[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]

[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]

[USER=”3103″]Spartan[/USER]

Hi,

1. Dr. Kang says he closes the inguinal ring in doing a indirect hernia repair where others before have not been able to for fear of cutting certain channels like the spermatic chord, testicular vessels, lymphatics and sensitive nerves. Please tell me what enables him to do this where other physicians have feared to tread? a piece of machinery? a tool? a technique? sheer skill?

Answer) Directly closing the internal inguinal ring was already begun by a surgeon named Marcy around 1870. However, Bassini repair, which was introduced later, has become a typical operation for inguinal hernia repair. This is probably because Bassini repair was easier for doctors to follow, anatomically easier to understand, and could be applied to both types of inguinal hernia, indirect inguinal hernia and direct inguinal hernia in one way. I think. Since this concept has been solidified for over 100 years, it is believed that all the inguinal hernia repair methods introduced afterwards have been out of this framework.
Surgery to close the internal inguinal ring is not a high risk of damaging the various structures that consist of the spermatic cord. The reason why this operation is not performed is because doctors who are accustomed to operating in one way do not think that they can close the internal inguinal ring for indirect inguinal hernia repair and they don’t know how to securely close it.

2. The Desarda Method uses External Oblique Aponeurosis(EOA) to close up the inguinal ring in a indirect hernia, why does Dr. Kang believe Traversalis fascia is as good or better?

Answer) The Desarda technique, which uses a narrow strip of external oblique aponeurosis, is the same concept as Lichtenstein mesh repair. The only difference is that the strip of EOA is used instead of the mesh to cover the inguinal canal. Lichtenstein repair, however, is estimated to have at least 5% recurrence rate, besides its mesh complication. I personally think that recurrence rates might be higher if EOAs are used that are less durable than meshes.
It does not matter, I think, which is stronger, EOA or transversalis fascia. What’s really important is, that Desarda doesn’t close hernia openings directly, while Kang repair closes hernia openings directly.

3. I noted that in Dr. Desarda’s Hernia Repair video that the posterior wall and many accompanying muscles(EO or IO) are a-dynamic or weak. Dr. Desarda could not stimulate one of these muscles even with a strong electrical current– according to Dr. Desarda happens every time he operates. Hence, they have to re-anchor the External Oblique.
What is Dr. Kang’s theory of why the posterior wall is a-dynamic and associated muscles are so weak and filled with fat? How does he remedy this problem of posterior wall and associated muscle inertness in the indirect hernia case because it just sound like he works on the inguinal ring?

Answer) All skeletal muscles respond to electrical stimulation. Thus, the transversalis fascia which is the skeletal muscle (also called the voluntary muscle) is also expected to respond to electrical stimulation. However, since it is not a thick muscle like an external oblique muscle or an internal oblique muscle, the response will be minimal. For reference, muscles that do not respond to electrical stimulation are smooth muscles that are involuntary muscles, that is, muscles surrounding the bowel wall or blood vessel wall.
Therefore, it is not well understood to explain the surgical technique by explaining the difference in the electrical stimulation response between the same skeletal muscles. Another thing I don’t understand is that the primary tissue Desarda actually uses is not external muscles that respond to electrical stimuli, but external oblique aponeurosis that cannot respond to electrical stimuli at all.
And in fact, kang repair uses not only the transversalis fascia but also the surrounding strong tissue and structure to close the internal inguinal ring together.

(Even I notice by feeling that my hernia side has a lot more fat in it, then the non- hernia side. I am assuming the all the fat is due to these muscles being inert)
Answer) I think that’s just a guess. Sometimes fat degeneration occurs in muscles, but it is not caused by inert muscles. And it does not happen to any particular muscle, but often to the surrounding muscles.
Thank you!

[drkang]

[USER=”935″]drtowfigh[/USER] Your analogy is very interesting and makes us to understand the situation clearly. Thank you for that.
But I think more discussions about mesh repair and non-mesh repair should be done within the expert group. I have no intention to twist your analogy at all, so allow me to apply it a bit differently.

I agree with you that a small umbilical hernia should definitely be operated on with non-mesh repair. In my experience, however, except for recurrent umbilical hernia or port-site umbilical hernia, all umbilical hernias can be successfully operated without mesh, regardless of size.

Inguinal hernia repair is even more so. I’ve done nearly 10,000 non-mesh inguinal hernia repairs so far but haven’t seen a case where any mesh must ever be needed. Of course, there were rare occasions where mesh would be a good idea, but in less than one in a thousand patients. Even in such cases, the operation was successful with non-mesh.

So I want to add the following few sentences to your analogy.
Almost all inguinal hernia are within a block, so no car is needed. And even if it is a little far away, it is still within walking distance.
As for the umbilical hernia, I would like to add similar sentences. But recurrent or port-site umbilical hernia are crippled ones according to your analogy, so I think you need a mesh for them.

[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.

[drkang]

[USER=”2658″]scaredtodeath[/USER] As I said, there is a part of your question that I do not understand. However, I will answer based on how I understood your question.
There are many tissue repair methods, which result in different outcomes. Most of the tissue repairs before the start of mesh hernia repair were modified Bassini repairs, which showed a recurrence rate that was too high back then.
However, the recurrence rate of original Bassini repair reported first in 1870 was 2.7%. I think the ‘modified’ surgery, which corrupted the original method, caused the recurrence rate to go as high as 30%, while that of the original method was 2.7%. As far as I understand, the fundamental difference between the original and the corrupt Bassini repair is that the one firmly saws together the defect margin of transversalis fascia to close the hernia opening created by a tear or a gap and the other does not.

I think that sawing the transversalis fascia defect should become the most important principle of hernia repair surgeries. In this context, there is nothing strange about the recurrence rate of Shouldice repair which fully embraces this principle, being as low as 1 to 2%. I believe that any tissue repair that fully embraces such principle can show the recurrence rate as low as 2%, and a better designed repair method may reduce the recurrence rate down to almost zero. Meanwhile a tissue repair not following such principle may result in the recurrence rate of 10 to 30%. Such principle of surgery is the most important element of a successful surgery for both indirect and direct hernias.

A tissue repair carried out fully following such principle will allow the patients to quickly recover, and the patients who received such repair will be able to return to their normal lives much faster than the patients who received other type of tissue repairs. So, I impose no restriction on my patients who received our inguinal hernia repair to engage in strenuous exercise, once three weeks pass from the repair surgery.
Meanwhile, the repairs that do not follow such principle – sawing transversalis fascia defect to close the hole there in – are relatively and inevitably vulnerable to recurrence and require a longer recovery period. Various forms of modified Bassini repairs and the mesh repairs administered nowadays, as well as Desarda repair recently attracted attention, are the repair methods that do not follow such principle.

McVay repair may be considered to follow the principle of inguinal hernia repair surgery, but it will cause the structure of the inguinal canal to be deformed after surgery, because it is not an anatomical repair (as Bassini repair or Shouldice repair are). That is, McVay repair is sawing the medial margin of the defect of the transversalis fascia laterally to the Cooper’s Ligament which is located deeper to the inguinal ligament. This repair method can close the gap that may cause femoral hernia. However, femoral hernia does not occur so frequently. Also, even the surgeons with considerable experience sometimes cannot accurately administer McVay repair, because it is so complex. So, McVay repair has a longer recovery period than those of Bassini or Shouldice repair, and the recurrence rate thereof could be higher. So, I do not prefer McVay repair.

[USER=”2908″]Bestoption[/USER] I am not sure whether you have an inguinal hernia or a sports hernia, because your symptoms are not typical and complex. You said that you have no bulging on coughing or sneezing. However, if the ultrasonography found bilateral inguinal hernia, I think we should believe that. FYI, sports hernia cannot be diagnosed by ultrasonography. Sports hernia frequently occurs to athletes who make sudden change of direction while rapid running, such as professional soccer or American football players. It rarely occurs to others who engage in light exercises. And it is hard to be found not only by ultrasonography, but also by any other testing methods. Thus, it can often be diagnosed by history taking and physical examination.

You will find that many doctors have their own different definitions of sports hernia. Although the same name of ‘sports hernia’ is used, doctors have different opinions on which area is damaged. So, the area of surgery also differs frequently depending on the doctor. Thus, many of you who searched information of sports hernia might have been confused.

I have so far performed about 500 sports hernia repairs mostly for professional soccer players. From my experience, I believe that the sports hernia is an event where the external oblique aponeurosis of inguinal canal is injured. So, I have administered a simple surgery, which repairs the external oblique aponeurosis only. They successfully recovered and made come-backs to their sports.

[drkang]

quote scaredtodeath:

Thank you dr Kang for your reply… if you have still interest in this thread of discussion would you mind giving your opinion of tissue repair success/challenges/risks of direct vs indirect hernia and also how each repair may impact flexibility

I am sorry that I can not catch the point of your question exactly. I have sometimes difficulty to understand English which is not my mother language. So please let me know your point again particularly about ‘risks of direct vs indirect hernia’ and ‘how each repair may impact flexibility’.
And your question could not be answered briefly in several sentences, so please give me a couple of days. Thank you.

[drkang]

[USER=”2658″]scaredtodeath[/USER] It is a kind of simplified Bassini or Shouldice repair. The scope of repair is just limited to Hesselbach triangle where the direct hernia occurs without the excision of the cremaster muscle. So it can be done through a smaller incision. Thank you.

[drkang]

Hi Bestoption,

Thank you for considering my surgery method as one of your options.
And I also thank Good Intentions – you have always been so devoted to this forum.

As I read the statements and questions posted to this forum, I have always wanted to say about a few things. I noticed the statements related to such things were posted here, so I would like to give you my opinion thereon.

The biggest difference between most of other inguinal hernia repair surgeries and Marcy repair is: while most of other inguinal hernia repair surgeries are type-nonspecific repair method, Marcy repair is type-specific repair method for indirect inguinal hernia. In other words, Marcy repair is, as far as I know, practically the only surgery method which repairs indirect inguinal hernia in type-specific way. (Unfortunately, it is difficult to find any information as to how Dr. Marcy administered direct inguinal hernia repair surgery.)
So, many people seem to think that any type-specific indirect inguinal hernia repair is always Marcy repair. However, what I think is that Marcy repair is just one of type-specific repair methods that can be administered for indirect inguinal hernia repair. This is the same as there being many different methods of type-nonspecific repair such as laparoscopic mesh repair, Lichtenstein, Bassini, Shouldice, Desarda and so on.
I have been administering non-mesh repair (where indirect type and direct type hernias are repaired by different surgery methods) for the last 7 years. And there is a big difference between the indirect type-specific repair I administer and Marcy repair.

Some think that Marcy repair is for children. In most hernia repair surgeries for children, only high ligation of hernia sac is administered. However, Marcy repair additionally closes the deep inguinal ring after administering high ligation of the hernia sac. (The high ligation of the hernia sac is a mandatory process of all existing surgery methods conducted when repairing indirect inguinal hernia.) Thus, Marcy repair is an indirect inguinal hernia repair method for adults. As far as I know, the recurrence rate of Marcy repair is very low (1~2%), once it is accurately administered. However, it is my understanding that there are not so many doctors who are used to this surgery method. Thus, when administered by inexperienced hands, the recurrence rate of Marcy repair would naturally increase.

Another thought I had after reading the postings to this forum was that a lot of people seemed to think that mesh repair is appropriate to some and non-mesh repair is appropriate to the other, depending on the patient’s condition of herniation. Also, it seemed that there were many people who thought that even if the mesh repair is administered: there is a better mesh repair method according to a patient’s condition of herniation; or it is better to choose the most suitable surgery method among many non-mesh repair surgery methods, such as Marcy, Desarda, Bassini, Shouldice, etc, according to a patient’s hernia condition.

Such thoughts may be quite reasonable and correct. However, what I have learned from my experience and convinced of is that whether a patient’s hernia is severe or in early stage; whether a patient’s muscles in the inguinal region is strong or not; whether a patient is exercising a lot or not; or whether a patient is obese or thin, the best result can be achieved by a method in all cases, as long as a good method is administered. Thus, I believe that different hernia repair surgery methods should be administered depending only on whether the inguinal hernia is indirect type or direct type, and I have been administering more than 10,000 non-mesh inguinal hernia surgeries as I believed. Thank you.

[drkang]

[USER=”2862″]kaspa[/USER] Sorry for the late reply.
Unfortunately, Gibbeum Hospital is the only clinic that administers our Kang repair. After I accumulate enough clinical data, I will announce the data on the result of Kang repair and disclose the surgery method. I hope you will find a good surgeon who will do the best surgery for you.

If there is one thing I can recommend for you is to choose the pure tissue repair, if possible. If I were to choose between tissue repair relapse and mesh complication, I would choose the relapse, because fixing the tissue repair relapse is much easier than taking care of mesh complication. Also, the relapse rate of mesh repair is much greater than you think. Also, if you make a right pure tissue repair method, the chance of relapse can be much lower than that of mesh repair.
Thank you.

[drkang]

Hi dog,

Thank you for asking for other doctor’s comment on my surgery method.

I fully understand Dr. Yunis’ position that he agrees with my thoughts in many part, but he tries to offer ‘the techniques that are validated by many other surgeons.’ Because a surgery is the only opportunity to cure a patient’s disease, surgeons must select their surgery methods very carefully, and Dr. Yunis must be thinking that the surgery method practiced by many other doctors is the safest.

However, if all doctors consider the surgery method practiced many other doctors is the best surgery method and stay satisfied with it, there would have been no development of surgery methods in various areas, as we have achieved today. When a new surgery method is practiced for the first time while there is a mainstream method, its start cannot help but being weak.

What is important is whether the currently practiced surgery method is so perfect that there is no need for further improvement. If so, the careful stance of Dr. Yunis is appropriate. I would do the same myself. However, if the current mainstream surgery method still has many problems that require imporvement, someone must try different things. As a matter of fact, many surgery methods have been developed through such processes.

I do not think that the current mesh inguial hernia repair is a perfect surgery method that require no further improvement. I am rather repulsed by the mesh method. That is why I thought a new surgery method had to be developed, and accomplished Kang repair one year ago after giving a lot of thoughts and efforts. Of course, a new surgery method must be validated over a certain time period. Thus, for the value of Kang repair to be fairly evaluated, it will take more time. However, when considered many elements, I anticipate that the good results observed so far will be successfully maintained when monitored over a long time.

[drkang]

Hi linzee,

I am glad to hear from you through your posting. It was my pleasure to administer the hernia repair for you. I hope you will completely recover from the surgery soon.

[USER=”2608″]dog[/USER] I do not repair the entire inguinal floor as most of the existing inguinal hernia repairs do. However, I do not repair the damaged part only. To be exact, deep inguinal ring is repaired in case of indirect inguinal hernia, and only Hesselbach triangle (but the entire Hesselbach triangle) is repaired in case of direct inguinal hernia. That is, I choose one of the two surgery methods (repairing only the deep inguinal ring and repairing the whole Hesselbach triangle) according to the type of the inguinal hernia.

[drkang]

Thank you, dog!

You can get some information at http://www.gibbeum.com/abroad/From-abroad.html

[drkang]

Hi dog,

Happy New Year!
Thank you or your interest in and question. I am very cautious about telling you about the outcome of our repairs but please understand that it is for your curiosity.

I have administered inguinal hernia repair to 1,849 patients in 2018. All of them were purely non-mesh repairs. I have not administered any mesh inguinal hernia repair at all since 2013. I have started to administer non-mesh repair since 2012, and have been fine-tuning my repair method until the end of 2017, so that my method will cause lesser relapse and complication. And it was the end of 2017 when I finally created a surgery method I deemed complete. Since January 2018, I have been repairing hernia using the final, complete surgery method. Thus, I think that the results of non-mesh repairs administered before I reached the final, complete surgery method are not so meaningful.

Although it is too short to meaningfully confirm the results of surgery, the results of surgeries I have conducted since January 2018 show: zero case of the same type inguinal hernia recurring; and 3 cases of what I call ‘pseudo-recurrence’. In all those 3 cases, direct inguinal hernia occurred after conducting indirect inguinal hernia repair, and I have administered reoperation. If these cases were to be included in the cases of recurrence, the recurrence rate will be 0.16%. As I said, the follow-up period is too short. However, it is not rare for an inguinal hernia to recur within 2 to 3 months of initial repair. Thus, I think the above results of 0% of true recurrence rate and 0.16% of pseudo recurrence rate are very encouraging.

As far as I can remember, there were less than 3 patients who re-visited my clinic because of chronic pain. So, I do not care almost at all about chronic pain. There may be patients who went to other clinic. However, because my clinic is trusted by many patients in Korea in terms of non-mesh repair, and I have guaranteed that I will re-operate on the recurred cases for free, I understand that most of the patients who suffered from a problem after the surgery come back to my clinic. Korea is relatively small in size and has a well-developed domestic transportation network – one can reach my clinic from any in Korea within 4 to 5 hours by, for example, high-speed train. Patients do not feel such a burden of re-visiting my clinic.

Of course foreigners, including Americans, can receive surgeries at my clinic. For your information, 12 Americans, 5 British people, 3 Australians and a Canadian received inguinal hernia repair at my clinic last year. Even at this moment, there are several American patients who are scheduled for the surgery. (Those numbers exclude Korean expatriates, such as Korean-Americans.)

[drkang]

To answer your question “which will inflict less pain and fewer potential complications, receiving type-specific repair twice or one-fits-all repair once?” I will have to consider many variables. However, I would definitely choose the latter – type-specific repair is less problematic.

First of all, receiving type-specific repair twice because of pseudo-recurrence can happen to one out of hundred inguinal hernia patients, according to my statistics.You are making a comparison assuming the worst case that you are the one out of one hundred patients.

First, let us compare the cases of: receiving mesh one-fits-all repair once and non-mesh type-specific repair twice. I would choose to receive two type-specific repairs which is 100% definitely non-mesh repair.I think many postings made to this forum can explain why.
Second, we could compare type-specific repair to non-mesh one-fits-all repair, such as Shouldice repair. Even in this case, I would choose to go with type-specific repair.Because two small pains are better than one big pain, and two minor repairs would pose smaller possibility of complication than one extensive repair would.This is especially so, when considered that most one-fits-all repairs including Shouldice repair sacrifice cremaster muscle and genital branch of genitofemoral nerve.

However, this is a scenario you must worry about if you were that 1%.

If you were not that 1%, but the 99%, the mesh, which was absolutely not necessary, would have been placed onto you, or you would have received a more destructive surgery that was not necessary at all.

Moreover, the possibility of true recurrence was excluded in the above.According to my judgment, the true recurrence rate would definitely be higher in case of one-fits-all repair than in case of type-specific repair. (Here, ‘true recurrence’ includes: any type of hernia, in case of one-fits-all repair; and the type of hernia identical to the type of hernia previously operated on, in case of type-specific repair.)It is because the line to be protected is longer in case of one-fits-all repair.

Shouldice hospital reports a low recurrence rate of about 1%. However, as far as I understand, Shouldice hospital strictly selects the patients who would go through the surgery, by excluding those who experienced recurrence and 1 year has not passed thereafter or who weigh a lot. Also, I understand that they use mesh, although it is uncommon, in case of recurrent hernia or severe direct hernia. After all, the patients who are deemed to have higher risks of recurrence are eliminated from the list of patients who would receive Shouldice repair. Thus, if non-mesh Shouldice repair is administered for all cases without excluding any patients, we can anticipate that the recurrence rate will exceed 1%.
In conclusion, I do not think that the re-operation rate of Shouldice repair (which is thought to be the method with the lowest re-operation rate among non-mesh repairs) would never be lower than the re-operation rate of type-specific repair.

Therefor, under any circumstances, my choice would always be non-mesh type-specific repair. And even in case of the pantaloon hernia, I perform two type-specific repairs once to save the cremaster muscle.

I do not know much about the insurance issue.However, when the opinion that type-specific repair is absolutely advantageous to the patients is widely accepted, excluding the occurrence of second type hernia, i.e. pseudo-recurrence, from true recurrence will not be so difficult.

[drkang]

[USER=”2468″]Baris[/USER] You have suggested that when a surgeon administers the type-specific repair, other types of inguinal hernia may occur in the future (direct type hernia after indirect repair or vice versa) and the patient may have to go through another surgery. This is a very important topic that will be an essential issue when discussing about the feasibility of type-specific repair. Thank you for pointing out such an important topic.

This is a great opportunity for me to hear the thoughts of Shouldice surgeon through your great question. In fact, the thoughts of Shouldice surgeons agree with the thoughts of most of the contemporary hernia surgeons (voluntarily or involuntarily).

It is natural for all surgeons who administer Shouldice or one-fits-all repair to ignore preoperative imaging. I would do the same, if I were in their shoes. You are going to make a large wound and visually check the area to conduct the surgery anyway. Why would you make efforts in advance to accurately check the area?
However, making a big incision and checking the area with your own eyes come with a cost. You may cause many injuries to a large area of normal structure and weaken the otherwise normal floor.

I think the Shouldice surgeon said what he/she said (that your second defect was what had been missed from the previous surgery) to protect his/her claim, and it was too conclusive. It is definitely difficult to tell before or during the surgery whether the second defect existed at the time of previous surgery or occurred thereafter.
Indirect hernia and direct hernia existing together is referred to as pantaloon hernia, and I cannot agree with the claim that 13 to 14% of cases are pantaloon hernia. According to the statistical data from my hospital gathered over the last 7 years, the share of cases where pantaloon hernia was identified from the pre-operation imaging test and the two types of hernias being operated was mere 0.27%.

Also, the share of cases where type-specific repair was administered and other type of hernia occurred thereafter (e.g. direct hernia occurring after indirect inguinal hernia surgery was administered, or vice versa) was 0.9% (as a result of follow-up for average 4 years). I mulled over it and named it as ‘pseudo-recurrence’. I wonder if the naming was appropriate. If you can come up with a more suitable name, please do not hesitate to make a recommendation. Anyway, even if all the 0.9% of the cases were the cases where it already existed at the time of previous surgery and was missed (although I personally do not think all of them were ‘missed’), the rate of pantaloon hernia at my hospital was no more than 1.2%. A long-term follow-up may reveal a greater rate of pseudo-recurrence. However, what happened after so long must not be the second hernia that had been missed during the previous surgery. Thus, the rate of pantaloon hernia during the surgery being 13 to 14% is exaggerated.

I guess that there are two reasons why the rate of pantaloon hernia was so exaggerated. One, for a surgeon to check if there were a second direct inguinal hernia, he/she must separate cremaster muscle from the floor of Hasselbach triangle. By the way, transversalis fascia, the floor muscle, often gets damaged during this process. Transversalis fascia might have been weakened during this process, and the surgeon might have deemed it as an early direct hernia. Two, transversalis fascia that forms the floor of Hesselbach triangle is elastic, thus, even when they are in normal condition they often appear bulged a little bit. It is often difficult to visually tell whether it is physiologic bulging or hernia occurred by torn fascia. I think the rate of pantaloon hernia is exaggerated because of the above reasons.

‘Pseudo-recurrence’ (where a second type of hernia that did not exist at the time of type-specific hernia repair occur at some point of time after the surgery) cannot be exactly deemed as a recurrence. When you pulled a decayed wisdom tooth in the upper gum and discovered another decayed wisdom tooth in the lower gum later, you cannot call the second decayed wisdom tooth a recurrence. Nevertheless, I think you can lower the chance of making another surgery because of pseudo-recurrence which includes the second hernia that had been missed at the time of type-specific repair, if you administer one-fits-all repair.

If the rate of administering another surgery after a type-specific repair was too high, there would have been no place for the type-specific repair. Thus the pseudo-recurrence rate after type-specific repair is very important. However, I understand that there is almost no study conducted related to this issue, unfortunately. The surgeons might have had no reason to be interested in the pseudo-recurrence, because most of the surgeries so far have been one-fits-all repair
Fortunately, I can check the pseudo-recurrence rate, because I have been administering type-specific repair since 2012 at my hospital. According to the records kept by my hospital, the pseudo-recurrence rate was 0.9%, as stated in the above. In fact, this is not a number that can be ignored, and the longer the follow-up period, the higher the number can be. But you should remember the fact that the average rate of repeated surgery after one-fits-all repair is usually 5% or above. Of course, the Shouldice hospital shows a very low recurrence rate.

Thus, a patient must choose which surgery method shall be administered, considering: the above statistical information; difference of invasiveness of each surgery method; post-surgery recovery process; difference in aftereffects, etc.
I think Shouldice repair is too invasive and chooses the patients (who would be repaired thereby) under the excessively strict standard. Mesh repair(which also belongs to one-fits-all repairs) also has serious problems, such as chronic pain. I think all these must be fully considered. Based on my experiences, I think there must be a way to bring the pseudo-recurrence rate after type-specific repair below the 0.9% established so far, and I am actually conducting a study in this regard.

‘Determining how prone the muscle is to rupture by imaging technique is almost impossible’ is a correct statement. What we can find out by imaging technique is whether there is a direct hernia or not, or whether there is an indirect hernia or not. Meanwhile, Shouldice repair is administered under the premise that it is 100% sure that the second area is the problem. When reviewed the historical data of my hospital, I think the pseudo-recurrence rate would be no more than 2 to 3%, even if the follow-up period is extended. (And I am studying the ways to reduce this rate.) Then, what we should do is to determine whether we should administer the less invasive type-specific repair, believing the 97 to 98% of possibility, or administer more destructive one-fits-all repair to remove the 2 to 3% possibility of administering a repeated surgery.

[USER=”1391″]UhOh![/USER] I totally agree with your opinion. For the surgeons to be interested in my type-specific repair(which is your defect-specific scope repair), we should make them be assured about the result of surgery. That is, the fact that so called pseudo-recurrence rate is not high must be fully confirmed. I am conducting a study related to this issue.

[drkang]

Thank you, dog. I am preparing the photos of my procedure and will upload it onto my website when it is ready.

[drkang]

Hi, dog!

You can find out more about me and Kang repair by visiting my hospital’s website (http://www.gibbeum.com).
I don’t think it is appropriate for me to directly contact Dr. Brown. I would appreciate it if you could let Dr. Brown know my website, if he has questions about me.
Thank you!

[drkang]

[USER=”1391″]UhOh![/USER] You have used two terms, ‘type-specific repair’ and ‘defect-specific scope of repair.’ I understood as follows and wonder if I understood them correctly: ‘type-specific repair’ means all cases where the indirect and the direct repairs are administered by different methods; and ‘defect-specific scope of repair’ means the case where only the applicable area is operated appropriately for each type. If I understood correctly, the ‘defect-specific scope of repair’ is the type-specific repair that I refer to. However, I think it is not really meaningful to operate on indirect or direct inguinal hernia by selecting different methods among many one-fits-all repair methods (the ‘type-specific repair’ you referred to). Because, you may reduce the recurrence rate by a little by doing so, but there is no other benefit (such as reduced area of, time of or damage from the surgery) to be gained. Thus, I would recommend uniformly using ‘type-specific repair’ to refer to ‘defect-specific scope of repair’ you mentioned, instead of using ‘type-specific repair’ or ‘defect-specific scope of repair’ respectively for different purposes.

To administer the type-specific repair, it is very important for a surgeon to make an accurate diagnosis before the surgery. However, the surgeon cannot immediately administer the type-specific repair just because he/she accurately checked whether the hernia is indirect or direct, because the type-specific repair is a completely new surgery method that a surgeon must learn anew and accustomed to – one may not just slightly modify the one-fits-all repair according to the circumstances when conducting the type-specific repair. You cannot make a child’s dress by just reducing the dimensions of a grown-up’s dress – you need to have a know-how on how to make a child’s dress to properly make one. For your information, it took more than 6,000 surgeries over 6 years or longer for me to accomplish the current Kang repair method after I first realized that a type-specific, non-mesh repair was necessary.

Also, as far as I understand, most hernia surgeons do not feel that type-specific repair is necessary. Thus, even if they understood the type of hernia in advance, they usually proceed the method they prefer among many one-fits-all repair methods almost automatically without wondering about which method to go with. For the mainstream of hernia repair to move from the current one-fits-all repair to the type-specific repair, I think we need a switch of ideas to a degree greater than that came into play when the tissue repair in the past shifted to the mesh repair.

[drkang]

McVay repair was devised by McVay, an American surgeon, in 1939. Under this method, cremaster muscle is divided and all transversalis fascia of inguinal canal, including the deep inguinal ring, is cut – which is the same process as that of the authentic Bassini repair. The difference is that the original Bassini repair sews triple layer of medial muscles to inguinal ligament in the lateral, while McVay repair sews triple layer of medial muscles to Cooper’s ligament, which is located deeper than inguinal ligament. Thus, McVay repair belongs to the surgery method that rebuilds the main anatomical barrier, and once administered correctly, recurrence should be minimal.

However, the problem with McVay repair is that it is technically difficult to identify Cooper’s ligament that is located in the deep and sewing triple layer of medial muscles to it. Thus, it is very difficult to correctly administer McVay repair, unless the surgeon is especially well aware of inguinal anatomy.

I remember that my professors, during my resident years, explaining that McVay repair is a very good method that has lower recurrence rate than that of Bassini repair. At the time I did not pay so much attention to such comment, but when I think of it now, the professors were just comparing the performances of corrupt Bassini repair and McVay repair. If my guess is right, it is only natural that the performance of McVay repair is much better.

I think the reason why the doctor you mentioned above told you that he would administer McVay repair for the direct inguinal hernia is that the corrupt Bassini repair shows higher recurrence rate especially in the direct type inguinal hernia. I think that is why the doctor said he would administer McVay repair for the direct type hernia. I do not think that McVay repair would have been required for direct inguinal repair, if the doctor knew about the original Bassini repair. Fortunately in case of indirect inguinal hernia, the corrupt Bassini repair would work better than for direct inguinal hernia.
Anyhow, the corrupt or the authentic Bassini repair or McVay repair are all ‘one-fits-all’ type of repairs.

Sac ligation is a process that must be carried out to cure the indirect hernia, and finishing the surgery by sac ligation is called ‘high ligation’, which is mainly administered to children. Marcy repair is a totally different surgery from high ligation. Marcy repair is a surgery method that narrows the enlarged deep inguinal ring by sewing, after treating the indirect hernia sac. Thus, Marcy repair is also a good surgery method that repairs transversalis fascia, the main anatomical barrier, which can be deemed as a limited version of the original Bassini repair.

Concept of Marcy repair is similar to that of Kang repair administered for the indirect inguinal hernia. However, the big difference between Marcy and Kang ‘indirect’ repairs is that cremaster muscle is always divided in Marcy repair. Also, Marcy repair and Kang ‘indirect’ repair have different areas of sewing the loosened deep inguinal ring.