[drkang]

Yes, of course. Since 2012, I have performed pure tissue repair on all inguinal hernia patients without exception. And pantaloon hernia is not rare.

[drkang]

Yes. Then, it’s a pantaloon hernia.

[drkang]

Hi,

Indirect hernias come out toward the feet and direct hernias come forward. Therefore, when coughing in a supine position, direct hernia still bulges easily, whereas indirect hernia bulges less or not.

[drkang]

Hello Pinto,

As a surgeon who operated on you, I was very sorry to hear that you had a recurrent hernia a week ago. I will do my best to fix your problem.
Unfortunately, Kang repair is not without recurrence. Through continuous improvement over the past nine years, I am now evaluating that Kang repair has almost reached the stage of completion, but it is still not perfect. The relapsed patients, including you, are my teachers and contributors to the completion of Kang repair. We have improved Kang repair through these failures. In that sense, I will take to heart your assertion that early ambulation might be the cause of relapse. Just like putting different kinds of materials in a furnace and melting them to make new steel, I will try to make better surgical methods by melting these many pieces of advice in the furnace of my thoughts.

Whenever I come to Herniatalk, I am very impressed that you, non-professionals, study harder and have more heated discussions than the expert doctors. Many of you already appear to be far beyond the professional level. I believe that your efforts will never be in vain. As a member, I will do my best to contribute to your discussion by occasionally presenting my opinion.
Thank you!

[drkang]

Dear Pinto,

Listening to the stories that have happened, I think I would have been very upset too if I had been in your position. I apologize once again for your being mistreated.
As you said, I feel direct responsibility for all this inconvenience you had.

But it was me who requested your photo. Because proper guidance can be provided only when the status is identified. As I remember, it was difficult to clearly determine whether there was a recurrence from the photos you sent, so I told Stephen to ask you to do an ultrasound there. If not the COVID-19 situation, I would have asked you to visit our hospital again and fix your problem.

In fact, in the context of covid 19, we moved the hospital in July 2020 to a new place and there have been several complicated things since. So I guess Stephen didn’t report enough to me. I know that’s not a good excuse for your being mistreated. But I want to comfort you as much as possible. From now on, we will do our best to solve your inconvenience.
I apologize again.

With best regards,

Yoonsik Kang

[drkang]

Dear Pinto,

It seems that there was a mistake in the delivery of the answer. Bulging that appears about a year after surgery is not considered normal.
I apologize again for not being able to give you a close follow-up of your condition.

Best regards,

Yoonsik Kang

[drkang]

Dear Pinto,

I apologize again for the helplessness you may have felt.
In the future, if there is a problem that requires consultation, please contact me by e-mail at any time and I will answer it. I hope you can understand even if the response is a little delayed due to my English skills.

surgeonkang@naver.com

Best regards,

Yoonsik Kang

[drkang]

Dear Pinto,

Today, I first learned in detail about the inconvenience you experienced. I was very surprised too. As the head of the hospital, I can’t help but apologize. Everything is my fault.

One thing I would like to say is that as a doctor I have no reason to shy away from your problems. Rather, I want to quickly find out what is causing the discomfort. As I repeat, COVID-19 has improved somewhat, so please take the time to come to Korea. We will do our best to solve your problem.

Best regards,

Yoonsik Kang

[drkang]

Dear Pinto,

There is no perfect hernia surgery in terms of recurrence or sequelae so far. Unfortunately, Kang repair, which I developed, is no exception.
We are just trying to minimize the possibility of these problems.

I have never shirked my responsibility for the patients I have operated on. In fact, the opposite is true. In case of recurrence after our surgery, we provide surgery for free. I also do many difficult recurrent hernias from other doctors and am taking risks to do mesh removal surgery for mesh complication patients.

Nevertheless, I deeply apologize for the experience you have had personally.
If I have to make an excuse, I think I have caused inconvenience to you because of not communicating directly due to my English skills, that I am practicing in a foreign country that you cannot easily come to at any time, and COVID-19, a global problem so far.

If you would come to Korea even now, we will do our best to solve your problem.

With best regards,
Yoonsik Kang

[drkang]

Dear Pinto,

First of all, I deeply apologize for all the inconvenience you experienced. And I am very sorry to hear that you have experienced worrying symptoms after surgery. Actually, I have many difficulties in English. If I communicated directly with you, it would have caused less inconvenience to you.

I have heard from Stephen that he has received your emails asking questions about your symptoms after surgery. Regretfully I didn’t know exactly what happened to you in the past. The last thing I heard from Stephen several months ago was that you had an ultrasound in Japan and it was diagnosed as not a hernia recurrence.
So, since the ultrasound results may not be accurate, I told Stephen to ask you to come to our hospital and have a thorough examination, and if recurrence is confirmed, I would re-operate for free. I’m also frustrated that I can’t confirm what kind of problem you’re having trouble with.

In the meantime, we haven’t been able to strongly recommend you to come to Korea because of COVID-19. But now things are a lot better. If you have completed your vaccination, then you go to the Korean embassy in Japan and get a self-quarantine exemption letter. If you get it, you can go out immediately after receiving a PCR test within 24 hours of arriving in Korea and confirming negative.

I’ll check with Stephen in detail about the inconvenience you’ve been experiencing. And I will take time to answer the other questions.

I deeply apologize again for any inconvenience caused.

With best regards,
Yoonsik Kang

[drkang]

Hi,

It takes many years to develop and complete new surgical methods. Because a surgeon should check feedback from patients regularly, and even if we complete the surgical technique, it will take several more years for the official result to come out.
It has been nine years since the development of Kang Repair began, and now I think it is almost complete. From now on, we are going to prepare for a clinical trial. However, it will be at least three to four years before the final results are published.
I think it is ideal for introducing the surgical method while presenting the final result. However, Kang repair was introduced too early for a couple of reasons.

First, someone asked Herniatalk about Kang Repair a few years ago. I found out about this by chance and gave a brief explanation to answer his curiosity, which led me to post several times later. The second reason is the sense of urgency to blow in the wind before the fire of the non-mesh hernia repair is wholly extinguished. In other words, I wanted to convince the patients that good or even better results can be obtained with a non-mesh repair so that they do not lose hope.

I have developed Kang Repair through dozens of improvements so far. To do that, I continuously had to monitor the surgical results. So the results are different from time to time.

The results of specific surgical methods indeed gain credibility when published in papers. However, the results published in the article do not mean the results themselves have been verified. It only means that the thesis adheres to the research principles well. Therefore, I do not believe that published results in papers are reliable and unpublished results are unreliable.

It is my main concern to complete a hernia surgery method that can minimize recurrence and sequelae. I have no intention of beautifying Kang Repair beyond reality. My personal goal is to keep the long-term recurrence rate below 0.5%, hopefully 0%, and minimize sequelae incidence. I’m pretty sure it’s possible.

Thank you!

[drkang]

Sorry!

“However, in the case of recurrent inguinal hernia, bulging may occur easily when coughing while lying down even in the indirect type.”

[drkang]

Hi,

There is a way to distinguish between a direct hernia and an indirect hernia without ultrasound.
More than 95% accurate.

Be sure to lie down in bed.
Cough hard.
If the hernia area is clearly bulging on coughing, it is very likely that it is a direct type hernia.
Conversely, if there is no change in the hernia area or only slight bulging when coughing, it is most likely an indirect inguinal hernia.

If you try to raise your head to check the changes while coughing, it may affect the result, so I think it would be better to check in a mirror or have someone else check.

However, in the case of recurrent inguinal hernia, bulging occurs easily when coughing while lying down even in the indirect type.

Thank you!

[drkang]

Hello, all!

I would like to address a more fundamental issue.
Inguinal hernia repair before mesh repair, represented by Modified Bassini repair, had a very high recurrence rate of 10-30%. Hernia surgeons attributed this high recurrence rate to high tension after repair.
Therefore, efforts to lower the recurrence rate have naturally led to efforts to develop surgical methods that lower tension.
Darn repair, mesh repairs that are currently mainstream, and even the Desarda technique, a non-mesh repair introduced around 2000, were all developed to lower the tension.

However, Shouldice repair works as an obstacle to this logic. Shouldice repair is a surgical method that is very similar to the original Bassini repair, so some doctors call it Bassini-Shouldice repair. It reports a relatively low recurrence rate of around 2%, even though it generates high tension after repair. 2% recurrence rate is not higher than that of mesh repairs.

If so, could the underlying cause of recurrence be something other than high tension?
I personally believe that the very high recurrence rate of modified Bassini repair was not due to high tension but due to technical defects.
It can be seen from the fact that Shouldice repair, which is being carried out in a very careful and meticulous manner, has a relatively low recurrence rate despite generating high tension.

But I want to go one step further here.
In order to achieve a low recurrence rate, Shouldice repair has a fairly large incision wound and a wide surgical range and is a 3-layer repair using a steel thread. There are also claims that many centers do not achieve the grades reported by Shouldice Hospital.

I want to find the reason in the one-for-all surgical method.
In other words, the operation is performed in the same way without distinguishing between the two subtypes of inguinal hernia, indirect type and direct type, so that it is not the optimal operation for each subtype.

In summary, the high recurrence rate of tissue repairs in the past is thought to be due to the fact that the specialized surgical method for each of the two subtypes of inguinal hernia was not performed, and the technical defect in not accurately suturing healthy muscles and ligaments during suturing. Tension, I think, is only a secondary consideration.
I am convinced that this idea is correct through more than 11.000 non-mesh repair surgeries that applied this idea.
This type-specific repair has a very small surgical wound and surgical range, the operation time is very short, around 15 minutes, and is sufficiently possible with local anesthesia. Although the surgical method is still being improved, the recurrence rate so far is about 0.8%

And, most importantly, it can eliminate the need to continue to perform mesh repair designed to lower the tension.

[drkang]

Thanks for the multiple comments on Kang repair.

As an executive running a hospital, it is natural for me to be interested in marketing. However, my greater interest is to inform many people that there is a non-mesh inguinal hernia repair that is better than mesh repair.
You already know that many people suffer from chronic pain after mesh repair. Many of the discussions in this Herniatalk are also related to mesh complications.

I know that many of you are dissatisfied with that Kang repair has not yet been published in the journal.
However, it takes a long time for a new surgical method to be completed.
To take examples, Desarda repair was published in The European Journal of Surgery in 2001, nearly 20 years after the first surgery began, and Lichtenstein repair was also published in The American Journal of Surgery in 1987 after more than 20 years of experience in his private clinic. And Shouldice repair, which is currently recognized as a representative non-mesh inguinal hernia repair, was first published in 1969, four years after Dr Shouldice’s death. For reference, Dr Shouldice in 1945 wrote his surgical method in Ont. Med. Rev., but it differs from the current Shouldice repair in many ways.

As such, it takes a long period before a new surgical method is released. The reason is that no matter what idea you start developing a surgical method, the final surgical method that can be shared with other doctors can be completed only through numerous trial and error and feedback processes.
As such, more verification time is still required before Kang repair, which has been only 9 years old, is released.

Nevertheless, the reason why I introduced Kang repair to Herniatalk and others is because I have a desperate feeling that I can no longer neglect the current situation. As many predict, if the situation persists, it is likely that you will rarely find doctors performing non-mesh repairs soon or later. Mesh inguinal hernia repair has been started for more than 30 years. As a result, most doctors who actively perform hernia repair at present have neither learned nor experienced non-mesh repair. Moreover, few training hospitals teach non-mesh inguinal hernia repair these days.
Sometimes, we are still discussing on which is better between mesh repair and non-mesh repair, but if there is no change in the current situation, it is clear that our discussions will move on to the topics such as ‘What is the best way to reduce mesh complication?’ or, “How do I treat mesh complications?”. In fact, these latter discussions are already dominant in the forum.
However, given the obvious fact that mesh complications exist and the best way to solve them is not to use meshes, the advent of an era in which everyone is forced to undergo mesh repair will be unfortunate for hernia patients.

This situation will be heartbreaking for me as an active advocate of non-mesh inguinal hernia repair. The reason why I introduce Kang repair’s experience, which has not yet been publicly published in thesis, is because of the urgency to prevent this from happening.

In the current situation, it is unlikely that doctors will voluntarily learn and perform non-mesh hernia repair which is unfamiliar to them after giving up familiar mesh repair. If so, the only way to reverse this situation is for many hernia patients to ask their doctors for non-mesh repair more actively. To do so, patients must first be confident that non-mesh repair could be better than mesh repair. In order to give this conviction to hernia patients, I am sharing the excellence of non-mesh inguinal hernia repair, which has been confirmed through many surgical experiences.

I will also explain why we named Kang repair for our surgical method. Very subtle differences in inguinal hernia surgery can lead to very large differences in outcome. Therefore, I think it is not advisable to add the word ‘modified’ to certain existing surgical methods. Even small differences in surgical methods can have a great influence on the surgical outcome. Therefore, I don’t think it helps to choose and develop a good surgical method for several different modified surgeries to share the same name. Therefore, even if there is a small difference, I thought it would be desirable to give a unique name and compare each other, so I bravely attached the name Kang repair to our surgery method.

Specifically, Kang repair for indirect hernia has the same idea of repairing the deep inguinal ring with Marcy repair, but the specific surgical method is completely different. Kang repair for direct hernia is actually closer to the original Bassini repair rather than the Shouldice repair. The difference is that ? does not incise transversalis fascia, ? does not cut inferior epigastric vessels, ? does continuous suture instead of interrupted button suture, and ? does not apply releasing incision to rectus muscle fascia. And unlike Shouldice repair, we preserve the cremaster muscle without cutting it. The operation time is about 15 minutes for indirect and 20 minutes for direct. For skin wound, the average indirect is 3-3.5cm and the direct is 4-4.5cm.
Thank you!

[drkang]

@Alephy.

Thank you for your good question.
Even under the name of non-mesh inguinal hernia repair, I think there are a wide variety of surgical methods.
I know that non-mesh hernia repairs performed in the past were in many cases modified Bassini repairs. We know that the Shouldice technique is also one of modified Bassini repair. That’s why some doctors call it Shouldice-Bassini repair.
As you said, the Shouldice technique started in the 1940s, and I know that it hasn’t changed much since then. Nevertheless, it is true that these days, the period of hospitalization for surgery has been shortened and the time to return to normal life has accelerated even after the Shouldice repair.

First of all, I think the reasons for the shorter hospitalization period and faster return to normal everyday life are as follows even though there are no major changes in the surgical method.

The first reason, I think, is that there is no change in the big frame, but improvements were made in a less invasive way in detail, as doctors’ experience accumulates and surgical techniques generally improve
.
Second, I think it is because the routine recommended to patients has changed in the first place, as doctors have learned from experience that there is no need to hospitalize the patient or to restrict normal activities for such a long period of time after surgery.

Third, I think, it is because the devices that actually manage pain and pain medication have developed.

As another category, the surgical methods performed by some non-mesh surgeons these days are much more simplified than the modified Bassini repair that was mainstream in the past, so I think these changes cause less postoperative pain and faster recovery than in the past.
In the case of Kang repair, we reduced the scope of surgery by performing different methods of surgery for the indirect type and the direct type. It is obvious that the smaller the surgical range, the less pain and faster recovery. Most people who underwent reoperation or other side hernia surgery in my hospital said that our surgery method was less painful than the mesh repair they had before.

[drkang]

Hello, everyone!
It has been a while.

Hernia mesh complication is already widely known, and hernia surgeons have acknowledged it. In order to solve this problem, new meshes such as absorbable mesh are being developed. However, I think the surest way to solve mesh complications is not to use meshes.

The problem is that there are different opinions among doctors about non-mesh inguinal hernia repair. However, the issues raised about non-mesh repair, unfortunately, often appear to be opinions of doctors who have little experience with non-mesh repair.
I had 15 years experience in mesh inguinal hernia repair.
Then I began to think more and more seriously about the complication of hernia mesh. and have devised and implemented a new non-mesh repair method from about 9 years ago. To date, more than 10,000 cases of non-mesh inguinal hernia repair have been accumulated. Based on that experience, I would like to tell you some facts below.
1. Many doctors say that non-mesh repair can only be applied to healthy, young people with small hernias.
However, I have performed over 10,000 inguinal hernia repairs over the past 9 years, all with the non-mesh technique, with no exception. Among them, there were hernias that recurred more than five or six times before, others over 100 years old, patients with severe ascites or receiving oxygen 24 hours a day for COPD, etc. There were also professional body builders, martial arts players, professional track and field players, singers and saxophonists. In the past 9 years, I have never refused surgery because of the patient’s medical condition or the like.
Nevertheless, the self-investigation has shown a recurrence rate of less than 1%.
Although we did not provide accurate statistics, the postoperative pain was extremely low.
Based on this experience, I can make the following conclusions.
Non-mesh inguinal hernia repair can be successfully performed in all hernia patients without exception.

2. In the same context of the above, most doctors say that you should choose a surgical method according to the patient’s condition. In other words, depending on the person, mesh repair must be performed, or the optimal surgical method must be selected and performed from among several non-mesh repair methods depending on the patient’s condition.
However, I disagree with the above statement from my past experience. All patients, regardless of their condition, can achieve successful results even if they perform the same procedure. The method used at this time should, of course, be a good surgical method. In fact, there is only one patient condition that must be considered in order to perform the optimal surgical method. It is whether the inguinal hernia is an indirect type or a direct type, and different surgical methods must be performed accordingly.
However, most surgeons currently perform the same operation without considering these subtypes. In other words, it’s like making a glove in one shape and putting it on your left and right hands.
This type of surgery results in the following results.
– It is difficult to perform the best surgery for each subtype.
– The operation is performed in a wider range than necessary.

3. Through this experience, there are things that I disagree with other doctors.
Most doctors point to tension as the main cause of hernia recurrence. That is why tensionless mesh hernia repair emerged. However, as we all know, mesh hernia repair also has a significant recurrence rate.
What I believe from personal experience is that the cause of hernia recurrence is due to the inability to perform optimal surgery and technical errors according to the subtype of inguinal hernia.
If my judgment on the cause of the hernia recurrence is correct, there would be no place for the mesh in inguinal hernia repair.
Thank you!

[drkang]

[USER=”3103″]Spartan[/USER]

I am afraid that you may misunderstand my word a bit. Desarda has no mesh complications, but its recurrence rate might be a little higher than that of Lichtenstein. Because both are surgery of a similar concept and the EOA is less durable than the mesh. I don’t know what Desarda claims about external oblique aponeurotic extensions, but I think it is to emphasize the importance of external oblique aponeurosis in hernia repair. But from my experience I am convinced that the transversalis fascia has full responsibility for hernia occurrence. I think external oblique aponeurosis has no role in the occurrence of inguinal hernia. If some abnormality is found in external oblique aponeurosis, it is the result of hernia, not the cause of hernia. In parables, the clothes could be torn because of their weight gain. Gaining weight is not because the clothes are torn.

[drkang]

And for the sake of communication, the hernia surgery team at our hospital calls this test method the lying down cough test or Kang test.

[drkang]

@alephy

Hi,

I said about 95% accuracy.
So I can’t say that you obviously have an indirect type.

However, according to my experience so far, I have seen occasional cases where the indirect type bulges out when coughing while lying down, but I have few memories of seeing no bulging in the direct type.

However, if it is a very small direct hernia, the bulging may not come out clearly.

Thank you!