[Watchful]

Who knows, but more than two weeks seems very possible. You’re still quite close to your surgery…

In what way does the tightness show up? What do you feel, and during what activity?

Any changes in the pain while standing up or walking (when not using the lifting trick)?

Shortly after surgery it’s like you’re in a fog of war and don’t know what’s just a fairly normal part of healing, and what may become persistent (hopefully nothing in that category). New symptoms can appear later on as well (again, hopefully not in your case).

[Watchful]

Right, but things get really uncertain with all these factors of hernia size, type of anatomy, tissue quality, body mass, and age. It’s not good that it gets iffy when you venture outside the realm of pretty ideal cases. For some reason, at Shouldice, they focus only on body mass as a criterion.

You mentioned the skill of the surgeon. There is an interview with Dr. Burul who was a very experienced surgeon when he joined Shouldice, and he was the chief surgeon there for a while. He said that it took him a year and half after he joined to feel comfortable with performing the Shouldice procedure on different hernias. He didn’t stay long there, by the way, and went to some other hospitals.

[Watchful]

I think an important question is what you can do to resolve chronic pain after tissue repair. If it’s caused by nerve damage, then neurectomy is an option. However, if it is caused by pressure on an area of excessive tension, then what do you do?

I heard of a case of chronic pain after a Shouldice repair where a surgeon recommended doing a lap mesh procedure as a possible solution with the goal of reducing the pressure on the Shouldice repair.

[Watchful]

@drtowfigh

Thanks for the response. My understanding (or maybe just wishful thinking) was that the Shouldice procedure reconstructs the area in a more clever way which largely avoids this tension thanks to the 4 layer repair, plus relaxing incisions if needed. I think I get what you’re saying, though, if there isn’t enough tissue to work with.

[Watchful]

@drtowfigh

Do some people have a “deep anatomy” which makes Shouldice (and some other tissue repairs) more difficult? If so, is there a way to know in advance using imaging?

Also, how does the size of the hernia affect the difficulty of performing a Shouldice procedure and its outcomes? Does it become a more complex procedure? It’s interesting that the Shouldice Hospital doesn’t reject large hernias for that repair, but most others do.

Your ability to use all these types of repairs is extremely rare. In the vast majority of cases, the patient essentially picks the type of repair by picking the surgeon, which is obviously far from ideal.

[Watchful]

Oceanic,

It’s a reasonable explanation. Did he say if he had encountered cases with the same post-surgery symptom before?

In the original Shouldice procedure this nerve is resected along with the cremaster. That would prevent this problem, although that’s not the main reason for this resection.

If this doesn’t improve or go away, I can give you some further information (beyond the lifting trick that I suggested) based on my personal experience, but hopefully it will just go away.

[Watchful]

Dr. Chen should be a good hernia surgeon, but he does have some bad reviews, and the posts from the body building forum concerned me. The guy there also did a lot of research, and decided on Lichtenstein with Chen. He ended up with some pain and discomfort for months (like the rest of us compulsive researchers…) Not sure if and how it resolved. He said that follow up was lacking. I don’t know how much personal attention you can get there. It’s a university, and Dr. Chen is extremely busy and has very long waiting times.

I did very little research on Lichtenstein surgeons. Without further research and if I had to pick someone now, I would probably go with Dr. Towfigh. If I had time, I would research it first, and then probably end up with chronic pain because we all know that this is the punishment for too much research.

[Watchful]

MarkT – It’s not so much about cosmetics. I personally don’t care about that at all (not sure about Chuck). The thinking is that larger incisions mean more trauma, cause more nerves to be affected, more pain, longer healing, etc. Also, they give you a hint of the extent of work internally. For me, the incision size per se wasn’t of much concern.

Chuck – Yeah, I don’t know what to believe either. It’s hard for a patient to get good data about anything in this area. If you look at the chronic pain numbers that Kang just posted, they look far from great. However, I don’t know what to conclude from that because we don’t know the true numbers for pretty much anyone else. All the anecdotes are of limited use.

I agree that people like us tend to overthink things. Maybe it actually makes the most sense to go with the most commonly practiced procedure, and it’s the most commonly practiced for good reasons, and not because of some irrelevant or nefarious reasons.

In most likelihood, I would have been better off with a Lichtenstein procedure since my hernia happened to be a tough one to repair with Shouldice. Not sure what that means more generally, though. I do think that Lichtenstein is more one-size-fits-all than any tissue repair, so in some sense it’s a safer bet. It’s probably best to go to someone who can tailor the repair, but extremely few surgeons are excellent at both tissue and mesh.

[Watchful]

I recall that my surgeon mentioned to me before surgery that the incision is larger for a large hernia, and my hernia was large, so he said that the incision would be 3-4in, and it turned out to be 3.5in.

[Watchful]

Mine (from the Shouldice Hospital) is about 9cm (3.5in).

Not sure about Oceanic’s incisions, but they look like they’re of similar length to mine. I thought they’d be smaller in his case because Dr. Conze told me that he does Shouldice with a 5cm cut, and he makes some clever use of the retractor with his assistants to gain enough access with a relatively small incision.

[Watchful]

Glad this worked for you, Oceanic. If jockey underwear doesn’t hold it high enough, you may want to look for some kind of truss.

If I were you, I would share this with Dr. Conze, and see if he has seen this before, or if this makes the potential cause clearer to him.

I hope this problem subsides soon as you heal. Please keep us posted.

[Watchful]

Thanks very much for sharing this data, Dr. Kang. It’s excellent that you did a phone survey for chronic pain. It’s extremely rare for surgeons to do this, unfortunately.

They don’t even do it at the Shouldice Hospital. They’re doing a study of chronic pain, but patients have to fill out many long forms just to participate, and then they have to keep filling out such forms on a regular basis. I didn’t bother with this, and neither did any other patients that I asked over there. They really should be actively following up with patients by phone, but they don’t do that.

I know it’s not your definition, but I’m not sure why number 3 (“pain present, cannot be ignored, but does not interfere with everyday activities”) is considered “no pain”. Seems serious-enough to me for qualifying as pain. The way I read it, 16.6% (1 out of 6!) had at least some chronic pain, 8.7% had significant chronic pain (i.e. cannot be ignored and worse), and 1.7% had chronic pain which is at least somewhat debilitating.

Do you believe that these numbers are better than what is obtained with mesh? A few mesh studies mention 15% rates of chronic pain, although definitions vary, and are sometimes unclear.

I know this problem is not specific to the Kang repair, and it is a general problem with inguinal hernia surgery. It’s very unfortunate that a problem which is typically minimally symptomatic needs to be repaired with a surgery that has a somewhat significant risk of causing worse chronic symptoms.

My experience with surgeons is that they aren’t at all transparent about this. I talked to about a dozen surgeons, and I asked most of them about the risk of chronic pain. A couple said zero, or that they had maybe one patient with chronic pain in their career. A few said 1%. One surgeon said 1-3%, and that was the highest among the surgeons I consulted. Until I asked, none of them even bothered mentioning this problem, and then quoted such low numbers. I don’t think any of them really studied it like you did (with phone follow-up).

I pretty much had no choice but to do the surgery because my hernia became too symptomatic. However, if it had been only mildly symptomatic, I would have been extremely reluctant to take these odds of chronic pain (plus other potential complications).

[Watchful]

Wow – your incisions are completely different than mine even though we both had a Shouldice procedure. Yours are horizontal, and mine is vertical.

[Watchful]

As long as you keep improving, it should turn out ok with some more time.

Does the pain and discomfort completely go away when you sit down or lie down?

If you lift your testicle/scrotum with your hand while walking or standing, does it get better? At the Shouldice Hospital, some surgeons give their patients a truss to lift the area during recovery.

[Watchful]

If I remember correctly, it was a quick recurrence, and it wasn’t a missed hernia. There was one hernia and it was a sliding hernia. Pinto can give more details.

My case was a matter of poor information to work with as you mentioned. The problem was that this information wasn’t really known until surgery because the size of the hernia defect and the nature of my anatomy were known only then. We knew it was a large indirect hernia, but not much more than that. My ultrasound had incorrect measurements. Mesh was more likely to give good results in my particular case, but a difficult and long Shouldice surgery was undertaken instead because that’s what they do over there. My mistake was going to a place that doesn’t tailor the repair.

[Watchful]

That’s a bit alarming and unexpected… I hope you recover completely soon. What did Dr. Conze say?

[Watchful]

Pinto doth protest too much, methinks.

[Watchful]

To avoid confusion, here’s what my colleague reported. He looked at 18 reviews specifically about hernia surgery at Gibbeum.

Out of these, two mentioned that their hernia recurred after their surgery at Gibbeum. One of these two mentioned that two of the four people he met at the hospital were also there for a second operation after their hernia recurred, and these people he met also had their previous hernia surgery (which failed) at Gibbeum.

Two reviews mentioned issues with pain which resolved eventually.

The remaining 14 reviews were good.

By the way, it’s extremely hard to find any reviews for the Shouldice Hospital complaining about recurrence. It’s not hard to find reviews complaining about pain, but not recurrence.

[Watchful]

Now that you’re reporting “some unusual sensation but not pain”, can you elaborate on what that is exactly? Do you mean paresthesias such as numbness, burning, itching, tingling, pricking?

By the way, sensations from damage done in surgery on one side can happen on the other side as well. That’s the case for me. My surgery was on the right side, but abnormal sensations extend to the middle and the left side. This includes both paresthesias and pain in my case. Not severe, fortunately, but enough to be annoying on occasion, particular when a belt or other clothing presses against the area.

[Watchful]

The thing is that it’s not just anecdotes. The chronic pain results you see in studies aren’t good (ballpark of 15%). Also, see the numbers just posted by Dr. Kang who is about as focused and high volume as it gets. It’s certainly a minority who get bad results, but a minority that’s too large for comfort.