Seeking Advice

[Kevin]

Since tissue repair seems to be the more complicated repair and requires more movement of the anatomy is it more likely to require dissection of nerves/cremaster vs. mesh?

Thanks-Kevin

[Jack2021]

My hernia’s apparently an indirect inguinal hernia.

Re surgeon choice, like many on here I’d prefer a tissue repair but I’m still procrastinating over who to go to for surgery.

Travelling abroad for surgery is a factor for me and my preference would be to have it done in the UK, though options are extremely limited here. I’ve posted about UK options previously.

In Germany, Dr Conze followed by Dr Lorenz would currently be my preferred choices, though I’m yet to speak with Dr Lorenz. There are good reviews for both Dr Koch and Dr Wiese and Dr Koch came across well when I spoke with him and I haven’t spoken with Dr Wiese.

I’m sure there are currently lesser-known surgeons in countries such as Poland for those nearer there, as the 15-year Desarda follow up study was done there, which I’ve posted about previously, as have others. I tried to contact Dr Kryspin Mitura, who was involved with the study, for more information but didn’t hear back.

If I was in Canada, I’d do my research on the Shouldice Hospital surgeons and try to book in with one who gets great reviews and is open to not fully cutting the cremaster, preserving the nerves and using prolene.

I’d start with Dr Towfigh in the US as IMO she clearly cares about her work, comes across as very knowledgable in her Hernia Talk interviews/discussions and appears to be well-respected by her peers. She also seems open to new perspectives, such as when discussing the Desarda repair with Dr Lorenz.

There are the South Korea options we’re aware of and Dr Kang has some great reviews on here, though no published research data yet.

I’ve also read positive reviews about Gerald Young in Auckland, who’s apparently done many hundreds of successful Desarda repairs, so for any members on that side of the globe, he may be worth contacting.

As you don’t seem to currently have a hernia Chuck and you’ve likely got all the knowledge available that you can find yourself and that this forum can provide, I’d try to look for ways to focus on the present and move on from this until you really need it, i.e. should you get a recurrence. Were this to happen, if it’s an option, I’d personally opt for a tissue repair and hope that lasts, as it appears to be easier to have mesh as a follow up surgery than vice-versa usually, as I understand things, but that’s just my opinion from the research I’ve done.

Re trying to find ways to move on from all this and the significant trauma you’ve experienced, I realise that it will be difficult or perhaps impossible not to be mindful of a possible future recurrence and that this may linger over you, as is often the case for people following serious illness, such as cancer and perhaps other surgeries too. This can affect our mental health and result in an emotional burden and/or PTSD for many people (as can working in jobs associated with this kind of thing) that I think often gets overlooked and isn’t talked about enough.

While a lot of us probably get a bit of low level support via this excellent forum, perhaps reaching out for some specialist emotional support to help focus more on the here and now could be beneficial for you and other members of the forum too possibly, be it in the form of counselling, cognitive behavioural therapy (CBT) or some lower level support with an organisation/s in your country that provide it. This is commonly offered and found to be beneficial in the UK for people with cancer, following bereavement and other traumatic events, so I’m guessing there should be some great options in the US too. Perhaps other members of the forum are able to share some signposting options.

I hope this is some helpful food for thought alongside the hernia stuff.

[Jack2021]

Chuck, re your question about whether Dr Conze and Dr Lorenz fully cut the cremaster muscle, of the German surgeons those of us on this forum are generally aware of, doctors Conze, Lorenz, Koch, Muschaweck and Wiese, albeit I’m unsure re Dr Muschaweck, my understanding is that none of the others completely cut the cremaster muscle as standard.

Apparently the genital branch
of the genitofemoral nerve is rarely visible immediately during open hernia surgery and is usually more posterior, becoming visible after the cremaster is divided. Perhaps that’s one of the reasons some tissue repair specialists divide/split/trim it, while generally preserving it.

My sense, rightly or wrongly, is that it’s less of a concern unless the cremaster is completely cut and some would argue it’s fine either way. I think I’d be more concerned about nerve damage.

Dr Muschaweck is the only one of them who apparently cuts the genitofemoral nerve (sometimes referred to as the genital nerve) as standard, as per the original Shouldice repair.

I believe the others identify and preserve all the nerves in the area, such as the genitofemoral nerve, ilioinguinal nerve and Iliohypogastric nerve and I think Dr Muschaweck identifies and preserves the ilioinguinal nerve and Iliohypogastric nerve.

I’d obviously recommend that people ask for clarification on all this when contacting/having a consultation with them or other doctors.

Re ongoing pain after hernia surgery, having read various posts on here and information elsewhere, it’s probably been covered on here already at some point, but a lot of the symptoms people mention sound like they may be due to genitofemoral nerve damage. Symptoms of this apparently include ‘…groin pain, paresthesias, and burning sensation spreading from the lower abdomen to the medial aspect of the thigh. It may present with scrotal pain in males, while females experience symptoms radiating to the labia majora and mons pubis.’

Here’s the link to where I read that – https://pubmed.ncbi.nlm.nih.gov/25377757/#:~:text=The%20symptoms%20include%20groin%20pain,labia%20majora%20and%20mons%20pubis.

[David M]

When you say “fairly large”, are you talking golf ball, bigger, tennis ball?

The problem comes down mostly to there being no consensus here about how to proceed. It probably depends on the individual. Looking broadly at results, it’s hard to come down as one method being preferable. The study stats seem to say that Lap is slightly the best, but the board would almost certainly have a different consensus, as there are a disproportionate amount of lap removals around here.

Dr Yunis has had a talk with Dr Towfigh. I imagine that you know this. If not, it would certainly be worth a watch. Having said that, I think there is a strong opinion here that if you have the means, you should probably travel to the overall surgeon and method of your choice.

As far as the cremaster, I can’t verify exactly the differences. I believe that the original Shouldice splits it around the middle like around the trunk of a tree, then uses the two “stumps” to suspend the testicles for the lower stump, and help create the internal ring for the higher. I think a substantial number of Shouldice surgeons no longer totally seperate the two parts of the cremaster.

Other methods open it up to remove hernia sacs in the case of indirect hernias, but probably don’t go so far as Shouldice. Still others may do nothing to it all if it’s a direct. Those are just my impressions, though.

I don’t think cutting the ilioinguinal nerve is common, as it is usually on the outside of the spermatic cord. Always important to ask, I guess. The genitofemoral is often found inside the spermatic cord, I think. It may get cut by Shouldice. This would be something to always ask for tissue or mesh.

I wish I knew more, because like you I have paralysis by analysis. If you didn’t have the insurance change, I would allow yourself some time to come to your decision.

[Good intentions]

All of your questions have been addressed in great detail over just the past year or two on the forum. Not exaggerating. If you don’t get many specific responses it might be because of that.

I just looked up an old email from somebody very much like you, in that they had had a mesh repair in the past that had only given them very minor problems, for 13 years. Then he got a hernia on the other side and the repair had a completely different outcome, eventually leading to mesh removal 17 years later. It’s unclear why, but I think that it illustrates the fact that you can’t simplify the situation down to just mesh versus pure tissue. And age might be a factor.
.
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Dr. Gilbert has retired apparently, but he might still be out there. He might be worth talking to, since he has a whole history of patients like you behind him.

http://hernia-institute.com/?page_id=76

https://www.doximity.com/pub/arthur-gilbert-md