Summary of research-forum experts? Watchful-JF -NFG- GI- Mike M- Bryant

[Unknown Member]

Brother you don’t want to make the same mistake as with getting the mesh, there’s no reason to jump into getting a recurring hernia fixed unless you get a CT scan, MRI, or Ultrasound to get very specific of what’s going on especially that’s it not even been a year since removal. At the year point I felt quite a bit better pain wise, all my UTI, PROSTATITIS, Crazy stomach sensations, having to pee every 29 seconds, getting swears went away within the first week after bilateral 3d max removal with tacks and the genital branch nerve cut on bot sides from being damaged and my spermatic cord was encased in the mesh and had to be peeled off slowly. Pain wise it’s crazy it does slowly go away at a year and a half it was even better. I’m 6 years put no with no pain on the right side at all and like 90% on the left pain free but the mesh flipped their in on itself so I’m always going to feel a Lil something. It takes time as watchful, Good Intentions and others will tell you on here. When I felt alot better at like 2 years and past that I stopped thinking about mesh, hernias etc. I just moved on and didn’t even think about any of it anymore and stayed of here which helped alot staying off forums. You’ll get better I’ve told you that many times and it will happen but the more you dwell and beat yourself up about getting mesh in etc we all do at first but it’s not our fault no matter how much we study it. It’s out the worst is over, get a test mri, CT scan or ultrasound and that will tell you what’s going on but don’t just assume, you have to get one of those tests and it’ll ease your mind also, much love my brother keep your head up!

[Good intentions]

For any future reader of this long thread, David M. has created a similar thread that is worth reading.

https://herniatalk.com/forums/topic/is-this-swedish-pain-study-from-2021-to-2015-the-best-pain-study-to-date/#post-37579

Is this Swedish groin pain study from 2012 to 2015 the best pain study to date?

[Unknown Member]

I’ve been on here before I messed up and got bilateral mesh 3dmax the worst with 3 huge tacks, had it in 18 months then got it removed in one piece with the tacks in one piece by Dr. Iacco which him and Dr. Randy Janzyck are pioneers in hernia repair robots surgery and are ICU surgeons! Alot of surgeons started to try to get on here after hernia mesh temporal was really coming about. Chen, Ramshaw, Towfigh, Belyansky, Peterson, Yunis, Kang, brown etc. Some persuade like Peterson, grishkan, brown and Kang not saying Kang is a bad guy but the others are. Saying yea I can remove bilateral mesh that was placed lap but I’ll do it open which is the biggest no no there is mesh has to come out the way it was put in first rule of it all. Some guys as I mention are only open surgeons so they talk you in to what they know, Dr. Ramshaw was the best of removing mesh supposedly bit would make you see a psychiatrist before and after, it’s to cover themselves a patient I know said hey I want it out robotically he said you can’t teach a dog new tricks as these guys that know open to remove mesh open place lap people are in wheelchairs and some gave up completely from there pain. Research yourself don’t make a wrong mistake and when mesh problems arise you have to get it out cause it’s just going to get worse and I woulwush it on my worst enemy! Once it’s out recovery shall come psychically and mentally! Much love!

[Unknown Member]

Thanks Gi — are you changing your tune on Kang? these tissue repairs are no slam dunk either—i thought i made a careful review of the options and selected the least bad. I made a life altering mistake. In retrospect going to one of the germans within months of getting the hernia was probably the right call. I cant beleive a simple painless little bulge has upended my entire life. I thought i would go out to cancer or heart disease…but a silly hernia? never expected it…didnt even know what one was.

[Good intentions]

Chuck, it would probably help your decision-making if you categorized and ranked the types of repair and the surgeons separately. Rank the methods, rank the surgeons, look for overlap.

So far it looks like you’re leaning toward a Lichtenstein repair. Dr. Chen seems to be the most rigorous in his thought process about how to do one. He also is learning about the many other various techniques and does mesh removal. Overall, he seems like the best person to consult with, to start. Since you have time, no urgency, you can schedule an appointment as far out as Dr. Chen’s calendar requires. Since he removes mesh he has probably seen cases of mesh sensitivity. He might know whether or not what you experienced was from the mesh or from some other factor. He probably has seen or heard of cases like yours or can have staff research it for him.

Even so, Dr. Chen is a believer in the mesh Guidelines even though he must know that they are suspect. So that’s a dilemma. He is toeing the party line. But, maybe, he has the mental capacity to realize that mesh can be wrong for some people.

In the end, even the experts are just normal people, susceptible to major marketing campaigns, like you are. Just like your anti-vax stance, most hernia repair surgeons are pro-mesh. They’ve been trained to believe in it and the message is reinforced throughout the educational and post-education fields, and the professional news media that they learn from. Similar to your opinions many have taken the absolute approach – mesh is always good. As you think that vaccines are always bad. Peas from different pods. Realizing that might help you communicate with the various hernia repair surgeons.

Dr. Chen’s web page looks pretty impressive. If I was starting over I might have tried to consult with him first.

https://www.uclahealth.org/providers/david-chen

[pinto]

Right you are, Mark T, Kang’s survey targeted 1-year-post-op patients, so I focused on his pain percentages provided. The issue is how to evaluate them. One might compare them to mesh surgery as apparently Watchful did with the 15% (as it seems a common estimate).

On the other hand it might make more sense to compare them with pure tissue surgery results. For example, “In 1996, Cunningham et al. published a prospective randomized trial of 315 patients comparing Bassini, McVay, and Shouldice repair[.] … After 1 year, 63% of the patients reported inguinal pain and 12% of patients suffered from moderate to severe pain.” Surely Kang’s patients fared better than the patients in Cunningham et al.’s study (assuming comparable measurement). Perhaps there has been much advancement in the related fields since the turn of the century and today the 63% figure greatly improved (but a huge gap to bridge). We don’t know, of course, how representative Cunningham et al’s study was. Nor do I want to write someone’s medical school dissertation here. Suffice it to say that Kang’s survey, likely exploratory in purpose, produced very promising figures for pure tissue repair and should give confidence to his prospective patients.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754000/#:~:text=Chronic%20postoperative%20inguinal%20pain%20(CPIP,after%20laparoendoscopic%20groin%20hernia%20repair.

[pinto]

About Dr. K’s stats: Watchful makes a good point in cautioning the including of Score 3 in the no-pain category. Let me point out though as the survey comes from the medical literature, it would be interesting to see how other researchers handle the same thing. Is it something generally done with this survey?

An issue I would make is considering chronic pain necessarily applied to cases of just a year post-op. Then too how is “pain” determined or categorized. Knowing the stats for each year esp. years 3 and 4 might be particularly revealing. Maybe these are matters already decided in the literature. Would patients in only the first year scoring 2 or 3 be justifiably “chronic” pain sufferers?

With those thoughts in mind I think Watchful is a little unfair in concluding 16% chronic pain (though he qualifies it with “some”). Much depends, I believe, how the hernia field handles such surveys. Watchful while applauding Dr. K’s survey for being so direct (phone contacts and not surmised data), points out that such appears not generally done by other surgeons. If correctly restated, then I must question Watchful’s 15% for the field. If such is surmised data— well then there can be no comparison. However, doubtless some similar surveys have been made.

Anyway, I think the bigger aspect is that over 90% had practically no pain. Even the 83% painless is certain achievement. Doubtless Dr. K’s survey is exploratory and he probably aims to refine such in the future. We look forward to it.

[MarkT]

Dr. Kang, I wonder if you might have more nuanced data at some point?

Since you accept all patients regardless of their health status, hernia characteristics, etc., I wonder if your overall statistics are being ‘dragged down’ by outcomes from the very difficult/complex cases…i.e., could it be that the recurrence and chronic pain rates are significantly lower for the average ‘normal’ patient?

Perhaps it might be worthwhile to supplement the overall statistics with subgroup analysis to see whether outcomes differ among primary hernia repairs, recurrence repairs, and very unusual/complex cases…whether they differ for patients based on health status…etc.

Some research suggests that much longer follow-up periods are necessary to accurately estimate recurrence and chronic pain rates, so hopefully such data will follow in the coming years.

It is great that you are taking the time to collect this data, thank you!

[Unknown Member]

Thanks Dr Kang for your continued participation in this forum…you have made my decision a lot easier if i have a recurance…i will be coming to see you…Please do not retire!

[Watchful]

Thanks very much for sharing this data, Dr. Kang. It’s excellent that you did a phone survey for chronic pain. It’s extremely rare for surgeons to do this, unfortunately.

They don’t even do it at the Shouldice Hospital. They’re doing a study of chronic pain, but patients have to fill out many long forms just to participate, and then they have to keep filling out such forms on a regular basis. I didn’t bother with this, and neither did any other patients that I asked over there. They really should be actively following up with patients by phone, but they don’t do that.

I know it’s not your definition, but I’m not sure why number 3 (“pain present, cannot be ignored, but does not interfere with everyday activities”) is considered “no pain”. Seems serious-enough to me for qualifying as pain. The way I read it, 16.6% (1 out of 6!) had at least some chronic pain, 8.7% had significant chronic pain (i.e. cannot be ignored and worse), and 1.7% had chronic pain which is at least somewhat debilitating.

Do you believe that these numbers are better than what is obtained with mesh? A few mesh studies mention 15% rates of chronic pain, although definitions vary, and are sometimes unclear.

I know this problem is not specific to the Kang repair, and it is a general problem with inguinal hernia surgery. It’s very unfortunate that a problem which is typically minimally symptomatic needs to be repaired with a surgery that has a somewhat significant risk of causing worse chronic symptoms.

My experience with surgeons is that they aren’t at all transparent about this. I talked to about a dozen surgeons, and I asked most of them about the risk of chronic pain. A couple said zero, or that they had maybe one patient with chronic pain in their career. A few said 1%. One surgeon said 1-3%, and that was the highest among the surgeons I consulted. Until I asked, none of them even bothered mentioning this problem, and then quoted such low numbers. I don’t think any of them really studied it like you did (with phone follow-up).

I pretty much had no choice but to do the surgery because my hernia became too symptomatic. However, if it had been only mildly symptomatic, I would have been extremely reluctant to take these odds of chronic pain (plus other potential complications).

[drkang]

I learned that there are people who have a skeptical view of the Kang repair that we are implementing. So, I post after thinking about it.

I am not writing this to advocate for or promote Kang repair. Rather, I want to show that pure tissue repair can be very successful. If many hernia surgeons actively develop surgical methods with confidence in pure tissue repair, good results will surely come. For this, you need to have confidence in pure tissue repair. Kang repair is just one example.

As some of you may know, I have experienced more than 16,000 cases of pure tissue inguinal hernia repair since 2012. In the meantime, except for one patient with acute leukemia, I accepted all other patients who wanted to be operated on by me. Among them, there were more than hundreds of recurrent hernias, including patients who had experienced multiple relapses, some with massive ascites due to liver disease, and many who were using oxygen masks 24 hours a day due to lung disease. In addition to that, it includes all kinds of patients, such as terminal cancer patients, heart disease patients, severely overweight people, people who use immunosuppressants after kidney transplantation, body builders, and martial arts athletes, etc.
I would like to summarize a few things that I have learned through this experience.
1. Many people say that the hernia surgery method should be different depending on the patient’s condition. However, in my experience, I do not agree with this claim. I believe that one well-designed surgical method can bring successful results to almost all types of patients. In that sense, it is regrettable that even Shouldice Hospital is performing mesh repair on 3–4% of their patients.
2. It has only been 3–4 years since our Kang repair was almost completed. Therefore, it is true that there is a limitation in that the long-term result cannot be confirmed yet. Among 2,296 patients 1 to 4 years (median: 22 months) after surgery, 13 patients (0.6%) had recurrences. (We have still more areas to improve) Of course, since this is based on patients who visited the hospital by themselves, it may be different from the actual recurrence rate. However, Korea is a small country, and transportation is very developed, so you can reach our hospital within 3–4 hours from anywhere in the country. And most of the people who have undergone surgery with us have a reluctance to mesh. And in case of recurrence, the treatment fee reduction benefit is provided. Therefore, in the event of a recurrence, most patients expect to return to our hospital.
3. Regarding chronic pain, there is data from a self-survey conducted through telephone interviews early this year targeting patients who have reached one year after surgery.

According to the chronic pain score used by K-J Lundström et al. in their paper titled ‘Patient-reported rates of chronic pain and recurrence after groin hernia repair’, out of 302 interviewees, Score 1 (no pain): 252 (83.4%), Score 2: 24 (7.9%), Score 3: 21 (7%), Score 4: 5 (1.7%), Score 5-7: 0.
K-J Lundström et al. defined a score of 4 or higher as chronic pain.
Therefore, 1.7% of those who underwent Kang repair complained of mild chronic postsurgical pain at 1 year after surgery.

Patient-reported rates of chronic pain and recurrence after groin hernia repair
K-J Lundström, H Holmberg, A Montgomery, P Nordin
British Journal of Surgery, Volume 105, Issue 1, January 2018, Pages 106–112, https://doi.org/10.1002/bjs.10652
Published: 15 November 2017

Score1, no pain; 2, pain present, but easily ignored; 3, pain present, cannot be ignored, but does not interfere with everyday activities; 4, pain present, cannot be ignored, and interferes with concentration on everyday activities; 5, pain present, interferes with most activities; 6, pain present, necessitating bed rest; and 7, pain present, prompt medical advice sought
Scores of 1-3 were defined as no pain, and scores of 4-7 as chronic pain.

These results have not been officially reported. So some might question the veracity of these results. However, I would like to say that my main interest is to find and improve problems rather than beautify the results of Kang repair.

[pinto]

Good intentions, you are welcome. Let me clarify your opening statement:
“The description of immediate pain after the first surgery was a distraction….” You must mean “no pain” immediately afterward surgery because I had no pain factually. “Immediate” can have different senses; hopefully we mean the same here. You make a good point about language used for recurrence and so on. Dr. Kang was satisfied based on imagining that it was indeed a recurrence. I have always known the word to mean the original hernia. As far as I know that is how it is used technically.

[pinto]

@Chuck, however you choose a surgeon is your own concern. It has nothing to do with me. You asked me multiple times about my condition. I tried to be transparent and be an open book (hopefully others will do the same in turn). Unfortunately you twisted this into false claims as I previously posted. I feel violated and used by you.

[Good intentions]

Thanks for the reply Pinto. The description of immediate pain after the first surgery was a distraction, it was not clear to me that you had apparently healed and been okay for two full years after the initial pain of the first repair. My new understanding is that the pain resolved and you were fine for two years. Then you had another hernia.

I have noticed that some surgeons will refer to a new hernia after a previous hernia as a “recurrence”. But, literally, recurrence means the same thing happened again. Was your second hernia the same, original, sliding hernia reappearing? Or a new type of hernia. This is an important distinction.

“Recurrence” implies a failure of the original repair. The appearance of a a different type of hernia could be a side effect of the original repair, from abnormal distribution of tension, or just a naturally occuring follow-through of weakening tissue.

[pinto]

@Good intentions, as you say, you were not reading postings regularly for a couple of years and apparently jumbled up some of my information.

Let me simplify for you: Both my Kang surgeries were painless. After the first week both were painless post-op. Never had I or have the need for pain meds. Recurrence of the first was never immediate nor can be described as so.

GI: You ask a good question: “prior imaging showed a sliding hernia and that Dr. Kang would have known this[?] Is this the case? It implies that Dr. Kang’s initial thought about how to repair a sliding hernia were not good enough or that he missed the sliding hernia. Did he say which it was?”

Unrelated to my hernia and before surgery I had a CT scan. Later, one internist looked at it at my request but could not find a hernia. He said prior he might want a scan for that specific purpose. Later I found hernia surgeons could identify one. Being so naive at the time, I never asked them anything other than about size. Years later when I had the recurrence, it dawned on me to show that scan to another hernia surgeon. In our talk he said he could recognize a sliding hernia. I never stated nor implied anything about Dr. Kang’s imaging of my hernia as sliding. I have no knowledge he knew before surgery. He told me about it only afterwards. Apparently you didn’t read my thread about sliding hernia. Your questioning makes it sound as though sliding hernia is unusual. It should not be nor difficult for the experienced surgeon.

• This reply was modified 1 year, 6 months ago by  pinto.

[Unknown Member]

Pinto. Relax. I am simply recounting the facts I have uncovered here and elsewhere. Am I a little paranoid sure. Statistics spouted by all these doctors cannot be trusted. Watchful and other posters here can be. If we have 1 kang recurrance out of 7 kang patients on this forum I think that bears consideration over statistics collected by self promoting doctors. I love kang and find him to be the most honest. But as mark Twain said I am cutting the cards. A waiting room full of recurrent Hernia patients speaks volumes to me as well. Particularly in light of Dr. towfigh’s concern about the kang repair being a Marcy repair that is prone to recurrence. A concern that I do not believe has been properly rebutted by Dr. Kang. As to the shouldice repair and concerns about chronic pain from it I scoured many forms and found large numbers of people complaining about their shouldice repairs. In addition 3 DC surgeons that I consulted said that they had encountered several patients each with chronic pain from “that clinic”. Look I don’t believe anyone after all the lies I’ve been told hernia surgeons. And for the record I don’t believe you either. One week of pain from a tissue repair would be unprecedented. And none of the other kang patients reported that. If you don’t like my posts don’t read them. I could care less what you think.

[Good intentions]

Sorry Pinto but I can’t understand what you’re saying in your account in the other thread. The writing style is strange, from first person to third person and there are details missing. It seems to say that you had intense pain immediately after the first surgery and lived with it for two years. My memory was that you had the pain but it was addressed soon afterward. Maybe it did take two years, I was uninvolved with the forum for a while as I was dealing with my own issues.

If you could just write a simple description, from the realization that you had a hernia all the way through the diagnosis and imaging and first and second repairs it would help people understand. You seem to be saying that prior imaging showed a sliding hernia and that Dr. Kang would have known this. Is this the case? It implies that Dr. Kang’s initial thought about how to repair a sliding hernia were not good enough or that he missed the sliding hernia. Did he say which it was?

Here is your account of “a” surgery. Doesn’t identify it as from Dr. Kang but I assume it was. Not clear.

“Overall, I had a painless surgery and quite pleased with my hospital experience. However there were two difficult post-op aspects in the first four days: immense pain getting out of bed and immense pain walking. After one-day hospital stay, I was discharged but only after requesting crutches. Bumps during my taxi ride back to my hotel were pure agony.”

Then you describe a second surgery two years later. By the writing, you had an attempted repair at the Gibbeum Hospital, had immediate pain and lived with it for two years, then went back to Gibbeum Hospital and had another repair. You’re implying that your “recurrence” happened immediately, probably from just getting out of bed. That’s what the words say.

“Given that Pinto followed the surgeons guide for a safe post-op, he believes if he was able to stay in the hospital in a motorized bed for at least three days, recurrence might not have occurred. It might have even proved the surgery was done flawlessly. He subsequently had a successful operation by the same surgeon two years later without any trouble—- without need for crutches or motorized bed.”

[pinto]

@Herniated, you state: “Yet the anecdotal reports in this thread indicate that recurrent patients have been seen in clusters.” What reports are those?

GI, please see my thread “Sliding Hernia…” for it’s not as fearsome nor rare as we might think.
https://herniatalk.com/forums/topic/sliding-hernia-part-1/

BTW, the CT scan about my own was done before my original surgery, identifying my original IH. So the 2nd surgery was for recurrence not a missed one.

• This reply was modified 1 year, 6 months ago by  pinto.

Sliding Hernia, Part 1

[Watchful]

If I remember correctly, it was a quick recurrence, and it wasn’t a missed hernia. There was one hernia and it was a sliding hernia. Pinto can give more details.

My case was a matter of poor information to work with as you mentioned. The problem was that this information wasn’t really known until surgery because the size of the hernia defect and the nature of my anatomy were known only then. We knew it was a large indirect hernia, but not much more than that. My ultrasound had incorrect measurements. Mesh was more likely to give good results in my particular case, but a difficult and long Shouldice surgery was undertaken instead because that’s what they do over there. My mistake was going to a place that doesn’t tailor the repair.

[Good intentions]

I thought that pinto’s case was one of a missed sliding hernia. Not a recurrence. People keep calling it a recurrence like it happened months or years later. It happened within hours or days, as I recall. As I understand things sliding hernias are unusual and often missed. It’s one of the reasons that Shouldice dissects the cremaster muscle. So they don’t miss anything.

https://herniatalk.com/forums/topic/pintos-2nd-surgery-with-dr-kang/

Pinto makes a good comment about being a lifer once you have a hernia. Besides the fear of future hernias, it really opens a person’s eye to how messed up the medical field is and how machine-like it is in treating patients. It’s actually very industrial and getting more so, with robotics and ambulatory surgery centers. The surgeon can walk in and perform the surgery without actually seeing the body of the patient on the table. It can all be done by video screen and control panel.

On various posters on the forum – there is a lot of “recency” effect happening here. Taking something they read on another web site, or heard from some guy down the street, within the last few months as indicative of the probability of success in the future. And very poor understanding of numbers overall, or willful misstatement. All of the decisions we make in life have a possibility/probability of being wrong or going wrong. If a surgeon has done 1,000 hernia repairs and had 20 pain or recurrence cases, that would be worse than a surgeon with 5,000 repairs and 20 pain or recurrence cases. A rational person would choose the 20/5000 surgeon over the 20/1000 surgeon. People are comparing only the 20 cases that they heard or read about, within the last few months, as indicative of the probability of a successful repair, without considering the successful repairs from the same surgeon. Numbers don’t work that way.

In the end it’s an educated gamble. Watchful went about his research in the right way. But he ended up as one of the 20. That doesn’t mean his decision-making process was wrong. It means he had poor information to work with or he just ended up as one of the unlucky ones. Not much different than getting killed by a drunk driver, or bitten by a shark, or struck by lightning. Don’t drive after midnight, don’t swim in shark-infested waters, don’t go outside in a thunderstorm. It can still happen though. Nothing is certain.

Pinto’s 2nd Surgery with Dr. Kang