[drkang]

Hi KodyH,
Are you recovering well?

Regarding Prolene, you don’t need to worry about it.
It does not increase the chronic pain risk but provides extra strength in case of extreme situations, I think.

[drkang]

My pain statistics include both Kang repair and Gibbeum repair results. There was no significant difference in pain statistics between the two surgeries. However, in case of sliding hernia repair, the pain risk seemed to increase slightly.

In gibbeum repair, the lateral fascia of rectus muscle is sutured to the inguinal ligament including the iliopubic tract back and forth twice.

It is true that I performed a hernia surgery on KodyH yesterday.

[drkang]

Hi all,

Just for clarification.
During the process of Kang repair (for indirect hernia) or Gibbeum repair (for direct hernia), we always check if there is another type of hernia, and if found, surgery is performed on that part as well.

We also always take steps to prevent other types of hernia from occurring in the future.

Many people think that Kang repair is a variation Marcy repair, but I do not agree with this opinion at all.
Just as Shouldice is a different surgery from Bassini or McVay, Kang repair and Marcy are completely different surgeries.
The only sharing aspect in both surgeries is that they do not fix the intact Hesselbach triangle.

And yes. It is true that there are some returning patients with pain several months or a few years after undergoing our procedure.
However, most of these people’s concern is not about the pain itself but whether it is a symptom of recurrence.
In other words, it is very rare for patients to come back because the pain itself is difficult.

I know most people on this forum will disagree with me.
However, through over 16,000 consecutive our pure tissue repairs, most patients achieved good results. Some of them were over 100 years old, and some were very weak due to chronic heart disease, lung disease, kidney disease, liver disease, etc.
There were also many patients who came with hernias that recurred once or multiple times (after open mesh, lapa mesh, or various tissue repairs), and some with a huge hernia larger than a child’s head size.
Through this experience, I am convinced that mesh has no place in inguinal hernia surgery.
Of course, as many people point out, we acknowledge that the follow-up period for our surgery is not long enough.
However, the results so far are enough to give me that confidence, and I am not concerned about the durability of our surgery.
Thank you!

[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.

[drkang]

Hello Watchful,

You seem to be now at a very sensitive point in making your final decision. So, I am very careful about posting new article.
Shouldice surgery is surely a very good repair technique. And I do not intend to influence your decision in any way. I think you’ve worked very hard, and have more information than surgeons, so you’re good enough to make the best decision for yourself.
Nevertheless, I am posting this simple article because I felt the need to answer your doubt about Pinto’s case. You pointed out that Pinto’s recurrent case was omitted in my previous statistics.

I have changed the surgical method dozens of times since I started non-mesh tissue repair in 2012. Just like a child growing up, Kang repair took on its present form as it grew up.
The reason the last statistics were for patients 7 to 32 months after surgery was because there was an important change in our indirect hernia repair method in December 2019, 32 months ago. Before then, all indirect hernias were repaired with absorbable 2-0 Vicryl. But from December 2019, I used permanent 2-0 Prolene in some patients, because I suddenly had a thought that an absorbable suture material might be the cause of recurrence.
At the beginning, Prolene was used only in patients with sliding hernia, recurrent hernia, large incarcerated scrotal hernia, or in patients with large internal ring or severe ascites etc. And for patients with average risk, I continued to use an absorbacle Vicryl. As a result, there was no recurrence in 401 high risk patients who used Prolene, but among 1405 patients who used Vicryl, recurrence occurred intermittently, and 12 patients have relapsed so far. So, since September of last year, we have repaired all indirect hernias with permanent 2-0 Prolene.
My previous statistic of no recurrence with 738 patients 7-32 months after indirect hernia repairs, were only about those with the permanent Prolenes.

Pinto, who underwent the first operation in August 2019 for left sliding hernia, was excluded from the previous statistic because he had surgery with Vicryl at the time. But Pinto’s reoperation was done using Prolene in March of this year.
Thank you all, and thank you Mike M!

[drkang]

Yes.
We do an ultrasound of both groin areas to confirm the presence of all possible hernias before surgery.

[drkang]

Hi Monika,

McVay or Shouldice method for a femoral hernia takes a transinguinal approach. Therefore, to repair the loose femoral canal through which the femoral hernia passes, the external oblique aponeurosis is opened, the spermatic cord is mobilized, and the transversalis fascia is opened before repairing a defect. This process is complex and thus may reduce the surgical success rate.

In our infrainguinal approach, after skin incision, the defect can be identified easily by finding the hernia sac and dissecting it from the surrounding subcutaneous fat tissue. In order to prevent recurrence in this operation, the most important thing is to separate the weak tissues around the defect, that is, the hernia opening, and to check the strong ligamentous structure. If this strong defect margin is accurately sewn and blocked, the operation is completed easily.
Usually, the diameter of femoral hernia defect is less than 1 cm, so there is not much tension after surgery.

[drkang]

Thank you, Mark T.

Thanks to you, I become to know how to operate on a femoral hernia in Shouldice hospital.

The reason that McVay repair, which is a representative tissue repair method for femoral hernia, is not an easy operation for the average surgeon, is that it requires suture to the Cooper’s ligament. Because the Cooper’s ligament is deeper than the inguinal ligament and is very close to the femoral artery and vein, it is very careful to access the Cooper’s ligament during surgery.

However, the femoral hernia repair method in Shouldice hospital seems to deal with the Cooper’s ligament more difficult than McVay repair in my opinion. Of course, Shouldice surgeons are likely to have a lot of experience in this operation, so I think that this operation could be performed more easily there.

[drkang]

Hi Monika,
I am sorry to hear you have multiple hernias.

Shouldice or Desarda or Bassini methods for inguinal hernia repair cannot be used to repair a femoral hernia. I don’t know if Shoudice hospital has a special tissue repair method for a femoral hernia.

Among the well-known tissue repair methods, the one that can be used for femoral hernia is McVay repair, but its surgical method is rather difficult, so I think it will be very difficult for doctors who are not familiar with tissue repair these days to perform this operation successfully.

Our hospital has developed and implemented a new and simple tissue repair method for a femoral hernia. Femoral hernia is not common, so we don’t have many cases. Over the past 7 years, about 80 cases of femoral hernia have been operated on with this tissue repair method. And there was one recurrence so far.

[drkang]

Hi William Bryant,

I haven’t thought of a specific retirement schedule yet. I think I will probably be working for at least 10 more years. As Mike M said, in our hospital, surgery is performed under local anesthesia with sedation, so many elderly people come to receive hernia surgery. So far, there have been over 100 patients over the age of 90, of which three were over the age of 100. All of them completed the surgery without any problems and recovered well.

[drkang]

Hi all,

I am not sure if I could personally answer the various doubts about Kang repair. Because I am afraid that my intentions may be perverted. However, I think it will be helpful to broaden our understanding by giving answers to the various doubts raised.

Marcy repair was developed around 1870. So it is difficult to say the exact surgical method nowadays.
Kang repair for indirect inguinal hernia is the same as Marcy, only narrowing the deep inguinal ring, but the specific surgery method is completely different.
Marcy was developed as a surgical technique for adult hernias. Therefore, the claim that Marcy is only applicable to child hernias is not correct. In most child hernias, high ligation of the hernia sac is sufficient, so repair of the deep inguinal ring is not required.

Therefore, to say that Marcy is a surgery that can only be used for child hernia is an expression of disrespect for this surgical technique, I think.

Surgeons don’t just do surgery. After surgery, follow-up and management should be done. Therefore, it is difficult to continue the operation if the results are clearly bad. Because many patients will continue to complain. However, I have done over 12,000 surgeries in a similar way so far, and I don’t feel any pressure to continue with this method.
The answer to why Marcy is rarely done if its result is good may be similar to the answer to the question of why mesh repair continues despite mesh complications. Anyway, Kang repair for indirect hernia differs from Marcy.

Most of the tissue repairs as well as the Shouldice focus on repairing the Hesselbach triangle. Therefore, it is difficult to say that these are the proper surgical methods for indirect inguinal hernia. Because most indirect inguinal hernias have a healthy Hesselbach triangle.

[drkang]

No clinical trial has been done for that part. And I think 1% or 5% of Shouldice pain incidence is much lower than that of mesh repair. The incidence of chronic debilitating pain after mesh repair is probably around 5%, I guess.

If Kang repair has a lower incidence of chronic pain than Shouldice, I think it may be because of the difference between the surgical scope and the surgical process. For Shouldice repair, the skin wound is about 3-4 inches, whereas Kang repair is about 1.5 inches. The size of the skin wound refers to the size of the surgical area.

And Kang repair preserves normal tissues as much as possible, whereas Shouldice repair cuts the cremaster muscle and genitofemoral nerve, etc. It means Shouldice is more aggressive. Due to this invasiveness, the chronic pain incidence could rise.

[drkang]

Hi Watchful,

After receiving your question and reviewing my surgical record again, I found that 12,363 non-mesh inguinal hernia repairs have been performed since 2013, and 217 patients have had reoperation due to recurrence. 1.8% of the total.
However, since 2013, my surgical method has improved over 50 times. Therefore, these statistics cannot be regarded as representing the recurrence rate of Kang repair in the final method currently being used.

The number of people who have had surgery with the current method so far is 1,528. Of these, 675 patients had more than one year after surgery, and 4 cases required reoperation, accounting for 0.6%.

This is not accurate follow-up data conducted through telephone interviews, etc. But I think people who have relapsed come back to me with few exceptions. This is because they are all people who have received Kang repair with a reluctance to mesh repair. However, I do not want to guarantee that no one will go to another hospital after a recurrence. Please refer to this and evaluate our recurrence rate.
Also, please evaluate the mention of chronic debilitating pain in my previous posting in the same context.
Thank you!

[drkang]

The Surgical Clinics of North America (SCNA), published under the title of Hernias in April 1984, three years before mesh repair was introduced, said, “Groin pain after normal convalescence from an inguinal hernioplasty is infrequent, but when it occurs, it invariably precipitates a visit to the surgeon by the patient, who believes that the pain indicates recurrence. Although groin pain may, in fact, herald a recurrence, in most cases it disappears spontaneously without sequelae.”

The author seems to have foreseen the excuses of today’s mesh repair surgeons, saying that there were many chronic pains in the past too and that it is not a problem only with mesh repair.

Also, on page 126 of Daniel B. Jones’ textbook ‘HERNIA’, Figure12.1 shows Google ngram comparison that the number of uses of the word ‘chronic groin pain’ in books listed on Google has increased sharply when compared with ‘inguinal recurrence’ since 1987. 1987 was the year when mesh repair was first introduced and gradually started.

The claim that tissue repair causes chronic pain as much as mesh repair might be a defocus strategy.
I have performed more than 70 mesh removal operations so far for a person who complained of chronic debilitating pain after mesh repair. However, while I’ve done over 10,000 tissue repairs, I can hardly remember anyone who has suffered from chronic debilitating pain yet.

• This reply was modified 2 years, 2 months ago by  drkang.

[drkang]

Sorry!
I have no US medical liscence, unfortunately.

[drkang]

Hi Monika,

After infrainguinal skin incision, find and treat hernia sac, and simple closure of hernia defect with non-absorbable 3-0 Prolene. It is performed under sedative local anesthesia, and the skin incision is about 4 cm, and the operation time is usually about 15 minutes.

Sorry.
This is a reply to Monika’s question.

• This reply was modified 1 year, 11 months ago by  drkang.

[drkang]

Also, the aponeurosis flap is not as tough as the mesh, and sometimes it may die due to insufficient blood circulation. So it may have a higher risk of recurrence.

[drkang]

Hi Watchful,

Many people think that doctors understand and are familiar with all surgical techniques, but unfortunately, this is not the case. The surgical methods taught in most teaching hospitals are not diverse, and it is common to teach a particular surgical method. Also, the greatest goal of most surgeons is to properly implement the surgical techniques they have learned. There aren’t many doctors who are thinking, researching and trying whether there is a better surgical method. Therefore, most doctors are performing the surgery they have learned, not trying many surgical methods and choosing the best among them.
Desarda’s method is almost identical to that of Lichtenstein’s surgery. The difference is that they use the patient’s external aponeurosis flap instead of mesh.
I think that a mesh or aponeurosis that is simply covered over a hernia opening, the muscle defect, without suture closure, can be lifted and eventually increases the risk of recurrence.

[drkang]

Hi William,

The genitofemoral nerve, the ilioinguinal nerve, and the iliohypogastric nerve are preserved uncut. In direct, the cremaster muscle is not injured at all, and in indirect, after split open along the muscle fiber plane, the sac is processed and the deep inguinal ring is repaired, so there is minor injury but no intentional damage.
Foreign patients usually stay in Korea for about a week after surgery.

[drkang]

@Good Intentions,

I always appreciate your deep knowledge and accurate analysis of hernia repair. I don’t think there are any doctors out there who probably have more relevant knowledge and standards of judgment than you.
I personally always agree that your assertions are closest to the truth.

A low recurrence rate is the number one priority among surgeons advocating mesh repair. However, in actual clinical practice, it is not uncommon to see patients who recur after mesh repair. So, I personally think it’s likely to be higher than the often claimed relapse rate of mesh repair.

There is a paper where you can estimate the actual recurrence rate of mesh repair.

Murphy BL, Ubl DS, Zhang J, Habermann EB, Farley DR, Paley K.Trends of inguinal hernia repairs performed for recurrence in the United States. Surgery. 2018 Feb;163(2):343-350.

Exerpt-

Results: In the Premier database, of the 317,636 inguinal hernia repairs, the proportion performed for recurrence had a small decrease in males from 11.4% in 2010 to 10.5% in 2015 (P < .0001); however, it remained constant in females (6.5% in 2010 to 6.7% in 2015, P = .46). In the National Surgical Quality Improvement Program database, of the 180,512 inguinal hernia repairs, there was no change for either sex: 10.5% to 11.2% (2005-2014, P = .12) in males and 6.2% to 7.1% (2005-2014, P = .11) in females. Within our institution, in the 9,216 patients identified, there was no change in the proportion of inguinal hernia repairs for recurrence in males: 13.3% to 11.5% (2005-2014, P = .25). In females, the proportion increased from 1.3% to 12.0% during the study period (P = .006).
Conclusion: Based on these larger evaluations of recurrent inguinal hernia surgery, the current literature on inguinal hernia repair recurrence is skewed and overly optimistic.

The above results indicate that at least 10% of new inguinal hernia repairs are due to recurrent hernias.
Considering that most of the inguinal hernia repairs are mesh repair these days, it is thought that most of these recurrent hernias are recurrences after mesh repair.

Moreover, if the following paper is true that the rate of recurrent hernia reflects only a part of the actual recurrence rate, the actual recurrence rate of mesh repair is likely to be much higher than 10%.

Kald A, Nilsson E, Anderberg B, Bragmark M, Engstrom P, Gunnarsson U, et al. Reoperation as surrogate endpoint in hernia surgery. A three year follow-up of 1565 herniorrhaphies. Eur J Surg 1998;164:45-50.

Exerpt-

Results: During 1992, 1565 hernia operations were done. The postoperative complication rate was 8% (125/1565). At 36 months postoperatively 108 recurrences had already been reoperated on, six patients with recurrences were on the waiting list for reoperation and a further 36 recurrences had been detected at follow-up. The interhospital variation in recurrence rate ranged from 3% to 20%. Postoperative complications, recurrent hernia, direct hernia and hospital catchment area over 100000 inhabitants were all factors associated with an increased relative risk of recurrence.
Conclusions: The recurrence rate exceeded the reoperation rate for recurrence by almost 40% which should be taken into account if the reoperation rate is used as the endpoint after repairs of groin hernia. An audit scheme, based on prospective recording, reoperation rate, and (periodic) calculation of the recurrence rate may be used to identify risk factors for recurrence and areas in need of improvement.