Surgeon recommendation in Oregon or Washington that repairs without mesh?

[SN]

Looking for a surgeon recommendation in Oregon or Washington, particularly someone with experience on doing non-mesh repairs?

[William Bryant]

Home Page – March Updates

There’s Dr Yunis in Florida. I don’t know geography as I’m in UK.

[Mike M]

The closest specialist I am aware of near the Oregon / Washington region would be the owner of these forums – Dr. Towfigh located in Bev Hills, Cali. (310) 358-5020

She has a lot of different options available and is a modern pioneer in the field.

I would be extremely careful when selecting your surgeon. There have been many not so positive stories passed on these forums of local surgeons who are willing to do the repair but are not “experts” with solid track record of positive patient experience.

A few quick searches on here will show you how bad some of the cases can get with the wrong surgeon.

Dr. Towfigh, Dr. Yunis, Dr. Sybai, and Dr. Kang (who I recommend if you are willing to travel overseas) all have positive stories on these forums from former patients.

[SN]

Thanks for the replies. I reside in the NW, hence, I was looking for surgeons close to me. However, I am fully aware of the other surgeons you mentioned that are farther East. Dr. Towfigh in California would be the closest travel.

However, going back to your statement regarding “being extremely careful when selecting a surgeon” — are you referring to surgeons that are doing non-mesh ala tissue suture repairs, or are you talking about any surgeon in general? If the former, that makes sense, as tissue repair surgeons (unless they’re trained or specialized like at Shouldice) are more rare. It appears majority of hernias are done with mesh, however, I believe I have a small hernia that may be better suited with tissue repair.

[Good intentions]

You might try Dr. Andrew Wright at UW Medicine. Although he is a mesh proponent he also removes mesh so is aware of the issues. If he doesn’t feel confident in his own skills he probably knows somebody that is good.

https://www.uwmedicine.org/bios/andrew-wright#about-tab

[JamesDoncaster]

Peter Billings can do a Bassini repair I believe. But, my recommendation is to go to somebody that specializes in tissue repairs, which means you will have to travel (I live in WA and know of nobody here that does tissue repairs as their primary practice.

Dr. Wright put mesh in me and removed it later. He is a competent surgeon for mesh repairs and told me he could do a McVay repair. But, he also suggested to me that, if I wanted to tissue repair, it might be best to go to Shouldice.

[Good intentions]

JamesDoncaster you are the second person that I know of, for whom Dr. Wright removed the very mesh that he had implanted. In the other case the person just could not stand the feeling of the mesh inside his body and had it removed within months of implantation. I don’t remember the details of your case, if you had posted them. I’ll have to look.

I wonder how Dr. Wright justifies implanting mesh then removing the same mesh that he had implanted. What changes does he make to his method to avoid performing two surgeries on the same patient, leaving them worse off than when they came to see him?

I realize that I have completely flipped sides, first recommending Dr. Wright, now criticizing him. The rationale behind what’s going on in the hernia repair field doesn’t seem consistent with logic. It’s all very strange.

[Good intentions]

Dr. Martindale at OHSU might be worth talking to. From what I’ve seen he is open-minded and takes on very difficult abdominal problems, both mesh-related and not. He is a bit older so has seen the rise of problems and probably knows more than a typical new surgeon of today who was never trained in how to perform a pure tissue repair.

Unfortunately OHSU tends to have a very long wait time to get in to see anyone. Worth a shot though. There is a forum member who has seen Dr. Martindale and might have some insight. I’ll see if I can find her posts.

https://www.ohsu.edu/providers/robert-g-martindale-md-phd

[Good intentions]

I found the member, she is mamadunlop. Also, apparently, Dr. Martindale has been on HerniaTalk LIVE on Youtube.

Click on Activity and you can see her old posts.

https://herniatalk.com/members/mamadunlop/

[SN]

Thanks for the recommendation. OHSU seems like it would be great. The surgeons there would be a good fit. Just viewed that video and it appears Dr. Martindale is truly an expert with ample experience. The only consideration is that he is in his 70’s, so I wasn’t sure if down the road if I were to need revision surgery, he would probably be retired.

[Good intentions]

Hope for the best, plan for the worst. I had the opposite feeling – get the benefits of his knowledge while he is still available.

Who is coming through today’s system that will be better? His colleague at OHSU, D. Orenstein, is very firmly in the mesh camp. When all you know is mesh everything looks like a mesh application.

[ajm222]

FYI – Shouldice is a 2-3 month wait just for a consultation. Then surgery would be another wait. If you need general anesthesia, like they suggested I might because of ‘all the damage from mesh removal,’ it’s a 2-3 YEAR wait for surgery. I do think I could convince them to do mine without GA.

[MarkT]

@ajm222 – where are you getting those timelines???

The consulation clinic used to be walk-in, but I see it is appt now (no referral req)…and surgery typically was anywhere from 1 to a few months out. I can imagine the backlog of cases from the pandemic has affected that…but 2-3 months for consult and 2-3 years for surgery…are you sure about that???

• This reply was modified 1 year, 1 month ago by MarkT.

[SN]

After consulting with a previous surgeon, he suggested no surgery due to no palpable bulge. I believe Shouldice would also mirror the same recommendation as they do not operate if there is no physical bulge. My main issue is I’m in a picky dilemma where I am mildy asymptomatic and the surgeon isn’t convinced that my symptoms are from the small hernia that is only reproducible on supine ultrasound with valsalva.

However, going back to your remarks on Dr. Orenstein — why do you suggest he is firm in the mesh camp whereas Dr. Martindale is more open? I know he also did a talk with Dr. Towfigh as well.

[ajm222]

Directly from the patient coordinator at Shouldice. I contacted them. The 2-3 years is for cases requiring general anesthesia. They just rarely do that. “2 per week, but demand for outweighs their resources.” Because I had mesh removal, they said it would probably need to be under GA. They stated specifically that at the moment “wait time for GA surgery is 22 months and the wait time for a consultation appointment is currently 2-3 months.”

[Dudley]

Just a quick comment to the above. I’m not so sure that you can completely infer that Dr. Orenstein would insist on mesh – at least to the degree that it might not be worth the effort to at least go for a consult to be sure of that assumption. He is a very well-regarded Hernia surgeon, and in many past societal gatherings has been a leading resource lecturing on all the different types of mesh’s available and various pros and cons etc. He frequently does the same when addressing different types of hernia’s and atypical presentations. While I do know there are various camps that lean a bit more heavily one way or the other in terms of mesh aversion or the belief it is necessary in most cases…I’m not so sure that we can be sure anyone is as firmly planted in every situation, or that a good surgeon might not be more amenable to offering a couple of options for each individuals particular case. I’ve met with a number of the top experts out there for a unique abdominal wall situation, and have found that while many are very vocal about the recommendation as they see best, many are still open to including the patient in the decision-making process about the various options with and without. Again, not speaking from experience with Dr. Orenstein but it might not hurt to have the discussion before you rule it out. That team there is known to be pretty sharp and specialized.

[Good intentions]

My impression was affected quite a bit by a presentation he gave at a SAGES meeting. I created a Topic about it. I do try to be open-minded but what I often see seems to be efforts to rationalize the state of hernia repair today. I do think that Dr. Orenstein’s first inclination would be to suggest mesh implantation for even the simplest hernia. He might offer a pure tissue repair but he would probably recommend a mesh repair. That is my impression.

Here is a link to that other thread. Feel free to correct my impressions, I won’t be offended. The first few minutes should be enough. He even jokes about the problem.

Mesh – Is it the Cause of the Problem? SAGES 2019

[Dudley]

Fair enough. It doesn’t surprise me that he may be of the ilk that leans more into the ‘mesh is a vital tool camp’ than some of the other tissue only/mesh aversion types. (And believe me, I wrestle with a similar concern of the material for a looming AWR reop, so I have significant appreciation for your desire to make your first foray tissue based if possible and certainly can see the validity in that preference. I will just say that I’ve seen a lot of these top name surgeons in the space, and many were more willing than you might think upon first blush to offer a couple of paths. Certainly with a strong preference and “if it were me” often in the recommendation, but not always as cemented to one particular path only. Just food for thought that might be worth the co-pay for a consult was all I was thinking.

[SN]

Thanks for the recommendations, everyone. If you have more experiences in Oregon/Washington/California (or even Idaho/Nevada), please let me know. I am trying to do my research on the best potential surgeon that specializes or can do a sufficient tissue repair.

[MarkT]

SN, you are correct that Shouldice typically will only operate if the hernia is palpable upon physical exam (there does not need to be a visible bulge, but they have to be able to feel it).

Not sure if crossing the border is a big inconvenience, but Shouldice is having an examination clinic in Vancouver, BC in case that is of interest:

Shouldice Hospital is returning to Vancouver!
Hernia Examination Clinic September 26, 27, 28 & 29
For further information call 1-844-712-1362

September 2022 – Vancouver Clinics

[Good intentions]

Dr. Brown’s practice is still open, under new management. Hard to tell much about him, he’s trained in laparoscopic and robotic methods but the non-mesh hernia repair is still described. The focus still seems to be athletic pubalgia.

He’s down in the Bay area.

Home

[ajm222]

@MarkT Directly from the patient coordinator at Shouldice. I contacted them. The 2-3 years is for cases requiring general anesthesia. They just rarely do that. “2 per week, but demand for outweighs their resources.” Because I had mesh removal, they said it would probably need to be under GA. They stated specifically that at the moment “wait time for GA surgery is 22 months and the wait time for a consultation appointment is currently 2-3 months.”

[Watchful]

The wait time there for surgery with local anesthesia isn’t short either (5 months). There’s a lot of demand for tissue repairs, and so few surgeons who can perform those well.

[MarkT]

Thanks for clarifying. 22 months if requiring GA is quite unfortunate…I guess they are basically saying ‘go somewhere else, if it is more urgent and you need GA’.

Five months for the usual repair with IV sedation and local is not *too* bad, all things considered (i.e., pandemic backlog) as it has historically been a few weeks to a few months anyway, depending on volumes…but it could be a consideration for those considering ‘watchful waiting’. It might be worth booking a date now, then rescheduling or cancelling later if you want to continue waiting for whatever reason (I still tend to not agree with watchful waiting, but I understand that everyone’s situations and priorities are different).

I really wish there were a dozen Shouldice Hospitals, perhaps with some practical changes (like eliminating the requirement of a multi-day stay and not being able to choose your surgeon). It is ridiculous that options are comparatively limited for those seeking tissue repairs by similarly expert-level, high-volume surgeons.

[Watchful]

@markt

Watchful waiting for inguinal direct/indirect hernias is a good thing for those whose condition allows for it. Sure, chances are they’ll need the surgery eventually, but there isn’t really a good-enough reason to do it sooner. The risks of surgery exceed the risks of not doing it in such cases, and the cure is worse than the disease. It’s better to wait until you really have to do it. I’ve been doing watchful waiting for decades, and now I need to have the surgery done, but I’m glad I didn’t do it before. The surgery could have easily affected my life more than the hernia did. When I decided to wait, I didn’t even know how problematic these surgeries were.

It is indeed very frustrating that the options are so limited for tissue repairs. If anything, I think the situation will get worse because of surgeon retirements. There is almost no training for a next generation.

I also wish changes were made at the Shouldice Hospital. Offer outpatient surgeries, maybe with an option for a stay at the hospital for those who want/need it, possibly in a private room for extra payment. Allow choice of surgeons. Research cutting the cremaster with the nerve and vessels to make sure it really makes sense to do it, and stop doing it otherwise. Find a way to help those in the 2% (or whatever it is) who end up with chronic pain after the surgery.

[William Bryant]

The not choosing surgeon at shouldice is a worry. Especially as I remember someone posting on here that the one thing patients have control over is surgeon, so make sure to choose good, experienced surgeon.

Also surprised not more surgeons afe learning tissue repair as there is huge opportunity. Especially true in UK and probably Australia as very limited tissue repair options.

[MarkT]

It is a worry, but IMHO it should not be as big a worry as it seems on the surface.

Why do we want to choose our surgeon? Because we know that surgeon skill/experience with any repair is an important factor in patient outcomes. How does a surgeon gain a high level of skill/experience? With proper training in the repair and by performing a large number of them with regularity.

Where is there likely to be better training in the Shouldice repair, and where is a surgeon likely to be performing more repairs with higher frequency, than at Shouldice Hospital?

Ask any surgeon you are considering how many Shouldice repairs they have performed to date and how many/how often they perform them today and then compare that to the numbers for even a ‘new’ or part-time Shouldice surgeon. I bet the answers will surprise you.

I don’t mean to imply that there are not excellent options for a Shouldice repair outside the Shouldice Hospital…or that there is not variation in outcomes between Shouldice Hospital surgeons (no doubt some are better than others)…but you are very likely getting a certain ‘high’ standard of skill/experience at Shouldice, regardless of which surgeon you get. That may not eliminate the concern at not choosing your surgeon, but that additional context should reduce it a great deal, IMHO.

[Watchful]

“Very likely” isn’t quite good enough with something like this, though… We have only one body which is irreplaceable, and we have to live with the consequences of surgery for the rest of our life. A lot can go wrong which is out of your control, but taking away your control over the one critical factor that can be controlled (the choice of surgeon) is not good. Some surgeons simply aren’t as good as others. You can even get a trainee operating on you under supervision. Also, they have visiting surgeons often, so your surgery can become a show with a distracted surgeon. Having the ability to pick your surgeon and insist that they focus entirely on your surgery doesn’t seem like a crazy requirement when considering what’s at stake here.

I read pretty much all the reviews, comments, and blogs about the Shouldice Hospital. There is definitely variation among surgeons. One striking thing is that recurrences must indeed be quite rare because people aren’t complaining about that. On the other hand, you do find reports of chronic pain and/or discomfort, testicular issues, and infections.

The chronic pain number they mentioned recently is 2%, although an estimate of 5% was mentioned in Dr. Netto’s interview with Dr. Towfigh. Not awesome, but I don’t know how it compares with mesh when implanted by top surgeons.

One nagging thing with them is this business with cutting entirely the cremaster. This is quite radical. It destroys that muscle as well as the genital nerve branch and the various blood and lymphatic vessels attached to the cremaster, including those responsible for collateral testicular blood supply (not the primary supply, but still). Almost no one does this outside the Shouldice Hospital these days, and the recurrence results when this is not done still seem extremely good, so it’s not at all clear that this radical step is justified. There isn’t as much data about the modified procedure, so who knows for sure, but it’s an area the deserves more evaluation by the Shouldice Hospital in my opinion.

[MarkT]

“Very likely” might not be good enough in your eyes, but in reality that is what we have to work with because we don’t have great data.

Of course there is variation among the Shouldice surgeons…the question is what the *range* of that variation looks like. Since we don’t know, we have to fall back on logical reasoning when thinking about it.

I will point back to what I said earlier…if skill/experience is a primary consideration, then where do you think surgeons are getting better training and more experience with the repair than at Shouldice Hospital? Per the website, all surgeons “regardless of prior experience” are required to assist on 50 repairs before being allowed to perform their own, and then must perform up to 100 more before being allowed to lead a surgical team. Do you think external surgeons are getting the same training and supervision before doing their own Shouldice repairs, never mind performing them with the same regularity?

So while there certainly is variation amongst Shouldice surgeons, that variation is likely to be fairly small after a rather brief period of time…and it is also likely that range still occupies a higher level of the skill/experience spectrum such that even the ‘low performers’ at Shouldice are likely to be comparable (if not better than) the majority of external surgeons who have performed fewer Shouldice repairs and with lower frequency. Of course we can’t KNOW this…but logically speaking, that is a reasonable belief absent evidence to the contrary (evidence we essentially can’t get).

Reviews, blogs, etc. are helpful, but they are neither representational nor verifiable. IMHO, they are mostly useful to identify potential red flags. For example, if you see multiple instances of the same criticism, then you might want to dig a little deeper or ask certain questions. But if you are basing your assessment of a surgeon largely on reviews and blogs, then you are fooling yourself into believing that you have anything close to a clear picture. Further, if you try to compare surgeons on that limited, non-representational, unveriable information, then you *at least* need to adjust the raw number of ‘bad reviews’ to account for differences in how many repairs each surgeon has done, how long they have been practising, etc.

How the cremaster is treated not terribly relevant to the debate on whether it is problematic to not choose your surgeon at Shouldice…it is more relevant when deciding whether to go to Shouldice in the first place.

Observers being allowed is also not relevant to the concern over not choosing a surgeon there…and is even not likely too relevant overall when you consider that hospitals routinely allow residents and other observers (and for much ‘higher stakes’ surgeries than inguinal hernia repairs). If it was such a potential hinderance to surgical teams, it would not be allowed…and Shouldice, as a private hospital that is not affiliated with a university, would presumably have even less obligation/motivation to allow observers if it were a problem. If you want to reach for a possible effect on allowing observers, you could also just as easily frame it as a positive…that a surgeon might be more careful as they want to ‘impress’ or at least not mess up in front of others.

The unknown chronic pain numbers are neither relevant to not choosing your surgeon at Shouldice nor a unique concern to Shouldice…what other surgeons have independently verified, long-term follow-up of their patients to nail down a firm number?

Having said all that, would I rather be able to choose at Shouldice, even absent good data to inform that choice? Sure…even limited, unreliable, non-representatioal information on blogs, forums, reviews, etc. is (hopefully) better than nothing…but my point was merely that not being able to choose at Shouldice is likely not *as big* a deal as it might seem on the surface…because of the training and experience that all surgeons will quickly gain there (compared to the training and volume/frequency of most external surgeons offering the repair).

To the broader question of choosing Shouldice at all, I share some of your concerns and there are things I would like to see changed/improved or be better studied. The multi-day stay is surely not critical for all patients and most other surgeons treat is as day surgery or an overnight stay…more study on the pros/cons of cremaster resection (and perhaps giving patients the option to choose how it is treated)…whether the ‘narrow’ patient profile is too narrow and should be expanded…and some updating of the hospital itself to match more modern facilities. I am also intrigred by Dr. Kang’s tissue repairs, particularly that he treats indirect and direct hernias differently and does not have such a narrow patient profile, and I hope they become better studied.

[Watchful]

MarkT,

We seem to be largely in agreement based on your last two paragraphs. You would like to see the same improvements. My point wasn’t that all these issues make the Shouldice Hospital a bad choice. It’s one choice among a number of options all with their own issues.

Not sure why you thought there’s some connection between not being able to choose the surgeon and other issues – no one was claiming that.

They are doing a study of chronic pain/discomfort among their patients finally, but it will end only in 2024.

If you want a minimalist procedure for an inguinal hernia, it’s definitely not the place to go. It’s about as far removed from the Kang approach as you can get… The incision is very large (5-6in!), massive dissection, exploration, and stitching, complete resection of the cremaster, genital nerve branch, and cremasteric vessels (seems pretty extreme to do that to young patients in particular!)

One alternative would be going to someone who performs a less aggressive version, such as Dr. Yunis, Dr. Towfigh, or one of the German surgeons. Smaller incision (hence faster recovery), and leaving the cremaster, nerve, and vessels intact. How the results compare in terms of recurrence and chronic pain isn’t completely clear, and we aren’t likely to get definitive answers any time soon.

Then you have Desarda which is a much simpler procedure. Research results have been pretty stellar so far, including long-term studies of 15 years. It has been adopted by quite a few surgeons around the world. There’s a surgeon in the US who has performed thousands of these (Dr. Thomas). There is a mention of Desarda on the Shouldice Hospital site, and the only negative they mention is that the entire area isn’t explored to find additional hernias. Seems like something that could be addressed by performing a careful ultrasound before surgery if it is a concern.

The Kang approaches (for direct and indirect) are even simpler, but longer term data is really needed there.

I’m leaning toward going with one of the surgeons performing a modified Shouldice (smaller incision, preserving the cremaster, prolene sutures).

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