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Yes, right now you don’t have surgical damage on the anterior side, only posterior. If you now get open tissue repair and then a recurrence, you’ll be messed up both anterior and posterior. I wouldn’t take a chance with anything that isn’t known as solid in terms of recurrence, which means either Shouldice or open mesh.
The major downside with the Shouldice Hospital is that they don’t tailor the repair. You will get Shouldice regardless of whether that’s a good fit for your case or not. They apply Shouldice by hook or by crook even in cases where it’s difficult and Lichtenstein is not. You don’t want a difficult surgery for many reasons, including the higher likelihood of chronic pain. Even in the rare cases where the tissues are falling apart, they will still do what they can with Shouldice, and reinforce with posterior mesh.
All this is not a problem for most patients because Shouldice is a reasonable fit in most cases. However, if you are one of the unlucky ones with a hernia and anatomy which make Shouldice difficult, you are in a bad situation there.
With Conze, you don’t face this problem. He is very proficient with both open mesh and Shouldice, he is not biased, he does a thorough exam and imaging, and he actually does some thinking and planning based on that before surgery.
If you are certain that your case is a good fit for Shouldice, then the Shouldice Hospital is a reasonable choice, but remember that they will not approve you without a significant hernia that’s evident in a physical exam.
If you decide on Lichtenstein, then Chen is an option, but he is extremely busy there at UCLA. A year ago, the wait time for a consultation was 4 months. Care after surgery can be a problem. I mentioned before the guy on the bodybuilding forum who had Lichtenstein surgery with him, and then had pain and discomfort for months. He said he couldn’t get follow-up help. I would feel more comfortable with Conze, but the fact that he’s in Germany makes things a bit complex. Towfigh is another option. I’m sure there are other highly capable open mesh surgeons in the US. I didn’t really research that much because I wasn’t going in that direction.
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It’s a more difficult surgery with higher recurrence rates. They have to go through the scar tissue from the previous surgery, may not be able to identify the anatomy and nerves, and the tissues may not be in a good condition.
As I mentioned before, I asked my surgeon at the Shouldice Hospital about what to do if my hernia recurs after my Shouldice surgery, and he said that most likely lap mesh would be my best choice in the unlikely case that this happens.
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Chuck,
In terms of tissue repairs, Conze does mostly Shouldice. He can do Desarda as well, but that’s not his preference typically. If you want Desarda, then Lorenz would be a better choice. Conze didn’t mention any other tissue repairs when I talked to him.
Recurrence shouldn’t be taken lightly. You pretty quickly run out of good options to fix it. You already had lap mesh, robotic removal, and now you think you have a recurrence. Say you fix it with Kang and it recurs down the road, what will you do? You really need this to be your last fix.
My advice would be the same as before. First, if all you have is some minor pain and no bulge, just wait, and don’t do anything. If it’s more serious than that, get properly diagnosed to see if you really have a recurrence. I’m guessing Dr. Towfigh could help you with that. You can decide on the procedure and surgeon later.
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Chuck,
None of these is really safe (all are a crapshoot), and it’s impossible to say what’s safest because for one patient one particular type of repair may be safer, and for another patient another type of repair may be better.
As I mentioned before, I have encountered people who had trouble from a Lichtenstein repair. One friend had it done 20 years ago, and still has occasional (albeit rare) pain. One of the surgeons I met needed a neurectomy due to chronic pain after this procedure, and he now always cuts the ilioinguinal nerve when performing this procedure. There was a guy on the bodybuilding forum who did a lot of research, and then went to Dr. Chen (considered one of the best) who performed a Lichtenstein on him. You can read his posts after his surgery. He had some pain and discomfort for months. He did get better eventually if I remember correctly.
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Jtk2,
Really sorry to hear about what happened to you with your Shouldice repair with Dr. Yunis. My experience with a Shouldice repair has been bad as well, and mine was done at the Shouldice Hospital. My surgery was about 6 months ago, and I also suffer from chronic pain, although I wouldn’t call it debilitating in my case.
The explanation I got upon follow-up wasn’t much more illuminating than what you got: large hernia, deep anatomy, so it was a long and difficult surgery. Well, the fact that it was a large hernia was known in advance during the exam. Not the exact measurements, but it was clearly a large (not giant) hernia with a scrotal component, intestine in the hernia sac, and hard to reduce.
My surgeon said there would be no problem repairing it with Shouldice, and that it would be the best or maybe one of the two best ways to fix it. I really gave him a lot of opportunity to tell me if he thought this wasn’t a good way to proceed, and he didn’t show even a smidgen of doubt. After the surgery, it was a different story, and the size of the hernia suddenly turned from something that wouldn’t be a problem to something that was a problem. Hard to understand, but I guess that’s just the way things are with medicine.
None of the other tissue repair surgeons with whom I consulted said that it might be a difficult surgery either. Maybe it’s just not clear until the surgeon cuts you open, but then they should have the ability to use the right technique for your situation. At the Shouldice Hospital, they almost never use mesh, but Dr. Yunis could certainly do it. I think he checks with patients before surgery if they are ok with him going with mesh if he feels it would be better during surgery. If I remember correctly, he even has some form related to that. Did you give him any guidance on that before surgery?
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Such relaxing incisions reduce tightness, but do they cause other issues? Seems like additional injury which could potentially cause its own trouble.
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This 15% figure for chronic pain after groin hernia surgery is consistent with what studies have shown in other countries as well. It’s not a Sweden-specific issue. It would be reasonable to expect some surgeons to get better results than others, but this is the overall picture, which is not good, and not something that’s commonly known to patients. There’s an incorrect perception that hernia is a minor routine surgery with excellent results.
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I believe Dr. Towfigh uses it occasionally, but not in large hernias. She told me mine didn’t qualify for it because it was large.
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Correct. Conze takes his time in the evaluation and follow-up, and he doesn’t cram surgeries. The evaluation appointment (including ultrasound) is scheduled for 3 hours. Very exceptional, particularly in the hernia field which is typically handled as a high-volume assembly line.
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Conze said he does 4-5 surgeries per day. This is one of the things I like about him. Shouldice Hospital surgeons do 6 per day. Yunis told me he does 6-9, which scared me – I kept imagining being the 9th.
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There’s a huge disconnect between what surgeons tell patients about this, and what the studies show. It’s pretty awful that groin hernia repair leads to so much chronic pain. 15% is not a reasonable incidence for persistent serious pain after 1 year (pain present, cannot be ignored, and interferes with concentration on everyday activities in the past week).
Interestingly, this paper shows similar results for laparoscopic and open in terms of persistent pain. Most other studies that I’ve seen show a lower incidence of chronic pain with lap than open.
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I don’t know anything about these particular surgeons, but there are hernia specialists in German general surgery departments in hospitals. The famous German hernia specialist Volker Schumplick was in general surgery at Aachen (where he was even the head of general surgery.) His protege Joachim Conze was practicing there for many years as well before going into private practice.
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Pinto,
Did your CT report a defect size? 14cm is the hernia sac size.
I believe at least part of the response to your question is that the female anatomy is different. Men have a spermatic cord going through the internal ring, and women don’t. Achieving a good Marcy-type repair of the internal ring on women is not equivalent to doing so on men.
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Not sure what is strange or odd. They are saying that open causes more chronic pain than lap TAPP. With open, mesh doesn’t cause more complaints than non-mesh (namely Shouldice).
What shocked me wasn’t the relative results. I just found the absolute numbers to be surprisingly high. The relative results are consistent with the mainstream thinking (virtual consensus) in hernia repair. Same as what Dr. Towfigh has been saying, and the same as even what my surgeon at the Shouldice Hospital told me.
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Here’s a German paper from 2004 that I looked at a while back, and it kind of shocked me:
Chronic pain after hernia repair
After 52 months, they had 36% of patients reporting chronic pain after Shouldice, 31% after Lichtenstein, and 15% after lap TAPP. Pain causing limitations to daily life: 14% of Shouldice patients, 13% Lichtenstein, 2.4% TAPP.
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William,
It was a Canadian hernia (mesh) surgeon who wrote in her blog that no groin feels the same (as a normal groin) after surgery.
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I don’t think we know the chronic pain rates with Kang. Has he provided them? They may be lower than Shouldice since his procedures are less extensive. On the other hand, if his techniques result in more tension, then there may actually be more pain and discomfort. One of the reasons for the 4-layer Shouldice repair is the reduction of tension.
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Looks like it wasn’t quite a routine case. How experienced was your surgeon? When it turns out not to be a “textbook” case, the experience, talent, and abilities of the surgeon make a big difference. Such surgeries also tend to take longer to get right, so you need a surgeon who doesn’t load themselves up with too many surgeries per day, and such surgeons are very rare in this high-volume hernia field.
I hope it’s just a temporary issue, and it resolves for you with time. You’re still very early at two weeks after surgery.
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Right, but this study didn’t include tissue repairs, which are admittedly a black art that has always been difficult, and thus almost gone from the world now.
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Fair question. These are the options I had:
1) Laparoscopic. As I mentioned before, the best lap mesh surgeon in my area wasn’t sure he could do it in my case. He said there was an 20% chance that he would need to convert to open. I definitely didn’t want something like that to happen. Dr. Towfigh recommended Lichtenstein in my case, although she was willing to do lap mesh. Beyond all that, I was biased against this procedure. I wanted to avoid general anesthesia because my mother suffered delirium and cognitive dysfunction from surgery with general anesthesia. Also, I simply didn’t like the invasiveness of TEP/TAPP and the large amount of mesh.
2) Open. Here I converged on two options. Lichtenstein or Shouldice. There was a third option of posterior mesh, but I didn’t have anyone who could do that – Reinhorn wasn’t taking patients from outside New England.
There were the options of other tissue repairs. I didn’t have a good gut feeling about Tomas, and the Germans recommended Shouldice over Desarda, so I dismissed Desarda. With Kang, I was concerned about recurrence for reasons I described in other threads. My dad had a recurrence from tissue repair, and I believe it was a Marcy-like repair based on what he described. He never had the recurrence repaired, and his hernia is really bad now. It would be a huge mess to fix at this point. Anyway, he has plenty of bigger problems, and surgery is not a good idea at his age.
Between Shouldice and Lichtenstein, I felt that Shouldice would be the better choice. Some studies show pretty similar chronic pain numbers for these, and some show more chronic pain with Lichtenstein. My thinking was why take any chance with mesh complications if I don’t have to, and if Lichtenstein doesn’t really offer an advantage. On the recurrence front, I felt that the Shouldice Hospital numbers are low-enough.
You know the rest of the story. In my particular case, Lichtenstein would have probably been a better choice because of the size of the hernia and my anatomy. My Shouldice surgery ended up being long and difficult, and it led to some chronic pain and discomfort (although not too awful at this point). Of course, I didn’t know all this when making the decision, and I had incorrect information about the size of my hernia because of a grossly inaccurate ultrasound.
With hindsight, I think I regret not going with Lichtenstein. However, if my chronic pain and discomfort resolve mostly over time, and there’s no recurrence, it may turn out that I’ll feel like I made the right choice. I don’t regret not going to Kang. If my hernia was challenging for a Shouldice repair in the hands of one of the top experts, I don’t see how it would have worked with a Kang repair – I don’t see how he would have stitched the huge defect that I had with his Marcy-like repair.