[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. Forutnately in case of indirect inguinal hernia, even 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.

[drkang]

Even though it is not the torn part, there are areas that must be sewn in the indirect inguinal hernia. It is the enlarged deep inguinal ring. The diameter of ring must be decreased to a degree that only spermatic cord can pass through by sewing the loosened area.

The original Bassini repair was not devised exclusively for the repair of direct inguinal hernia, but was devised to be applied to both direct and indirect inguinal hernias. For the sake of briefness, I will skip the process of treating hernia sac and explain only the process of restoring the anatomical barrier.

First, cremaster muscle (that acts as a fence) is cut, so that the surgeon can visually confirm the deep inguinal ring. In the original Bassini repair or Shouldice repair, the surgeon definitely cuts cremaster muscle, to confirm the deep inguinal ring.

After confirming the condition of deep inguinal ring by cutting cremaster muscle, the surgeon starts to cut transversalis fascia from the lower part of the ring to the pubic tubercle – the entire transversalis fascia (which forms the floor of Hesselbach triangle) is cut and made into one big defect. Now, the small hole (i.e. deep inguinal ring) is changed into a hole as large as the entire inguinal canal. Thereafter, all defects in the lower area is sewn together, leaving only a gap in the upper area (the area where the deep inguinal ring used to be) enough for spermatic cord to pass through. Because the transversalis fascia on the entire inguinal canal floor is repaired leaving only the gap for spermatic cord to pass through, this method can be applied regardless of indirect or direct inguinal hernia. So original Bassini was already an ‘one-fits-all’ repair.

Thus, the corrupt version was not modified to allow the ‘one-fits-all’ approach. I do not know the exact cause thereof. I think someone mistakenly administered the surgery omitting this process, without recognizing the importance of transversalis fascia as the anatomical barrier, and the wrong method was handed down to the next generation of surgeons in the course of knowledge transfer. A hernia textbook said that the authentic Bassini repair remained quite much in its original state in Europe, while only the corrupt version became known to America – maybe the persons who transferred the knowledge to America have made a mistake.

Authentic Bassini or Shouldice rebuilds the entire inguinal floor, regardless of the type of inguinal hernia, as seen in the above, and I personally wonder if that is the only solution. So, in Kang repair, only the enlarged deep inguinal ring is narrowed to an appropriate degree, in case of indirect inguinal hernia, and only the transversalis fascia that covers Hesselbach triangle is rebuilt, in case of direct inguinal hernia.

It is because I think there is no reason why even the healthy Hesselbach triangle must be intentionally cut and sewn back again in case of indirect inguinal hernia, or why a portion of healthy (which had not been loosened) deep inguinal ring must be intentionally cut and sewn back again in case of direct inguinal hernia.

By restoring only the damaged areas, as I do with Kang repair, area, time and damage of the surgery can be reduced, which can consequently reduce aftereffect and accelerate recovery. Also, Kang repair can preserve cremaster muscle (in which many people are interested) as is, without any damage.

[drkang]

Scaredtodeath, not yet but I would like to in the near future.

UhOh, You have correctly understood Bassini repair. And the correct title of such procedure is ¡®triple layer repair.¡¯ I would like to correct my reference (¡®3-layer repair¡¯) in my previous answer.

Under Kang repair in case of direct hernia, the parts of torn transversalis fascia which still remain strong are identified and sewn together, so that the sewn transversalis fascia will fully function as a barrier, rather than just sewing together the torn part of transversalis fascia. This is because the transversalis fascia has a very important role as the main barrier. In addition to the above operation, the conjoined muscles (transversus abdominis and internal oblique muscle) are attached to and sewn together with the inguinal ligament to build the auxiliary barrier.

In case of indirect hernia, narrowing the deep inguinal ring (transversalis fascia) by sewing has the same meaning as that of rebuilding the main barrier. However, because it is a very narrow area, it is often difficult to differentiate the layers, and the tissues of other layers are usually sewn together.

[drkang]

quote Jnomesh:

Thanks Dr. Kang. Fascinating and kudos to be able to take a complex subject matter and brilliantly conveying it to the readers on this forum.
Some of the surgeons here in the US who do a non mesh repair used what they term a modified Bassini. I wonder if this is the authentic or corrupted version.
Thanks dr. Kang for your contribution!

Hi Jnomesh,

Thank you for your encouragement. According to some hernia textbooks I read, Bassini repair passed onto North America was sadly the corrupt Bassini repair. If it was the authentic Bassini repair that was passed onto North America, Dr. Shouldice would not have created his own surgery method that was very similar to Bassini repair. Because he did not know about the authentic Bassini repair, he had to develop his own surgery method to minimize recurrence. The modified Bassini repair I learned when I was a general surgery resident in the 1980s was actually the corrupt Bassini repair, when I think about it now. I think it was because most of the professors at Korean university medical centers at the time went to the U.S. and learned surgery methods there.

However, if there is a surgery being administered under the name of ‘modified Bassini repair’ in the U.S., I do not know if it is the corrupt Bassini repair or the authentic Bassini repair. A surgeon who is aware of the above particulars may administer the authentic Bassini repair. I cannot rule out the possibility of a surgeon who is not aware of the above particulars administering the corrupt version of Bassini repair.

[drkang]

quote UhOh!:

Very comprehensive explanation, and very interesting (particularly the part about the ‘two Bassinis’). So is the auxiliary barrier in your repair a four-layer repair as in Shouldice, or more similar to the two-layer Shouldice performed by some surgeons?

This brings up two other questions, partially based on the info here and part on my previous thread (about absorbable mesh):

1. If the original Bassini repair had a 2.7% recurrence rate without an auxiliary barrier, why do an auxiliary barrier at all; is there a true need or is it more about the difference between a 2.7% recurrence and the 0.5% you report? That is, of course, unless the recurrence rate was artificially low compared to today, given how many more people would be eligible for surgery/how many more years they live and need the repair to hold…

2. Is the purpose of the auxiliary barrier to hold the repair in place while the fascia heals, or because the fascia will never be “as good as new” again? If it is the former, what would be the likely result of combining a Kang/Bassini (original) fascia repair with a piece of fully absorbable mesh and no auxiliary barrier?

In Kang repair, the auxiliary barrier is erected much more simply than it is done in Shouldice repair. Although I do not fully understand the two-layer Shouldice repair, I think Kang repair is close to it.

Answer to question 1: The authentic Bassini method repairs the hernia by sewing all three medially located muscle layers (transversalis fascia, transversus abdominis and internal oblique muscle) into the lateral structure (lateral leaf of transversalis fascia and inguinal ligament) as one. This is called 3-layer repair. However, in case of Shouldice repair or Kang repair, the auxiliary barrier is additionally needed, because only the defect in transversalis fascia is sewn first. Transversalis fascia is a relatively thin muscle layer, and when there is a direct inguinal hernia, this muscle layer is significantly weakened by the hernia. Thus, although the transversalis fascia is indeed a normal anatomical barrier, it will not be enough to repair only this muscle layer without building any auxiliary barrier.

Answer to question 2: The auxiliary barrier is required not just during the recovery period of sutured transversalis fascia – we must make it work as the permanent barrier. It is because the transversalis fascia of inguinal hernia patient (especially the one who suffers from direct inguinal hernia) would have been weakened. I have administered some 6,000 consecutive non-mesh inguinal hernia repairs and never once felt that I needed any mesh during the surgeries. Some patients out of the 20 to 30 patients whose hernias recurred might not have suffered from recurrence, had I used the mesh. However, I believe that the number would be negligible. Thus, I think it is inappropriate to indiscriminately use mesh (which is risky) to all 6,000 patients for the benefit of only a few. My understanding is that mesh, whether it is absorbable or not, is not free from complication.

[drkang]

Hi UhOh!

It has been a while!

Thank you or your interest in and question about Kang repair. At the same time, please accept my apology – when I think of it now, I think there was something wrong with the contents of table.

As a matter of fact, I am still finding out more about inguinal hernia bit by bit, day by day. I sometimes understand new facts during surgery or organize my thoughts as I read related publications. So, I now have an opinion that is somewhat different from that I had when I created the table. Thus, I believe that the part on ‘new barrier’ in the table you mentioned must be updated.

What I am going to explain hereafter is what I have recently discovered.

Dozens of inguinal hernia surgery methods introduced by many hernia textbooks can be largely classified into the methods which erect the new main barriers (Group 1) and which repair the existing damaged anatomical barrier and reuse it as the main barrier (Group 2).

Group 1

All open and laparoscopic mesh repairs, including Bassini repair (? see below) and Desarda technique, can be regarded as the surgery that erects the new main barrier. In most of the surgeries that erect the new main barrier, the existing damaged anatomical barriers are not repaired. Here, the existing anatomical barrier refers to the transversalis fascia.

Group 2

Meanwhile, Shouldice repair reuses the existing damaged anatomical barrier (i.e. the damaged transversalis fascia) after repairing it. However, most surgeries that belong to this Group additionally install auxiliary new barriers, because just repairing the transversalis fascia (the original anatomical barrier) may not be enough. But what is certain is that the main barrier of surgeries that belong to this Group is the transversalis fascia.

Here, I must address this:

Although I said the Bassini repair belonged to Group 1, the Bassini repair published in 1890 was a surgery that belonged to Group 2. The essence of original Bassini repair was to repair the damaged transversalis fascia barrier. While the recurrence rate of inguinal hernia repair announced by other hospitals exceeded 50%, the same rate announced by Bassini in 1890 was merely 2.7%. Owing to this remarkable performance rate, the Bassini repair quickly became famous and many surgeons adopted it. However, it was unfortunate that the method was ‘corrupted’ in the course of it being widely propagated – the initial (and essential) process of transversalis fascia repair was omitted, and the new main barrier was built by pulling and sewing together the separated muscles and ligaments. Some called so ‘corrupted’ surgery method the ‘corrupt Bassini repair’ and the original Bassini repair the ‘authentic Bassini repair’. Thus, the Bassini repair that was said to belong to Group 1 in the above was actually corrupt Bassini repair. However, the authentic Bassini repair is certainly a method that belongs to Group 2 and should be regarded as the most advanced method in the Group. In fact, the processes of repairing transversalis fascia (the main barrier) under the Shouldice repair and the authentic Bassini repair are almost the same. The only difference would be how to create the auxiliary barrier. Thus, some call Shouldice repair the ‘Bassini-Shouldice repair.
Sadly, the Bassini repair most surgeons learned, knew and practiced was not the authentic type, but the corrupt type.

I believe that correctly and strongly repairing the transversalis fascia, the anatomical barrier, is the most important issue in preventing recurrence of hernia. That is why the recurrence rate of initial authentic Bassini repair was only 2.7%, which is an excellent rate even today.
However, as the corrupt Bassini repair became the golden standard of hernia repair thereafter, the recurrence rate had to show a high level of 10 to 30%.

Mesh repair was a surgery method introduced to respond to such a high level of recurrence rate. Unfortunately, mesh repair is also a surgery method that belongs to Group 1 which builds the new main barrier. The only difference from corrupt Bassini is that it builds the new main barrier using mesh, instead of using muscles and ligaments. The mesh inguinal hernia repair should have almost no recurrence, because it uses tough mesh and generates no tension. However, the recurrence rate of mesh inguinal hernia repair appears to be in between 5 to 10% according to the recently announced data. I think it is because the mesh inguinal hernia repair does not repair the transversalis fascia, the main anatomical barrier.

Kang repair I invented is a surgery method that belongs to Group 2, which repairs damaged transversalis fascia, the main anatomical barrier. The difference between Kang repair and other methods in the same Group, such as Shouldice repair or authentic Bassini repair, is that it administers a type-specific repair.
Both Shouldice repair and authentic Bassini repair incise lengthwise the entire transversalis fascia that covers the Hesselbach triangle, including the deep inguinal ring, regardless of the type of inguinal hernia, and repair the entire transversalis fascia again (one-fits-all repair).

However, Kang repair: closes only the stretched deep inguinal ring to its original status (i.e. restoring the damaged transversalis fascia in this area) in case of indirect inguinal hernia; and repairs only the transversalis fascia that covers the Hesselbach in case of direct inguinal hernia (i.e. type-specific repair). In case of indirect hernia, no auxiliary barrier is additionally created, and in case of direct inguinal hernia, the auxiliary barrier is created, similar to what is done in case of Shouldice repair.
The differences between Kang repair and Shouldice repair (which belong to the same Group) are that Kang repair: has very small area of surgery (skin incision of 1.5 inches); does not divide the cremaster muscle; takes little time (20 minutes); has fast recovery time (same-day discharge); and inflicts very little pain. Chronic pain is negligible, and recurrence rate is less than 1%.

I hope I had explained as briefly as I could. In conclusion, ‘yes’ under ‘new barrier’ in ‘Kang repair for direct inguinal hernia’ in the table posted in the website should be changed to ‘no’. I will make sure that the correct information is posted.

I also hope my explanation made sense to you. If you have any question, please do not hesitate to ask me. My explanation in the above is not quoted from any existing information, but derived from what I have understood by administering surgeries and reading reference publications. Thus, other surgeons may not agree thereto. Thank you.

[drkang]

Hi dog,

I said before that ‘if the tissue repair is performed properly’ at post #7. Actually, it has a very long and complicated story in it.
I think it is still hard to find the ‘properly designed’ tissue repair technics for the inguinal hernia. In my point of view, most of them are type non-specific repair technics, and it means that the hernia defect(s) sometimes could not be repaired properly. Shouldice or Desarda also belongs to that category, I think. They are one of the ‘one-fits-all’ kind of repair technics.
So I think that the new concept tissue repair method should be developed to meet the condition of ‘if the tissue repair is performed properly’. Hopefully, it should be a kind of type-specific technic.

Lack of expertises doesn’t justify us to accept the present situation. Doctors, I think, must be properly prepared to meet the patients’ needs

I am afraid that few fellow surgeons will agree with me.

[drkang]

No, I don’t think that the mesh support is necessary no matter how the patient’s condition is if the tissue repair is performed properly.

[drkang]

Hi UhOh!,

I completely agree with you. It would be better for now to set aside mesh complication issues and focus on the recurrence.

The majority of doctors believe that the biggest reason for hernia recurrence is the tension. That is why they began to use prosthesis for a so-called tension-free repair. Mesh and autologous aponeurosis (in the case of Desarda) are all prostheses for such objective.

However, I believe that a more important reason for hernia recurrence is that existing surgical methods do not directly close the muscular defect, through which the bowel is coming out. I think, therefore, the best way to prevent recurrence is to precisely close the hernia opening (muscular defect). So, I believe it is necessary to perform the type-specific repairs for direct and indirect hernia respectively. Unfortunately, however, it seems rather difficult to find the doctors who agree with me.

Despite, I still stand by my claim that the most important principle of hernia repair is to close the defect completely. The importance of this principle can be realized in the incisional hernia repair.

Due to the big size of the defect in some cases of incisional hernia, some doctors disregard closing the muscular defect completely because it is technically difficult to do so. So they just cover the open defect with mesh but it results in a very high risk of recurrence. That is why the defect has to be completely closed with its own tissue no matter how hard it is. Mesh is, of course, needed for a large incisional hernia, but it is only plays an auxiliary role to protect the stitched muscular defect from opening again. Thus, for the case of incisional hernia, whether to use mesh or not could be decided upon considering the size of the muscular defect but the procedure of closing the defect is an absolutely necessary step that should not be disregarded.

This principle applies to the inguinal hernia repair as well. Closing the defect is an essential procedure. Also, whether to use or not use prosthesis such as mesh depends on the patient’s condition or the doctor’s preferences. This stage is where mesh complications should be seriously considered. From personal experience, for inguinal hernia repair, I believe there is really no reason to use mesh while risking complications because closing the defect is sufficient.

Therefore, as you have doubted, there may be problems concerning the conclusion on the effectiveness of absorbable mesh made in the study that you have quoted because they probably did not close the hernia defects properly. I believe the results could have been different if the defect was properly closed and then supported by absorbable mesh.

Your last question is not easy to answer. If they follow the principle of closuring the hernia defect, then as you mentioned, it could be helpful to use prosthesis until they get familiar with and confident of their new trial of tissue-based repair. However, I believe there is no point in using prosthesis if the principle is not followed. Tissue repair that does not close the defect directly is in effect the same as existing tissue repair which, in my point of view, is not type-specific repair closing the hernia defect directly.

[drkang]

Hi UhOh!,

I have searched about the Guarnieri technique to answer your question on whether it is similar to my repair method.

The only similarity is that direct inguinal hernia and indirect inguinal hernia are treated in separate ways. I have read that this technique is no longer used even in that hospital, and I can guess why. In my opinion, it is because this technique is too complicated. On picture, it looks like a very detailed and delicate method but not only is it extremely difficult to carry it out the way it is on picture, it would not be easy to get successful results. Reason being, surgery in reality, is like a battle so it does not proceed as planned or pictured. This is why surgeries have to be as simple as it can be. That way, the possibility of errors or unforeseen situations will be minimized and increase in the possibility of a successful surgery will follow. Furthermore, the simpler the method, more doctors will be able to provide equal quality of the surgery, which leads to its generalization.

One big reason behind the widespread implementation of mesh repair is that it is simple and easy for doctors to repeat the process. Thus, I believe that simplicity and easy-to-follow are important conditions for new tissue repair methods in the future.

[drkang]

Hi Jnomesh,

I feel strong companionship with some people on this forum. It is the job of doctors like me who know the seriousness of mesh to pose issues concerning mesh. But you all on this forum are taking the trouble to do so. As a doctor, I am regretful of this.
I am actually more fundamental than you think. Through the 15,000 inguinal hernia surgeries that I have performed, I have gained firm conviction that mesh is not required for successful inguinal hernia repairs. By successful, I mean minimizing recurrence and complication.
Doctors that support mesh hernia repair always reiterate “evidence-based medicine’. But why is it that only a portion of published studies can be called “evidence”? Not only are there many “evidence” on this forum, mesh pain stories frequently appear in actual clinical fields. I do not understand why these cannot be called “evidence”.
Some emphasize that there are people who get good results through mesh repair. This is true. 80-90% of patients that underwent mesh inguinal hernia repair are satisfied with successful results. However, this also means that 10-20% of patients awaiting mesh repair will encounter issues post-surgery. This is not a risk that can be overlooked.

The most effective way to make doctors realize the seriousness of mesh complication is to have them personally remove the problematic mesh that they have implanted. Once this is done, no doctor will be able to disregard the gravity of mesh complication. The problem is, many doctors avoid personally removing the mesh that they have implanted. Their reason is that they are not capable of performing such removal surgery. This is merely an excuse. Doctors who perform mesh removal were not born with the skills to do so. Also, this surgery is not something that can be learned from someone else. It is a surgical process that has to be carried out personally and requires familiarizing and mastering of the process. So, doctors that claim they do not know how to remove mesh implants and direct patients to another doctor are really saying that they do not want to perform such a laborious surgery. Therefore, patients suffering from mesh pain have to persistently request for the doctor that implanted the mesh to remove it personally.

I have conducted mesh removal on more than 50 patients and for every one of them, one thing always came to my mind. It is that the doctor that implanted the mesh would be able to remove it the most safely. This is because each doctor has a distinct method of mesh repair and thus naturally, would know the inserted state better than anyone else. Therefore, if suffering from mesh complications, patients should continuously complain to the doctor that performed the hernia repair and if mesh removal is decided, patients should persistently demand that doctor to personally remove it. If many patients do this, the number of doctors performing mesh repair will rapidly decrease.

[drkang]

If your hernia bullges eaily by cough or with a Valsalva on lying positon. yes it is very likely a direct type.

[drkang]

Yes, dog is right.

Of course, in most cases, lying positon is OK for the ultrasonic exmanination for the inguinal hernia. However, standing position makes the exam easier and more precise even if the hernia sac is very small. And it makes the discrimination of the type of hernia easier as well.

[drkang]

Hi dog,

That is why Desarda technique is one of the ‘one-fits-all’ repairs. Yes, if I were a Desarda doctor, I also would not do the ultrasound examination to diagnose the type of inguinal hernia before operation. As the repair will be the same anyhow. We do the inguinal sonography to check the type of hernia before operation. It shoud be done in standing upright position with Valsalva maneuver.

[drkang]

Hi dog,

Yes, correct. However, this is only my personal rule.

It is true that direct hernia and indirect hernia are located on opposite sides of the inferior epigastric vessels, which pass through the center of the inguinal floor. Although, in contrast to what you heard from a certain doctor, it is possible to almost accurately determine whether it is direct or indirect through ultrasound prior to surgery.

The only similarity between these two hernias is that they share the same name ‘inguinal hernia’ because they both occur in the inguinal canal. I personally believe that they are completely separate types of hernia, because not only do they occur on different locations, they have different occurring mechanisms.

[drkang]

Hi dog,

Yes, correct. However, this is only my personal rule.

It is true that direct hernia and indirect hernia are located on opposite sides of the inferior epigastric vessels, which pass through the center of the inguinal floor. Although, in contrast to what youI’ve heard from a certain doctor, it is possible to almost accurately determine whether it is direct or indirect through ultrasound prior to surgery.

The only similarity between these two hernias is that they share the same name “inguinal hernia” because they both occur in the inguinal canal. I personally believe that they are completely separate types of hernia because not only do they occur on different locations, they have different occurring mechanisms.

[drkang]

Hi UhOh! & dog,

To my knowledge, the majority of tissue repair methods to fix direct hernia causes tension. But Desarda repair seems normally not to cause tension in the floor of the Hesselbach triangle.

Most hernia surgeons unload their responsibility of inguinal hernia recurrence on tension. This is in fact the reason why the use of mesh prosthesis began; since by having prosthesis replacement tension can be prevented. It seems that Dr. Desarda agrees to the necessity of prosthesis replacement in order to prevent tension. Although, he seems to have designed a method that uses a strip of external aponeurosis instead of mesh to avoid mesh complications.

However, I do not believe tension is the decisive cause of inguinal hernia recurrence. Hence, I do not believe that the best way is to perform surgery in a way that focuses to prevent tension. As I consistently mention, I believe that the main cause of recurrence is because proper type-specific repair is not being executed.

Anyway, the majority of tissue repair methods with the exception of the Desarda technique induces tension. Thus, in my personal opinion, it is most desirable to use a material that can hold the sutured defect until it regains enough strength. Some suitable suture materials are non-absorbable Prolene or PDS, which is slowly absorbed. It has come to my knowledge that Shouldice Hospital uses steel. Although I have no experience using steel thread, I do not ever plan to use it because the above mentioned suture materials are sufficient enough. I am currently alternately using 2-0 PDS and 2-0 Prolene on my direct hernia patients and observing the operation results. When performing indirect hernia repairs, I am using 2-0 PDS.

As of now, for indirect inguinal hernia repair I believe PDS is sufficient, and for direct inguinal hernia repair I am going to use 2-0 Prolene until we get the results of the above mentioned comparative study.

Scar tissue has a weaker tensile strength than normal tissue. Hence, I do not believe it is a good idea to use additional absorbable sutures to sacrifice normal tissue and create additional scar tissue.

[drkang]

Hi dog!

With frequent mesh complications, the necessity of tissue repair magnifies more and more. Desarda and Shouldice are no doubt big assets in the field of tissue repair, and I believe they are better than any mesh repair methods. But I do not believe that they are the best tissue repair methods with no need of further improvements. I am quite certain that there can be other tissue repair methods that are smaller in scale, simpler, and produce better results; and it is in the direction of type-specific repair.

I agree with Dr. Brown on many parts. However, we are different in the sense that Dr. Brown selects one among existing tissue repair methods in accordance to the individual’s conditions while I designed and am performing my own type-specific repair method that can be executed on all patients regardless of their conditions. Dr. Grischkan’s modified Shouldice method looks like mixing the Shouldice repair and mesh repair. I presume it is a type of mesh repair.

I have not yet presented my techniques to medical society as I had been continuously improving my procedures until several months ago. I am now accumulating my data to submit to a medical journal. It will take some more time. So there is no American doctor doing my procedure yet.

[drkang]

Hi dog!

With frequent mesh complications, the necessity of tissue repair magnifies more and more. Desarda and Shouldice are no doubt big assets in the field of tissue repair, and I believe they are better than any mesh repair methods. But I don’t believe that they are the best tissue repair methods with no need of further improvements. I am quite certain that there can be other tissue repair methods that are smaller in scale, simpler, and produce better results; and it is in the direction of type-specific repair.

I agree with Dr. Brown on many parts. However, we are different in the sense that Dr. Brown selects one out of existing tissue repair methods in accordance to the individual’s conditions while I designed and am performing my own type-specific repair method that can be executed on all patients regardless of their conditions. Dr. Grischkan’s modified Shouldice method looks like mixing the Shouldice repair and a mesh repair. I presume it is a type of mesh repair.

I haven’t yet presented my techniques to medical society as I have been continuously improving my procedures until several months ago. I am now accumulating my data for reporting to a medical society. It will take some more time. So there is no American doctor doing my procedure yet.

[drkang]

quote dog:

“Defect specific” word is not applied to direct or indirect typing of hernia. Defect specific treatment means treat only that hole and leave other area as it is.

Because, direct or indirect or femoral types have their own established treatments like mesh or Bassini or Marcy or Shouldice etc.

UhOh! [h=2]Prof. Dr. Desarda M. P. Kindly Responded to your concern ..please read above[/h]

Hi dog,

Just as how umbilical hernia and inguinal hernia are different, femoral hernia and inguinal hernia are completely different hernias. Many doctors use a different repair method for femoral hernia to that of inguinal hernia (however, in the case of laparoscopic mesh repair, mesh is usually covered on the whole area where indirect, direct, and femoral hernia can occur). Therefore, when discussing type-specific repair, it is better to regard only indirect and direct inguinal hernia.

As Dr. Desarda pointed out above, the term ‘defect specific’ can cause misunderstanding. This is why I think it is preferable to use the term ‘type-specific’. Type-specific repair means that the whole area of each indirect and direct type is repaired.
From the mentioned surgeries, Marcy is a type-specific repair for indirect hernia; meaning that it is not applicable for direct type inguinal hernias. Unfortunately however, only a tiny fraction of doctors are currently using this method for indirect inguinal hernia. Aside from this method, if we were to classify the Bassini, or Shouldice, or Desarda repairs, they lean more towards the direct type. Nonetheless, these methods are being used in all cases without consideration of type; whether indirect or direct. Among open mesh repairs, Lichtenstein mesh repair falls with the likes of Bassini kind of repair since it is used type-nonspecifically.

Therefore, the intention of insisting type-specific repair is to encourage the use of an ideal method for each indirect and direct hernia instead of Bassini or Shouldice-like ‘one-fits-for all’ repairs. However of course, it is very rare at the moment to find hernia surgeons who agree with this. So I believe it will be sufficient enough for you to simply be aware that such assertion exists as well.