News Feed Discussions Surgeon recommendation in Oregon or Washington that repairs without mesh?

  • Surgeon recommendation in Oregon or Washington that repairs without mesh?

    Posted by SN on August 16, 2022 at 1:17 am

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

    Watchful replied 1 year, 10 months ago 9 Members · 29 Replies
  • 29 Replies
  • Watchful

    Member
    September 4, 2022 at 2:43 pm

    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).

  • Watchful

    Member
    September 2, 2022 at 12:15 pm

    “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.

  • William Bryant

    Member
    September 1, 2022 at 11:39 am

    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.

  • Watchful

    Member
    September 1, 2022 at 11:33 am

    @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.

  • MarkT

    Member
    September 1, 2022 at 10:07 am

    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

    Member
    August 31, 2022 at 8:01 pm

    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.

  • ajm222

    Member
    August 31, 2022 at 10:54 am

    @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.”

  • Good intentions

    Member
    August 28, 2022 at 10:02 am

    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.

    https://www.sportshernia.com/

  • MarkT

    Member
    August 28, 2022 at 9:38 am

    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

    https://www.shouldice.com/remote-clinic

  • SN

    Member
    August 28, 2022 at 1:11 am

    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.

  • Dudley

    Member
    August 20, 2022 at 5:44 pm

    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.

  • Good intentions

    Member
    August 20, 2022 at 10:19 am

    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.

    https://herniatalk.com/forums/topic/mesh-is-it-the-cause-of-the-problem-sages-2019/

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

  • Dudley

    Member
    August 20, 2022 at 8:40 am

    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.

  • SN

    Member
    August 20, 2022 at 2:05 am

    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

    Member
    August 18, 2022 at 1:00 pm

    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.

  • Good intentions

    Member
    August 18, 2022 at 11:40 am

    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.

  • SN

    Member
    August 17, 2022 at 3:44 pm

    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

    Member
    August 17, 2022 at 1:04 pm

    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/

    https://www.youtube.com/watch?v=ypUHTX64gNM

  • Good intentions

    Member
    August 17, 2022 at 12:59 pm

    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

    Member
    August 17, 2022 at 11:22 am

    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.

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