Watchful
Forum Replies Created
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notanewbeeok,
See link above.
Please share the study here if it has useful recommendations for reducing cognitive damage from anesthesia or sedation. There’s one sedative (dexmedetomidine) that’s known to be less bad than others (propofol, midazolam) on this front.
Yes, I saw the video with Dr. Sbayi, but I don’t recall that he ever participated in this forum.
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notanewbeeok,
Canada dropped the vaccination requirement for entry.
I don’t recall that Dr. Sbayi was an active participant in this forum. When was that? Dr. Towfigh said he would notify her of his new practice in Nov. We’re still in Oct.
I wish lawsuits made surgeries and healthcare in general safer in the US. Unfortunately, that’s not the case. If you look at studies, you’ll see that there are hundreds of thousands of deaths per year from medical errors, it’s the third most common cause of death, and the US has the highest rates of medical error deaths in the world. I don’t know how accurate all these studies are, but it’s clear that the picture is bleak. I read a recent study that showed that a shocking percentage of US nurses aren’t able to perform arithmetic at the level required to calculate dosages, getting the values wrong by an order of magnitude.
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I don’t let lawsuit potential be part of my criteria, but if it is a critical factor for you, then this pretty much rules out doing it outside the US. That’s a problem because most of the best tissue repair options are outside the US.
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It is possible to do local only with no sedation, and it’s possible to do local with light sedation. You need a surgeon who is extremely good with local anesthesia, and even then it can hurt sometimes.
The no sedation or light sedation options are offered only by very few surgeons in the developed world. The standard these days is deep sedation, typically using propofol. There are some rare exceptions like the Shouldice Hospital where they tend to use lighter sedation with Versed (midazolam). However, patients are complaining about being awake and being in pain during surgery. Things get confusing with Versed because you may be awake and in pain, and then not remember it because Versed causes amnesia. I heard that Dr. Chen at UCLA also offers little or no sedation (for Lichtenstein procedures).
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Anesthesia and sedation are known to cause delirium and cognitive dysfuction in some patients, particularly elderly patients with a low cognitive reserve. There are many papers about this. I researched it when it happened to my mother. We had to put her in a nursing home due to her rapid cognitive decline after the surgery. Her surgery was a “minor” orthopedic surgery. The anesthesia caused the problems. It causes some brain damage and inflammation, and rapidly accelerates dementia.
Sedation has such bad effects as well. It doesn’t need to be general anesthesia. I don’t think local anesthesia does it, but sedation does.
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Is it understood why mesh causes more issues in women than men? Also, why is tissue repair considered to be less problematic in women than men?
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Looking at many studies, I get the impression that chronic pain rates for open mesh and tissue repairs are roughly the same, and higher in both cases than what I feel comfortable with. Some studies show better results for TEP mesh, although that doesn’t seem all that conclusive.
Clearly, these surgeries are something to be avoided other than for some pretty bad hernias. I think many people are not aware of this. I know I wasn’t. Also, surgeons don’t recommend watchful waiting as much and as often as they should.
I’ve had my hernia for many decades, and a number of surgeons told me over the years that I should really have it fixed. That seems to be true now, but definitely wasn’t necessary back then, and I’m very glad I didn’t listen. I didn’t even know the relatively poor outcomes of these surgeries, and surgeons certainly weren’t divulging that. At some point, surgeons started listing a bunch of bad post-surgery scenarios in their notes, but weren’t talking about those during the consultation.
The first time I realized that this surgery wasn’t a trivial matter was when a surgeon mentioned to me that he had chronic pain after his hernia was repaired with a Lichtenstein procedure, and he needed a neurectomy. In his mind, though, this wasn’t something to be concerned about if the ilioinguinal nerve is cut as a prophylactic measure during surgery, and that’s what he started doing with his patients.
Some surgeons I talked to insist to they have essentially zero cases of chronic pain, or maybe they had one or two in their entire career. I don’t really know what to think of that. Maybe they have a different definition of pain, or maybe they’re in denial, or not being truthful, or maybe some surgeons are really that awesome. In some cases, I find reviews from patients of these surgeons complaining about chronic pain, so I don’t know how that can be consistent with the claims of no chronic pain.
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Really sorry to hear that, Bob. It’s very strange that both your testicles are painful. How would the surgery affect the testicle on the other side? Different nerves, blood supply, etc.
Do you know if your surgeon resected your cremaster completely?
I was leaning toward having a Shouldice procedure done, but I’m getting cold feet after reading too many patient reports of chronic pain and discomfort. It must be a small minority, but still larger than I expected.
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Regarding the cremaster… There’s a difference between the perspective of the provider and the patient.
We’re talking about a high-volume provider which has done hundreds of thousands of surgeries. From that perspective, reducing overall recurrence by a couple of percent (say from 3.5% to 1.5%) makes a difference of thousands of cases that don’t bounce back to them with recurrence.
From the perspective of the individual patient, though, the picture may be very different. It may not be worth taking the damage of this part of the procedure for lowering recurrence from very unlikely to even more unlikely. Also, maybe at least a tailored approach is better where it’s cut completely only in some patients.
There’s also the alternative practiced by some tissue repair surgeons in Germany where they perform a thorough dynamic ultrasound rather than chopping everything up to look for “hidden” hernias. That’s the approach that should really be compared to.
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Who knows with nerve cutting… On the one hand, it seems like a bad thing, and you hear about neuroma, etc. On the other hand, many open mesh surgeons routinely cut the ilioinguinal nerve, and the Shouldice Hospital routinely cuts the genital nerve branch, and has done that in hundreds of thousands of patients. What’s the conclusion? Beats me.
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The difference between a sports hernia as she defines it and a regular direct hernia wasn’t clear. When asked, she said it was just fat without intestine, but a direct hernia doesn’t need to contain intestine to be a hernia, so I didn’t get that. I also didn’t understand why the genital nerve would get damaged by the sports hernia. I understand why there would be pain (protrusion pressing on the nerve), but not nerve damage unless this was some truly severe compression.
Her objections to Desarda didn’t seem all that solid. Surgeons who practice it have had really good results with it, and the studies have been great so far, including a couple of long-terms studies. Surgeons who don’t practice it come up with all kinds of theoretical reasons for not liking it, talking about possible issues which don’t seem to be seen in practice.
The most surprising comment she made was that she has never seen chronic pain resulting from surgeries that she did.
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You should ask him what layer he skipped. I’m guessing he didn’t want to dissect your posterior wall because you didn’t have a direct hernia.
The local anesthesia is supposed to take care of the pain, so I’m a bit surprised it was very painful when they woke you up during surgery. I guess it’s pretty tricky to get the local just right.
How large was your hernia? Do you know the defect size and/or hernia sac size?
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Good summary, MarkT.
There is no evidence that steel wire sutures are bad, but there are issues with them. They sometimes prick the hand of the surgeon, which can cause blood-borne diseases to be transmitted between patient and surgeon. Patients at the Shouldice Hospital are sometimes asked to do a blood test after surgery when the surgeon got pricked during surgery. Also, steel sutures have a tendency to break. In his later years as a surgeon, Dr. Bendavid actually switched from steel to prolene for these reasons when performing the Shouldice procedure.
The fact that the cremaster cutting issue isn’t settled is the most disturbing thing about the Shouldice procedure. Cutting it completely is not supported by most surgeons outside the Shouldice Hospital. This is a radical step which includes cutting the genital nerve branch, and the cremasteric blood and lymphatic vessels, which include the collateral (not primary) testicular blood supply. Seems like there would need to be a really good justification for doing something this radical, but nothing particularly compelling has been provided – the justification seems weak. It’s along the lines of somewhat better visibility and an expectation of slightly lower recurrence rates with this step.
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I didn’t dig further into this particular potential complication. It’s just one of many possible complications with inguinal hernia surgery.
If your hernia becomes too symptomatic, what can you do? You have to go under the knife, and hope that the cure will be better than the disease in your case. It is scary that you might be trading a relatively minor problem for more serious problems, but the odds seem to be against something like that happening.
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It is on the list of risks that some surgeons mentioned to me. For example, pain with ejaculation was mentioned, and one surgeon even mentioned that he started tightening the internal ring around the spermatic cord less during surgery after some of his patients complained about this problem.
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Bob,
Sad to hear that. It doesn’t sound “normal” for the procedure, but who knows how many patients suffer from something like this and how long it lasts. In reality, no one collects and publishes such information in any reliable or detailed manner.
Do you have pain in both testicles, or just the one on the side where the surgery was done?
Was your surgery done in the US?
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Must be what they’re comfortable doing. They don’t mention what version of Bassini they perform. They call it a “Bassini type repair” which would raise questions in my mind. There’s the original Bassini, and there are corrupted versions of it. The Shouldice technique is an evolution of the original Bassini.
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William,
Here’s a 15-year follow-up study of Desarda:
Dr. Lorenz in Germany has been performing it for many years (over a decade I think). Would be worth considering if you’re interested in that repair, and you’re located in the UK.
We have this unfortunate situation with tissue repairs where the most proven techniques are also the more invasive ones. The most proven is Shouldice, and then Desarda, and then Kang. This is the inverse of the order of invasiveness where Kang is the least invasive, and then Desarda, and then Shouldice. Then you have the modified Shouldice as practiced by most surgeons outside the Shouldice Hospital. With that one, they don’t completely cut the cremaster, genital nerve, and vessels. There aren’t enough studies to clarify the impact of that on recurrence and chronic pain.
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Good questions. I would add a question about recurrence rates as well as chronic pain rates that she sees with tissue repairs in her practice. Is she able to follow up with patients over the long run? What are the results?
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There was a study by Schumpelick and others which I cited a while back. It did indeed show a somewhat lower recurrence rate and higher pain rate when resecting the cremaster. The surgeries were performed at two different centers in Germany, so not exactly apples-to-apples.
It is bothersome that you can go back to the Shouldice Hospital in case of recurrence, and they’ll take care of it, but you’re on your own in case of chronic pain. Patients say that they are told that they are one of the unlucky, and that they need to live with it or go somewhere else for help.
Recurrence should not be the only focus. As you mentioned above, aspects of the procedure which reduce recurrence but increase chronic pain may not provide a good tradeoff for the patient. The patient should be the focus, not the provider. I don’t really know if the complete resection of the cremaster/nerve/etc. falls into this category, but there is some reason to believe that based on the paper I mentioned. If the hospital had to treat chronic pain as well as recurrence, maybe that would affect aspects of the procedure that they perform.