most helpful truth becomes hard to determine. Herniatalk helps greatly in truth discovery. And your contributions are always appreciated.

[Alephy]

@drkang Thanks for your answer, which I think touched on all the points/questions that were raised, and in a very precise manner!

[drkang]

Thanks for the multiple comments on Kang repair.

As an executive running a hospital, it is natural for me to be interested in marketing. However, my greater interest is to inform many people that there is a non-mesh inguinal hernia repair that is better than mesh repair.
You already know that many people suffer from chronic pain after mesh repair. Many of the discussions in this Herniatalk are also related to mesh complications.

I know that many of you are dissatisfied with that Kang repair has not yet been published in the journal.
However, it takes a long time for a new surgical method to be completed.
To take examples, Desarda repair was published in The European Journal of Surgery in 2001, nearly 20 years after the first surgery began, and Lichtenstein repair was also published in The American Journal of Surgery in 1987 after more than 20 years of experience in his private clinic. And Shouldice repair, which is currently recognized as a representative non-mesh inguinal hernia repair, was first published in 1969, four years after Dr Shouldice’s death. For reference, Dr Shouldice in 1945 wrote his surgical method in Ont. Med. Rev., but it differs from the current Shouldice repair in many ways.

As such, it takes a long period before a new surgical method is released. The reason is that no matter what idea you start developing a surgical method, the final surgical method that can be shared with other doctors can be completed only through numerous trial and error and feedback processes.
As such, more verification time is still required before Kang repair, which has been only 9 years old, is released.

Nevertheless, the reason why I introduced Kang repair to Herniatalk and others is because I have a desperate feeling that I can no longer neglect the current situation. As many predict, if the situation persists, it is likely that you will rarely find doctors performing non-mesh repairs soon or later. Mesh inguinal hernia repair has been started for more than 30 years. As a result, most doctors who actively perform hernia repair at present have neither learned nor experienced non-mesh repair. Moreover, few training hospitals teach non-mesh inguinal hernia repair these days.
Sometimes, we are still discussing on which is better between mesh repair and non-mesh repair, but if there is no change in the current situation, it is clear that our discussions will move on to the topics such as ‘What is the best way to reduce mesh complication?’ or, “How do I treat mesh complications?”. In fact, these latter discussions are already dominant in the forum.
However, given the obvious fact that mesh complications exist and the best way to solve them is not to use meshes, the advent of an era in which everyone is forced to undergo mesh repair will be unfortunate for hernia patients.

This situation will be heartbreaking for me as an active advocate of non-mesh inguinal hernia repair. The reason why I introduce Kang repair’s experience, which has not yet been publicly published in thesis, is because of the urgency to prevent this from happening.

In the current situation, it is unlikely that doctors will voluntarily learn and perform non-mesh hernia repair which is unfamiliar to them after giving up familiar mesh repair. If so, the only way to reverse this situation is for many hernia patients to ask their doctors for non-mesh repair more actively. To do so, patients must first be confident that non-mesh repair could be better than mesh repair. In order to give this conviction to hernia patients, I am sharing the excellence of non-mesh inguinal hernia repair, which has been confirmed through many surgical experiences.

I will also explain why we named Kang repair for our surgical method. Very subtle differences in inguinal hernia surgery can lead to very large differences in outcome. Therefore, I think it is not advisable to add the word ‘modified’ to certain existing surgical methods. Even small differences in surgical methods can have a great influence on the surgical outcome. Therefore, I don’t think it helps to choose and develop a good surgical method for several different modified surgeries to share the same name. Therefore, even if there is a small difference, I thought it would be desirable to give a unique name and compare each other, so I bravely attached the name Kang repair to our surgery method.

Specifically, Kang repair for indirect hernia has the same idea of repairing the deep inguinal ring with Marcy repair, but the specific surgical method is completely different. Kang repair for direct hernia is actually closer to the original Bassini repair rather than the Shouldice repair. The difference is that ? does not incise transversalis fascia, ? does not cut inferior epigastric vessels, ? does continuous suture instead of interrupted button suture, and ? does not apply releasing incision to rectus muscle fascia. And unlike Shouldice repair, we preserve the cremaster muscle without cutting it. The operation time is about 15 minutes for indirect and 20 minutes for direct. For skin wound, the average indirect is 3-3.5cm and the direct is 4-4.5cm.
Thank you!

[Alephy]

I think in general it is crucial that any new method be published and discussed with peers, as it is the only Scientific way. This has also another big advantage: any new valid methodology can then be picked up by other doctors and offered in other places; remember, the number of hernia cases is in the hundreds of thousands if not millions worldwide eery year! I think the Shouldice clinic also often has surgeons visiting the center to learn the technique (if I am not mistaken) which makes sense to me…One surgeon can help many patients, but one surgeon’s procedure can help 100 times more…

On the Scientific method, I find it appalling how new mesh implants are funnelled into the market without any real long term testing, just because they are “similar” to already existing products…

[dave11]

Thunder Rose, you need to read the gibbeum.com web site describing exactly who Dr. Kang is and what he has done. And yes, that web site is so smooth and effective you would think marketing was involved, but Dr. Kang has spent some time in Great Britain where he honed his English skills. I have also had some personal communication with him through his chaplain Stephen where I got a little better idea who he is. I guesstimate that he has done about 12,000 Kang repairs going back to beginning use of the repair in 2012. He has his own hospital just for mainly hernia repair in Korea. Reports from his patients, which have all been positive, state that he is doing about 6 repairs per surgical day. He spent many years experimenting with even mesh before choosing his current no mesh method because it better favored his patients’ well being. To the best of my knowledge, he has not SOLD his procedure to anyone yet. I too am frustrated by not having a video and more specific details of his repair, but he seems focused on making sure the longer term recurrence rates stay quite low at 1/2%. On the very rare occasion he has a recurrence, he performs the surgery free of charge. He will also on occasion donate his services to those in extreme need. His direct repair only affects a 4cm X 4cm area of surgical space. His incision is a tiny 1.5 inches BECAUSE he has highly competent ultra sound techs who can determine direct or indirect BEFORE he cuts, and he completes the surgery in a remarkable 20 minutes. I heard a price of about $3000 for his repair, but that may have changed. He has dedicated his life to finding a less harmful and more efficient way to perform inguinal surgery. However, he shares the same problem as Dr. Desarda in establishing his surgery in the USA in that our surgeons work in a very expensive business in a country where the prices of everything are exploding. However, we are lucky to have a few excellent surgeons who are willing to offer no mesh procedures. You seem to have found one in Dr. Yunis.

Good Intentions, I have appreciated your contributions. In reading what I have wrote, I actually seem like Dr. Kang’s PR department, but I agree with you that he does NOT seem to seek personal fame. He certainly does not need a PR department since his enormous successful body of excellent refined work speaks for itself. He just wants to help hernia patients get well as efficiently and effectively as possible. I admire his pioneer spirit and all he has accomplished.

[Thunder Rose]

I apologize– I don’t mean to denigrate Kang and I don’t fully understand his method(s). I do find it frustrating that someone would pass up highly skilled surgeons in the US and be so dismissive of their techniques simply because Kang is touting a repair that is supposedly so superior. Comparing the Sue and Peter Jones 2-layer Shouldice on YouTube to the old school 4-layer Shouldice video on YouTube from BioHernia, my view is that the 4-layer Shouldice takes more time and more skill. I feel better about having the 4-layer, but to each his/her own.

[Thunder Rose]

Also: there’s plenty of research showing that highly experienced hernia surgeons can achieve low recurrence rates with tissue repairs.

[Good intentions]

A 1/2% recurrence rate seems worthy of replication.

Also, I don’t think that Dr. Kang has fully described his methods. There are two, apparently. So a person can’t really determine that it’s like any other method unless they know what his is. He’s either obfuscating or he has disclosed. Sorry, but I see a contradiction there.

If you read through Dr. Kang’s post from the beginning, not just the last week or two, you can get a good idea of what his goals are. I don’t think that he’s trying to become famous. I think that he just wants people to know about successful alternatives to mesh. Not many people have the ability and/or time to research and understand the variety of non-mesh possibilities like you did. Plus he’s competing against very very powerful marketing of mesh products from the mesh makers.

Here’s the Gibbeum web site link, if anyone wants to see the marketing.

http://gibbeum.com/main/main.php

[dave11]

Hey AJ, thanks for the reply. Yes, I realize some foreign matter will be used to repair my hernia, but I try to keep such material to a minimum. I checked out Ovitex, which is a mix of biologic and synthetic, but the synthetic part remains in the body. Also, the actual hernia sac is not processed the best way I believe as is true in many mesh repairs. Leading an active life, I have avoided the installation of a screw in part of my femur, a screw and wire in my shoulder, and had a plate removed after it was needed to heel a fracture of my wrist. My body has done a very good job of healing these problems without the hardware. My healthy lifestyle and supplements have helped a lot. Some suturing is a minor concern compared to this hardware I have avoided. The tough part, when a seeming 99% of current hernia surgeons only do mesh, is finding the best no mesh doctor and procedure. I know people who have suffered from having mesh and other hardware placed in their bodies. I wish you the very best with your recovery.

There are probably other hernia surgeons doing the two layer Shouldice, but those three I mentioned are the only ones I confirmed with and felt comfortable with the number of such surgeries they have done. Perhaps, some other people can add to this short list. That is the power of Herniatalk in that the research of many is always vastly more comprehensive than the individual. Dr. Kang does not offer a two layer Shouldice, but he does his own unique repair (seems like some version of Bassini lite to me) using just the Hesselbach triangle for the direct. I have asked him to establish a USA Kang Repair base similar to what Desarda did in Fort Myers, FL. It would be great if he was able to do so with Dr. Yunis in Sarasota, FL. Neighboring cities competing for patients would be quite interesting and offer a very welcome other choice for us no mesh believers. I believe if Kang Repair is to become the “new norm,” then he must spread his technique outside Korea. I think he is waiting on the stats to further verify his very low recurrence rate of less than 1/2% treating all types of patients (and not cherry picking them). Perhaps, Dog can use his influence once again as he did with the Desarda method.

[dave11]

Thunder Rose, thanks for prompt reply. Like you, I have been doing regular exercise while waiting on the hernia. Also, I have done a ton of research and some contact with various hernia surgeons. I respect your technical comments on the inguinal anatomy. Very busy area of the body. Other than Grischkan in OH, I think only Brown in CA and Yunis in FL perform the two layer Shouldice. Your preference for the four layer Shouldice with prolene sutures is interesting. My concern with the four layer is the extra amount of suturing placed in my body. I have to weigh my desire to keep extra foreign matter out of my body versus a lesser recurrence rate of the four layer. Grischkan is quite enthusiastic about his two layer using a very small incision. So, I kind of feel the two layer may be optimal for me. Your thoughts?

In contacting the venerable Dr. Kang, I learned that he emphasizes that he only uses about HALF the suture material of other no mesh repairs. That is all part of his desire to minimalize the total surgical field to the least area disturbed. Less area affected means less time needed for recovery usually. Plus, he uses 1.5 inch incision vice Yunis four layer about 3 inches. Big problem is he is in Korea.

I admire your choice of Yunis versus all the other surgeons you contacted. Your high technical level of inguinal hernia knowledge may have surprised a few of those surgeons. I sincerely hope your surgery is totally successful.

[dave11]

aj9000 & Thunder Rose, thanks for sharing about Dr. Yunis. I wonder if you had the two layer Shouldice and what is the length of your incision. Hope you both are still doing well. I have been nursing a smaller right side inguinal hernia for seven years, but it has gotten larger this last month. I love Dr. Kang’s prescriptive approach of repairing specifically only what is needed, but Korea is a long haul from North Florida, especially during a pandemic.

[drkang]

@Alephy.

Thank you for your good question.
Even under the name of non-mesh inguinal hernia repair, I think there are a wide variety of surgical methods.
I know that non-mesh hernia repairs performed in the past were in many cases modified Bassini repairs. We know that the Shouldice technique is also one of modified Bassini repair. That’s why some doctors call it Shouldice-Bassini repair.
As you said, the Shouldice technique started in the 1940s, and I know that it hasn’t changed much since then. Nevertheless, it is true that these days, the period of hospitalization for surgery has been shortened and the time to return to normal life has accelerated even after the Shouldice repair.

First of all, I think the reasons for the shorter hospitalization period and faster return to normal everyday life are as follows even though there are no major changes in the surgical method.

The first reason, I think, is that there is no change in the big frame, but improvements were made in a less invasive way in detail, as doctors’ experience accumulates and surgical techniques generally improve
.
Second, I think it is because the routine recommended to patients has changed in the first place, as doctors have learned from experience that there is no need to hospitalize the patient or to restrict normal activities for such a long period of time after surgery.

Third, I think, it is because the devices that actually manage pain and pain medication have developed.

As another category, the surgical methods performed by some non-mesh surgeons these days are much more simplified than the modified Bassini repair that was mainstream in the past, so I think these changes cause less postoperative pain and faster recovery than in the past.
In the case of Kang repair, we reduced the scope of surgery by performing different methods of surgery for the indirect type and the direct type. It is obvious that the smaller the surgical range, the less pain and faster recovery. Most people who underwent reoperation or other side hernia surgery in my hospital said that our surgery method was less painful than the mesh repair they had before.

[aj9000]

Hi all,

Thank you Dr. Kang for weighing in.

Here’s a report on the outcome of my surgery (inguinal, right side only), in case any are interested.

The day before surgery, Dr. Yunis went over several options with me. We decided that in the case of a direct hernia, he would perform a modified Shouldice procedure in which the cremaster muscle and genitofemoral nerve would be left intact, and Prolene sutures would be used instead of stainless steel. If the case of an indirect hernia, he would avoid division of healthy transversalis fascia. As it turned out, I had both a direct and an indirect, so the former procedure was performed.

Although I hadn’t planned to have general anesthesia, I ended up opting for it after talking to the anesthesiologist.

Recovery followed what I understand to be the normal pattern. Pain was not bad the day after surgery, and I stopped taking pain meds that day. The next day (day 3) I had to resume pain meds (ibuprofen and acetaminophen). Pain was the worst on days 3 and 4, but manageable as long as I moved slowly when changing between standing, sitting and lying down (think Feldenkrais speed). I found that standing up and touching my toes alleviated pain. Around day 5, swelling and bruising of the genital area began, and lasted for several days.

I am now almost 4 weeks out from surgery, and there is no pain, bruising, or swelling beyond a small, hard ridge that is diminishing under the incision.

My only issue is that have a bit of lower back pain, probably because I have not been doing my usual workout and have been sitting and lying down a lot. I go back to the gym today, and will report back on how that goes.

One bit of advice: if you have to fly anywhere for open hernia surgery, schedule your return flight for the morning after surgery, or stay in town for at least a week. Pain apparently can peak anywhere from day 3 to 5, and I ended up flying at my peak.

Overall, I think the surgery went extremely well, and based on my experience I’d recommend Dr. Yunis to anyone seeking a non-mesh procedure.

[Alephy]

@drkang Thank you for your post. It would be great if your data could reach as many doctors so that your method/procedure would be available in other countries too.

I wanted to ask you an unrelated question. Many doctors say that in the old days when treating hernias without a mesh the patients often had to stay in bed for several days, which led to other complications. They also argue that the pain level was severe, and that many weeks (5 or more) had to pass before the patient could go back to work or start again with any physical activity.
These days however it seems non mesh pure tissue repair is performed in day hospital (or max one night in hospital): of the two one, either what the doctors are saying of the “old days” is not accurate, or the surgical procedures/ anesthesiology in the last 20/30 years have improved so much that today’s pure tissue repair is anyway very different from what it was like before? But I was also under the impression that the Shouldice clinic has not changed much in the way they do things (they have been doing it since the 1940s?), so I am really confused by the statements above that I have read from many doctors…

Thanks again!

[drkang]

Hello, everyone!
It has been a while.

Hernia mesh complication is already widely known, and hernia surgeons have acknowledged it. In order to solve this problem, new meshes such as absorbable mesh are being developed. However, I think the surest way to solve mesh complications is not to use meshes.

The problem is that there are different opinions among doctors about non-mesh inguinal hernia repair. However, the issues raised about non-mesh repair, unfortunately, often appear to be opinions of doctors who have little experience with non-mesh repair.
I had 15 years experience in mesh inguinal hernia repair.
Then I began to think more and more seriously about the complication of hernia mesh. and have devised and implemented a new non-mesh repair method from about 9 years ago. To date, more than 10,000 cases of non-mesh inguinal hernia repair have been accumulated. Based on that experience, I would like to tell you some facts below.
1. Many doctors say that non-mesh repair can only be applied to healthy, young people with small hernias.
However, I have performed over 10,000 inguinal hernia repairs over the past 9 years, all with the non-mesh technique, with no exception. Among them, there were hernias that recurred more than five or six times before, others over 100 years old, patients with severe ascites or receiving oxygen 24 hours a day for COPD, etc. There were also professional body builders, martial arts players, professional track and field players, singers and saxophonists. In the past 9 years, I have never refused surgery because of the patient’s medical condition or the like.
Nevertheless, the self-investigation has shown a recurrence rate of less than 1%.
Although we did not provide accurate statistics, the postoperative pain was extremely low.
Based on this experience, I can make the following conclusions.
Non-mesh inguinal hernia repair can be successfully performed in all hernia patients without exception.

2. In the same context of the above, most doctors say that you should choose a surgical method according to the patient’s condition. In other words, depending on the person, mesh repair must be performed, or the optimal surgical method must be selected and performed from among several non-mesh repair methods depending on the patient’s condition.
However, I disagree with the above statement from my past experience. All patients, regardless of their condition, can achieve successful results even if they perform the same procedure. The method used at this time should, of course, be a good surgical method. In fact, there is only one patient condition that must be considered in order to perform the optimal surgical method. It is whether the inguinal hernia is an indirect type or a direct type, and different surgical methods must be performed accordingly.
However, most surgeons currently perform the same operation without considering these subtypes. In other words, it’s like making a glove in one shape and putting it on your left and right hands.
This type of surgery results in the following results.
– It is difficult to perform the best surgery for each subtype.
– The operation is performed in a wider range than necessary.

3. Through this experience, there are things that I disagree with other doctors.
Most doctors point to tension as the main cause of hernia recurrence. That is why tensionless mesh hernia repair emerged. However, as we all know, mesh hernia repair also has a significant recurrence rate.
What I believe from personal experience is that the cause of hernia recurrence is due to the inability to perform optimal surgery and technical errors according to the subtype of inguinal hernia.
If my judgment on the cause of the hernia recurrence is correct, there would be no place for the mesh in inguinal hernia repair.
Thank you!

[drtowfigh]

Great discussion, everyone.

With regard to the rIPT (robotic iliopubic tract) repair, I only recommend it for normal weight (BMI) patients with small inguinal hernias.

[aj9000]

Hey all, I opted to go with a modified Shouldice with Dr. Yunis. Surgery is in a couple of weeks. I’ll try to post a follow-up after.

[James]

I am unfamiliar with the muscle you mentioned, but Dr Grischkan made no mention of removing any muscle. He also said he does not cut any nerves as some like Sbayi do (to my knowledge). His surgical report made no mention of removing any muscle as well. He’s a low key and very impressive guy passionate about not using mesh. He has done 24k operations and has an impressive facility. If it’s worth it to you to go to Ohio, I’d get a consult.