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This really varies. It can stay the same size for very long, grow very slowly, or grow fast. It can grow at different rates at different times.

One thing to keep in mind is that larger hernias are harder to fix, particularly with tissue repair.

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WilliamT,

Thanks for the detailed write up.

I had an inguinal hernia repair at Shouldice recently. Their sedation protocol is very different now. They use IV sedation with midazolam and fentanyl. Sometimes they add propofol as well. I woke up toward the end of the surgery while the surgeon was performing some stitching, and it was very painful, although not as excruciating as what you describe. They increased the sedation when they noticed that I woke up. Seems like a common thing there based on reviews. The anesthesiologist also told me that it’s normal. I think they try to go with as light a sedation as they can get away with, which is a good thing – this stuff isn’t good for your brain and other organs. Unfortunately, the local anesthesia isn’t as effective as one would hope. Not sure why – maybe skills of the surgeon, maybe they don’t want to use too much of that either, maybe it really needs to be done ultrasound-guided and they don’t do it that way, I have no idea.

I also have abnormal skin sensations around the area – similar I think to what happened in your case. Some numbness on one side of the incision, and paresthesia on the other side. It feels like something more than just the nerves being cut at the incision – I think ilioinguinal nerve irritation is causing the paresthesia.

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William,

Both Kang and Shouldice use local with sedation, so that’s not it. Being overweight is a risk factor for recurrence, and makes the surgery a bit harder, so the philosophy at Shouldice is that weight loss is part of the treatment.

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There’s also a study from Japan cited here before that shows that a Marcy-type repair worked well for adult male indirect hernias. It’s not clear why it’s inappropriate if there’s all this experience with it working well (Kang, Brown, and these studies).

Dr. Kang has reported great success with it on the whole gamut of adult male indirect hernias. He doesn’t cherry pick his cases other than that they’re mostly Korean. There’s the theoretical concern about recurrence, but it looks like in practice this hasn’t been shown to be a problem, so the basis for the objection isn’t clear.

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You can look up reviews for the Germans on jameda, and there are some on Google as well. The problem with jameda is that they make it hard to post bad reviews, so keep in mind that you’re probably not seeing the whole picture. However, their top hernia surgeons do have many excellent and detailed reviews, and they are pleasant people. I talked to a few of them, and almost went there.

Dr. Kang may be a good choice. There’s less information available out there from patients since he’s in Korea.

How did Carvajal diagnose your direct hernia before surgery? Was he able to palpate it?

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Merry Christmas, Chuck.

It’s true that most don’t have significant issues after inguinal hernia repair, but many do based on the studies that I’ve seen. Looks like well over 10% have at least some long-term pain, discomfort, numbness, paresthesias, etc.

I agree that a hernia that’s too bothersome or that’s increasing in size should be treated, but at this point you don’t even know for sure that you have a hernia, and you have no bulge. I also get pain after certain activities which feels like hernia pain after my Shouldice procedure, but I don’t suspect a recurrence. The same type of pain can be caused by a hernia and by groin surgery.

You have to focus on what you have now, not what you had before. You can’t go back in time and change how you treated it. Also, you don’t know how alternative approaches would have turned out – there’s really no point in torturing yourself about your past decision.

If your current pain is bothering you too much, my advice would be to try to get it diagnosed by the best specialist you can find as mentioned above. Don’t put the cart before the horse. What’s your alternative? Would you really want another hernia surgery done without even knowing that you have a hernia? You may end up with the same pain plus complications from another surgery. See what you learn from diagnosis, and then decide on next steps.

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Hi Chuck,

My case was very different from yours. I had a large indirect hernia with a large defect, and a large hernia sack reaching down into the scrotum. In your case currently, you may or may not have a small direct hernia recurrence.

Like I said before, you need a diagnosis first. I don’t know for sure, but I get the impression that Dr. Towfigh is good at diagnosing non-obvious hernias, and other causes of groin pain. Not sure who else in the US. Maybe Dr. Krpata, and Dr. Chen. In Germany, there are a number of surgeons who are very skilled with ultrasound (such as Dr. Conze), but I think there are occult hernias that even that can’t show, and maybe other types of imaging help with those.

As to how to fix the hernia if it’s there, maybe put off that decision until you find out what’s going on exactly.

I don’t know how frequent and how bad your pain is. If it’s not something that bothers you too much, I personally wouldn’t do anything about it quite frankly. Hernia surgery can cause a lot of trouble as you well know. Also, watch out for shooting-in-the-dark type surgeries (exploratory, random nurectomies) which can be harmful.

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Chuck,

I don’t know what weights you were lifting, but I agree that lifting heavy weights should be avoided. Hernia probably isn’t actually the most common damage this causes. I think spine damage is the big one to worry about with lifting.

My understanding is that most inguinal hernias are unavoidable. Indirect hernias are almost always caused by a congenital defect, and direct hernias are caused by tissue weakness.

In retrospect, my parents should have taken me to surgery as an infant because my hernia would have been trivial to fix back then. As an adult, surgery becomes a lot more questionable because the repair isn’t trivial, it can easily be worse than the disease, and the earlier you have the surgery done, the larger the chunk of your life that may be impacted by bad outcomes such as chronic pain. The caveat here is that if you want tissue repair, you may want to pull the trigger on surgery as soon as you notice that the hernia is progressing and becoming worse.

You don’t know how bilateral tissue repair would have turned out in your case. Also, there was no way for you to know that you would end up being one of the few percent with issues after TEP. You made a rational and informed choice about the procedure, and you took your time with the decision. You could have ended up being one of the few percent with issues after tissue repair, and regretted not getting mesh.

I prefer tissue repair to mesh, but I’m not an absolutist about it, and I know that bad outcomes are possible with both. Also, in some cases tissue repair may be a better fit, and in others mesh may be better. One thing I realized late is that hernia repair really should be tailored. For example, it turned out that I was not a good fit for a Shouldice repair, but it was done anyway because of where I went to have it done. That’s not good.

My advice to those who want tissue repair is to first figure out if they have an “easy” case or not. If it’s a large, long-lasting hernia, be careful. Go to one of the few surgeons who do both tissue repair and mesh, and let them decide what is best either before or during surgery. Such surgeons include Dr. Yunis, Dr. Towfigh, and a few German surgeons. Possibly also Dr. Reinhorn.

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Watchnwaitin,

You can pick based on names you see in reviews. Tell the patient coordinator that you want a specific surgeon.

There is no vaccine requirement. By the way, visitors are still not allowed.

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I find it pretty shocking that chronic pain rates for TEP are so high. This is supposed to be the technique with the lowest rates of chronic pain…

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What federal government subsidies encourage medical conglomerates to be formed? The doctor in the podcast states this, but isn’t able to explain it when asked. The article you cited is about health insurance prices in different areas, not conglomerates/monopolies.

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It’s not clear from this podcast how “govt. subsidies” are involved in the emergence of these medical conglomerates. This doctor never really explains how that works. He makes some bizarre statements about FBI money and CIA money, and some other vague comments when asked about this.

You can actually find examples of the opposite where state governments go after medical conglomerates/monopolies with antitrust lawsuits. For example, see the $575M antitrust settlement between California and Sutter Health.

I don’t see how government can be blamed for the emergence of these medical monopolies, although it’s reasonable to say that the government doesn’t do enough to pursue antitrust.

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I wouldn’t call it “socialized”. These medical conglomerates and monopolies are capitalistic entities. It is true that they effectively limit the quality and quantity of care, so there’s some similarity to what happens in socialized medicine.

Another aspect of this is shared medical records within the conglomerates and across them. Patients have no privacy rights limiting access to their medical records by medical providers. This constrains the ability to seek meaningful additional opinions or obtain care from additional providers. Again, this effectively limits care. It’s also a very dangerous situation where any incorrect diagnosis or some other misguided opinion becomes sticky and ubiquitous negatively affecting your care.

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Chuck,

Like I mentioned, I would think about it in two steps. The first is getting an accurate diagnosis, and the second is potential surgery. If you’re pretty sure it’s a hernia, I think it’s reasonable to go to Dr. Kang to be diagnosed and possibly treated. You have to decide based on what’s actually going on in there, and you don’t really know yet. Maybe you can have it looked at in the US first (Dr. Krpata, Dr. Towfigh) before going all the way to Korea. If nothing else, it will give you another opinion about what you have and how to treat it.

What does Dr. B. think? How bad is your pain, and when does it happen?

After extensive digging on the Internet and asking a bunch of people, I also found a surprising number of reports of short term as well as chronic pain after Shouldice Hospital repairs. The thing is that you can also find such reports after Lichtenstein as well as TEP. The conventional wisdom is that TEP is the least problematic in this regard.

Who knows what the real numbers are, though. Shouldice sometimes claims 1%, sometimes 2%, and there was even a mention of 5% on that interview with Dr. Towfigh. It’s definitely an issue. They are doing a multi-year study on that, but I don’t know how many patients bother with it because the questionnaires are lengthy and time consuming to fill out. German surgeons sometimes say 0% chronic pain with Shouldice, and sometimes they say 1%-3%. Basically, who the heck knows, but the numbers I’ve seen for mesh are worse. I really don’t think there are reliable numbers for any of these.

There’s also the question of how to treat chronic pain. There are some methods to treat it on mesh repairs (including removal). Not sure about Shouldice.

I know what you’re saying regarding the success of the local general surgeons. I observed the same thing. I have a couple in my area who have many stellar reviews. I actually consulted with one of them. He told me that he always cuts the ilioinguinal nerve, and that pretty much turned me off. However, he has many great reviews. He suffered from chronic pain himself after a Lichtenstein procedure, and required a nurectomy.

Honestly, much of it is luck. You need to pick the best surgeon you can, but it’s still a Russian roulette. Different people react differently to the same exact things, there are anatomical variations (such as with nerve locations), surgeons can be tired and pressed for time, etc.

I think you just got unlucky, and you shouldn’t be hard on yourself. You actually made the rational choice. I’m the one who went out on a limb more by going to Shouldice, and we’ll see how that turns out in the long run, but so far it has not been so good as I mentioned above.

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Chuck,

Would I do it differently? I can’t answer that yet. I really have to wait for further recovery. If I absolutely had to answer that question now, then my answer would be that I would pick a different way of fixing it because of the nature of my particular case. This wasn’t known all that well at the time I made the decision, though.

If I were in your situation, I would first try to get the best diagnosis, and then decide if and how to do surgery. Maybe go to Dr. Krpata or Dr. Towfigh for diagnosis. Dr. Kang might be good for that too, but if he doesn’t find a hernia, where does that leave you? Maybe others could diagnose what’s causing the pain even in that case.

I don’t think you really made a mistake with your choice of procedure. Maybe the choice of surgeon – I don’t know. The vast majority do fine with lap mesh and even open mesh as you mentioned.

Dr. Kang is a reasonable choice if your case is a good fit for his procedure, and it may very well be. Also, he’s a very experienced surgeon. The part I don’t quite see is why you put what he does in a different category than other tissue repairs. His technique for direct hernias is a variation on Shouldice/Bassini as I understand it. Not quite as extensive, but similar in principle. It’s not exempt from recurrence or from pain. Have you read Alan’s account of his recent surgery with him? Very similar to what happened to me at Shouldice in terms of the pain.

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Chuck,

I’m too close to the surgery to know if I’ll be dealing with any lingering issues or not. I need to see where I am when a reasonable healing period is done. I’m not where I expected to be in terms of recovery at this point, but healing is still going on, and things should get better.

The observation that my case was a fairly poor fit for a Shouldice procedure isn’t coming from me or from my research. It came from my surgeon. This doesn’t mean that I won’t have a good outcome, but it resulted in a challenging surgery which is something that one should really try to avoid.

There’s a problem with going to places that use a single procedure such as the Shouldice Hospital, Dr. Kang, and Dr. Tomas. The problem is that you act as your own doctor in the sense that you pick the treatment, and you may pick wrong for your particular case. I think for non-trivial cases, it’s best to go to someone who is good with a number of procedures (tissue repair as well as mesh), and can make an informed decision before or during surgery. Too bad there are only very few such surgeons.

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GI,

Most indirect hernias are a result of a congenital defect (persistent processus vaginalis), and long-standing indirect hernias are common. They see large long-standing indirect hernias at Shouldice regularly – I was told they operate on such hernias every week.

I don’t think the different environment in the inguinal canal is an issue. Yes, there was a hernia sac there for a long time, and now there isn’t, but that’s par for the course with indirect hernia repair. None of the experts I talked to considered that to be a potential issue.

One problematic aspect was just the way my anatomy was laid out which made doing a Shouldice repair more difficult, but still possible. On top of that, the hernia defect was large, and the tissue quality was decent, but not great. I was pretty far from an ideal candidate for Shouldice, but this is not something that I could tell in advance. The ultrasound that I had gave an incorrect picture. The skill for doing it correctly for an inguinal hernia doesn’t seem to exist in the US (or Canada), and that’s the reason hernia surgeons find it to be useless. I hear they do a much better job of that in Germany, but we’re talking about hernia surgeons who do it themselves after developing specialized expertise.

Anyway, that’s the reason I mentioned that tailoring the repair is important. I think surgeons who do both Shouldice and mesh would have made the intraoperative (or maybe even preoperative) decision to use mesh in my case. I’m not saying that the fact that it was a more challenging repair explains my pain, but it might. On the other hand, I could have ended up with mesh-related trouble, so who knows.

Having said all that, look at Alan’s case of pain after his Kang repair. Different case, different tissue repair procedure, similar issues after surgery.

We’ll see what happens. Things may settle down, and I may end up being a happy camper with no pain, no recurrence, and no mesh. If anyone is curious about how I would do it with the benefit of hindsight, ask me in a few months.

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I just read Alan’s thread about his surgery with Dr. Kang. Very similar positional-dependent pain symptoms after surgery to what I experienced at Shouldice.

One difference in the experience is that Dr. Kang told Alan that it’s normal, while my surgeon thought it wasn’t, and that something bad happened.

Threads like these are very important because surgeons don’t provide enough information about the true range of “normal” symptoms that can be experienced after surgery, and what helps with those symptoms. Maybe they don’t want to scare people, or maybe they don’t even know.

I’ll keep posting about how this develops, and I hope Alan does as well. A natural question is what the healing process looks like in such relatively bad cases of post-surgery pain, and whether (heaven forbid) chronic pain becomes an issue.

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Thanks for your thoughts, ajm222. I definitely agree with your points about the importance of positive thinking and optimism in healing. Good luck with your procedure if you decide to go ahead with it.

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Alan, the pain you mention when standing up for more than a few minutes is very familiar, and also your experience with being the only patient around with this pain.

I also still have that problem, although much improved compared to what it was initially. It’s interesting that Dr. Kang said that your pain is expected. Did he explain what causes it specifically? My surgeon said my pain was unheard of and was thinking about issues with the surgery (like nerve impingement) which seriously freaked me out, and this still worries me.

If I was told this is rare, but known and goes away eventually, I wouldn’t be so worried. I hope it’s just caused by swelling which is pressing on something, and this will go away when the swelling goes away, or maybe caused by some other tissue damage from dissection and stitching that will heal completely with time. These tissue repairs are certainly not as benign as I thought they were, but the alternatives don’t seem to be great either.