Watchful
Forum Replies Created
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You’ll be feeling good much sooner than a couple of months other than in the very unlikely case of something going wrong.
Having a great surgeon definitely helps, and that’s the way to go. Stuff still happens even with them, unfortunately. Different patients react differently to the same things. One will be fine, and another will get some bad reaction or rare complication. With some patients, all nerves can be identified and avoided. With others, it’s not so easy. You do maximize your chances of success with the best surgeons, and hopefully with some luck on your side so that the surgeon is in top condition during your surgery, and not tired or distracted.
I don’t know about your surgeon, but I feel that most of the ones I know (including my surgeon) cram too many surgeries into a surgical day. I don’t know how they do it. I certainly wouldn’t be able to do it, and I’m younger than most of them…
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Your procedure sounds relatively minor. It should be an easier and faster recovery than a full Shouldice. When they cut open your groin there’s always risk of impacting some nerve or other issues, but those should be rare when you’re in good hands.
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G,
The Marcy thing goes beyond mesh vs tissue repair. Even within the small group of surgeons who perform tissue repair, Marcy-like repairs are not used in adult male hernias (Kang is an exception.) If you ask them, most will say the risk of recurrence is too high, and others will say further study is needed before using it that way.
Some Lichtenstein mesh surgeons (like Dr. Chen) do a Marcy in addition to the mesh. The Marcy isn’t considered sufficient by itself.
I’ve always been very curious about this because if Marcy-like repair works well for adult male indirect hernias, why on earth isn’t such a minimal procedure done instead of mesh, Shouldice, Desarda, etc.? It’s the question I find the most perplexing in inguinal hernia repair.
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G,
I think ajm222 is right about the sutures because Dr. Brown indeed told me that he was going to use silk sutures for my procedure when I asked him about that.
Marcy is a very minimal procedure, and it’s great that it has worked so well for you so far. Was your hernia very small? The only surgeon left that I know of who does a Marcy-like procedure on adult male hernias is Dr. Kang.
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I’m guessing it was Desarda which can be done with absorbable sutures.
Dr. Brown was a fan of the Desarda technique, although he didn’t like to call it that. He used to mix and match it sometimes with other procedures which was strange. For example, in my case he wanted to do something that sounded like a combination of Marcy and Desarda. It was hard to get specifics about what he was going to do exactly, which scared me away.
I think he had the right idea of tailoring repairs to patients, but for him that didn’t mean simply picking the best repair among the proven ones. He would sometimes perform a combo from a couple of procedures or more, essentially creating his own hybrid procedure, which was hard to assess.
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Whenever I see these 10-20% chronic pain rates, I’m shocked. That’s an order of magnitude higher than what surgeons typically quote (I’ve actually encountered a few surgeons who claim 0%.) Also, it seems just unacceptably high. I know it’s all levels of chronic pain, and not necessarily severe or debilitating pain, but, still, it’s crazy high.
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Desarda hasn’t been studied extensively. There isn’t a critical mass of interest in tissue repair out there to change that picture. The few surgeons who practice it and are active at hernia conferences don’t consider it a one-size-fits-all (unlike mesh). It’s another tool in the tissue repair arsenal. Depending on tissue quality and the nature of the hernia, sometimes the patient is a good fit for that, sometimes for Shouldice, sometimes for neither. That’s not going to take over the world of hernia repair when mesh is so entrenched and so widely-applicable across patients. Also, even though Desarda is relatively simple for tissue repairs, it still requires training that surgeons can’t get almost anywhere these days.
I always liked the principle of the Desarda repair, and how much simpler and safer it seems when compared to most other techniques, particularly Shouldice. It’s still open surgery, so the disadvantages of that are still there, but the amount of dissection and stitching is so much lower, and the sutures can even be absorbable.
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I had to pay for consultations in the US, but not Germany.
Tissue repair for adult inguinal hernias is a tiny niche. It’s not just a matter of the level of difficulty of particular procedures. Mesh is considered the “gold standard”.
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Thunder Rose did indeed report that she was happy with her Shouldice repair by Yunis. I recall she mentioned some issue, but considered it minor or part of the healing of the incision – I don’t remember exactly.
Most of these turn out fine it seems, but some (too many) don’t.
I haven’t found it hard to get an appointment or two either in person or by video with surgeons. You need to have all your questions ready. Sometimes (but not with everyone), you can have a couple of follow-up e-mails as well. Kang is actually harder because he doesn’t do video consultations, and doesn’t communicate directly by e-mail. You can only go through his assistant, or sometimes on this forum.
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The blood supply thing was speculation by Kang. I asked Lorenz and Yunis (who both perform Desarda) about that, and they both said it’s not at all a concern, the strip doesn’t need much blood, and they’ve never seen such a problem happen.
I didn’t ask them about the time to recovery.
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I think people are just a little baffled by it since it’s a very different approach. It’s not nearly as well studied as Shouldice or mesh. Dr. Yunis really likes it. Some of the German surgeons like to use it in some cases.
I asked one surgeon who doesn’t like it so much, and he said that people with a weak posterior wall causing a hernia also tend to have a weak EOA (external oblique aponeurosis). A strip of the EOA is used instead of mesh in Desarda, so you need a good EOA.
I think this points to the big issue with tissue repair. It really needs to be tailored to the patient’s anatomy, tissue quality, type and size of hernia, etc. There are cases where Kang may be the best choice, or Desarda, or Shouldice, or in some cases mesh is the best option. Since pretty much no surgeon can do all of these well, such tailoring almost never happens in practice. Mesh may cause problems sometimes, but it’s an effective “one size fits all” solution. Tissue repairs aren’t really like that, not even the most extensive one which is Shouldice.
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Yes, the patient’s anatomy makes a difference.
I’m not sure why there was a common impression here that tissue repair doesn’t cause chronic pain. In the heyday of tissue repair, chronic pain wasn’t studied much, and the focus was on recurrence, so I think this sometimes gives people the wrong impression that chronic pain wasn’t an issue, and it started with mesh.
The question is really the likelihood of chronic pain with the different methods. I don’t think there are good answers, and the picture is obfuscated by the differences in surgeon competence. Just by looking at the details of the techniques, it’s not really possible to say which ones are more or less prone to cause chronic pain – the potential for chronic pain or other discomfort is in all of them.
The “conventional wisdom” among many surgeons appears to be that laparoscopic or robotic mesh when done right are generally the least likely to cause chronic pain, but I don’t know how well this is supported in research.
Like you said, the patient’s anatomy plays a part as well, and it’s not typically known all that well before the surgery.
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William,
Definitely don’t listen to doctors who went to the “it’s all in the head” school of medicine. Mesh can absolutely cause chronic pain as shown by studies.
In terms of which techniques cause more or less chronic pain – who knows. All of them can and do cause it. A lot depends on the surgeon and how careful and meticulous they are.
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It might be him. Here’s the video:
The Germans I mentioned do primarily Shouldice and Lichtenstein, not 5 types of hernia surgery.
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There’s a BioHernia video demonstrating Shouldice performed by a surgeon who I thought was located in the UK, although I’m not sure. I think he was Indian and mentioned that he does more mesh now because that doesn’t take as long. I always wondered who this surgeon was – he seemed very competent with Shouldice.
Like I mentioned before, if I were in the UK and wanted tissue repair, I would just go to Germany.
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Shouldice is a 4-layer repair. There are surgeons who do 2 of these with permanent sutures, and 2 with absorbable. Dr. Wiese, for example. I think Dr. Koch does it that way too. They claim good results.
I don’t know about “2-layer Shouldice”.
Not sure this is something that’s worth obsessing about too much. My understanding is that a clinically significant reaction to the sutures is extremely rare.
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There is no perfect path, unfortunately. I didn’t feel comfortable with any of the options either, and waited until I practically had no choice but to have the surgery done. I don’t regret waiting, and I would have waited longer if it had been possible. The risk of trouble with this surgery is simply too high to do it unless you truly must in my opinion.
Once I had to pull the trigger on it, I picked based on a huge amount of research. I researched it in my spare time and talked to many surgeons for over a year once I knew watchful waiting wasn’t going to work for much longer.
Still, even after all that research, and making what seemed like a very solid choice, it hasn’t turned out great in my case so far, but I don’t know if it would have turned out better with another approach. My surgery would have been a lot easier with Lichtenstein than Shouldice, but who knows about complications beyond that.
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It means Kang’s results aren’t independently verified.
Waking up during surgery has nothing to do with the Shouldice procedure. It can happen in any surgery which uses light sedation, and patients report it with Kang as well. I think it’s still better than taking the damage and risks of deep sedation or general anesthesia. If it is noticed that you woke up in pain, sedation is increased.
Cutting into good tissue happens with all surgery…
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Agreed, so the right question is whether the patient suffers from less bothersome symptoms after the surgery than before the surgery. I don’t know the statistics on this, and whether they’ve been studied well. The impression that I have based on the studies that I have seen is that in most cases the patients are better off overall after the surgery, but the opposite still happens way too often for comfort.
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The issue, though, that these surgeries too often cause other problems like chronic pain or discomfort. The hernia is fixed, but the patient ends up in worse shape overall because of damage caused by the surgery.