robotic pure-tissue, Kang repair, long-term mesh studies, exercising w/hernia
01/04/2021 at 12:50 pm #28383
I have been combing this site for the past few days, and finally decided to create an account and ask some specific questions.
I’m in my mid 40s, 6’1″ and 195 lbs., about 10-15 lbs. overweight for my frame size. I have a right-side inguinal hernia. It is the first hernia I have had. It was diagnosed in December 2020. I first noticed it in July 2020 after doing some heavy lifting while working on my house (normally I don’t do heavy lifting, neither for work nor in the gym).
A bump is visible, but not too pronounced, and it is not extremely painful. It bothers me a bit when walking or biking, and sometimes I push it back in during those activities. The bulge only appears when I’m standing and disappears when I lie down. I do not know whether it is direct or indirect.
I am in the NYC metro area, but willing to travel wherever is necessary for a great surgeon. I recently had a consultation with a very reputable hernia surgeon in the city, who specializes in laparoscopic mesh repair using 3D Max polypropylene mesh.
Before scheduling surgery, I decided to do a bit of research and learned about some of the potential issues with mesh, and I read about a number of pure-tissue repairs, such as Shouldice and Desarda.
Now that I know a bit more, I feel like the optimal repair method, if it exists, would meet the following criteria:
- Does not use mesh.
- Results in a low rate of recurrence.
- Is not destructive to uninjured tissues (for example, I am a little concerned about the removal of the cremaster muscle in the Shouldice repair).
- Does not involve general anesthesia.
From what I have read so far, Dr. Kang’s method seems to meet these criteria, but I understand that he is in the early stages of validating long-term outcomes of his repair and that the repair technique itself is not yet published.
My specific questions:
- I am still open to mesh if I can get a handle on the rate of long-term mesh-related complications (adhesions, chronic pain, systemic reaction, etc.), in the range of 20+ years. I’m relatively young, so the mesh would have to last 30+ years without issue. Are there any doctors on this forum who can point me to studies on the rates of long-term complication, of all kinds, for various forms of plastic mesh?
- I have read on this forum several positive experiences with Dr. Kang. It would be great to hear status updates from any former patients who have already posted, or from anyone who has had a Kang repair but has not yet posted.
- Specifically for Dr. Towfigh: I understand that you have pioneered a method of doing pure-tissue robotic hernia repair (https://link.springer.com/article/10.1007/s10029-020-02259-7). Is this available to all of your patients at this time, or are there certain conditions (health, weight, size/type of hernia, etc.)?
- Finally, my hernia coincided with efforts to lose a bit of weight. Are there any recommended exercises I can do, prior to surgery, that will not exacerbate my hernia?
Thanks in advance!
01/04/2021 at 3:20 pm #28384Good intentionsParticipant
Here is a link to Dr. Kang’s hospital. There are testimonials and maybe more of the information that you’re looking for.
You have probably read about Peter C’s bad result from Dr. Brown’s attempt to fix his problems from prior surgeries. But you might also read dog’s account, and others, of Dr. Brown’s hernia repair results. He seems to know how to repair a hernia.
The one thing that you should consider is that if a pure tissue repair fails, you can get essentially the same results from a mesh repair afterward. No matter the method, the surgeon will just lay down a piece of mesh that covers all possible future hernia sites, including recurrences from pure tissue repairs.
But if you have mesh problems you can never go back to a pure tissue repair.
Your hernia sounds like my direct hernia in the early stages. Direct hernias form what looks like a small pyramid, that disappears when you lie down. Indirect hernias work their way down to the scrotum through the inguinal canal. I was very physically active, going to the gym, playing soccer, running, and working around the house. I tried to learn to live with it but playing soccer made it bigger. If I was starting over with what I know now, from my personal experience, I would get it fixed via a pure tissue repair, as soon as possible. I almost did that for mine but a surgeon friend convinced me that I would be okay with a laparoscopic mesh repair.
Don’t try to work out or lose weight, beyond changing your diet and doing more walking or light running or biking. Avoid any exertion that causes you to hold your breath to generate power. Avoid twisting and lifting at the same time also, that seems to cause abdominal pressure and uneven load on the abdominal wall.
I would let Dr. Brown repair mine, if I was starting over. Or Dr. Kang, if we weren’t in the middle of this mess.
01/04/2021 at 7:59 pm #28387
Thanks for the response, Good intentions.
Since I posed my initial questions, I found some information that runs counter to my intuition about exercise. Here, Drs. Towfigh and Jacob claim that almost any exercise is OK, but that coughing and straining are most problematic:
Another question that occured to me: with mesh, infection and undesireable foreign body response are two worries; I wonder if there is are similar worries about tissue-only repair with permanent Prolene sutures?
01/05/2021 at 6:07 am #28392
“But if you have mesh problems you can never go back to a pure tissue repair.”
I would add that in fact it’s my understanding it would be possible to get a pure tissue repair after mesh if the mesh was placed and removed robotically. Both Belyansky and Procter advised me that an open tissue repair would be feasible if mesh was placed and removed robotically because the tissue in the front would be undisturbed.
01/05/2021 at 8:49 am #28393Good intentionsParticipant
The damage that the mesh does can never be undone. The tissue that is left behind when the mesh is tediously peeled back out is not the virgin tissue that was there before the mesh was implanted. There is a new layer of “scar” tissue, thicker and stiffer than what was there before. That was my point.
01/05/2021 at 9:25 am #28394
Understood. But from a surgical perspective there’s a difference between the anterior and posterior surgical realms of course, and these two surgeons suggested in fact that surgery via open method after robotic mesh placement and removal would still be working with virgin tissue. I always forget which is anterior and which is posterior. So yes, the area behind the muscle wall and that general vicinity will be changed after mesh placement and removal, but the other side of the muscle should still itself be so-called virgin tissue.
- This reply was modified 3 months ago by ajm222.
01/05/2021 at 9:29 am #28395
Perhaps in reality, the area behind the muscle wall after removal is so damaged that it impacts sensation and feeling and function on the other side. I could see that. But they suggested the tissue itself would be undisturbed. I was also interested to hear Dr. Towfigh suggest that very little actual tissue is removed during removal surgery – the amount was fairly negligible.
01/05/2021 at 5:31 pm #28397Thunder RoseParticipant
Regarding exercise: I had a large direct inguinal hernia for more than 5 years of watchful waiting. Most exercise was indeed fine: running, x-country skiing, swimming, downhill skiing, dancing, road biking and stationary biking, figure skating, and hiking.
Mine finally worsened last summer and I do think it was in part due to a change in exercise as well as having waited so long. HIIT (esp. squats and lunges) is not recommended. I also started doing longer trail runs (7 miles+ with lots of hills) and single-track mountain biking with lots of hills.
So yes my experience is that most forms of exercise are fine.
Regarding the cremaster muscle, it wasn’t relevant to my anatomy, but my understanding is that Yunis works around it but Brown prefers to “shave” it. Shouldice it’s optional to take it but Sbayi always takes it. Kang and Muschaweck don’t take it.
I’m very happy with my Shouldice repair from Yunis. I wouldn’t go to Brown because I wouldn’t want a Desarada repair on top of my Shouldice repair. The Desarda repair is destructive of non-injured tissues in order to create the flap of External Oblique Aponeurosis to use as a patch.
Anterior is toward the front of your body, posterior is toward the back. The posterior-placed mesh (laparoscopic or robotic) is much larger than the mesh used in the anterior repair, and typically covers the direct, indirect, and femoral spaces. It’s also usually a contoured mesh and the procedures are less studied than anterior-placed mesh. Anterior mesh is in the inguinal canal, so it’s in the same space as the spermatic cord and the ilioinguinal and genital branch nerves. I’d choose Nyhus if I were to have mesh– posterior-placed mesh from an open, anterior repair — as it’s a smaller mesh with the benefits of being in the posterior space.
- This reply was modified 3 months ago by Thunder Rose. Reason: tiny typos
01/05/2021 at 7:51 pm #28399
Thunder Rose – thank you, this is extremely helpful! I read a few posts on the site about your positive experience with Dr. Yunis. I did not know that he avoided resection of the cremaster. I think I will reach out to him for more information.
I have read comments from doctors who say that Shouldice repair is not as “tight” without the removal of the cremaster. Googling around for more information led me to a study, https://pubmed.ncbi.nlm.nih.gov/2180642/, that shows an increase in the rate of hernia recurrence for Shouldice repairs where the cremaster is left intact. The difference is significant, but still not terrible: between 1 and 2 years out from surgery, it looks like the recurrence rate is about 2.6% for repairs that leave the cremaster intact and less than 1% for repairs that involve excision of the cremaster.
Nyhus sounds promising as well. I have not read anything about that technique yet. In your research, did you encounter any doctors with a lot of experience performing the Nyhus repair?
One other question: in one of your posts, you mentioned that you wanted prolene sutures instead of stainless steel. What was your reasoning for this? Are the prolene sutures more comfortable?
01/05/2021 at 8:27 pm #28400Thunder RoseParticipant
The article you linked to cites 4 recurrences vs. 1 recurrence: that isn’t a lot of data. Have you found any similar studies? I’m swayed by the research showing that the recurrence rates for the Shouldice repair are correlated with a surgeon’s experience with the repair, so I’m inclined to trust Yunis if he says he can do a strong repair without resecting the cremaster.
I believe Dr. Reinhorn in Massachusetts prefers doing Nyhus repairs. He wasn’t taking out-of-state patients last summer but perhaps that’s changed. Towfigh and Yunis both perform Nyhus repairs but I don’t know their algorithm for who gets one.
My reason for not wanting stainless steel was concern over it breaking. I’ve worked with 32 gauge stainless steel doing beading projects with my kids so I know from personal experience with the material how easily it snaps and breaks apart. I benefitted from another patient sharing their notes on a large number of surgeons (that’s how I have data on the cremaster) and he had notes about Muschaweck preferring Prolene. I liked that Towfigh and Yunis both use Prolene and that it is known for ease of removal if there were a need to do so. I didn’t want Polybutester (used by Grischkan) as it’s polyester and hence more inflammation-inducing. The YouTube videos of Drs. Sue and Peter Jones doing Shouldice repairs use Prolene (you can see the color is blue on the periphery of the view although it looks more purple where it’s over flesh) and we were impressed with their technique.
01/06/2021 at 1:31 pm #28402
The study had something like 390 participants, so yeah, not so many people. I agree that these things don’t often control for surgical expertise.
Thanks for the list of doctors — looks like I should reach out to Drs. Reinhorn and Towfigh as well. I scheduled a telemedicine appointment with Dr. Yunis, so now preparing questions to ask.
01/28/2021 at 5:03 pm #28513JamesParticipant
I too live in the NYC area which is chock full of surgeons. For non-mesh surgery however, I ended up going to Dr. Grischkan in Ohio. My hernia was massive, but Dr. Grischkan repaired it with no mesh. It’s been 3 weeks and the healing was rough at first, but I’m over the worst of it. So far so good. I am more than impressed with this surgeon’s skill, experience (24k hernia operations) and commitment to not using mesh whenever possible. PS. He doesn’t take insurance, and he ain’t cheap, but NOT having a sheet of plastic in me for the rest of my life is priceless.
01/28/2021 at 11:01 pm #28516AlephyParticipant
I also think that exercising with an hernia is mostly ok, and in fact I would argue it should be recommended! Movement will keep the body healthy in general and prevent other problems…
There are many (among doctors) who claim exercising will make an hernia worse, I wouldn’t be surprised if it was in fact the opposite….at the very least it could get worse whether you exercise or not, so you might as well do it:) (and for some sports/physical activity is a fundamental part of their identity, me included)
01/29/2021 at 11:10 pm #28528
@James, did you have a Shouldice repair? I am currently leaning toward Dr. Yunis because he does a modified Shouldice that doesn’t involve removal of the cremaster muscle. From Dr. Grischkan’s website it looks like he also has modified the standard procedure. Does you know if he removed the cremaster?
@Alephy, I lost a few pounds in anticipation of surgery, and now my hernia doesn’t bother me at all when exercising. Admittedly, it was not large to begin with.
01/30/2021 at 6:34 am #28529JamesParticipant
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.
03/16/2021 at 6:24 pm #28746
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.
03/16/2021 at 8:44 pm #28749drtowfighKeymaster
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.
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