[drkang]

Hi Jeremy B,

For a direct inguinal hernia, I perform a different repair method.
That is fundamentally similar to Shouldice repair; except it has been very simplified.

[drkang]

quote Good intentions:

One major shame of the whole situation, assuming the origin of the idea for this mesh is Lichtenstein’s work, is that Lichtenstein’s original work actually had value, and still does. The concept is valid and proven, but it has been exploited to where the good, and the potential good, is far overshadowed by the damage being done by the device makers’ devious methods to get market share.

Here is another link to the story for anyone that missed it. https://www.cbsnews.com/news/boston-…0-women-suing/

Hi Good Intentions,

I have almost always agreed with your writings and at times have earned new insight and knowledge. To that I want to express my respect and gratitude to you.
However, I disagree with your reference on Lichtenstein. I personally believe that Lichtenstein repair lead inguinal hernia repair in the wrong developmental direction. But that doesn’t mean Dr. Lichtenstein is responsible for it and thus cannot be criticized. That is because although it wasn’t intentional, Lichtenstein repair represented the thoughts of most doctors at the time.

Tissue repair, which was the gold standard of inguinal hernia repair at the time, had a very high recurrence rate and most doctors thought that the tension after surgery was the cause of such a high recurrence rate. The vast majority of doctors still believe so. Therefore, the concept of the tension-free Lichtenstein repair using mesh was a necessity. Using foreign material instead of one’s own tissue has been attempted from the past by some doctors as it was one of the easiest way to solve problems of tension.

I do acknowledge that excessive tension is partly responsible for high recurrence rate of tissue repair but I believe the core cause lies elsewhere. It is that only one surgical method was applied without separating the two subtypes of inguinal hernia: indirect inguinal hernia and direct inguinal hernia. The problem is, almost all tissue repair including Bassini repair and McVay repair are in fact surgical methods more suitable for direct inguinal hernia repair but have been identically applied for indirect inguinal hernia. These methods have tried to narrow the deep inguinal ring where indirect inguinal hernia comes out. But in my view, they were very insufficient and inappropriate methods for indirect inguinal hernia. This issue is likewise present in Shouldice repair and Desarda repair, which are being appraised as good methods of tissue repair.

(I attach you a link to a video of my lecture relating to this. It is a lecture on inguinal hernia that I gave when I was invited to the Surgical Grand Rounds held in the Department of Surgery in Seoul National University Bundang Hospital. It is a 33 minute long lecture in Korean but there are English subtitles. I hope it is of help to those interested in the overall aspects of inguinal hernia repair.)

Aside from this, there are a few other factors that I believe cause a high recurrence rate of the existing tissue repair but I do not wish to ramble on lengthily.

Therefore it is my perspective that instead of Lichtenstein repair, which had the objective to reduce tension using mesh at a time where a new surgical method was required to prevent high recurrence rate, it would have been much better to classify indirect inguinal hernia and direct inguinal hernia separately and develop ideal surgical methods for each. I believe it is still not too late. As the problems of mesh complication are increasingly magnified currently, we should go back to the start and find the ideal surgical method. Unfortunately however, I do not think there are many doctors that agree with me as of now. So there will have to be more time and effort to adjust the current situation.

In addition, I believe some recent theses that presume the recurrence rate of mesh inguinal repair to be close to 10% supports my claim that mesh inguinal hernia repair is not the best option to reduce the recurrence rate.

Niebuhr H and Köckerling F. Surgical risk factors for recurrence in inguinal hernia repair –a review of the literature. Innov Surg Sci 2017;2(2):53-59,

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

Zwaans, Willem A., R., MD; Verhagen, Tim, MD; Wouters, Luuk, MD; Loos, Maarten J., A., MD, PhD; Roumen, Rudi M., H., MD, PhD; Scheltinga, Marc R., M., MD, PhD. Groin Pain Characteristics and Recurrence Rates: Three-year Results of a Randomized Controlled Trial Comparing Self-gripping Progrip Mesh and Sutured Polypropylene Mesh for Open Inguinal Hernia Repair. Annals of Surgery: June 2018 – Volume 267 – Issue 6 – p 1028–1033

Non-mesh Inguinal Hernia Repair ‘Kang Repair’ – YouTube
https://www.youtube.com
Surgical Grand Rounds Lecture at the Department of Surgery, Seoul National University Bundang Hospital (December 13, 2017)

[drkang]

quote Jnomesh:

Thanks for sharing Chaunce. Super important. Glad that Concerns regarding mesh seems to be making its way to the forefront. Hoping that in the near future surgeons will be equally trained in mesh and non mesh repairs so that not only can the patient be presented with a choice but receive expert care in either procedure.
the thing that I always come back to that is quite remarkable is the “mis-truths” that surgeons and the industry seem to spread regarding the inferiority of non mesh repairs-that they carry a higher recurrence rate than mesh-I’ve even heard this quoted by some surgeons on this forum-yet the shouldice Hospital (non mesh repairs) has data showing less than 1% recurrence rates and less than 1% chronic pain. There it is in black and white-if a surgeon has a expertise in doing non mesh repairs these repairs blow out and are far superior in regards to both the recurrent rate and chronic pain rate of mesh repairs.
so when you hear a surgeon say that mesh is superior to non mesh repair it is really code speak for either the use of mesh or for the fact that they don’t have the expertise , confidence because they just don’t do enough of these type of non mesh repairs-which is a huge problem and disservice to patients. It’s a shame that one has to travel to another country for a non mesh repair or at the very least travel out of state to see one of the few surgeons left who specialize in non mesh repairs. Sad.

I completely agree with you except for one thing. You mentioned that you hope that in the near future surgeons will be equally trained in both mesh and non-mesh repairs so that not only can the patient be presented with a choice but receive expert care in either procedure. For the past 5 years, I have been executing non-mesh inguinal hernia repair that I have developed. Through such experience, I have developed strong conviction that non-mesh repair can be successfully applied to all patients with no exception.
At first, I was hesitant in writing this as it may be misunderstood as an act of advertising. However, I decided to speak my thoughts since the topic of the necessity of non-mesh repair came up, and I thought it’d be meaningful to share my experience based opinion.
I have been reading several posts on this forum and I have come to notice that the majority of participants have the perception that the patient’s body type or lifestyle decides whether mesh repair or non-mesh repair is suitable. I believe the objective here is to minimize recurrence and complications.

However, I have not felt the necessity of mesh repair while performing only non-mesh repair on over 6,000 inguinal hernia patients for the past 5 years. There were many patients that I had to conduct partial omentectomy concurrently because they had incarcerated omentum, and many came to me due to recucurrence after open repair or laparoscopic repair. And there were two patients over 100 years old, some with massive ascites due to liver cirrhosis, and some receiving hemodialysis due to chronic renal failure. Furthermore, I treated a professional body builder who had to continue weight training even after surgery, a professional weightlifter who have to lift 200kg(440lb), and obese patients weighing over 100kg(220lbs). As such, I have performed non-mesh repair to very diverse patients. Yet, the recurrence rate is less than 1%.

Some doctors claim that non-mesh repair increases the risk of nerve injury and therefore can increase the frequency of chronic postsurgical pain compared to mesh repair. However, I do not agree with this. I believe you will agree with me on that it’s not logically admittable for an operation using absolutely no foreign matieral has a higher possibility of complications than an operation where a big plastic mesh is implanted in the body.

Thus, I do not believe there are certain cases where mesh repair or non-mesh repair is better.
I believe if an experienced surgeon takes an appropriate approach, non-mesh repair can result to successful outcomes for inguinal hernia patients in any sort of condition. A successful outcome here means very low possibility of recurrence and complications.

Thank you!

[drkang]

Hi Chaunce1234,

If I follow your definition of the hidden hernia, I have a lot of experiences of repairing the hidden hernias so far.
Among patients who come to surgery with visible hernias on the one sides, the small inguinal hernias are often found on inguinal sonography on the opposite sides.
If the patient wants, the hidden hernia on the opposite side is operated on at the same time.
However, I remember that very few of these unknown small hernias caused discomfort, including pain.
Of course, I think that even a very small hernia without bulging can cause pain but this does not seem to be that much.
Thus, I need more time to find out whether the pain will disappear after repairing a painful small inguinal hernia.

[drkang]

quote Tilbis:

Dear Dr. Kang,

I am a 58 year old female. I’ve had intermittent groin pain and classic hernia symptoms for 4 years but no visible or palpable bulge. There was no injury and both my parents have had inguinal hernias. Two years ago, an ultrasound revealed a small, 6mm indirect inguinal hernia. My questions for you:

– In your opinion, is this not what is often referred to as an occult or ‘hidden hernia’? If not, what would you call it or how might you diagnose it?

– Do you believe that a 6mm defect is too small to cause pain and that my symptoms are likely caused by something else?

– do you believe that this hernia will inevitably grow bigger and that a bulge will eventually appear? If so, would it not be better to get it repaired while it is small – particularly as it is symptomatic?

– would you perform surgery on such a hernia?

Thank you!

Hi Tilbis,

I believe small hernia could cause pain and the pain sometimes even more worse when a hernia is small.
I also believe the small hernia probably grow bigger and visible in some time.
And yes I sometimes perform my tissue repair on that small hernia.

Thank you!

[drkang]

quote Tilbis:

Dear Dr. Kang,

I am a 58 year old female. I’ve had intermittent groin pain and classic hernia symptoms for 4 years but no visible or palpable bulge. There was no injury and both my parents have had inguinal hernias. Two years ago, an ultrasound revealed a small, 6mm indirect inguinal hernia. My questions for you:

– In your opinion, is this not what is often referred to as an occult or ‘hidden hernia’? If not, what would you call it or how might you diagnose it?

– Do you believe that a 6mm defect is too small to cause pain and that my symptoms are likely caused by something else?

– do you believe that this hernia will inevitably grow bigger and that a bulge will eventually appear? If so, would it not be better to get it repaired while it is small – particularly as it is symptomatic?

– would you perform surgery on such a hernia?

Thank you!

Hi Tilbis,

I believe small hernia could cause pain and the hernia pain sometimes even more worse when a hernia is small.
I also believe the small hernia probably grow bigger and visible in some time.
And yes, I sometimes perform my tissue repair on that small hernia.

Thank you!

[drkang]

quote katiebarns:

[USER=”2019″]drkang[/USER] ,

Anyways the 2 doctors think it’s a sports hernia but I’m not sure because I don’t have all the symptoms. Is it still possible to have a sports hernia if I don’t have all the characteristics?

Thank you so much!

Hi katiebarns,

I read your another post to understand your situation better.
Well, I don’t think your symptoms come from a sports hernia.
Sports hernia, as far as I have experienced through the patients so far, is wear and tear of the external oblique aponeurosis, a thin and tight membrane of the inguinal canal just beneath the subcutaneous fat layer.
It could be injured by the repeated violent exercise such as playing soccer, and then you could get a sports hernia.
However. I read that you had open mesh hernia repair in 2015.
After mesh implantation, there is some fibrotic adhesion around the aponeurosis, so there might be little chance for you to get a sports hernia there.
Instead, I think your symptoms might come from the injury of the tissue around the implanted mesh.
The mesh is conglomerated with the surrounding tissue.
So after unusual physical movement, there could be some injury to the muscular structure which is attached to the mesh.
I have one patient with inguinal mesh who repeatedly complained of inguinal pain for some period after extreme activity once or twice a year.

Thank you!

[drkang]

Hi katiebarns,

Sports hernias almost always occur in people who enjoy violent sports such as soccer or ice hockey.
I think the most critical factors for the diagnosis of a sports hernia are the pain characteristics and the location of the pain.

Characteristics of the sports hernia pain:
The pain from a sports hernia always occurs during hard exercise such as running, playing soccer, etc.
It also occurs with coughing, sneezing, and sit-up as well..
And the pain sometimes gets worse more after exercise than during exercise,
Some patients have the worst pain at the next day, so they hardly get up from a bed nor get off from a car
And it usually goes away after several days’ rest and comes back easily with an exercise.

Location of the pain:
You feel pain in the inguinal canal without a bulging.
Someone complains of pain around an inguinal area such as over pubic bone, rectus muscle or upper thigh, etc.
But they are not from sports hernias, but from other sports injuries.
So you should localize your pain just in the inguinal canal to be diagnosed as having a sports hernia.
You could, of course, have extra pain around an inguinal area at the same time, but the inguinal pain is essential for a sports hernia diagnosis.

Thank you!

[drkang]

Hi Chaunce1234,

Yes, about 30% of my hernia patients complained of pain together with a hernia bulging.
And occasionally, I have some patients who had inguinal pain for some periods before they finally got the visible inguinal hernias.
But I don’t do the hernia repairs without the sonographic diagnosis of inguinal hernias, even if they complain of inguinal discomfort.
Of course, the sports hernia is a different story.

Actually I don’t know exactly what the ‘hidden hernia’ means, I am afraid.

Thank you!

[drkang]

Hi UhOh!

I understand what you mean but that kind of approach probably increases the risk of recurrence a lot.
The internal inguinal ring is located about 2cm apart from the external inguinal ring upwardly and outwardly.
So it would be very difficult to manage the hernia sac and to fix the internal inguinal ring correcty just through the external inguinal ring without making an incision at the overlying external oblique aponeurosis.
And that kind of approach needs the larger incision and puts more damage to the surrounding tissue during operation, resulting in more pain after operation and longer recovery time, etc.
I think there is no advantage at all

So I wouldn¡¯t try that kind of approach.

[drkang]

Hi,

I see.

To take out some blood sample from the vein, they usually apply a tourniquet around your upper arm to block the venous return.

If you are obese then, more pressure is needed because your fat works as a cushion.
But if you lose your fat, the vein can be blocked more easily.
Sorry for this sort of example, but it’s the same story.

So, they remove some of the bulky cremaster muscle to decrease its cushion effect when they are trying to close the deep inguinal ring inside by squeezing the cremaster muscle from outside.
It is for an indirect inguinal hernia repair.

Yes, I understand what they intended to.
But I don’t know whether it works and whether it is necessary, because the tubular cremaster muscle contains the bulkier spermatic cord inside as well.

As for me, I close the deep inguinal ring not from outside but directly from inside for indirect inguinal hernia repair.

Thank you!

[drkang]

Hi SighFigh,

I think if the ilioinguinal nerve or the genitofemoral nerve is injured while operating on the cremaster muscle, it might cause chronic pain.
If the cremaster muscle was cut or damaged a lot, you could get some testicular discomfort because it would sag down.

I am sorry but I don’t know about that technique you mentioned.
If you give me any link or information of the technique, I could give you my thought more precisely after reviewing them.

[drkang]

Hi, SighFigh.

For a direct inguinal hernia, I fix the Hesselbach triangle after putting the cremaster muscle and the spermatic cord aside.
So the cremaster muscle is not injured during my direct inguinal hernia repair.

For an indirect inguinal hernia, I open the cremaster muscle by splitting the muscle fibers to find the hernia sac inside.
After treating the hernia sac, I close the deep inguinal ring by stitching.
So the cremaster muscle is not cut or removed but slightly injured during my indirect inguinal hernia repair procedure.

Thank you!

[drkang]

Hi, SighFigh.

I don’t think some people are fit for tissue repair and the others are fit for mesh repair.
According to my experience of more than 6,000 non-mesh repairs, it always works very well for anyone who has an inguinal hernia.
I know most surgeons would disagree with me.
But, I am just saying from my experience.

Thank you!

[drkang]

Hi,

I thought you had the open mesh surgery.
I’m so sorry for having misunderstood your history.
Removing the meshes which were inserted laparoscopically might be very difficult and invasive, so it should be decided very carefully.

Anyway if you prefer no mesh tissue repair, there are, I think, two options for you.
1. Removing the old mesh laparoscopically or robotically, then doing the open tissue repair at the same time or later.
2. Undergoing the open tissue repair without removing the old meshes.

Sorry again.

[drkang]

quote nesd:

Is exploratory surgery something that can be done safely to see if the mesh is removable or not?

Hi, nesd.

You don’t need exploratory surgery.
Mesh removal does not depend on the finding of exploratory surgery, but mainly on your mind.
If you want, mesh removal would be carried out.
Sometimes, of course, we have to leave some portion of the mesh for the safety reason, but it doesn’t happen so often.
In most cases, the open mesh could be removed though not easy.

However, you’d better leave it as it is if you have no significant mesh problem.
Just do hernia repair then.

[drkang]

Hi,

I understand you, but it is just what those doctors said.
I always do no mesh hernia repairs successfully even for the multirecurrent hernias after open or laparoscopic mesh surgeries.
So it is valuable to try to find a doctor who can do it for you.
Adding or replacement of the mesh in your situation would be very risky.

I guess that polypropylene mesh can be seen as the hyperechoic line on ultrasound, but they can be seen on CT scan in small proportion.

I don’t think we can evaluate whether the open mesh could be removed or not by any test.
Ultrasound just shows whether the mesh is there or not.
It doesn’t tell if it is removable or not.
It is just a matter of deciding to do or not to do.

[drkang]

Hi, nesd.

Sorry to hear your story.

You look like thinking about only two options, adding another mesh or changing to new one.
Why don’t you consider the third option of no mesh hernia repair?
I think it would be the best option for you.

Adding another mesh could increase the risk of mesh problem, and changing mesh could have even more difficulties.
Mesh removal during the hernia repair depends on the state of the old mesh.
If it is solidly fixed to the adjacent structure without significant complication, it would be better to leave it there.
But if you have any significant complication or the old mesh is displaced and dangling, it could be removed.

[drkang]

Thank you, Chaunce1234!

Since I started new no mesh hernia repair five years ago, I have continued to change and improve my repair methods.
And three to four months ago, I made the final version.
So now, I am collecting surgical cases and would submit a paper on my new repair method sometime next year.

Although I have personally confirmed good results with less than 1 % recurrence rate for the repairs of last five years, I think the results of my final no mesh inguinal hernia repair are more critical.

[drkang]

Waiting just does not make sense.
Your hernia will eventually get bigger and bigger.
Waiting is only delaying the decision time.

It is understandable that you are concerned about complications after a hernia repair.
Obviously it is important to have a surgery with few complications.
If so, it is better to search for a hospital or doctor who has a low-complication hernia operation, not just delaying the operation.
In general, tissue repair is safer than mesh repair.
So try to find a doctor who is good at tissue repair.
I think that’s what you need to do at this point.