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Seroma was mentioned to me as a risk by a robotic mesh surgeon that I talked to about my inguinal hernia. He made it sound like it was pretty common if I remember correctly. He said that if this happens, you wait and it goes away eventually. It was yet another thing that I learned about hernia surgery that made me not want to do it…

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Are core exercises really a good thing with an inguinal hernia? Mine got worse with these excercises. I think applying muscle pressure in that area where you have a defect and a hernia can backfire. It did for me (unless it was a coincidence). My hernia started giving me more trouble after that. Pushed me from watchful waiting to seriously contemplating surgery.

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MarkT… That’s great. Did they give you surgical notes? Do they say that they cut the cremaster muscle and genital nerve branch?

More importantly, how are your repairs holding up? Any long-term pain, discomfort, or other issues?

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Mike M… The Shouldice Clinic cuts the muscle and the nerve, and so does Dr. Sbayi. I believe this is regardless of whether the hernia is direct or indirect. My understanding is that they need to do it to visualize and access the entire area, not just for the tighter repair.

If I remember correctly, Dr. Kang said that he does some minimal cutting of the cremaster in his procedure.

I read that Dr. Grischkan shaves the muscle by 50%, but doesn’t cut the nerve.

Dr. Yunis supposedly keeps both the muscle and the nerve intact. I don’t think he has some special method to avoid this. It’s basically a simplification of the procedure where you are willing to sacrifice one thing for another – there’s a tradeoff there. Keeping the cremaster/nerve, but possibly having a higher recurrence rate (as shown in some studies of this), and maybe not doing as thorough a repair because the cremaster gets in the way. This is just my understanding as a lay person based on reading – I’m not a surgeon or expert on this.

By the way, based on a discussion I had with Dr. Brown, cutting the cremaster and its nerve wasn’t a part of his standard procedure, but maybe he did that in the case of PeterC for some reason. He wasn’t going to do it in my case of an indirect inguinal hernia. I ended up not going with him because his combo procedure of both Shouldice and Desarda seemed like overkill to me. However, maybe this is the reason he could get away with not cutting the cremaster while still minimizing recurrence – he was strengthening the repair with the Desarda.

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Mike M… I’m not a surgeon, but my understanding is that the cremaster muscle is part of the cord, and it is sometimes dissected, or “shaved”, etc. in tissue repair procedures. The genital nerve branch is there as well, and it is cut in the Shouldice procedure (at least the original one).

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Chuck… You are right. The last thing anyone wants is an emergency surgery. However, that is very rare. I don’t think I’m on the verge of that. I think it’s important not to get too freaked out about these things, and take your time to do thorough research, and also wait until you are psychologically ready for it. No need to rush it, but, yeah, it needs to be done.

I agree that Dr. Kang looks like a good option. I’m just a bit bothered that his technique isn’t published. Also, it takes some time to digest having to go to a foreign country with a foreign language, very long flight, etc.

Otherwise, the options are either mesh, or extensive Picasso-style surgeries with a lot of dissection, rearrangement of your anatomy, and suturing.

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I have gurgling sometimes which is confined to the hernia, and my hernia often gets pushed out when this happens. Not a good sign, but not a sign of doom either. It’s still reducible when I lie down.

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How bad are your symptoms? Is your hernia reducible when you lie down? If your condition isn’t too bad, there is the option of waiting. The risk of strangulation exists, but it is quite small.

Many choose to live with it for a long time rather than do surgery. You could potentially just do your research, and once you’re done with that, wait, and pull the trigger on the surgery only if and when you can’t live with the symptoms. This would reduce the pressure on your mind.

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Great summary, worldpeace. Glad it went well.

Do you have any more details on why you (and Dr. Yunis) decided to go with Desarda vs Shouldice, and general anesthesia vs sedation/local?

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Thanks, Dr. Kang – this makes it clearer.

It looks like Dr. Ponsky simplifies even further and just performs high ligation even in adults (same as in children) without repairing the deep inguinal ring. He says recurrence has been only 4% so far. He does this laparoscopically in both adults and children.

If even just that works so well, then if you add repairing the inguinal ring, results should be really good.

I’m still wondering why tissue repair surgeons who know how to do Marcy choose not to do that in most cases of adult indirect inguinal hernias, and prefer Shouldice, Desarda, etc. There must be a reason… Maybe just misguided accepted wisdom?

By the way, what are your thoughts on the Desarda repair?

Thanks again for helping us understand your approach, Dr. Kang.

• This reply was modified 2 years, 9 months ago by  Watchful.

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Thanks, Mike M. I don’t know how much he modifies Marcy, but if it’s very close to Marcy, and it works so well, then why does anyone do the much more complicated Shouldice on indirect inguinal hernias? Why is Marcy so rarely done in adults?

I consulted with Dr. Brown before he retired. He used to do a bunch of tissue repair techniques, including Marcy. For my indirect inguinal hernia, he was going to do a combination of Shouldice and Desarda. The Desarda was for further reinforcement and for reduced tension. He did not mention Marcy as an option even though it was in his repertoire. Why would he even think of such a complex procedure if the repair could be done successfully with the much simpler Marcy? He knew how to do Marcy. This whole area is quite baffling…

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Thanks for the details, Mike M. I still don’t really know what Dr. Kang does, and it’s hard to understand the English in the quotes you posted from him. It sounds like he does do something to the cremaster, but leaves it mostly intact – it’s hard to understand the description. Also, it sounds like his approach is tailored to the patient, so you aren’t really necessarily getting some standard well-known procedure. Anyway, the results that he quotes speak for themselves, and are wonderful (assuming accuracy).

Not sure how to reconcile what Dr. Grischkan is saying about the cremaster (repair won’t be tight-enough without shaving it) and the fact that a number of other surgeons (including Dr. Yunis) seem to be able to get good results without doing this.

Recurrence isn’t something to be taken lightly, but if you’re still in the single-digit percentage points, then taking the chance is reasonable. Who knows, though… We’re just guessing since this hasn’t been studied much, and the little that’s out there is contradictory (which is not unusual in the medical field, unfortunately).

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Good Intentions… There are two possibilities. One is that the surgeons in this survey wouldn’t agree with your statement that “the numbers about mesh implantation say that a pure tissue repair is the safest for long-term welfare.” The other possibility is that they think the skill of the surgeon overrides that.

The most interesting part of that survey was that more than half (56%) were in favor of avoiding surgery until symptoms progressed beyond minimal. The problem is that it’s not clear what minimal vs non-minimal means exactly, and it may mean different things to different surgeons.

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15% with chronic groin pain severe-enough to impact the ability to concentrate on a daily basis. That’s scary. Could it really be true? This would be around 120,000 new people in the US with such serious chronic pain caused by hernia surgery every year. Wouldn’t there be a lot more noise about it and awareness? Still, inguinal hernia surgery is somehow considered no big deal by most doctors and people I know…

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Mike M… I think the modification in the “modified Shouldice” is simply that the cremaster muscle and the genital nerve branch aren’t cut. I don’t believe they do anything to eliminate the need for this – they just don’t do this part. There’s a tradeoff there, and whether it’s a good or bad tradeoff is controversial – there’s no consensus on that among surgeons.

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Glad to hear your repair is holding up so well after all these years – that is awesome.

The cremaster keeps coming up because it’s a controversial part of the procedure. Some surgeons don’t believe in doing it. Also, patients tend to prefer not to have a muscle and nerve cut if not necessary. Some people do complain about a low hanging testicle after this. Also, some sensation is lost in the scrotum, although supposedly this comes back eventually, maybe because other nerves compensate.

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I started experiencing much more frequent episodes of large protrusion of the hernia after I started doing core exercises. It comes out more frequently, and I have to lie down to get it back in. Fortunately, it’s still reducible.

It could be a coincidence – maybe it would have happened anyway. I had noticed that it was getting a bit bigger and a bit gurgly even before I started these exercises. Still, it feels like the exercises pushed it into the territory of something that I most likely need to do something about fairly soon rather than continuing to wait.

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Mike M… Gurgling doesn’t mean the hernia is incarcerated – it can gurgle and still be reducible. It probably just means that some intestine gets pushed into it or even just moves a bit away from the normal location.

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Thanks for the update. Did you ask him if he would be willing to leave your cremaster intact even though he normally trims it? Did he mention why it’s so important to trim it?

Are you sure that Dr. Kang doesn’t cut any nerves or the cremaster?

You can do open mesh (Lichtenstein) without general anesthesia. However, my understanding is that this method has a higher risk of nerve damage when compared to lap and robotic, and some surgeons cut one (typically the ilioinguinal) or more nerves pre-emptively.

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Sometimes there is even an additional step in Shouldice which is a relaxing incision with the goal (I believe) of bringing closer together tissues that need to be stitched and reducing the tension. I don’t know the details. I guess this would depend on the quality of the tissues and the size of the defect. Shouldice is not a simple technique.

A big problem with hernia surgery is that insurance companies don’t pay much for it, and this leads to preferring simpler and faster procedures which can be higher volume.

• This reply was modified 2 years, 9 months ago by  Watchful.