[drkang]

quote UhOh!:

Thanks for sharing that! I suppose I should have been more specific (as both Dr. Kang and Dr. Brown are) about using “defect-specific” repairs; they are talking about direct vs. indirect (and Dr. Brown also mentions femoral). It appears that Dr. Desarda’s answer is speaking mostly to direct hernias of different shapes, sizes and locations, based on his answer.

His answer doesn’t appear to address indirect hernias in as specific a way as Drs. Kang or Brown (Dr. Kang has his own repair; Dr. Brown referees the Marcy repair). As those doctors explain it (or at least as I understand it), it is an entirely different type of defect, and even if a reinforcement repair like Desarda would patch it up, it still leaves the fundamental problem unsolved.

Hi UhOh!,

I completely agree with you. From what I know, the Desarda method is a more suitable method for direct inguinal hernia. If you watch a YouTube video of the Desarda procedure for indirect inguinal hernia, you can see that more than half of the surgical procedure is a process of reinforcing the Hesselbach triangle.

Doctors widely claim that the reason for disregarding the specific type of inguinal hernia and rather repairing the entire inguinal area is to prevent the recurrence of another type of hernia later on. Thus, they claim that if only indirect is repaired, direct hernia can later occur, and vice versa. However, there are not any detailed evidence to support this claim. This is because there were not any opportunities to gain the outcome of type-specific repairs in the first place since all the surgeries were “one-fits-for-all” repairs.

Despite, the key here is not to dispute but to regard the actual results. The recurrence rate of previous “one-fits-for-all” repairs came out to be between 10 – 30% and that of recent mesh repair stand by near upto 10%. How could these numbers be explained?
Perhaps that type-specific repairs could be in fact more helpful in reducing reoperation possibilities. Such questions triggered the beginning of my development of type-specific repair. And the results from my personal experience came in accordance to support the fact that type-specific repair noticeably reduces the recurrence rate. Another merit of type-specific repair is that the extent of surgery is less than half of pervious surgeries. As the extent is reduced, it means less surgery injuries, less aftereffect, and quicker recovery. Each of these merits cannot be disregarded. Thus, “one-fits-for-all” repairs, in order to prevent a slight possibility of what hasn’t occurred yet, operate on unnecessary areas and cause unnecessary injuries to all patients being treated.

Another surprising thing to me is that Dr. Desarda, in his reply, mentioned that he made his first and last improvement in operation technique when he operated on his second patient. This is just amazing because it took me 4 years and 11 months to first set my eyes on type-specific tissue repair and develop a final method, which by that time was at the very end of 2017, after operating my 5,000^th patient. I have come to a stage where I feel self-satisfied of an almost impeccable method every time I treat a patient. However, that does not mean there will absolutely be no changes in the future. For even for a seemingly tiny improvement, adjustments should be made.

Thank you!

[drkang]

Hi Good intentions,

I understand that it is not easy for the non-medical people to understand the anatomy of inguinal area which is also difficult even for the medical personels to understand fully. I respect many participants here including you who are very dedicated and have very precise knowledge about hernia repair and mesh problem sometimes more than doctors do. I also frequently learn something and get the useful information from many of you. That is why I sometimes visit this forum and look around.

Thank all of you for that.

[drkang]

quote Good intentions:

I can’t add anything very specific to why “pure” tissue repairs fail, but I have realized that one of the difficulties with hernia repair is that the tissue that fails is not normally injured so does not have a robust healing mechanism. It is very like an ACL tear of the knee, which can only be repaired well by replacing it entirely. That’s why, I think, they call mesh a prosthetic. It’s an aponeurosis replacement. The pure tissue repairs are attempts to tie a “ligament” back together. It doesn’t work well.

The aponeurosis is essentially a wide flat ligament, at the ends of the abdominal muscles. I supplied the Wikipedia link below. Each suture point in the ligament is a new hole that can elongate and tear. That’s why Shouldice uses so many, to spread the load across many holes. There are some basic engineering principles involved. It is a lot like darning a sock or a pair of Levis. More sutures are better. To avoid that, many of the multitude of repair techniques involve moving tissue that heals, over, to take the place of the failed aponeurosis, which will, essentially, never really “heal”. As I understand things.

What you’ are saying is to some extent true concerning femoral hernia, umbilical hernia or incisional hernia. That is because for these types of hernias, the margin of the hernia hole is composed of ligaments or ligament-like fibrous tissue. This leads to the possibility of recurrence as the hard and inelastic tissue may tear after tissue repair. Despite this, based on my personal experience, the majority cases of femoral hernia and umbilical hernia with less than 2cm in diameter underwent pure tissue repair without recurrence.

It is however very different for the circumstances of inguinal hernia. The defect margin of inguinal hernia is composed of soft and elastic muscle instead of hard ligamentous tissue. And, not only for indirect hernia but for direct types of hernia as well, almost all cases have only a definite single defect. Thus, pure tissue repair can be performed on inguinal hernia for all patients very successfully. The high recurrence rate that existing tissue repairs have is not because of a tissue problem but because they are not the ideal surgical methods.

Therefore, what I believe was needed to solve the high recurrence rate of previous tissue repairs was not a surgery that uses durable mesh as reinforcement but rather the development of a new ideal tissue repair method. I think that the fundamental approach of solving the mesh problem is even now leaving aside the attempt to develop a so-called safe mesh and instead come up with a new optimal tissue repair method.

[drkang]

It has been a while since I am writing.

In reality, I believe this topic is the key inquiry concerning inguinal hernia repair. The reason being, pure tissue repair in the past had high failure rate, which caused the introduction of mesh repair to be performed worldwide. This resulted into mesh complications. Therefore, if it is possible to find the exact cause of tissue repair failure and develop a new repair method that is reliable not to fail, the risky use of mesh will not be necessary.

The problem here is that it is not easy to identify the reason of failure of tissue repairs. Many would think that research will eventually reveal the cause. However, considering all the variables in research, it is almost impossible realistically to exactly pinpoint the cause. So, the most realistic approach is for a doctor with deep interest in solving the issue to set a hypothesis for the cause of failure and see if it works by performing the method devised on the hypothesis.

Hypotheses for the cause can differ based on the experiences and inspiration of each doctor. Dr. Lichtenstein and those who support his method claim that repair failure is caused by the weakening and tearing of tissue after the repair. Doctors who prefer laparoscopic mesh repair also agree on the tearing of tissue as a cause of failure after the repair and that it is important to implant mesh in the inside of the hernia defect in order to reduce failure rate.

Dr. Desarda seems to agree with doctors that perform mesh repair as well. Except that to avoid mesh complications, the patient¡¯s strip of external oblique aponeurosis is used instead of mesh in his operation.

On the other hand, Dr. Shouldice seemed to have a different opinion. He seemed to believe the insufficient tissue repair methods of the past were the main cause of recurrence. So he developed his own quite meticulous and extensive method.

However, it appears as though the Shouldice hospital carefully selects patients eligible to undergo their repairs. According to posts on this forum, patients who recurred since less than a year ago are not subject to the repair and obese patients are required to lose weight. Patients with early stage inguinal hernia when the bulging is not grossly visible are excluded from the eligible list. At first glance, it may look as though carefully selecting eligible patients is for the better of the patients. However, I also see it as a way to maintain their good surgery outcome. Excluding high-risk patients and selecting only low-risk patients will definitely result in favorable and consistent outcomes. Likewise, frankly speaking, doctors mentioning smoking, collagen deficit, and chronic cough etc. as factors increasing hernia recurrence could be making excuses to defend themselves.

I believe that rather than strictly and selectively performing surgery on patients in accordance to the various problems they have, there should be a tissue repair method that will bring successful results to high risk patients as well. Below are what I believe to be the three main problems of existing tissue repair methods that cause high failure rate.

The first problem is performing the same or similar method for both indirect and direct inguinal hernia without distinction.

Second, suture closure is not directly done on the hernia opening.

Third, the hernia sac is not mobilized sufficiently to push it back into its original location.

These three aspects are my personal hypothesis on the cause of tissue repair failure. Therefore, I have developed and am currently in conduct of a new pure tissue repair method where the hernia sac is sufficiently mobilized to restore it back into its original location, specific methods ideal for each direct and indirect type is used, and suture closure is directly done on the hernia opening. For the whole time, I haven¡¯t selected patients relatively ¡°safe¡± to treat nor rejected patients with high risk factors to perform my method on. From my experience until now, I can say that the various high risk factors have little to no influence like taking from or adding a cup of water to a fully filled bath tub.

Factors that are considered high risk are in fact mere aspects of life to many people. Rather than demanding patients to modify their life to the surgery, it is necessary to develop the surgical method to cover the way one¡¯s lifestyle is. Accordingly, an ideal tissue repair should be able to give successful results consistently despite whatever risk factor that the patient may hold.

Thus, I believe the essential reason for tissue repair failure is because existing methods are not impeccable.

[drkang]

quote Jeremy B:

Good Intentions, thank you for your response.

I am a 37yo male, 170lb thin, 6’2″ diagnosed with a right side inguinal hernia by two local surgeons (both hernia specialists);
Neither of them were able to determine subtype upon examination.

The reason I would like to know the subtype is to develop a plan with a very conscious surgeon who can perform a quality no-mesh repair with minimal trauma. Please chime in with any thoughts or opinions.

If it is a Direct hernia I will try to live with it as long as possible as the surgery is more traumatic and involved.
If it is Indirect then I will travel anywhere to have one of the all time masters repair it:

1. If It is a very small opening in the internal ring, Dr Ponsky has what seems to be the least invasive approach (High ligation Laparoscopic) Yet limited data is concerning.

2. If it is a defect that is larger in size, than Dr Kang and Dr William Brown have methods to isolate just the Indirect defect by high ligation and narrowing of the ring.

3. I wish I knew more details of what Dr. Towfigh offers as I would consider her as well.

I would also be open to documenting (video) the surgery so that others may see and benefit. @Dr. Kang I know that many people would like to see your technique, I’d be honored if you used me as an example.

Thanks!
Jeremy

I totally agree with Chaunce1234’s opinion on ultrasonography and CT scan regarding the diagnosis of the inguinal hernia. If possible, you would better check with ultrasound.
But there is one way you can identify yourself. In many cases the hernia type can be distinguished if you try to cough strongly after lying flat in bed. That is, if bulging is easy when a big coughing is done, it is likely to be a direct type. If bulging is not done well, it is more likely to be an indirect type. Of course, when the size of the hernia is not large enough, it will not be easy to distinguish that way.

I have tried to make a video recording on my surgical procedure, but the skin incision and the operative field is so small that the procedure inside seems not clearly visible and understandable.
So, I will take several important cuts with a fine camera and make them into illustrates and will show them to you soon or later.
And one more thing I want to say. Even with direct inguinal hernia, surgery is not much larger or much more traumatic than indirect type. In fact, the recovery process after surgery is similar. Therefore, even if you have a direct type, it is better to get it fixed soon.

[drkang]

quote UhOh!:

The hernia I have is very easily reducible, but every time I do, it sort of slides against (what I assume is) the pubic bone; could rubbing against a hard surface like that cause the sac, or whatever layer is between the sac and bone, to itself develop a hole (like a hernia within a hernia, lol)?

A newly formed hernia sac is so thin and weak that it is easily torn during the operation. But with time it becomes larger and also thicker. And any irritation including rubbing I think also makes the sac wall thicker. That is how our body usually responds. So do not worry about any chance of hole formation as a result of rubbing against the hard structure.

[drkang]

Hi Heystevieboy,

I regret to say this but from reading your story, I predict you have had a mild infection for a long time. And the mesh and tissue probably tore and became detached while moving the heavy sofa, resulting in bleeding. Blood is a very good nutrient for bacteria so it seems that the increased bacterial activity caused the infection to flare up.
When there is an infection with the mesh in place, it cannot be completely treated no matter how strong or how long antibiotics is used until the mesh is removed. Right now it is most urgent to remove the mesh. Then observe for 3-4 weeks and when the infection is completely dealt with, if necessary undergoing umbilical hernia repair again would be good. If the hernia hole is not big, I recommend non-mesh tissue repair. Doctors may have different judgments but if the diameter of the hole is less than 2 cm for umbilical hernia, I do not use mesh for repair.

[drkang]

Hi Jimbohen,

It is great news that there is possibility of the development of a new medical device that has no side effects to replace current mesh being used. I thank you for such pleasant information. This is because implanting is essential to prevent recurrence for incisional hernia including port-site hernia. However it will be for the best of our interest to confine our discussion to inguinal hernia repair since it accompanies mesh complications the most.

I personally believe that implantation is not necessary at all for inguinal hernia. I confirm this after more than thousands of non-mesh open inguinal repair that I have performed. Of course there are many doctors who disagree with my opinion. However, before disputing over whether implantation of mesh is necessary or not, I would like to point out that current mesh repair has a fundamental flaw.

As everyone knows, hernia is caused due to an anatomical defect on the abdominal wall muscle. Simply explained, to treat hernia the defect should be closed. Directly closing the defect is what tissue repairing means. However, in current mesh inguinal hernia repair, mesh is covered on top with the defect left open. Therefore, it is a technique that overlooks the fundamental cause. Recent theses state that the recurrence rate of mesh inguinal hernia is near 10% and I believe this is because it has a flaw. So despite being it a tensionless repair having used a large and durable mesh to cover the whole inguinal region, the recurrence rate is higher than expected. And there does not seem to be another reason why.

That is why I believe that despite the possibility of the development of an ideal implant without side-effects in the future, the fundamental treatment of inguinal hernia is through tissue repair to close the anatomical defect. I predict the possible new implant will have limits utility-wise. Therefore the first step is to directly close the anatomical defect (tissue repair) and then implant for support if thought necessary by the operating surgeon. The ¡°IMPLANTABLE and INJECTABLE bandages that will NOT be REJECTED by the HUMAN BODY and will NATURALLY BREAK DOWN after the wound has healed up¡± mentioned would be an ideal device for supporting the tissue repair.

You have requested for detailed explanation of my Kang repair. But I hope you understand it is almost impossible to accurately and completely explain the surgical process through words. But I will film the process in the near future and inform you once it is posted on our website. A few aspects about my repair is that sedative local anesthesia is used, skin incision is less than 1.5 inches, and that it is a very simple surgery that takes from 15 to 20 minutes only. The outline of the process is to deal with the hernia sac then closing the muscle defect (hernia hole) by suturing.

[drkang]

quote UhOh!:

Very interesting. Potential genetic causes of differing tissue strength aside, it would be interesting to know what other lifestyle differences might be contributing factors. Perhaps the way westerners do (or do not…) exercise, or the vastly different diets across cultures…

If statistically validated, it sounds like there could perhaps be some interesting guidelines for lifestyle changes that lead to better health beyond direct hernia occurrence/recurrence in westerners.

You have pointed out an interesting point but a massively sized survey will be needed to clarify the difference in the lifestyle of Koreans and Westerners. As already been known relating to lifestyle, repeated increase in abdominal pressure is very important as a factor in raising the risk of direct or indirect inguinal hernia. Therefore, it is recommended for people prone to inguinal hernia, those who have already had it in one side or have relatives who had it, to avoid activities that increase abdominal pressure. Life habits that increase abdominal pressure include chronic coughing, continuous straining during defecation due to constipation, eating habits resulting to excessive abdominal obesity, and exercises that cause abdominal pressure. Smoking weakens muscular tissue so it also increases the risk of hernia; and recurrence as well.

Looking at the active discussions, I understand that many people have deep interest in minimal laparoscopic repair. I can feel the sense of fear that people have towards existing inguinal hernia repair methods; starting from mesh repair. However, I believe more than necessary fear can result into looking at only the trees instead of the whole forest.

If it succeeds, it is definitely delightful but only 1~2% at most, I believe, of the total number of inguinal hernia patients are subject to so called minimal laparoscopic repair. Most inguinal hernia patients will not be able to undergo this surgery. Therefore it will not be of much needed help looking into this technique excessively.

The real question here is which technique is practical for the majority of inguinal hernia patients. So, in my opinion, we need to concentrate our discussion on mesh repair and non-mesh open repair. I believe there are two directions we can take. The first is developing the ideal mesh with no side effects; though I do not know if it is possible or not. The second is finding or developing a new minimal non-mesh open repair different from existing ones and then educating it. It is an issue that each and one of us have to decide on. Every doctor may have different opinions but I personally believe the second direction is the best way.

[drkang]

quote UhOh!:

I’m guessing you see a more homogeneous patient population than a surgeon here in the US might, right? That makes me wonder: Is the difference racial/ethnic (in that Koreans are more genetically predisposed to an indirect hernia) OR cultural (fewer Koreans spend their lives sedentary only to wake up one day and decide to do something stupid like attempt to lift the refrigerator, meaning a lower rate of direct hernia)?

Hi UhOh!

That is an intriguing question you made.
As you mentioned, most patients that we treat are a mostly homogenous group. If our numbers are statistically significant, I believe it is possible it may be due to ethnic differences.
But rather than Koreans having genetic tendency of indirect hernia, I believe there is higher possibility that Westerners are more susceptible to direct hernia. Reason is, Koreans have a lower prevalence rate of inguinal hernia than that of you Americans. And from my personal experience of surgeries, I have noticed that tissue of many Westerners are slightly softer than that of Oriental people. While indirect types of inguinal hernia are more affected by hereditary anatomical factors, direct types have more relation to the strength of tissue. Therefore, if my above mentioned observation is correct, there is higher possibility of direct type inguinal hernia for Western people.
Bear in mind that I am not saying this with proper or accurate reference, but it is my personal opinion on your interesting inquiry.

[drkang]

quote Jeremy B:

Thanks for the discussion @Dr. Kang @Dr Towfigh [USER=”2533″]Jimbohen[/USER]

Has anyone developed a way to perform the high ligation and put a stitch in to narrow the deep inguinal ring using laparoscopy?

Also, is the sac usually adhered pretty well to the cord?
Is that why healing a hernia naturally is not possible?
My thought was that if you could “get the sock out of the door” the muscles could theoretically tighten back up.

-Jeremy

Hi Jeremy,

I heard that some surgeons are attempting non-mesh laparoscopic inguinal hernia repairs for adult patients but I personally don’t know much about this. So I am very careful in talking about this topic.

However, I believe that although this technique may be possible someday, there are not many inguinal hernias that can undergo non-mesh laparoscopic repair without the risk of recurrence. I guess that it is almost impossible for direct inguinal hernias, and only possible in cases where the deep inguinal ring is very small for indirect inguinal hernia. Furthermore, there are still problems for the few section of inguinal hernia that non-mesh laparoscopic repair can be performed on. This makes pre-surgery evaluation of patients eligible for this technique very important. But there is no evaluation that is 100% accurate and there are many times when borderline indications while examining. According to the evaluation, it may seem that non-mesh repair can be performed but during actual surgery, mesh repair may be required as the condition is found to be worse than expected. Of course non-mesh repair can despite be performed but a very high risk of recurrence will have to be dealt with. Like this, patients may wake up to mesh repair when they were expecting non-mesh repair prior to surgery. This isn’t ideal for both patients and doctors.

Therefore I believe non-mesh inguinal hernia repair should be performed in an open method. Through experience, I have found that in open method, non-mesh repair can be used on whichever condition the inguinal hernia is.

Also, unfortunately the formed hernia sac does not heal on its own because the intraabdominal organ keeps going in and out of the sac incessantly.

[drkang]

quote Jimbohen:

Hi Dr. Kang,

Apparently, based on your patient records direct hernias increase with age. And, apparently more strenuous, activity since the incidence of these decreases around 60 when most become more sedentary. That would be expected since they’re often the direct result of a strain and or injury. However, your percentages seem somewhat higher than I’ve heard before. Could that be due to some other doctors misdiagnosing direct as indirect hernias?

Since the deep inguinal ring normally shrinks and closes rather than remains open. Even when it abnormally does, isn’t it more likely to just remain the size of a child’s since it shouldn’t normally grow as the body grows regardless? If the deep inguinal ring abnormally doesn’t shrink and close the result is a patent process vaginalis defect. Thus, a loop of the intestine may herniate through it and create a gross (visible) bulge in BOTH a child and an adult. Hence, why would only the adult, and not the child, be a bad candidate for laparoscopic high ligation simply on that basis alone?

Of course, I’m not a doctor so I’m certainly not trying to challenge your theory. Rather, I’m just seeking clarification for a better understanding. Thanks for sharing your insightful wealth of knowledge.

Hi Jimbohen,

In the majority of textbooks on hernia, the ratio of indirect and direct hernia for an adult man is 2:1. From the statistics that I collected for adult males, the ratio is 2006 to 646 men, making it approximately 3:1. Thus, my ratio of direct inguinal hernia is not higher but rather lower than that written in text books. I’’m not sure if my numbers have statistical meaning. But if it does, I think it might be due to racial differences.

Deep inguinal ring is a hole made up of muscle. This is where the testicular vessel and lymphatics, vas deferens and genitofemoral nerve travel from their preperitoneal space and come out together to become a spermatic cord. Then it goes down the inguinal canal, and this muscular hole is the deep inguinal ring. Hence, deep inguinal ring is a muscle structure covering the spermatic cord.

Deep inguinal ring doesn’’t shrink or close as we grow. Rather, the diameter of the spermatic cord widens as our body grows to contain the spermatic cord inside. The widened diameter maintains its size after maturing in age. This is how each part of our body grows with balance.

Processus vaginalis is a structure that forms during fetal growth. It usually reduces a lot in size at the time of birth. It is called the patent processus vaginalis(PPV) if it remains as a very narrow pit even after birth. Its diameter is usually 1-2mm and looks like a very thin pocket. At birth, 80-90% of babies have it. Just like a cat tail under the door, PPV looks as though it’s stuck between the deep inguinal ring and spermatic cord. PPV usually shrinks further and obliterates as babies grow but some remain even in adulthood that it can be found in 20-30% of autopsy cases. Some of PPV develop into indirect inguinal hernia later but the majority naturally disappears or remains harmless. As such, PPV and indirect inguinal hernia are different from each other. For hernia, the intraabdominal organ goes through the deep inguinal ring and out to the inguinal canal but for PPV, the size is too small that the intraabdominal organ doesn’’t herniate. Therefore, surgery is not applicable for PPV. We don’’t know the cause of PPV exactly, but it is definitely not because the deep inguinal ring doesn’’t shrink.

An infant’’s spermatic cord is too small in diameter that the deep inguinal ring, which covers around it, is very small as well. In hernia patients, deep inguinal ring widens with it, because the muscle forming the deep inguinal ring is stretched due to the bulk of the herniated organ. However, as an infant’’s hernia sac is small, the deep inguinal ring remains small even if a child has an inguinal hernia. During actual surgery, it can be seen that there’s no space for even a single pencil in the deep inguinal ring after the hernia sac has been tied off and pushed back in, that is called the high ligation. Also, an infant’’s deep inguinal ring is much more elastic and has better recovery than that of an adult’s so a simple high ligation of a hernia sac will almost completely prevent recurrence.

They say the diameter of an adult’’s spermatic cord is 11-27mm. So I think the deep inguinal ring has an inner diameter as large as that. Since an adult’’s hernia is much larger than an infant’’s herniated organ, the former’’s deep inguinal ring is stretched much more than the latter’’s. So the diameter of the deep inguinal ring becomes much larger and muscle fiber of the ring is more damaged. In the case of an adult, there are many times when there is more space than an adult’’s index finger in the deep inguinal ring where the stump of the hernia sac is cut, tied off and pushed back inside. Furthermore, an adult’’s deep inguinal ring lacks elasticity compared to that of an infant’’s, and it is also prone to having more serious stretching injury and lacks in recovery. So for most adult males, it is difficult to avoid recurrence just by high ligation of the sac.

Therefore, after high ligation of the sac for adults, it is absolutely necessary to close or make narrow the extra space in the deep inguinal ring where the hernia sac used to be.

[drkang]

quote Jeremy B:

Thank you Momof4; Yes, this is exactly what I’m in the process to have done. I will keep you all posted on my journey. Crossing my fingers for an indirect hernia.
Dr. Kang, Dr. Towfigh, what is your estimated incidence of Direct vs Indirect? And if It is Indirect, Is there often a weakness in the Direct area?
Thanks in advance!
-Jeremy

Hi Jeremy B,

I reviewed my inguinal hernia repair cases of the past 2 years, 2016 and 2017.
The percentages of the male direct inguinal hernias are as below;

20s: 0% (0 out of 160 total inguinal hernia repairs)
30s: 8.4% (17 out of 202)
40s: 18.1% (67 out of 370)
50s: 32.8% (183 out of 558)
60s: 30.1% (209 out of 695)
70s and plus: 25.5% (170 out of 667)

It is not common that the indirect inguinal hernias have the concomitant weakness of Hesselbach triangles(direct area).

I am very sorry but let me say something. I don’’t really want to discourage you and also hope I’’m not being misunderstood for trying to disparage and criticize other doctors’ methods. All that I wish is to give the correct advice based on my knowledge to everyone on this forum.

Dr. Todd Ponsky introduces himself as a Pediatric General Surgeon and it is mentioned under his video (link above) that ““it is the technique for laparoscopic high ligation of an indirect inguinal hernia””. The open high ligation is the technique that has been used for the pediatric inguinal hernias for last 120 years. Laparoscopic high ligation and open high ligation share the same concept. If you search Dr. Patkowski’’s repair which this technique was based on, you can see that they performed this technique mainly on pediatric inguinal hernias. Recently, one hospital in Seoul performed the similar non-mesh laparoscopic inguinal hernia repairs on adults for a couple of years. But now they abandoned this procedure and returned to using mesh.

To my knowledge, for this technique to be successful on adults as well, the size of the deep inguinal ring has to be as small as that of a child. It means this technique is seldom applicable for the average adults. As you know, it is not applicable for direct inguinal hernia, and can only be performed for small indirect inguinal hernia. At the end of the video, the Dr says that this will work well in young adults that have a small indirect inguinal hernia that is essentially a patent processus vaginalis. This means that it is not adequate to perform if there is gross inguinal bulging in an adult patient.

5 years have passed since this video was uploaded in 2013. So I think you’’d better ask him the total number of the repairs on adults so far and the surgical outcome before making a final decision.

[drkang]

quote Jeremy B:

Thank you Momof4; Yes, this is exactly what I’m in the process to have done. I will keep you all posted on my journey. Crossing my fingers for an indirect hernia.
Dr. Kang, Dr. Towfigh, what is your estimated incidence of Direct vs Indirect? And if It is Indirect, Is there often a weakness in the Direct area?
Thanks in advance!
-Jeremy

Hi Jeremy B,

I reviewed my inguinal hernia repair cases of the past 2 years, 2016 and 2017.
The percentages of the male direct inguinal hernias are as below;

20s: 0% (0 out of 160 total inguinal hernia repairs)
30s: 8.4% (17 out of 202)
40s: 18.1% (67 out of 370)
50s: 32.8% (183 out of 558)
60s: 30.1% (209 out of 695)
70s and plus: 25.5% (170 out of 667)

It is not common that the indirect inguinal hernias have the concomitant weakness in the Hesselbach triangles(direct area).

I am very sorry, but let me say something. I don’t really want to discourage you and also hope I’m not being misunderstood for trying to disparage and criticize other doctors’ methods. All that I wish is to give the correct advice based on my knowledge to everyone on this forum.

Dr. Todd Ponsky introduces himself as a Pediatric General Surgeon and it is mentioned under his video (link above) that “it is the technique for laparoscopic high ligation of an indirect inguinal hernia”. The open high ligation is the well-known technique that has been used only for the pediatric inguinal hernias for last 120 years. Laparoscopic high ligation and open high ligation share the same concept. And if you search Dr. Patkowski’s repair which this technique was based on, you can see that they performed this technique mainly on pediatric inguinal hernias.

Recently one hospital in Seoul performed the similar non-mesh laparoscopic inguinal hernia repairs on adults for a couple of years. But now they abandoned this procedure and returned to using mesh.

To my knowledge, for this technique to be successful on adults as well, the size of the deep inguinal ring has to be as small as that of a child. It means this technique is seldom applicable for the average adults. As you know, it is not applicable for direct inguinal hernia. and can only be performed for small indirect inguinal hernia. At the end of the video, the Dr says that this will work well in young adults that have a small indirect inguinal hernia that is essentially a patent processus vaginalis. This means that it is not adequate to perform if there is gross inguinal bulging in adult patient.

5 years have passed since this video was uploaded in 2013. So I think you’d better ask him the total number of the repairs on adults so far and the surgical outcome before making a final decision.

[drkang]

quote Chaunce1234:

[USER=”2019″]drkang[/USER] Thanks again for the response, and I understand what you are saying. From a patients perspective, I can hope you present your method and results as I think you have a lot of value to add to the international surgical community and to future patients.

Hi Chaunce1234,

I appreciate your encouragement and support. I respect you for your large contribution with vast knowledge in helping hernia patients on this forum. At first I thought you were a doctor.
I myself have a lot of expectations for my method, and I believe it will help hernia patients over the globe. As I mentioned, I will publish a thesis late next year and share my experience and surgical method with other doctors.
Thank you!

[drkang]

quote Chaunce1234:

[USER=”2019″]drkang[/USER] I would echo what [USER=”2533″]Jimbohen[/USER] said and kindly request that you share your particular experiences and details of your surgical approach with some US-based surgeons so they too can learn from your technique. I imagine both Dr William Brown and Dr Shirin Towfigh [USER=”935″]drtowfigh[/USER] would be receptive to learning more and perhaps applying it themselves as they are two of the more open-minded hernia surgeons in the USA.

With luck, perhaps the repair can become widely adopted and named after you – The Kang Repair! – and it could be expanded to other patients around the world who are unable to travel to South Korea for your expertise.

Thank you for the consideration and responses.

Hi Chaunce1234,

I as well feel that I should officially present my surgical method some day. I have performed non-mesh inguinal hernia repair for the past 5 years but it was around the end of last year that I ultimately finalized my method. I wish to present the results of my finalized non-mesh inguinal hernia repair. So I plan to follow up for one year and publish my thesis along with surgery results and everything about my surgical method around the second half of next year. It is a rather sensitive issue at hand than what ordinary people think concerning teaching and learning surgical methods without ever having acquainted each other or without there being some sort of cause. Of course, I am willing to explain in detail to doctors who are interested in my method but I humble myself to approach first to offer to explain. They also don’t have objective data on the results of my method yet so I doubt that they will be interested. Furthermore, Dr. Towfigh has already great achievements in her own field as a laparoscopic hernia surgeon and is still actively playing an important role. So it would be terribly presumptuous of me to try to teach her something. I believe it is best shot to publish my thesis and then naturally share my surgical method to those that are interest.

[drkang]

quote Chaunce1234:

Dr Kang, I want to thank you directly for your detailed explanations and posts here, your knowledge is extensive and you are doing a great service to share this information with the public.

Out of curiosity, how common is it for patients to have BOTH the indirect and direct hernia? Does that make the repair more difficult? Do you ever unexpectedly find the other hernia type once you have already begun the operation? Finally, does the procedure work with a femoral hernia?

Hi Chaunce1234,

After receiving your inquiry, I reviewed my record of surgeries that I performed since 2015. During this period, I performed a total of 4,700 inguinal hernia repairs and there were 15 cases(0.32%) where indirect and direct hernia were both present (pantaloon hernia). It is very rare to come across it. In cases of pantaloon hernia, it can simply be treated by operating on both indirect and direct hernia simultaneously.
It is true that there are a few times when the pre-surgery ultrasonographic diagnosis and the actual hernia type found during surgery are different. However, a well-experienced radiologist almost always gets it right.
When treating femoral hernia, I localize the hernia sac below the inguinal ligament (in the thigh) and tie it off. Then I push the sac stump through the femoral canal into the preperitoneal space and close the opening(ligamentous orifice) with a continuous locking suture using 3-0 Prolene. It has the identical concept with indirect inguinal hernia repair. I have performed 25 cases like this since 3 years ago and currently, f/u averages on 19 months with just 1 recurred patient.

[drkang]

quote Jnomesh:

Thank you Dr. Kang. Your insight is very helpful. And I think a lot of us appreciate the detail you provide Bc there are a lot of us who are interested and probably spend a good amount of time familiarizing ourselves of this complex anatomy to help understand our own particular situations. Most surgeons don’t do this and make a strong line in the sand in surgeon/patient relationship.
toj probably have answered this before somewhere but do you use absorbable sutures for your realized or permanent.
id also like to asks your thoughts on a couple of things
1) classic non mesh hernia repairs and what seems to happen to a lot of people who have laparoscopic mesh repairs and then when they have the mesh removed there are no hernias found as the mesh has promoted scarring and scar tissue that close up the defect. Would this be as strong as a classic non mesh hernia repair? Or weaker because muscle isn’t initially being brought together and stitched. Just curious on your thoughts Bc my self included I’ve come across a good number of people who after lapro mesh is removed don’t hsve any hernias and I’m wonderknf what the prognosis is Fein the line is ther more chance of a recurrence compared to a classic non mesh repair?
2) this leads me to another question regarding this concept that mesh seems to be a process where the defect is closed up upon removal of mesh and a relatively new mesh called absorbable mesh. Could absorbable mesh be a middle ground between mesh and non mesh relairs? For example a lot of people after having mesh removal do not want mesh out back in their bodies but a lot of surgeons rx putting mesh back in because the area may be weakened even if there are no hernias. I’m wondering if absorbable mesh may make sense as a compromise in this situation (and some surgeons are offering this)-the two brands are tiger and phased absorbable mesh that don’t start to break down and absorb/dissolve until 18-24 months and by this time the hernia is repaired through scar tissue formation.
this absorbable mesh could also be a option due to so few surgeons who offer non mesh repairs and the fact that even some that do aren’t experts at it. I’m wondering if the absorbable mesh is a option. Case in point my sisters husband has a hernia ( not sure if direct or indirect ) and wen to see a local surgeon. He expressed concern about permanent mesh and was interested in a non mesh repair. The surgeon told him she doesn’t do non mesh relairs but offered him a absorbable mesh as a compromise. He doesn’t have a lot of money to travel to Canada to the shouldice Hospital and pay out of pocket so he is considering this option.
Woukd be very interested to hear your thoughts on the above questions-and again thanks so much for providing a much needed service as a alternative to mesh and taking the time to answer questions on this forum.

Hi Jnomesh,

In my opinion, for hernia repair to be successful (which ever type of hernia it is), both ends of the muscle margin of the abdominal wall opening, where the hernia comes out, must be made to have direct contact with each other. Thus, the tissue on both ends of the hernia opening need to be attached to heal the tissue in the margin. Even for large incisional hernia repair, which requires mesh, mainly has its focus on the approximation of the own tissues(make contact). Mesh plays a role in supporting the prevention of re-widening of the sewn defect on each margins for the tissues to heal.

The problem is that this is not being followed in mesh inguinal hernia repair. This means that the hernia opening is covered with mesh without it being closed. Fortunately, the opening is most times not large so it still doesn’t seem to have a not so high recurrence rate but recent theses claim the recurrence rate of mesh inguinal hernia repair to be close to 10%. I believe that the reason for it having a rate of 10% despite using mesh is because the opening hadn’t been closed. I believe the reason for hernia not recurring is because it heals itself and blocks the opening since the latter is not big.

I myself have had 38 cases where I removed the implanted mesh through open repair but there were merely 13 cases where I simultaneously performed hernia repair. Of course even in cases where the self-healing process goes well, it is necessary to further reinforce it if there is severe injury on the abdominal wall while removing the mesh.

Concerning the use of absorbable mesh, it is difficult to give you a responsible reply as I do not have enough experience and knowledge on it. However, as I mentioned above, I do not believe that there is any guarantee that the hernia opening will heal itself before the absorbable mesh dissipates because the opening is not blocked in the majority of mesh repair being carried out.

Personally, I don’t recommend Shouldice Clinic because they do not conduct a specific repair for indirect inguinal hernia. That means that the surgery is nonspecific and makes the scale of the surgery very large. I believe Dr. William H. Brown based in California will be of better aid.

[drkang]

quote Jimbohen:

Hello Dr. Kang,

I’ve been reading your posted comments and you’re arguments are very persuasive. I would come to Korea to have you repair my indirect inguinal hernia if I could afford to but I can’t. Do you perform the repairs yourself or just other surgeons under your supervision? Who the best and most talented surgeon on your staff aside from yourself. Since you may now have to devote most of your time operating your clinic rather than on patients.

You seem very sincere in your desire to help hernia sufferers regardless of their country and that’s very commendable. Since my health insurance will cover most of the cost. I can afford to see Dr. William H. Brown mentioned above as the doctor that’s now doing the Marcy repair in Fremont, California, USA. Since we can all learn something from each other and you’re both performing the non-mesh Marcy repair. I implore you to contact him without delay and discuss the nuances of your modified Marcy repair for indirect hernias and your modified Shouldice/Desarda repair for direct hernias. You could put your heads together and exchange thoughts and ideas and thereby sharpen each others swords or scalpels. Doing so for the very noble and compassionate cause of advancing hernia repair to greatly improve patient outcomes and thereby save many lives.

I assure you he didn’t put me up to this but I think he would be very receptive to it. Because, like yourself and a few others, he’s a rare breed who’s dedicated to making his patients well rather than making big pharma wealthy by implanting their often devastatingly harmful mesh time bombs.

Hi Jimbohen,

After reading your writing, I have thoroughly checked Dr. William Brown’s website. I could clearly see that he supports non-mesh inguinal hernia repair.
In his explanation of Marcy repair, I can see that he has abundant understanding, experience and confidence on it. This makes me worried whether he’ll be interested in my surgical method. There are of course different aspects compared to my indirect inguinal hernia repair. However, details of surgical methods can cause misunderstandings when discussed in simple conversations. So it is very difficult to completely understand and conduct the method.
If however he is interested, I am willing to try my best to explain my repair, if he want, though.
One thing that confuses me is that he seems to introduce himself as a sports hernia specialist rather than a hernia surgeon. Sports hernia is a completely different illness from inguinal hernia and I treat sports hernia and inguinal hernia differently. Plus, I am currently personally performing 6 non-mesh inguinal hernia repair on average every day. My 6 staff surgeons are also fully capable of performing hernia repair. Our hospital mainly treats inguinal hernia but we also treat femoral hernia, umbilical hernia, epigastric hernia, incisional hernia and sports hernia.

[drkang]

quote Chaunce1234:

Sometimes Ultrasound can differentiate between direct and indirect, and femoral, but sometimes it can erroneously display one or the other, or none, they are not perfect, and I suspect operator and interpreter matters as well.

As far as I know, Marcy repairs are usually done in children and adolescents, I think it basically shrinks the entrance to the inguinal canal so as to make it too small for something to pass through it that does not belong, therefore it would work on indirect but not direct or femoral. I personally know people who had those marcy hernia repairs as children and have never had a recurrence or any other problem.

Interestingly, Dr Todd Ponsky appears to be actively involved in a study on testing this repair done laparoscopically on adult indirect hernias.

https://www.youtube.com/watch?v=nsIHTlfhrM4

Comment from Dr Ponsky found in that YouTube comments says the following:

“We will soon have data from a prospective trial treating all adult in directing a hernia is with this technique and we will have a better understanding on who fails and who succeeds.”

Does your hernia hurt or bother you in another way? Is it large or small?

Hi Chaunce1234,

Before performing hernia repair, it is our principle to accurately diagnose what type of inguinal hernia it is. This is because not only is the surgical method different for each indirect inguinal hernia and direct inguinal hernia, the location of skin incision is also different. The subtype of inguinal hernia can be precisely identified by ultrasonography.
Surgical methods for open inguinal hernia on adults is largely divided into two. It is similar to a football match where it is divided into first and second halves. For the sake of convenience, I will refer to “open indirect inguinal hernia repair for adults” as “INDIRECT HERNIA REPAIR”, and “open direct inguinal hernia repair for adults” as “DIRECT HERNIA REPAIR”.

The first half of INDIRECT HERNIA REPAIR is the step when the hernia sac is located then tied off and the stump is placed back into its preperitoneal space. This step is proceeded on every INDIRECT HERNIA REPAIR; whether it is a mesh or non-mesh repair. However, it is different in the second half. In Lichtenstein repair, the inguinal floor is completely covered by mesh sheet, and in mesh plug repair, the mesh plug is placed where the hernia sac is. In the case of tissue repair as well, the inguinal floor is reinforced each in its own method whether Bassini, McVay, Shouldice or Desarda. As such, all INDIRECT HERNIA REPAIR are composed of two sections. In DIRECT HERNIA REPAIR, there are at times when the handling of the hernia sac (first half) is not clearly carried out. But the second half, when the inguinal floor is reinforced, is always carried out.

However, inguinal hernia repair on children is certainly different from that on adults. For children, inguinal hernia is unconditionally the indirect type and surgery is completed by handling the hernia sac and simply placing it back to its preperitoneal space. This is called high ligation. The second step is unnecessary for children because in infantile hernia, the muscle break called the deep inguinal ring is too small for the hernia sac to escape in the first place.

It is unfortunate that many people are confusing high ligation with Marcy repair. Marcy repair consists of both the first and second half mentioned above. This means that in the latter half of Marcy repair, the deep inguinal ring is stitched and closed. In most textbooks, it is written that Marcy repair can only be applied on small indirect inguinal hernia; when the deep inguinal ring is very small. However, I have conducted my repair(Kang repair), which has a similar concept to that of Marcy repair, for the past 5 years on more than 3,500 patients with indirect inguinal hernia continuously with a recurrence rate of merely less than 0.5%. Among these patients, there were many who came to me due to recurred indirect inguinal hernia, and many who needed partial omentectomy during surgery due to an immense amount of omentum being incarcerated. Thus, I have applied my repair on all indirect inguinal hernia patients without exception and have found out that in contrast to existing knowledge, my repair successfully works no matter how severe the indirect inguinal hernia is.

Dr. Todd Ponsky’s laparoscopic repair is a method where the orifice of the hernia sac (peritoneum) is closed and thus, has the same surgical concept as high ligation. This method does not include the procedure of blocking the deep inguinal ring; making it completely different from Marcy repair.

In addition, I’d like to further explain. It is similar to the content of my previous posting.
Most of the existing tissue repairs, as latter parts of the procedure, are surgeries reinforcing the posterior wall of the inguinal canal called the Hesselbach triangle. And according to the difference in the method of reinforcement, they are each called Bassini, McVay, Souldice, Desarda and more. The surgical method for reinforcing the Hesselbach triangle is the ideal surgery for direct inguinal hernia. This is because hernia that is formed as the Hesselbach triangle weakens and widens is direct inguinal hernia.
In contrast, indirect inguinal hernia doesn’t form in the Hesselbach triangle but rather forms slightly above on the lateral where the deep inguinal ring loosens and widens for it to come out. Therefore, INDIRECT HERNIA REPAIR has to block the widened deep inguinal ring. Marcy repair is a method that carries out this concept. However, as there are several surgical methods according to the difference in the method of reinforcement of the Hesselbach triangle, there can be many ways in blocking the deep inguinal ring. Marcy repair is one method, and my repair method is another of them. And my surgical mehod for a direct inguinal hernia is similar to Shouldice repair; except it has been very simplified.