Tension-free, non-mesh IH surgery possible?

[pinto]

Dr. Kang,

Thank you for your considerate, thought-provoking yet still balanced commentary. If I got it straight, pure tissue repair by nature involves some amount of tension of the IH tissue; some methods more, some less. Thus it is not possible to eliminate all tension. Mesh sees to erase it all, but as Good Intentions and others, Jnomesh, Uh-oh, point out, mesh has its own tensions to deal with (or not!).

I thought it interesting that you referred to mesh as the “gold standard” as it is by virtue of its having cornered the market in the rich, developed world, but it is not yet developed itself. Various members here who have had this treatment will attest that it failed them beyond reason. World-wide are these cases, so there must be a better way.

Your own work has intrigued us and you so kindly opened a window to it for us. You appear to give the central thrust of your approach:
>we believe that the most important surgical procedure to >prevent recurrence is to seal the hernia hole directly.
Fascinating! Too bad I am a sufferer; otherwise I might pursue a medical degree. 😀 Seriously, that helps much in understanding your approach.

Now don’t all methods of pure tissue repair do that? Apparently not and this can become an important criterion for comparing the various surgical methods. Striking about Dr. Kang’s work is something else–his departure point. He begins not with prior textbook dogma, but what he found as a practitioner: failed mesh devices. That as his inspiration, he has steadily developed his pure tissue repair, much distinguished in South Korea and elsewhere.

Dr. Kang’s post leaves us much to contemplate.

[drkang]

[USER=”2804″]pinto[/USER], [USER=”2029″]Good intentions[/USER], [USER=”2042″]Jnomesh[/USER] and [USER=”1391″]UhOh![/USER],

Hi you all,

I think you are discussing a very important topic. And everyone’s opinion is all right in some ways. In particular, I think pinto has pointed out a very important issue that no one really cares about.
Pure tissue repair has a short term tension just after surgery, and mesh repair can cause chronic tension over time. Immediate postoperative tension of the tissue repair may be the cause of pain during the recovery period and recurrence over a long period of time. On the other hand, the chronic tension in the mesh repair can cause the complication of the mesh such as chronic pain.
As pinto says I do not claim that my surgery is tension-free. However, when I was asked about the difference between the existing non-mesh repair method and my surgery method from the operated patient, I sometimes answered that our surgical procedure especially for the indirect inguinal hernia is ‘tension-free’ to emphasize its very low tension. But as pinto points out, it is true that all tissue repair produces tension, less or greater, immediately after surgery.

However, I think there is more important discussion than whether pure tissue repair has tension or not. Most pure tissue repair until now causes severe tension after surgery, which causes severe pain immediately after surgery. Many doctors also believe that this tension is the reason for the high recurrence rate of as much as 10-30% for the past non-mesh hernia repair. On the basis of these claims, mesh hernia repair called tension-free surgery has begun, and this surgery is now becoming a mainstream operation.

But really? We raise serious questions about this.

My opinion on this matter is entirely different. If post-operative tension is a major cause of recurrence, the recurrence rate of mesh hernia repair should be close to 0%. Because the tension of mesh hernia repair is almost zero. But the reality is not. The recurrence rate of mesh hernia repair is at least 5% on average, although there is a difference according to the report. Others claim to be more than 10%.
The fact that the recurrence rate of tension-free mesh repair is higher than expected suggests that the most important cause of recurrence after a hernia repair may be other than tension. Here we need to remember the recurrence rate of Shouldice repair, which is only 1-2%. Many doctors say these results are only available at the Shouldice hospital and ignore the results. However, it is clear that the recurrence rate of Shouldice repair in Shouldice hospital is very low. Shouldice repair would not be a tension-free operation if they do it at Shouldice hospital. Ultimately, this suggests that recurrence rates may not be high if you do technically correct surgery, independent of tension.

Then what does ‘technically correct surgery’ mean? I think this is a direct suture closure of the hernia hole. In most non-mesh inguinal hernia repair, the main reason for the high recurrence rate is possibly that the hernia hole is not sealed directly. In this way, the hernia hole is not obstructed, but the muscles and ligaments of the outer layer are forcibly pulled and attached together to create a covering wall in front of the hernia hole.

Mesh inguinal hernia repair also leaves the hernia hole open. In other words, the hernia hole is not closed by direct suture in mesh repair. I think this is why the recurrence rate of mesh hernia repair is higher than expected even though it is tension-free. Fortunately enough, it is a tension-free repair that covers the hernia hole with a tough mesh, so it has lesser recurrence than non-mesh repair does, even though the hernia hole is left open as well.

Therefore, we believe that the most important surgical procedure to prevent recurrence is to seal the hernia hole directly. In fact, this procedure is only possible with tissue repair. If the hernia hole is sealed and tightly closed, I am sure there will be no recurrence even if tension occurs. This is supported by the fact that the Shouldice repair at Shouldice hospital and Kangs repair we are doing have a very low recurrence rate despite not being tension-free repair.

Our surgical technique is a non-mesh repair that only seals the hernia hole directly. Because of the type-specific repair of the indirect and direct hernia in different ways and because of the very small operating range, the tension is significantly less than the other one-fits-all non-mesh repair methods. There is little tension, especially after the indirect inguinal hernia repair. So many patients who have very little pain after Kangs repair usually go to work in 3-4 days.

Conclusion.
What is the most important reason why the current tension-free mesh repair remains the gold standard? This is because most doctors believe that mesh repair can effectively prevent recurrence thanks to its tension-free characteristics. So, despite the many mesh complications, it is still regarded as the best surgery. However, based on some of the above, we think that the current assessment of tension needs to be reviewed from the very beginning to see if it is true.

[pinto]

Thank you, Good Intentions, I appreciate it and your continued valuable guidance.

Hey, everybody, we are onto something. I have not seen any challenge anywhere else about this tension-free issue. This is the central plank upon which the mesh establishment is built: Tension-free: Mesh proponents claim that 1) suture repair involves stitching to close up the IH hernia and 2) that inherent tension (stretching tissue and/or stitching) results in higher recurrence. Thus mesh, simply as a cover, sidesteps the tension from stitching/stretching, if I got it correctly. So they ask, “why risk recurrence with non-mesh?” Probably a big selling point.

If however some suture repair has overcome the stitching/ stretching drawback (and recurrence), then why go mesh? With the problems of mesh identified at this Forum and elsewhere, it seems a no-brainer.

But just like food manufacturers slapping the word “natural” on all their products as a gimmick, the proof of being “tension-free” is in the pudding. Can tension-free non-mesh methods bear scrutiny?

Thank you all, and let’s continue on together.

[Jnomesh]

It’s a good point Pinto-hopefully dr. Kang can clarify.

[Good intentions]

[USER=”2804″]pinto[/USER] I misunderstood the point of your first post. I apologize.

[UhOh!]

quote pinto:

Seems you both are barking up the wrong tree. ‘Tension‘ here is neither shrinkage nor tissue rejection. By definition suture repair involves tension because it stretches the IH membrane together to patch the IH gap or hole. Because mesh repair instead ‘covers‘ not stretches the membrane, mesh repair is hailed as tension-free. If suture repair also can do that then its the biggest story ever–and begs to be told.

I think this is why the Desarda repair is considered a “tension-free” repair. As I understand it, it utilizes a flap of muscle to cover a defect without the need to stretch structures to suture them together.

I believe one of Dr. Kang’s two repairs is also tension-free, that for an indirect hernia. For a direct hernia, if you look at the repair type comparison chart on his hospital’s website, it says there is some tension when creating an auxiliary barrier with existing structures. Again, as I understand it, there are two parts to his direct hernia repair: suturing together the torn fascia (no tension) and creating the auxiliary barrier similar to the original Basini repair (some tension).

[pinto]

You state, >Tension-free” is meant to refer to sutures not pulling through tissue<
This seems impossible: suture is a stitch or row of stitches holding together the edges of a wound or surgical incision (OED). Penetration of the tissue by stitches ultimately must put pressure on the surrounding tissue not to mention that tissue must be pulled together to close the IH gap.

You falsely claim (by implication) that I “want to criticize Dr. Kang’s claims.” Do I?? Has he made such claim that his suture repair is tension-free in the sense used by proponents of mesh repair? Please point to his own direct statement about it. I have not seen such, so I am careful not attribute possibly false claims to someone.

Simply because I criticized your previous post must mean that my original inquiry is meritless? That seems your point. I admit you are knowledgeable and a great contributor: I have already applauded you both privately and publicly at this forum. I am simply trying to sort out a very complicated medical matter that is IH. Nothing more, nothing less.

Your first sentence of your first reply to my inquiry: “I can’t argue the use of “tension-free” as a term, but mesh actually is full of tension.” Then please dont argue it but it turns out you do. Second you side-track us by taking aim at the mesh approach. This present thread is not focused on mesh; rather it inquires if suture repair actually can say it is tension-free.

Presumably this term was not in parlance prior to the advent of mesh repair. If I am not mistaken this is a key difference between the approaches–at least from the view of mesh proponents. Thus a worthwhile question this present thread asks.

[Good intentions]

quote pinto:

Seems you both are barking up the wrong tree. ‘Tension‘ here is neither shrinkage nor tissue rejection. By definition suture repair involves tension because it stretches the IH membrane together to patch the IH gap or hole. Because mesh repair instead ‘covers‘ not stretches the membrane, mesh repair is hailed as tension-free. If suture repair also can do that then its the biggest story ever–and begs to be told.

quote Good intentions:

“Tension-free” is meant to refer to sutures not pulling through tissue, I believe. So, a surgeon that takes care to evenly distribute the sutures and layers the tissue so that it attaches to itself, could end up “tension-free” after healing occurs, I’d guess.

I think that my words said just that, if you look a little deeper. You can’t pull through the tissue without tension. Pulling is tension.

If you want to criticize Dr. Kang’s claims you should just do so directly. Not really clear what you’re trying to accomplish. We made some good comments about what “tension ” is, or means, by definition of the word tension. Neither of us is barking up a tree, just responding to your remarks.

[pinto]

Seems you both are barking up the wrong tree. ‘Tension‘ here is neither shrinkage nor tissue rejection. By definition suture repair involves tension because it stretches the IH membrane together to patch the IH gap or hole. Because mesh repair instead ‘covers‘ not stretches the membrane, mesh repair is hailed as tension-free. If suture repair also can do that then its the biggest story ever–and begs to be told.

[Jnomesh]

Also mesh is known by the medical community to shrink in some cases as much as 50% pulling and rigging on tissue and muscle and structures and sutures/tacks/ staples which caused tension. The only technically on paper benefit of mesh is that it covers the other areas in the inguinal region where hernias can be caused. So I’m lapro mesh it covers direct indirect and femoral hernia. In open surgery it covers direct and indirect areas .
It after reading dr. Browns reply In which he repaired Dog’s indirect hernia without mesh and also in the same surgery reinforced the direct space as it was weak and possibly a hernia cools form down the line it seems in the hands of a talented pure tissue expert (in which there few) non mesh repairs can also do what mesh is touted to do in regards to strengthening the surrounding areas without the use of mesh

[Good intentions]

“Marketing” is interwoven through everything we do these days. Selling.

[pinto]

If I recall my readings correctly, explanations of mesh surgery typically consider suture-repair as the same as tension. That and the claimed lower recurrence rate, as I recall, are main arguments for mesh repair. If suture-repair can be made tension-free (seemingly paradoxical by definition), then please anyone edify me about this. Good Intentions graciously responded and made a well reasoned response. If so, it begs the question why suture-repair and tension are so closely associated, at least from what I have seen.

[Good intentions]

I can’t argue the use of “tension-free” as a term, but mesh actually is full of tension as the healing process happens. It’s just massive and distributed over a large area.

“Tension-free” is meant to refer to sutures not pulling through tissue, I believe. So, a surgeon that takes care to evenly distribute the sutures and layers the tissue so that it attaches to itself, could end up “tension-free” after healing occurs, I’d guess.