Watchful
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I saw a couple of good mentions of his work on this forum. I never talked to him. He has his own 2-layer tissue repair procedure reinforced with a Gore-Tex mesh (seems like he agrees not to use the mesh in some cases). He calls it a “modified Shouldice”, although it seems a bit of a stretch to call it that. I heard that he does trim the cremaster, but doesn’t cut it completely. He’s very experienced, and has done a very large number of surgeries.
I haven’t explored him beyond that since the pros and cons of his specific procedure weren’t clear to me.
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MarkT,
We seem to be largely in agreement based on your last two paragraphs. You would like to see the same improvements. My point wasn’t that all these issues make the Shouldice Hospital a bad choice. It’s one choice among a number of options all with their own issues.
Not sure why you thought there’s some connection between not being able to choose the surgeon and other issues – no one was claiming that.
They are doing a study of chronic pain/discomfort among their patients finally, but it will end only in 2024.
If you want a minimalist procedure for an inguinal hernia, it’s definitely not the place to go. It’s about as far removed from the Kang approach as you can get… The incision is very large (5-6in!), massive dissection, exploration, and stitching, complete resection of the cremaster, genital nerve branch, and cremasteric vessels (seems pretty extreme to do that to young patients in particular!)
One alternative would be going to someone who performs a less aggressive version, such as Dr. Yunis, Dr. Towfigh, or one of the German surgeons. Smaller incision (hence faster recovery), and leaving the cremaster, nerve, and vessels intact. How the results compare in terms of recurrence and chronic pain isn’t completely clear, and we aren’t likely to get definitive answers any time soon.
Then you have Desarda which is a much simpler procedure. Research results have been pretty stellar so far, including long-term studies of 15 years. It has been adopted by quite a few surgeons around the world. There’s a surgeon in the US who has performed thousands of these (Dr. Thomas). There is a mention of Desarda on the Shouldice Hospital site, and the only negative they mention is that the entire area isn’t explored to find additional hernias. Seems like something that could be addressed by performing a careful ultrasound before surgery if it is a concern.
The Kang approaches (for direct and indirect) are even simpler, but longer term data is really needed there.
I’m leaning toward going with one of the surgeons performing a modified Shouldice (smaller incision, preserving the cremaster, prolene sutures).
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“Very likely” isn’t quite good enough with something like this, though… We have only one body which is irreplaceable, and we have to live with the consequences of surgery for the rest of our life. A lot can go wrong which is out of your control, but taking away your control over the one critical factor that can be controlled (the choice of surgeon) is not good. Some surgeons simply aren’t as good as others. You can even get a trainee operating on you under supervision. Also, they have visiting surgeons often, so your surgery can become a show with a distracted surgeon. Having the ability to pick your surgeon and insist that they focus entirely on your surgery doesn’t seem like a crazy requirement when considering what’s at stake here.
I read pretty much all the reviews, comments, and blogs about the Shouldice Hospital. There is definitely variation among surgeons. One striking thing is that recurrences must indeed be quite rare because people aren’t complaining about that. On the other hand, you do find reports of chronic pain and/or discomfort, testicular issues, and infections.
The chronic pain number they mentioned recently is 2%, although an estimate of 5% was mentioned in Dr. Netto’s interview with Dr. Towfigh. Not awesome, but I don’t know how it compares with mesh when implanted by top surgeons.
One nagging thing with them is this business with cutting entirely the cremaster. This is quite radical. It destroys that muscle as well as the genital nerve branch and the various blood and lymphatic vessels attached to the cremaster, including those responsible for collateral testicular blood supply (not the primary supply, but still). Almost no one does this outside the Shouldice Hospital these days, and the recurrence results when this is not done still seem extremely good, so it’s not at all clear that this radical step is justified. There isn’t as much data about the modified procedure, so who knows for sure, but it’s an area the deserves more evaluation by the Shouldice Hospital in my opinion.
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Watchful waiting for inguinal direct/indirect hernias is a good thing for those whose condition allows for it. Sure, chances are they’ll need the surgery eventually, but there isn’t really a good-enough reason to do it sooner. The risks of surgery exceed the risks of not doing it in such cases, and the cure is worse than the disease. It’s better to wait until you really have to do it. I’ve been doing watchful waiting for decades, and now I need to have the surgery done, but I’m glad I didn’t do it before. The surgery could have easily affected my life more than the hernia did. When I decided to wait, I didn’t even know how problematic these surgeries were.
It is indeed very frustrating that the options are so limited for tissue repairs. If anything, I think the situation will get worse because of surgeon retirements. There is almost no training for a next generation.
I also wish changes were made at the Shouldice Hospital. Offer outpatient surgeries, maybe with an option for a stay at the hospital for those who want/need it, possibly in a private room for extra payment. Allow choice of surgeons. Research cutting the cremaster with the nerve and vessels to make sure it really makes sense to do it, and stop doing it otherwise. Find a way to help those in the 2% (or whatever it is) who end up with chronic pain after the surgery.
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The wait time there for surgery with local anesthesia isn’t short either (5 months). There’s a lot of demand for tissue repairs, and so few surgeons who can perform those well.
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@good-intentions
I read the full paper. I think the most controversial aspect of the procedure as they do it there is completely cutting the cremaster and the genital nerve branch. Most surgeons outside the Shouldice Hospital don’t do this.
It’s interesting that there’s some disagreement on this within the Shouldice Hospital as well. The paper shows that 73% of the responding surgeons there agreed that this was needed, 9% were neutral, and 18% disagreed. Hence, this was not considered to be within the consensus. Cutting some parts of the cremaster was within the consensus, however.
The use of steel sutures was also outside the consensus – 55% agreed, and 45% were neutral.
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This is dangerous territory. Pretty much anyone who has significant medical issues (including surgeries or sequelae of surgeries) can be diagnosed with “psychological disorders” by one mental health practitioner or another. It’s a field where pretty much everyone can be diagnosed with something by someone, and they’ll be happy to “treat” it with some therapy or dangerous drugs.
Throwing people with hernia into their hands is scary. Also, those poor souls who go there and have it on their records will be dismissed in perpetuity by gaslighting doctors and potentially insurance companies as well.
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@good-intentions
This confusion of cause and effect (as well as correlation and causation) is really disturbing to see. How can it be one thing in the abstract, and then the opposite in the conclusion? Some sort of circular logic?
This kind of vague ammunition for dismissing patients with chronic pain after groin surgery is likely to be abused. There are already way too many doctors who belong to the “it’s all in your head” school of medicine. Encouraging this convenient escape is not good.
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Interesting. Did he explain why he thought it would work very well in a 46 year old? Just treating the sac without treating the defect seems like begging for recurrence…
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@good-intentions
Yes, that’s an interesting approach for indirect hernias. Much less problematic than mesh or tissue repair when it works. However, I think I passed the age where it would apply.
It’s laparoscopic high ligation of the hernia sac which should work fine if the internal ring tightens by itself after the hernia sac is removed. That is actually what normally happens up to a certain age – not sure what it is, but I’m pretty sure I passed it. My understanding is that at some point a muscle defect develops there if you don’t treat the hernia earlier in life, and then you need either mesh or tissue repair to avoid a high recurrence rate.
Still, I will contact him to hear the latest on this.
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@markt – thanks.
The loss of the cremaster reflex with this procedure is a certainty, not a risk. It’s mentioned in the German paper that I cited earlier in this thread. You can also search for cremaster in the following document which is in English and cites that paper:
New Clinical Concepts in Inguinal Hernia
“Tons and Schumpelick reported the cremaster reflex to be absent in all patients after division of the genital branch”
Whether that actually matters or not is a different question. In the same paragraph:
“Clinical implications of an absent cremaster reflex are unclear.”
Beyond that, there’s a higher pain rate when performing this part of the procedure according to that German paper. However, they still conclude that it is essential to do it. I read in another paper that there’s a higher risk of a hydrocele as well when doing this. Anyway, these are risks, but the loss of the cremaster reflex is a certainty.
I’m more concerned about other things with the Shouldice Hospital. I think if you get one of their best surgeons, it’s right at the top as long as you’re ok with cutting the cremaster/nerve. When Dr. Burul was asked where he would go if he needed the operation, he said one of the best surgeons at the Shouldice Hospital. If you read the link I posted above from the Scottish Parliament, you’ll notice that Dr. Netto mentions that some of their surgeons are part time. If you look them up, a couple of the new ones appear to also work elsewhere doing other types of surgeries.
Their reviews are mostly good, but I would say a bit mixed. Some surgeons get more bad reviews than others. Quite a few reports of chronic pain. Some infections. A significant number mentioning issues related to the level of sedation and local anesthesia – being conscious and in pain during the procedure, etc. Maybe it’s just the statistical reality of doing a large number of procedures.
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Going by the requirements of the Shouldice Hospital, you don’t need to be under a particular age, or have an athletic build. You just need to have a normal BMI (not overweight).
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Maybe. I don’t know if the scrotum itself can contract without muscles doing the work.
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@good-intentions
The only other muscle there is the dartos muscle, and it is innervated by the same nerve that’s cut (the genital branch).
Maybe the muscles on the intact side have some residual effect on the operated side.
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@Mike M
It is a removal in that section.
One stump of the ligated cremaster is used in the internal ring repair.
The other stump is “included into the external ring or subcutaneous tissue to prevent any possibility of the testis becoming dependent.” This prevents a dangling testicle.
I’m not an expert on this, but I don’t see how whatever remains of the cremaster could possibly function after this. Recall that the nerve is cut as well. This means that the testicle will not be moving up and down anymore as far as I can tell.The loss of cremasteric function is not something that I would care about all that much personally. Still, the removal of a muscle/nerve and the loss of function seem like something to be avoided unless they are essential. There is disagreement among surgeons about that. Some remove it (Shouldice Hospital, Dr. Sbayi), some “shave” it (thin it down and don’t remove the nerve), and some only open and close it. A very confusing situation for patients trying to decide where to go for a Shouldice procedure.
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Mike M,
There was a recent thread with extensive discussion of this, but it disappeared.
The original Shouldice technique as practiced at the Shouldice Hospital and Dr. Sbayi completely cuts the cremaster, and leaves two stumps. One stump is used in the reconstruction of the inner ring to make the repair more resilient to indirect hernia recurrence. Search for “cremaster” in this paper to understand what is done:
This paper also explains how the procedure avoids a dangling testicle.
The cutting of the cremaster is mentioned as an essential part of the repair in a number of papers. It makes it possible to visualize the area better and find hidden hernias, get a better reconstruction of the inner ring, and it’s shown to reduce the recurrence rate. I found one paper (cited earlier) which mentions more pain when this is done, but still concludes that it’s an essential part of the repair. Outside the Shouldice Hospital and Dr. Sbayi, this part of the procedure isn’t widely performed. An obvious question is why deviate from a proven technique which has been performed on hundreds of thousands of men with seemingly excellent results overall. Well, at least in terms of recurrence. I think the chronic pain results are less clear.
The other thing to keep in mind about the Shouldice procedure is that it’s a 4-layer repair which reduces tension by spreading the load. Again, geared toward reducing the risk of recurrence.
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WB,
That’s the reason the words “tailored approach” always make me uneasy. You just don’t know what you’re going to come out with: Shouldice, Desarda, mesh, or some combination or variation. The criteria are very unclear, subjective, vary from surgeon to surgeon, and even contradictory between surgeons.
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Thanks for looking up Lindsay’s case, William – this helps. It’s a good sign that he moved on – he must be happy with his repair.
I used to think that treating inguinal hernias was straightforward, so I didn’t bother researching it much all those years while watchful waiting. I thought I would just go to a good general surgeon and get it done when the time comes.
When the time finally came, I went to a general surgeon, and he told me that he himself had had an inguinal hernia which was repaired with open mesh, and he had chronic pain after that, and needed a neurectomy. Also, he told me that he routinely cuts the ilioinguinal nerve while performing the procedure. At that point, I realized that I knew nothing, and this was absolutely not a trivial thing.
I then went to a laparoscopic hernia surgeon, and he said he was 80% sure he could do it that way in my case, but there was a 20% chance that he would have to abort the procedure, and convert to open. At that point, I started being even more concerned.
The next step was to research mesh because those were mesh procedures, and this freaked me out even more. Meanwhile, my hernia symptoms kept getting worse. The next phase was researching tissue repairs, and looking into the very few places that offer it. I’m still shocked that treating this simple condition has so many pitfalls, and you need to travel far and maybe even to a different country to get it treated in the least bad way.
Anyway, I’m at the tail end of the research part, and it’s time for action. I really wish my hernia hadn’t become so symptomatic over the last year. It was minimally symptomatic for many years. That’s what aging does to you, I guess. Your existing issues get worse, and new ones pop up to make things even more interesting.
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I posted at the same time you did, Dr. Kang, and hadn’t seen your post. This helps me understand what happened there. I certainly need to decide soon. I’m in bed right now trying to get my hernia back in!
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Does anyone here know of anyone who had surgery for an indirect hernia with Dr. Kang? The only case I heard of is Pinto. He posted that he had an indirect sliding hernia, and his hernia recurred pretty much right away after surgery by Dr. Kang. A second operation by Dr. Kang has been successful so far. I know we have successful direct hernia experiences, but what about indirect? Those are two completely different procedures with Dr. Kang.