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

[aj9000]

@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.

[Alephy]

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)

[James]

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.

[aj9000]

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.

[Thunder Rose]

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.

[Thunder Rose]

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 years, 4 months ago by  Thunder Rose.

[ajm222]

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.

[ajm222]

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 years, 4 months ago by  ajm222.

[Good intentions]

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.

[ajm222]

“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.

[Good intentions]

Here is a link to Dr. Kang’s hospital. There are testimonials and maybe more of the information that you’re looking for.

http://www.gibbeum.com/main/main.html

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.

Good luck.

[Thunder Rose]

I read Kang’s website in depth last summer. I am not swayed. Science requires replication and independent verification. Have you taken the time to watch videos of these surgeries? If you have the stomach for it I highly recommend it.

[Thunder Rose]

Yes he offers two methods: a Marcy repair for indirect and a 2-layer Shouldice for direct. But he calls it a Kang repair and claims it’s different? If you look into what he’s suturing I don’t see any significant difference except for some very cute comic strips.

[Thunder Rose]

What is it that makes you think Kang Repair is so worthy of replication? I see him as having hired excellent marketers, but I don’t see that to be correlated with being a great surgeon. There are other surgeons offering a tailored approach (Towfigh, Yunis, Muschaweck, Wiese). I see Kang and Muschaweck both obfuscating the details of their two-layer repairs while using their branding to sell their procedures as unique, when they’re in fact not functionally different from the other two-layer Shouldice and Bassini repairs being offered by various surgeons through the E.U., U.K, and U.S. — surgeons with strong enough word-of-mouth followings that they don’t need to invest in expensive marketing strategies.

[aj9000]

Hi Dave, I had the same as Thunder Rose – 4-layer Shouldice. Same motivation: to prevent recurrence. My incision looks like it is about 3 inches, but even at only 1 month out it is hardly noticeable.

If your main goal is to minimize foreign material in your body, there is a hybrid mesh product, Ovitex, that I read about here: https://herniatalk.com/forums/topic/telabio-study-of-reinforced-biological-meshes/#post-27854

It might end up being less material than is used for suturing only in some cases. I considered Ovitex briefly, but there was not enough historical data for me. Either way, you are going to have some stuff in your body – sutures or a plastic mesh – unless you get a biologic mesh, which I understand does not work so well.

Telabio study of reinforced biological meshes

[Thunder Rose]

I don’t think Brown, Yunis, Grischkan, and Kang are the only surgeons offering 2-layer Shouldice. I do think many are calling it Bassini.

I strongly considered Grischkan but ultimately did not feel comfortable with his use of polyester suture material. Similarly Brown uses highly inflammatory silk sutures. I was more concerned about choice of suture material rather than the volume of material.

For me the healing at the subcuticular wound closure was much more bothersome than the internal suturing, where I have never noticed any significant change of sensation. I would rather have a one-and-done surgery than endure another surgical wound.

I can see how that’s an argument for the smaller incision offered by Kang. But I don’t think it’s a straight up smaller-is-better metric — a too short incision could result in increased bruising/internal bleeding, i.e. more trauma at the surgical site. I feel confident that Yunis is doing the smallest incision that reasonably balances those negative effects. Since my incision was only 6 cm, I do think he’s to some extent adjusting incision length to body type.

I’m just over 6 months since surgery now and still very happy with my repair.

[Thunder Rose]

Hey Dave, my repair is 4 lines of Prolene on the posterior wall (formed by 2 running sutures), what’s commonly referred to as a 4-layer Shouldice. I wanted the 4-layer repair to reduce likelihood of recurrence. The incision length was roughly 6 cm (just under 2.5 inches). I think I was told it would be 3.5 inches so it was shorter than I expected. Good luck!

[Thunder Rose]

Hey AJ9000! I’ve been reflecting that my surgery with Dr. Yunis and recovery were particularly easy because we live at over 7000 ft. in Wyoming, so sea-level in Sarasota was akin to a hyperbaric chamber. It’s good to hear you also had a good experience (most likely without that elevation benefit)!

We flew home on day 6. I kept up with the highest recommended dose of Tylenol and ibuprofen for the first week or so to prevent pain escalation.

I hope your return to the gym goes well!

[aj9000]

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?

[aj9000]

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:
https://www.youtube.com/watch?v=jhXCmTeP1vc&t=10m10s
https://www.youtube.com/watch?v=jhXCmTeP1vc&t=13m15s

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?