Herniated
Forum Replies Created
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Hi Lisa. You might try contacting the Canadian Hernia Society. Their directory is open only to members, but perhaps a call or email requesting a few contacts would work. Their Executive Board includes Dr. Peter Glen, MD FRCSC; Ottawa, ON. MarkT’s advice regarding a free consult with the Shouldice also makes sense if you can afford it (you could also ask the consulting surgeon to suggest a few names near Ottawa/Montreal).
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The following paper from Japan compared a type of tissue repair (Marcy) against mesh for treatment of indirect inguinal hernias (“diameter of the internal inguinal ring was up to 3.0 cm (I-1 or I-2 of Japanese Hernia Society Classification)”). You could try contacting them to ask if they know of surgeons in your area with the tissue repair expertise you are seeking.
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typo: “Cordon” should have been Robert E. Condon
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You could find out directly by getting assessed by Shouldice: “All medical assessments are free of charge.”
https://www.shouldice.com/become-a-patient/ -
In women the round ligament (from the uterus) passes thru the inner inguinal ring. Apparently the round ligament can be cut without significant consequences. Doing so enables the Marcy repair to rigorously seal the inner inguinal ring in women.
In men, the spermatic cord and associated structures pass thru the inner inguinal ring. Cutting those structures would similarly enable a rigorous seal, but most men would object to the consequences. Thus repairs to the inner inguinal ring in men must find other solutions. The standard Marcy repair in adult men had a very high recurrence rate.
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@drtowfigh uses dynamic ultrasound. See for example: https://www.facebook.com/Dr.Towfigh/videos/this-is-an-inguinal-hernia-perfectly-captured-by-ultrasound-see-how-the-fat-cont/4654382541302639/
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Watchful, if you have not already done so, perhaps it is time for a physical exam/blood work/imaging to rule out other potential issues (e.g. infection, tumor, bleeding)?
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I would avoid the CT option due to the associated radiation (increased cancer risk for you and mutation risk of any future offspring).
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@drtowfigh has a helpful video in her HerniaTalk Youtube channel discussing the relative merits of US, MRI and CT imaging. She reports that observation of an inguinal hernia by US is definitive for primary hernias. However, she also noted early in the video that the presence of mesh and scar tissue from previous hernia surgery can render US imaging unreliable. MRI seems to be her preference in such circumstances.
If I have correctly interpreted her comments, then it would seem that the primary question is how reliable is the evidence that you actually have a hernia in the same region? If you are not confident in your surgeon’s opinion, then perhaps ask @drtowfigh for an assessment.
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The recurring issue of Kang recurrence. Dr. Kang claims the very low recurrence rate of <0.5%, corresponding to less than 5 recurrences per 1000 patients. Yet the anecdotal reports in this thread indicate that recurrent patients have been seen in clusters, which is hard to reconcile unless for some reason recurrent patients are scheduled together, or some of the various claims/observations are misleading. No way to know without an audit.
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A few corrections regarding your Shouldice Hospital option:
– “you may not be able to [choose] the surgeon if you knew” – If you contact the hospital and specify a preferred surgeon they will attempt to accommodate.
– “shouldice is reported to cut the cremaster and some nerves” – this varies with the surgeon. Some will cut only a portion of the cremaster and attempt to preserve nerves. Discuss with your preferred surgeon.
– “they also use stainless steel” – this is their preference due to reduced inflammatory response to stainless steel in comparison to Prolene, but if you ask for Prolene they will accommodate.
John’s Hopkins has a hernia clinic. You might want to investigate their options as well, if you have not already done so.
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It has long been recognized that the recurrence rate for Shouldice repairs is much lower for high volume surgeons than it is for low volume surgeons. This paralleled its reputation as a difficult surgery to master. So much so that one of the benefits touted for the Lichtenstein Repair of Inguinal Hernia using mesh was that successful repairs could be routine for surgeons with minimal experience.
To give a sense of time: I.L. Lichtenstein (1986) Hernia repair without disability.
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I write to correct some of the false statements made in this thread regarding the practices of the Shouldice Hospital.
1. You can’t select your surgeon. This is false. You are welcome to request a specific surgeon, and they will do their best to accommodate. This is discussed in the HerniaTalk interview of the Shouldice Chief of Surgery Dr. Spencer Netto.
2. They use staples to close the wound, and only remove them after 2-3 days.. In fact, their current practice is to remove every other staple the morning after surgery, and the remainder the next day. They then apply a special wound tape dressing. The resulting scar is minimal.
3. They force Ontario residents to pay for a “hotel” room, not covered by OHIP. This is what Shouldice calls a semi-private room. However, OHIP will cover a room in the ward. The complication is that the ward is currently closed as a COVID precaution. If you can’t afford the semi-private expense you can discuss with them and they will work with you to find a solution.
4. The wait time for Shouldice is 6 months. In fact, you could get your assessment tomorrow if you are flexible and don’t require an appointment. If you want an appointment for your assessment, the current wait time listed on their web site is 5 months. However, they also offer walk-in assessments. Their web site currently lists 234 walk-in slots available for the coming week.
5. They require you to stay like a week in their “hotel”. This is false. Their web site states: “You should plan to stay at Shouldice the afternoon and evening before, and for three (3) nights after surgery.” In fact, if you have no complications they encourage discharge after the staples are removed (two nights post surgery). Total of 3 days. -
Two thoughts for Chuck.
1. You might enjoy the following brief introduction to indecision: https://www.psychologytoday.com/us/blog/still-procrastinating/202103/what-makes-people-indecisive2. If I recall correctly you are located in the DC/Baltimore region. If so, Johns Hopkins University Hernia Center is in the neighborhood, and offers a large number of expert surgeons. IF you haven’t already ruled them out, it would be worth some time exploring their surgeons: https://www.hopkinsmedicine.org/surgery/specialty-areas/hernia-center/index.html#:~:text=The%20Johns%20Hopkins%20Comprehensive%20Hernia%20Center%20offers%20world-class,patients%20whose%20complicated%20conditions%20cannot%20be%20treated%20elsewhere.
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There was a recurrence rate study that compared the recurrence rate of patients whose primary repair occurred at the Shouldice Hospital with those of patients whose primary repair occurred at various other Ontario hospitals. They did this by scanning the Ontario Hospital Insurance Program (OHIP) records, which captures recurrence codes in hospital billing requests (which captures Ontario recurrences regardless of whether the recurrence is repaired at the site of the primary repair. They found that the recurrence rate for patients receiving their primary repair at the Shouldice was dramatically less than that of patients served at other Ontario hospitals.
Not perfect because it missed the subset of patients who had their primary repair in Ontario but then had a recurrence repaired outside of Ontario. Nor would it capture patients not covered by OHIP (e.g. foreign patients). Also it only studied patients whose primary surgery occurred prior to 2008, and things have changed since then…
Malik et al., 2016, Recurrence of inguinal hernias repaired in a large hernia surgical specialty hospital and general hospitals in Ontario, Canada. Can J Surg, 59, 19. DOI: https://doi.org/10.1503/cjs.003915
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The following is a quote from the Beverly Hills Hernia Clinic web site (Dr. Towfigh’s clinic):
“Since the introduction of mesh in the 1980’s, most surgeons have lost the art of non-mesh tissue repairs of the inguinal hernia. Dr. Towfigh is experienced in non-mesh tissue repairs and regularly offers it to her patients who she feels are good candidates for that. Dr. Towfigh offers robotic-assisted laparoscopic non-mesh hernia repairs as well!
The benefit of tissue repair is mainly to reduce the risks associated with mesh implantation.”
Cost – I have no idea – but I have heard that everything in California is very expensive.
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Hollywood is close to Orange County, and Hollywood offers the esteemed hernia specialist Dr. S. Towfigh, who offers no mesh repairs.
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The surgeon seems to have honestly presented his background preparation for introducing the Shouldice procedure into the Kyoto hospital. The surgeon also seems willing to discuss the procedure in detail with patients. Both seem very positive signs. If you decide to visit them for a consultation, it would be good to come prepared with a list of questions addressing your concerns.
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Great! It is important to ask how the surgeon performs the Shouldice repair. Also ask what “trained in Shouldice Hospital means?”. The following is from the Shouldice Hospital web site FAQ. Note what they say about training:
Can I get the Shouldice Repair done elsewhere?
At Shouldice Hospital, we set high standards. Our surgeons are fully qualified and licensed to perform surgery by the appropriate Canadian authorities. Then they are required to spend up to 6 months of intensive training in the Shouldice Technique to perfect their skills before they are approved to lead a Shouldice surgical team. Only surgeons practicing at Shouldice Hospital receive this training. The Shouldice technique is very detailed and must be practiced in high volumes to ensure consistently superior results.
Most general surgeons will repair 20 to 30 hernias in a year. Shouldice surgeons average over 700 cases a year, which provides the highest level of practice and experience in the world. This is why Shouldice surgeons are the world‘s most experienced leaders in hernia repair
Surgeons come from around the globe to observe the Shouldice technique. For two or three days, they can watch as the Shouldice repair is performed by Shouldice specialists. However, this is not training. Although many surgeons perform hernia repairs, we cannot offer a training program for them. As a result, we cannot guarantee the quality of any hernia repair said to be a Shouldice repair when it is performed by doctors outside of our hospital. -
@maxl – Dr. Shirin Towfigh, who created this HerniaTalk web site, is in California. She is a hernia repair surgeon offering either tissue or mesh repairs.