[David M]

Hi William,

I have no idea about the about the answer with this, but had to remark at the irony of the acronym for post operative urinary retention being… POUR!

[David M]

Watchful, I wish I understood scar tissue better. How, when and where it’s formed.

From reading the forum, I get the sense that it’s mostly formed as an encapsulation of foreign material, not necessarily from the healing of tissues that were cut. If i cut myself, for instance, generally the healing process of tissue to tissue doesn’t leave that much of a scar. This is not always the case, but generally so. I had thyroid surgery almost 15 years ago and I can’t even tell where my scar is, though it was fairly prominent and swollen after the surgery. (On the other hand, I have a fairly prominent scar on my knee where I cut myself with a coke bottle at a young age, and there are people who do have to watch the over-scarring.)

So, here’s a question I asked a surgeon a couple of weeks age. If you double breast the transversalis fascia, do the two layers grow together. He said something about there always being scarring, but does that sound like the right answer? It seems to me that tissue to tissue of the same kind like that would be less likely to scar than to either do nothing or grow together stronger.

So, my thinking -very possibly incorrect – is that most of the permanent scarring in an operation will come from the foreign matter being encapsulated and open wounds of different types being in proximity to differing types of tissue. in the case of Shouldice, mightn’t most of the scaring be in the area of the stitching?

Do you (or anyone else) have any thoughts on this?

[David M]

William

Dr Kang’s operation for an

indirect

hernia is similar to a Marcy. On his last post, he said he is now still calling that the Kang repair. As you know, he performs totally different operation for a direct hernia. He said he was now calling that a Gibbeum (sp?) repair. That repair is supposed to be similar to the original Bassini, but I don’t think he has explained exactly what he does there.

It’s true that the Shouldice is supposedly based on the original Bassini, but I have no idea what that means either. I’ve looked around over the internet and have been unable to define the difference between the Shouldice and the Bassini, because you can’t really get much information on the Bassini.

There is a seemingly good version of a 4 layer Shouldice on youtube, though, by
biohernia. Here’s my understanding, though I’m just someone trying to understand this from afar.

Ignoring the cremaster aspect of the Shouldice, here is how the four layers of the Shouldice are done.

For the first two layers, imagine the patient is lying on the operating table with his/her buttoned shirt on and the surgeon standing on his right side. The shirt represents the transversalis fascia, which is the border between the inguinal canal and the inner gut and hernia sac. The surgeon undoes the buttons (cuts the transversalis fascia) and pulls the right side of the shirt (where the buttons are on a man’s shirt) underneath the left side of the shirt and stitches that to the underside of the far left side of the shirt (in line with the left armpit). Then he takes the left side of the shirt (where the buttonholes are on a man’s shirt) and pulls that over the top of the right side of the shirt and stitches that in line with the right armpit (in the actual operation, this portion of the transversalis fascia is stitched to the inguinal ligament). That process is called the double breasting of the transversalis fascia and represents the first two layers. The one layer of the transversalis fascia has now been doubled up to form two layers for a stronger barrier against the hernia.

The surgeon in the biohernia video calls this the most important part of the shouldice. Indeed, in a study in 1994, they stopped right there with the Shouldice and the results were similar to the results of the four layer.

Concerning the final two layers, though, what I think is true, but have never heard or read anywhere, is that it’s almost a misnomer to refer to the rest as two more layers. The aponeurotic part of the transversus (conjoint tendon?) is pulled over and stitched to the inguinal ligament for the third layer. For the fourth “layer”, however, nothing else is pulled over (hence, not really another layer). This time the aponeurotic part of the same layer is stitched to the inner part of the external oblique just above the inguinal ligament. So that stitch is moved ever so slightly away from the inguinal ligament and I guess has a slightly different angle pulling on the aponeurotic part of the transversus (conjoint tendon). It’s not really much of a different “layer” of cover, but the slightly different angle maybe distributes the pressure a little away from the inguinal ligament is all I can imagine. Maybe like your two different arms pulling on a something from slightly different angles makes it easier to hold that thing in place(?)

The sutures are also run different in the shouldice than the bassini. So, with the shouldice, you have different tension bearing aspects sharing against the pressure of a direct hernia pushing through the transversalis fascia and the aponeuroses pulling against the inguinal ligament. I cant find good information on the Bassini, unfortunately, but as far as I can tell there isn’t as much distribution of the pull of the tissues against each other.

[David M]

Let me apply a little skepticism to your post.

First, maybe reread the last paragraph that I quoted. The idea here seems to be that even if all tissue strengths were the same, the tension applied to the sutures could vary to some degree based on anatomy. Think of it like stringing an archer’s bow. The further you have to bend that bow both stringing it and pulling the string, the more tension on the string. That seems to be what it’s saying here. Perhaps this is what Watchful’s surgeon meant about “deep anatomy”, though he could have meant something totally different.

Second, if the tension is too strong, it seems possible that the sutures will be eating through the bite that is taken pulling the conjoint tendon side over to the inguinal ligament side. This is probably going to start immediately and the healing process to that tension may have trouble keeping up. I know I’ve read, or maybe heard it on one of the podcasts, that it’s usually not the sutures that fail, but the part of the body that they suture.

Third, there’s likely some weakness in the body collagen process already to even have a direct hernia, so although some healing is going to happen, the sutures are still probably going to be an element to the the continued success of the repair.

I’d love to avoid a mesh repair, but I need to be as realistic as possible.

[David M]

Spinotza,

Thank you for the upbeat, positive sounding report!

[David M]

The idea here was to make a sort of link map for someone new to educate themself fairly quickly.

For example, the first page would have general categories:

Data studies
Surgery experiences
Preferred doctors

Then you link on one of these topics, say surgery experiences, and there would be further links, such as

Experiences with Dr Kang surgery
Experiences with shouldice
Experiences with Lichtenstein
Experiences with Laparoscopic

Then you click on one of those and have the ability to read about the individual forum members experience.

In other words, it would be a way to create different folders. But for some reason, it is skipping the next thread linked and linking to the link in the first post of that thread.

[David M]

Sorry, this isnt working like it should. Instead of linking to the thread, it’s linking to the link on the first post on the thread. Strange.

• This reply was modified 1 year, 4 months ago by  David M.

[David M]

Blank

• This reply was modified 1 year, 4 months ago by  David M.

[David M]

That is an excellent question by John concerning the importance of knowing the hernia location beforehand and one that I hope Dr Towfigh will cover in her talk. Some surgeons will say it doesn’t matter because the operation would be the same regardless, but I don’t think all surgeons agree. Perhaps the way the cremaster is handled would be different with some, depending on direct vs indirect?

[David M]

https://herniatalk.com/forums/topic/study-comparing-tapp-and-shouldice-discomfort-after-5-yrs/

Study comparing Tapp and Shouldice discomfort after 5 yrs

[David M]

I wouldn’t take this study that much to heart. Most of the studies say something like this for one year and trail off quite a bit after that. I’m not even sure what to think of this one, but I wanted to put something up comparing the relative pain of the two. The relative pain is probably the main thing to take away from this.

The conclusion i’m seeing from most of these studies is that, yes, lap has, give or take, maybe 75- 80% the chance of long term pain to open mesh or open tissue, but that difference in the grand scheme is probably not going to convince me to go with Lap.

Maybe the negatives are simply in my head and I need to get past them, but…

1) I don’t like the mesh being that much internal ( possibly sticking to the intestines. Possibly causing some sort of internal stiffness)
2) I don’t think I should do the general anesthesia (I’ve had a heart attack)
3) The mesh is probably a little harder to remove if need be
4) Way too many people here have had trouble with it. Yes, that’s anecdotal, but there is still a strange odds factor that doesn’t make sense. (There might be some sort of nagging discomfort that doesn’t show up on the pain stats.)
5) There might be other reasons why a surgeon might need to go inside at a later date.
6) It’s probably impossible for the mesh not to stick to the cord and the blood vessels on the inside.
7) A chance of causing an incisional hernia

Am I looking too much for confirmation of my bias? Maybe, but that’s the way I lean.

• This reply was modified 1 year, 4 months ago by  David M.

[David M]

I haven’t yet found the 6% number that Dr Towfigh cites in her recent Hernia frustrations video, but I notice in this video that if you split the difference between the pain at rest and pain at exertion for TEP that you come out with exactly 6%. For Lichtenstein the split was 7.9% in the Tep comparison and 7.6% in the Tapp comparison.

• This reply was modified 1 year, 4 months ago by  David M.

[David M]

Wow,everything sounds great!

Do they say anything about dividing the cremaster in line with the fibers on the right side looking for an indirect on that side? I’m still not sure how it works, but I think there are three basic possibilities with the cremaster. 1)leave it alone aside from seperating it from the transversalis fascia adhesions. 2)cut it along the fibers to help look for an indirect (in which case it heals back, I guess?) 3) cut it in half perpindicular to the fibers like the do with shouldice

Good to hear how well it’s going.

[David M]

Very interesting Spinotza, especially the statetment that you might have been conscious but didnt remember it. I know that in the biohernia Shouldice on YouTube, the surgeon said something about asking the patient to cough to see how firm the stitching was.Ive been curious about whether this is ever done after the plication of the transversalis fascia in the Lichtenstein. From your post, it seems that they could have had you cough and you not remember doing so, but who knows? This wouldn’t be a necessary thing for the surgery, anyway, but it might give some feedback to the surgeon, perhaps.

[David M]

Spinotza
I reread your initial reporter to find out if your were conscious during the surgery. I take it that you were sedated for the most part and probably wouldnt remember much. Did you choose to have sedation beforehand, and could you have chosen otherwise if you wanted. What kind of sedation, if I may ask?

[David M]

Mike M: Direct inguinal hernia repair

https://herniatalk.com/forums/topic/dr-kang-direct-hernia-repair-update-3/

[David M]

Thanks,

I think I would be more inclined to have my repair done by Dr Kang if it were indirect, as in your case. I haven’t decided yet where to have my (direct, I think) sugary done.

[David M]

It’s just one study, but seems to indicate that open removal of mesh slightly less complications than lap removal.

https://www.ormanagement.net/Clinical-News/Article/03-22/Mesh-Removal-How-Much-Does-Surgical-Approach-Matter-/66120

[David M]

Jacob,

Would you be willing to rate your pain on the Swedish scale? Here’s the question they posed:

“The question put to the patient was: grade the worst pain you have felt in the operated groin during the past week. The seven possible scores were: 1, no pain; 2, pain present, but easily ignored; 3, pain present, cannot be ignored, but does not interfere with everyday activities; 4, pain present, cannot be ignored, and interferes with concentration on everyday activities; 5, pain present, interferes with most activities; 6, pain present, necessitating bed rest; and 7, pain present, prompt medical advice sought.”

[David M]

This is interesting. It doesn’t tell you how they developed the cohort of patients getting removal. There were quite a few more lap/robotic removals than open, but I dont see an indication of why that was.

It does indicate, seemingly, that open removal has less complications than lap/robotic.

https://www.ormanagement.net/Clinical-News/Article/03-22/Mesh-Removal-How-Much-Does-Surgical-Approach-Matter-/66120