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Chuck,
I considered it briefly, but didn’t do much research on it because I didn’t have a surgeon who would do this. Reinhorn wasn’t taking patients from outside New England at the time. He probably still doesn’t.
I remember reading somewhere that this surgery has its own set of non-trivial risks and potential complications, but I didn’t go deep into it.
One of the things I didn’t realize while researching was that in the rare cases (2% or so) where they do mesh for inguinal hernias at Shouldice, their preferred technique is posterior mesh (like Kugel), not anterior (like Lichtenstein). I learned that only when I was there.
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I have regular US health insurance (employer provided), and they paid for my hernia surgery in Canada as out-of-network with no problem.
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There was an anesthesiologist when I was there. I’m not sure if he stayed with me throughout the entire operation, or moved from operating room to operating room. I have to say that this was one of the areas where I didn’t feel confident with the way they were doing things.
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I don’t see how this has anything to do with insurance. Why would the surgeon get less from insurance for tissue vs mesh? Regardless, insurance doesn’t pay much for these surgeries, which is problematic. Surgeons can’t pay too much attention per case, and they have to rush through many per surgery day to compensate with volume for the low pay. For example, Dr. Yunis told me he does 6-9 per day.
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Fixing a tissue repair recurrence with another tissue repair is possible, but considered problematic. Higher recurrence rates, hard to see and protect the nerves because of the scar tissue, etc.
The Shouldice Hospital does repair recurrences with tissue repair, but it seems that the thinking there on what’s best has shifted on this. I asked there what I should do if my hernia recurs, and was told that lap mesh would most likely be my best option at that point.
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I think my dad was in his 50s when he had the surgery. The recurrence wasn’t caused by activity, but he was significantly overweight.
He never fixed it again after the recurrence. It’s crazy large now. He’s in his mid 80s now. I think it recurred about 15 years ago – I don’t remember exactly.
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I think you should actually ask them in 10+ years. The recurrence risk with tissue repair increases with time.
My dad had tissue repair of an inguinal hernia, and his hernia recurred after a few years. I’m not sure how long it was exactly, but it was around a decade I think.
Dr. Felix also recurred years after tissue repair, and went to Dr. Chen for lap mesh to fix that.
The long-term risk of recurrence was the main reason I didn’t go with Dr. Kang, and picked Shouldice. I realized the risk with Shouldice would still be higher than with mesh, but still quite low based on long-term studies.
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I was shocked when they started using deep sedation in colonoscopies. For mine, I went to a place that agreed to do it with light sedation (midazolam). It’s not so much the difference between propofol and midazolam – they are both bad for your brain, although some people react worse to one vs the other. The problem is deep sedation (where propofol is typically used) vs light sedation (normally with midazolam).
Surgery under light sedation (as they do it at Shouldice) has its issues. I did wake up during surgery, and felt pain during the stitching. They increased the sedation a bit when they noticed that. They try to keep you sedated just enough, but not beyond that. It minimizes the brain insult and the airway risks.
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Does he really use propofol rather than midazolam? Propofol (or a propofol/midazolam combo) is typically used in heavy sedation. Not a fan of that personally because of the effects on the brain. One of the (few) things I like about the Shouldice Hospital is that they normally go with light sedation using midazolam. They use propofol only in unusual circumstances. Most other places use heavy sedation with propofol.
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Yes, Dr. Conze should be able to diagnose some other pain causes as well. He has experience with chronic pain cases, and he does revisional surgery.
I still have different types of pain from the surgery. It’s not debilitating and it’s not constant, but it’s fairly disturbing at times. I hope it improves with time. I still have quite a bit of hard tissue in the surgical area – it takes months for the muscles, fascia, and other tissues in the area to heal and soften.
These open surgeries are pretty brutal. Dr. Kang has the right idea with minimizing the scope of the surgery – less tissue damage and faster healing, but I just don’t know how resilient his technique is in bad cases like I had. The good thing for you is that your hernia (if you have it) must be very small.
I haven’t looked into your health board yet.
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Chuck,
It sounds like this is not minor pain, and it’s at a level where you feel that surgery (with all its risks) is justified.
In that case, I would go to a surgeon who is good at diagnosis. For example, Dr. Kang, Dr. Conze, or Dr. Towfigh. I wouldn’t have the imaging done at some random place. Dr. Kang and Dr. Conze do their own ultrasounds. I don’t know anything about MRI for inguinal hernias, and whether it matters if you go to a specific place recommended by Dr. Towfigh, or you can get it done properly locally, and send her the disc.
Among these three, pick the one(s) you are most comfortable with. If money is tight, then pick just one. I would pick two: Dr. Towfigh and either Dr. Kang or Dr. Conze. Start with Dr. Towfigh, and then go from there. This way, you have two opinions using two different imaging types. I never talked to Dr. Kang, but I had good conversations with Dr. Conze, so I would personally pick Dr. Conze, but Dr. Kang is likely a fine choice as well.
I guess you must have concluded that Dr. B. isn’t particularly good at diagnosing this? He would be the natural choice for you if he had the expertise.
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Most of the symptoms you’re describing are not symptoms of inguinal hernias.
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One thing that’s never studied for some reason is what percentage of patients feel 100% normal after inguinal hernia surgery. By this I mean a groin that feels completely normal as though nothing ever happened. No pain, numbness, burning, discomfort, foreign body sensations, etc. None of this at all, not even occasionally.
A Canadian mesh surgeon posted on her blog that “a groin which has been operated on for hernia will never feel the same as before the hernia repair”. I think she meant that it will not feel like a normal unoperated groin. This seems a bit extreme. I have talked to a couple of people who claim that their groin feels 100% normal after Shouldice repair, but it would be nice to have some studies looking into that with different procedures. Somehow, this question never seems to be asked. Patients with minor symptoms are effectively bundled with patients with zero symptoms.
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Have you been able to find out what repair technique he used?
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I was told by a robotic mesh surgeon that seroma was the most common complication, and that it goes away on its own.
What kind of anesthesia did you have? General, or local with sedation?
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Scar tissue shouldn’t be a problem because his pervious surgeries were posterior (lap and robotic), and this one would be anterior.
Still, I agree with not doing anything about it unless the pain is serious enough.
If the pain is too bothersome, I would first try to have it diagnosed (such as with Dr. Towfigh), and worry about where to go for surgery later.
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That was one side. The other side recurred more quickly for Dr. Felix.
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Recurrence rates increase with time with Shouldice as well. There’s a paper showing an increasing recurrence rate graph. It increases with time, but still stays under 2% if I remember correctly. I think this was based on Canadian insurance data for the Shouldice Hospital, so presumably independent data about the procedures performed there back then.
Studies of Shouldice performed elsewhere showed worse results, and who knows what more current results would be even at the Shouldice Hospital because the surgeons are different and they aren’t all adhering as strictly to the original way of doing it.
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He trained his son, but he hasn’t done any of the other things you mentioned in terms of spreading his techniques, unlike Dr. Desarda.
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It truly varies from patient to patient. I didn’t have much visible swelling after the surgery. Only a bit around the incision area. I could feel internal swelling, though. It was nothing like the size of my hernia, but my hernia was very large.
My roommate had more visible swelling, even though his recovery was much better than mine. He basically had almost zero pain or discomfort.