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Here’s an update on my condition. It has been about two months since my surgery.

I still have some hard “healing ridge” in the incision area, but it has been growing smaller gradually. Skin sensation in the area is still somewhat abnormal (some numbness and paresthesias), but that has been improving as well. I think my ilioinguinal nerve was disturbed based on all the skin sensation abnormalities, but I hope it goes back to normal with time. If I press in the incision area, there’s some pain, but, again, better than before.

I sometimes get internal groin pain with certain kinds of exertion, but it typically resolves pretty quickly when it happens.

I don’t feel any tightness or pulling or anything abnormal like that internally in the groin. It feels normal. This is a big change for me since I never had a normal groin on that side before – my hernia was congenital.

As I mentioned before, I had another issue in the groin which led to serious pain after the surgery. I’m not going into detail on that because I’m pretty sure it doesn’t apply to anyone else here. It was sorted eventually, but only after going in some wrong directions. That’s a whole story by itself.

I’m still healing, and will write another update in a month or so. I hope the remaining issues resolve completely over the next few months. If I’m lucky, maybe in a couple of months.

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William,

Thanks for the good wishes – much appreciated.

Baris went to Dr. Koch in Germany, and then to Shouldice. At Shouldice, Dr. Alexander helped him. Unfortunately, he retired during the pandemic. He was one of the extraordinary surgeons there. The other great one in recent times was Dr. Degani, but he’s mostly retired now.

Lichtenstein would have certainly been a much easier surgery in my case, but as to what would have been better in the long run – who knows. The main problem wasn’t really tissue vs mesh in my case. I don’t think anyone outside the Shouldice Hospital would have done Shouldice in my case, but that’s just a tangential point that I’m making.

I had another problem in my groin which wasn’t handled correctly, and that created a (non-funny) comedy of errors for me over there. I’m not going into much detail on that because I think it’s irrelevant to others here, but my point on this is that it’s not the right place for complex cases. If you have one of those, be less focused on tissue vs mesh, and more focused on how you can get the right care for a complex case.

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I will write an update about my condition when I have some more time.

Meanwhile, in terms of whether I would make the same choice again or not… No, I wouldn’t in my particular case, but my case was complex and unusual. For that, you really need to go to a place with more personalized care, and broader expertise. The Shouldice Hospital is a very focused factory, and that’s not a good fit for anything complex or unusual. It’s also problematic in case of complications, and they don’t have much experience with diagnosing or treating post-surgery pain issues. Ideally, you want a surgeon who is well-versed in that because they know better how to avoid those issues to begin with, and they’re better positioned to help you correctly if something happens.

I think if you have a run-of-the-mill inguinal hernia case, it’s fine to go there as long as you get to pick one of their best and more experienced surgeons (I mentioned some names – Hall, Simmons, Slater). If I had such a case, would I go there knowing what I know now? It wouldn’t be my first choice, but nowhere near the bottom either.

I would go to one of the top German surgeons. I mentioned some names before – Conze, Wiese, Lorenz. They perform good diagnosis and follow-up, they are very careful, and they don’t force tissue repair on cases where it’s not a good fit – they are good at figuring that out, and using mesh if needed. They’re capable of doing Shouldice well, and they do many of those, but they avoid doing it in cases where it’s likely to be problematic. Dr. Conze would be my first choice since he also has experience with treating post-surgery pain issues.

By the way, going far away, and particularly abroad is far from ideal. It’s not at all easy even if everything goes smoothly. If there are complications or other issues, you can be in a very stressful and difficult situation, which may even influence you to make sub-optimal decisions at that point. Unfortunately, there are very few good choices for tissue repair in the world, so local options don’t exist typically.

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Chuck,

Can you really tell if it’s the same pain or not?

I’m not an expert on the diagnosis of occult hernias. Mine was very large and obvious, and it was an indirect hernia.

Has anyone told you what the best imaging would be for this? Why not ask Dr. B to order it?

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Chuck,

There are bad results with all these techniques (including Kang). It’s not true that Shouldice is particularly bad. It has its pitfalls, but so does mesh as you well know. You mentioned Lichtenstein – as I said before, I consulted with a surgeon who does this procedure, and he had a bad result (chronic pain) when it was done to him, and he needed a nurectomy. He now routinely cuts the ilioinguinal nerve.

You’re drawing conclusions from anecdotes. The only valid conclusion to draw is that there is no perfectly safe solution. You need to do your best the pick the best surgeon and technique for your case. However, you don’t know all the factors in advance, and even if you made the perfect choice, there’s still scope for trouble.

Even the best surgeons make mistakes, and medicine isn’t engineering – it’s a complicated mess of unpredictable repercussions from intervention. Evolution did not engineer the body to be friendly to surgeons (or drugs). The best of them are good at avoiding mines in this minefield, but no one and no technique can guarantee success. All you can hope to do is maximize your chances of a good outcome.

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PeterC,

Sometimes the nerve itself is injured by the surgery, caught in stitches, the mesh, or scar tissue, etc. This can result in chronic pain. In such cases, a nurectomy can be the right treatment.

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This surgeon had quite a few bad reviews. He doesn’t perform surgeries there anymore.

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Chuck,

Right, I think back then when you were researching it they were indeed cutting the cremaster completely, cutting the genital nerve, and using steel sutures. This changed more recently as I mentioned before.

I selected the surgeon based on experience and reviews. Hall, Slater, and Simmons have many years of experience performing this procedure, and they get mostly good reviews. Netto is pretty junior actually – he has been doing this for only 3-4 years. The best surgeon there in recent times was Alexander, but he retired during the pandemic. Another great one was Degani, but he is mostly retired now, and really old (in his 80s I believe).

The place is not what it used to be, unfortunately. Shouldice who used to monitor things closely passed away, and the other big names who kept the strict tradition there retired or passed away. They now diverged in how they do the procedure, there are a number of young part timers there, etc. Also, the property was sold for redevelopment recently, and it’s not clear what will happen to this hospital.

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My understanding is that the Muschaweck minimal repair is primarily for “sports hernias” where weakness in the posterior wall causes pain, but there isn’t necessarily an actual hernia, or the hernia is small. I believe the genital nerve branch is typically cut in this procedure because it’s supposed to play a role in the pain in these particular cases.

The Kang method for direct hernias is for actual direct hernias, and not limited to small hernias. The genital nerve branch is not normally cut.

Both techniques are simplified Shouldice/Bassini of a more limited scope than the original. Not sure about all the differences.

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I talked to him more than a year ago. He was pleasant, and even humble enough to say that the best place to go for a Shouldice procedure is the Shouldice Hospital, even though he was able and willing to do it. Also, he said that tissue repair would be his preference on a “virgin abdomen”, so he definitely had a favorable view of tissue repair. I ended up not going to him because of a number of reasons: he himself thought it would be better to go to Shouldice, he hadn’t done a very large number of these, I wasn’t sure if he would end up doing Shouldice or Desarda or even mesh, and I didn’t get a clear understanding of what he was doing for anesthesia. I don’t know if he changed or not since then.

People and organizations can and do change, of course. Also, on-line reviews can be misleading because many patients prefer not to leave bad reviews. I remember that Dr. Brown used to be considered good to deal with, and he had mostly good reviews. However, when I met with him when he was close to retirement, he seemed very impatient and almost scary.

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William,

Since you’re in the UK, why not go to Germany? Conze, Lorenz, Wiese.

If you are really so limited in lifting, then I would consider doing it, but if it’s not so bad and things are stable, I would personally wait.

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The bulge size varies because the content sometimes comes out more, and sometimes it gets reduced back in. The question is whether you’re noticing a worsening overall. If not, and if it isn’t really bothersome, then my personal preference would be to wait, but you should listen to your consultants, and it sounds like they don’t think you need to rush to do surgery. How big is the bulge when it protrudes the most? People typically compare to the size of a fruit of a similar size. What fruit would it be?

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If the bulge is larger than it used to be then obviously the hernia has become bigger. The size of the hernia sac and defect can be measured by ultrasound, although having it done accurately may be challenging.

If the hernia becomes too bothersome, it’s reasonable to do surgery even if it hasn’t been growing in size.

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David M,

Some of the German surgeons are really good with ultrasound. I’m told they’re able to tell with a high level of confidence if mesh is needed (by their criteria) based on that.

I’m not sure what they would have said about my case after exam/ultrasound, but my hernia was way outside their guidelines for Shouldice, so I think there’s a high probability that they would have recommended mesh. Also, my deep anatomy made the surgery even more difficult. My surgery took twice as long as it normally takes, and that was with a surgeon who had done thousands of Shouldice procedures.

You will need to ask me again in a few months. If all is good at that point, then my answer will be different than if I have some lingering issues that can be attributed to the type of repair I had. Of course, I could have had mesh and had issues from that as well.

At this time, it doesn’t look like going with a Shouldice procedure (vs Lichtenstein) messed me up, even with my difficult case, but it’s still early days.

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I agree, but the paper linked by Good Intentions was about chronic neuropathic pain after inguinal hernia surgery, and neurectomy can be a valid treatment for that.

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To be fair, only one pain clinic referral out of a few hundred surgeries (if true) is pretty impressive, but, still, it doesn’t give the full picture. Maybe some patients didn’t go back to him, for example, and there are those who get chronic pain which is not so severe. Another aspect is that with mesh the complications can come even years down the road.

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That’s the thing – patients don’t typically get referred to a pain clinic for intermittent and tolerable pain. You need to ask him how many have any level of chronic pain, and I’m pretty sure he doesn’t know and doesn’t keep track of that.

We know that most mesh surgeries for inguinal hernia turn out just fine. The problem is that the incidence of complications (including mild, moderate, and severe ones) is too high for comfort.

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How many has he done over the last year? Also, how does he define chronic pain? Many define it as debilitating pain, or pain that requires medication, and don’t count less severe pain.

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I believe all 3 I mentioned are very good. My first pick among them would be Dr. Conze.

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I’d be freaked out too. It seems that the post-surgery pain with this technique can be really bad, but this resolves in most cases. Still, I would be frightened because how can you tell initially if it’s the “normal” pain, or something more serious? You really need to have faith during those first few days.