[Jack2021]

Thanks for your reply @drtowfigh

It does sound like your opinion has shifted somewhat following your conversation with Dr Lorenz if you now consider the Desarda repair another tool in the toolbox.

Re you not having seen a situation among your patients yet to use Desarda vs another more vetted technique, is there a situation you can think of that would warrant it’s use from your perspective, or do you still feel that greater evidence over more time is needed?

Thanks

[Jack2021]

It’s understandable that you were worried. I think it’s no insignificant trauma going through hernia surgery, worrying about recurrence, possible mesh issues (for those who have a mesh repair) and mesh removal as in your case unfortunately. There’s clearly plenty of people on this forum who regularly have it on their minds pre and post operation and it’s an emotional burden to carry and deal with.

On the plus side, it’s great that a bit of rest and ibuprofen sorted things out for you and hopefully that was reassuring, somewhat at least. It’s also very positive that your range is still lengthening, which must indicate that your long-term perseverance with physical rehabilitation following your surgeries is paying off. Definitely something to be pleased about.

With the variation in the course of the genitofemoral nerve in different people and I guess in all likelihood, other nerves too, it’s more understandable that hernia surgery has a risk of pain resulting, regardless of the repair method, as your reference alludes to as well, where it notes in relation to the nerves which ‘…serve regions of the abdominal wall, pelvis, and perineum.’ that ‘Any clinical involvement of these nerves may result in pain, loss of sensation, or motor deficits and reduce an individual’s quality of life.’

This may also be one of the key factors why some people have pain with a hernia before surgery and others not so much, due to nerve compression from the hernia and such like, depending on individual nerve location.

I know that there can also be long term pain and numbness following caesarean surgery in women, so surgery related nerve damage is likely a risk of many operations, with potential risks vs potential benefits always the key deciders.

With all surgeries, we clearly need an excellent surgeon to improve the odds in our favour.

[Jack2021]

My hernia’s apparently an indirect inguinal hernia.

Re surgeon choice, like many on here I’d prefer a tissue repair but I’m still procrastinating over who to go to for surgery.

Travelling abroad for surgery is a factor for me and my preference would be to have it done in the UK, though options are extremely limited here. I’ve posted about UK options previously.

In Germany, Dr Conze followed by Dr Lorenz would currently be my preferred choices, though I’m yet to speak with Dr Lorenz. There are good reviews for both Dr Koch and Dr Wiese and Dr Koch came across well when I spoke with him and I haven’t spoken with Dr Wiese.

I’m sure there are currently lesser-known surgeons in countries such as Poland for those nearer there, as the 15-year Desarda follow up study was done there, which I’ve posted about previously, as have others. I tried to contact Dr Kryspin Mitura, who was involved with the study, for more information but didn’t hear back.

If I was in Canada, I’d do my research on the Shouldice Hospital surgeons and try to book in with one who gets great reviews and is open to not fully cutting the cremaster, preserving the nerves and using prolene.

I’d start with Dr Towfigh in the US as IMO she clearly cares about her work, comes across as very knowledgable in her Hernia Talk interviews/discussions and appears to be well-respected by her peers. She also seems open to new perspectives, such as when discussing the Desarda repair with Dr Lorenz.

There are the South Korea options we’re aware of and Dr Kang has some great reviews on here, though no published research data yet.

I’ve also read positive reviews about Gerald Young in Auckland, who’s apparently done many hundreds of successful Desarda repairs, so for any members on that side of the globe, he may be worth contacting.

As you don’t seem to currently have a hernia Chuck and you’ve likely got all the knowledge available that you can find yourself and that this forum can provide, I’d try to look for ways to focus on the present and move on from this until you really need it, i.e. should you get a recurrence. Were this to happen, if it’s an option, I’d personally opt for a tissue repair and hope that lasts, as it appears to be easier to have mesh as a follow up surgery than vice-versa usually, as I understand things, but that’s just my opinion from the research I’ve done.

Re trying to find ways to move on from all this and the significant trauma you’ve experienced, I realise that it will be difficult or perhaps impossible not to be mindful of a possible future recurrence and that this may linger over you, as is often the case for people following serious illness, such as cancer and perhaps other surgeries too. This can affect our mental health and result in an emotional burden and/or PTSD for many people (as can working in jobs associated with this kind of thing) that I think often gets overlooked and isn’t talked about enough.

While a lot of us probably get a bit of low level support via this excellent forum, perhaps reaching out for some specialist emotional support to help focus more on the here and now could be beneficial for you and other members of the forum too possibly, be it in the form of counselling, cognitive behavioural therapy (CBT) or some lower level support with an organisation/s in your country that provide it. This is commonly offered and found to be beneficial in the UK for people with cancer, following bereavement and other traumatic events, so I’m guessing there should be some great options in the US too. Perhaps other members of the forum are able to share some signposting options.

I hope this is some helpful food for thought alongside the hernia stuff.

[Jack2021]

https://www.kenhub.com/en/library/anatomy/iliohypogastric-nerve

My research ruled out the likelihood of Pudendal neuralgia from hernias, though it is linked to pelvic mesh placement following pelvic organ prolapse, most commonly with women. If you’ve been a regular cyclist over the years it may be worth investigating, as this can apparently be a cause of Pudendal neuralgia.

Anatomy, Abdomen and Pelvis: Genitofemoral Nerve –
Perhaps an indicator as to why some people may get pain while others don’t following hernia surgery and why it’s so essential for surgeons to locate and carefully preserve the nerves during hernia surgery, albeit some may argue this is why it’s better to cut the genitofemoral nerve, is that apparently,

‘In at least 50% of individuals, there is some variation in the course of the genitofemoral nerve as it travels within the retroperitoneum and ultimately entering into the inguinal canal. Variation is also found at the level of its bifurcation into genital and femoral branches.’
This is from the ‘Structure and Function’ section of this link –
https://www.ncbi.nlm.nih.gov/books/NBK430733/

[Jack2021]

I don’t recall the post you mention GI and after all you’ve unfortunately been through, I guess the cause of your irritation may just be as you’re thinking.

I’m certain you’ll have thoroughly researched the following already, but just in case and for general forum info, here are some links re pain associated with hernias and hernia surgery that I’ve come across. I’ve had to split them into a couple of posts as it’s not allowing me to put them all in one reply:

Genitofemoral neuralgia – https://pubmed.ncbi.nlm.nih.gov/25377757/#:~:text=The%

Ilioinguinal neuralgia – https://www.ncbi.nlm.nih.gov/books/NBK538256/

Iliohypogastric neuralgia – https://bmcsurg.biomedcentral.com/articles/10.1186/s12893-018-0391-6

[Jack2021]

Chuck, re your question about whether Dr Conze and Dr Lorenz fully cut the cremaster muscle, of the German surgeons those of us on this forum are generally aware of, doctors Conze, Lorenz, Koch, Muschaweck and Wiese, albeit I’m unsure re Dr Muschaweck, my understanding is that none of the others completely cut the cremaster muscle as standard.

Apparently the genital branch
of the genitofemoral nerve is rarely visible immediately during open hernia surgery and is usually more posterior, becoming visible after the cremaster is divided. Perhaps that’s one of the reasons some tissue repair specialists divide/split/trim it, while generally preserving it.

My sense, rightly or wrongly, is that it’s less of a concern unless the cremaster is completely cut and some would argue it’s fine either way. I think I’d be more concerned about nerve damage.

Dr Muschaweck is the only one of them who apparently cuts the genitofemoral nerve (sometimes referred to as the genital nerve) as standard, as per the original Shouldice repair.

I believe the others identify and preserve all the nerves in the area, such as the genitofemoral nerve, ilioinguinal nerve and Iliohypogastric nerve and I think Dr Muschaweck identifies and preserves the ilioinguinal nerve and Iliohypogastric nerve.

I’d obviously recommend that people ask for clarification on all this when contacting/having a consultation with them or other doctors.

Re ongoing pain after hernia surgery, having read various posts on here and information elsewhere, it’s probably been covered on here already at some point, but a lot of the symptoms people mention sound like they may be due to genitofemoral nerve damage. Symptoms of this apparently include ‘…groin pain, paresthesias, and burning sensation spreading from the lower abdomen to the medial aspect of the thigh. It may present with scrotal pain in males, while females experience symptoms radiating to the labia majora and mons pubis.’

Here’s the link to where I read that – https://pubmed.ncbi.nlm.nih.gov/25377757/#:~:text=The%20symptoms%20include%20groin%20pain,labia%20majora%20and%20mons%20pubis.

[Jack2021]

There are two surgeons in Seoul, South Korea who claim to have very good success rates with their own differently modified Marcy tissue repairs, if you’re happy/able to travel there.

Both have posted on here – Dr Kang at the Gibbeum Hospital and Dr K. Y. Chung (posting as KC) at the Ewha Womans univsersity hospital.

Dr Kang definitely sees patients from abroad, but you’d have to check with @kuyongchung (KC) or contact the Ewha Woman’s Hospital for further information.

All the best.

[Jack2021]

Hi @kuyongchung (KC),

Many thanks for joining the forum recently to talk openly and candidly about your modified Marcy repair, it’s very much appreciated.

It’s extremely important for innovative surgeons such as yourself to be openly sharing their techniques within their field and to explain and publish all the details of their work, as you’ve begun to do, for which I applaud you, thank-you.

The sooner this happens, the sooner it can be peer reviewed and validated/learnt by other specialists around the world if justifiable to do so and here’s hoping!

@drkang has apparently operated on thousands of patients with his modified Marcy ‘Kang’ repair and claims excellent low recurrence and long term chronic pain numbers, but he still doesn’t appear to be ready to explain and share exactly what his technique is.

As @drkang’s repair apparently takes around 20 minutes to complete, which is less than half the time of other open tissue repairs, one would imagine that the modification/s he’s devised have made his repair relatively straightforward for a skilled surgeon to complete and ergo easier to teach to other surgeons than say the Shouldice repair.

This in itself is or could be a groundbreaking leap forward in many ways, but it needs to be shared and peer reviewed, which @drkang doesn’t appear open to currently, leaving question marks against his claimed results and the method itself, regardless of whether it may be the biggest innovation in hernia repairs for a generation or two of hernia repair specialists, or not.

Perhaps yours may prove to be a long awaited groundbreaking repair KC and your openness makes that a greater possibility.

KC, how long does your modified Marcy ‘KC’ repair take you to complete and do you use permanent Prolene sutures?

What is the size of your incision too please?

Also, it’s interesting that both yourself and @drkang are based in Seoul and you’ve both devised your own modified Marcy repairs with apparent great success which is evidenced in your case, but not @drkang’s yet, although hopefully it will be soon.

Is the Marcy repair very prevalent in South Korea, thereby increasing the likelihood of surgeons such as yourself and @drkang making their own modifications, as seems to be more common with the Shouldice repair internationally, or have there been conventions or similar in South Korea focussing on modifying and simplifying hernia tissue repairs to streamline the repair so more surgeries can be completed in less time, with better long term outcomes and an improved patient experience overall? I guess what I’m getting at is what was the inspiration behind your ‘KC’ repair and the ‘Kang’ repair; is it just a major coincidence that two surgeons in the same city have devised successful modified Marcy repairs, or is there something in common that has inspired you both to create your own modified Marcy repair and could they even be very similar or exactly the same repair?

@drkang, we really need and would very much welcome your input and explanation of your ‘Kang’ repair here too please?

As Watchful mentioned, Dr Ralph Lorenz, who already has some interest and apparent knowledge of the ‘Kang’ repair and no doubt @drtowfigh and all other open-minded hernia specialists will (and should) be interested to learn more about and discuss your repair KC and the findings from your research paper, especially as you appear open to this.

Like you’ve done, we also need @drkang to be open to explaining and publishing the details of his repair, as Professor Desarda did (there are now numerous studies and many in Europe, including 15-year follow up study in Poland which evidenced excellent long-term results) and the sooner the better so it can be peer reviewed, validated and hopefully improve patient outcomes in this common, yet complicated area of surgery.

It would be good to hear your initial thoughts after reading the above posted study and posts too @drtowfigh please?

Many thanks,

Jack

[Jack2021]

A consultation with Dr Conze, including him doing a dynamic ultrasound himself, cost in the region €400 a couple of years ago I think, if you just wanted to get his opinion initially.

[Jack2021]

Hi Krisztian,

Dr Muschaweck and Dr Conze (who would be a clear preference of the two in my opinion, as I’ve covered in previous posts) are the most expensive hernia specialists in Germany from my research.

Dr Lorenz, Dr Wiese and Dr Koch, who are the other better known specialists in Germany, were all less than half the cost when I last looked into it a couple of years ago, though that may have changed.

[Jack2021]

Just to add, it’s knocking on 2 years since I was in touch with Gonzalo, so he may have moved on I guess.

[Jack2021]

Hi Gale,

Sorry to hear about your situation.

I’m also based in the UK. My suggestion would be to contact Dr Joachim Conze, who runs a clinic in Munich – 0049 89 9209010 / https://www.hernien.de/

He worked in partnership with Dr Ulrike Muschaweck for many years until, from my understanding, buying her out or coming to some agreement of sorts and taking over the clinic.

Dr Muschaweck is renowned for her sportsmen’s groin repair (the Muschaweck repair) which doesn’t involve the use of mesh. She does run a clinic in the UK once a month still I think, so you could see her also, even just for advice. A consultation will cost £400-£500 so not cheap and she’s not registered with many private medical insurance companies either, even if you have cover.

Dr Muschaweck is mid-seventies now so well beyond standard retirement age for a surgeon in Europe and is expensive too. She’s operated on the likes of Alan Shearer and Michael Owen many years ago.

To find out about UK appointments, you can contact her either through Biohernia, or more directly via her PA, Gonzalo Rojo at [email protected] / 0049 89 9545 338 20.

Dr Conze treats many top athletes and sports people too and can offer the same treatments at similar prices, though you’d need to travel to Munich. He’s probably in his fifties, I’d guess and would be my preference of the two if you were to undertake surgery, because he also looks to preserve the nerves and my understanding is that Dr Muschaweck is more likely to cut them, as they’d say in basic layman’s terms, which she does with her inguinal hernia repairs as standard I believe. He would Taylor any surgery and can use mesh if it’s required.

Were you to travel to Germany, they’d provide all the details about where to stay etc, so it should be relatively straightforward, aside from having to travel for it.

They can both do open surgery repairs for a variety of hernias and would both do their own dynamic ultrasounds, rather than relying on a report from a radiologist, as they know exactly what they’re looking for.

Hope that’s helpful and please feedback on the forum regarding how you get on, as it’s always really helpful for other members to know.

All the best,

Jack

[Jack2021]

Thanks Pinto and G.

I agree Pinto, that KR could turn out to be revolutionary. In my humble opinion, that would be regardless of whether it’s a case of having changed the suturing technique/positioning, or multiple modifications.

If it’s a minimally invasive technique with low recurrence and chronic pain rates over the long term and takes less than half the time of other hernia repair surgeries, then it would surely be the biggest leap forward in hernia repair surgery in many years.

Along with that, if it turned out to be easier to teach than the Shouldice repair and perhaps the Desarda repair too, which the speed that Dr Kang does his KR surgeries may indicate, then it could be of huge benefit across the world, apart from to the mesh industry of course.

There appears to be some interest already from Dr
Lorenz and perhaps others in his circle. However, we all need @drkang to explain and publish all the details of his repair, as Professor Desarda did and the sooner the better so it can be peer reviewed and validated.

Here’s hoping this happens soon. 🤞

[Jack2021]

Hi William,

I remember reading the post/article you mention about the two farmers whose Desarda repairs recurred. I think it may be a post somewhere here on HT. If not on here, maybe it was patient info.

It was in reference to a surgeon in New Zealand (hence the sheep farmers!) and from memory, I think the person said that the surgeon had just those two recurrences from a large number of Desarda repairs. I’m not sure of the numbers but 300+ rings a bell.

I think it was part of a thread from someone looking for tissue repair in Australia, but I’m not 100% certain.

[Jack2021]

Hi Pinto,

I’ve read through the Kang Repair information on the Gibbeum Hospital website (http://gibbeum.com/whykr/Why-and-What-Kang-Repair.php) and in the ’Direct Closure’ section, it does actually state that ‘Kang repair for indirect hernia is similar to the one described by Dr. Marcy in the past, but modified to avoid the high recurrences.’

That is possibly the main source for Dr Towfigh referring to it as a modified Marcy repair, though from what he said in their Hernia Talk Live discussion on YouTube, Dr Lorenz seems to have further insight into the modifications.

With regard to a Marcy repair apparently having a higher risk of recurrence for men than for women, Dr Towfigh has previously mentioned the differences in anatomy in this area being a factor and perhaps the sentences I’ve pasted below from Dr Kang’s ‘Direct Closure’ section that follow on from what I pasted above, qualify, or at least allude to the higher risk for men.

@drtowfigh or @drkang, would need to give the expert medical perspective on this for clarity.

‘In fact, most of the internal inguinal ring is occupied by the spermatic cord which contains the testicular vessels, lymphatics and sensitive nerves. So it is very difficult to close the internal inguinal ring securely without damaging the aforementioned sensitive structures.’

I hope that the Kang repair will soon become more widespread, because if it really is as effective as the feedback on HT and explanations on the Gibbeum website, surely @drkang must urgently publish all the details of his Kang repair and share it globally as a priority, as Dr Desarda did with his repair, to encourage a reduction in the use of mesh and all its associated risks and to offer more choice to those wanting a non-mesh repair.

With @drkang’s repair apparently taking less than half the time vs other tissue repair methods, perhaps that may equate to a shorter teaching duration for other surgeons also.

If Dr Lorenz is correct in his statement about the Kang repair differing to Marcy purely in the way that the suturing is done, I like the idea of that.
I can imagine how Dr Kang would have taken significant time to work out how this would make an effective repair for adults vs the original Marcy method and to finesse his technique.

Despite it perhaps sounding a simple modification to the average layman, if it has groundbreaking results then it’s a huge discovery, regardless.

Keeping things simple and straightforward is often the best way to go in life, hence the KISS acronym commonly used by skilled tradespeople in the UK – keep it simple stupid!

Hopefully for all watchful waiters and future hernia affected people, @drkang will be forthcoming with sharing his technique in the very near future, perhaps starting with an interview on Hernia Talk Live with @drtowfigh. Come on, please get it organised!

[Jack2021]

I was disappointed that Dr Lorenz didn’t answer Dr Towfigh’s question about who did his Shouldice repair, just saying it was a friend.

It would have been helpful if Dr Towfigh had asked more about their repairs and why they chose Shouldice at the time. Did their respective bio-data dictate only Shouldice repair, as you say Pinto, or did they have their repairs before they knew much about the Desarda repair, was Dr Lorenz’s friend unable to do a Desarda repair and personally preferred the Shouldice option etc etc.

It was also very interesting to hear Dr Lorenz mention @drkang’s repair and explain how he believes it differs from its Marcy repair based origins.

@drkang, @drtowfigh mentioned the possibility of having you as a guest on Hernia Talk Live, to talk about your repair. I think that all forum members would welcome that.

[Jack2021]

I’ve just watched it too and agree this is definitely worth watching.

It was very interesting to hear Dr Towfigh say that Dr Lorenz had got her rethinking her perspective about the Desarda repair – “I need to go and visit Dr Desarda. You’re making me rethink my thoughts about it.”

[Jack2021]

Great, thanks Dr Towfigh.

[Jack2021]

Hi @drtowfigh,

Hope all’s good with you.

I missed this and it doesn’t appear to be on YouTube yet. Do you know when it will be available please?

Many thanks

[Jack2021]

Thanks for your posts Oceanic and for sharing your experience so openly, I really appreciate it.

I’m also UK based and posted about Dr Conze and the other surgeons in Germany, along with the very limited surgeon options in the UK early on in my research, probably a couple of years ago now. From speaking with them all apart from Dr Wiese, Dr Conze was my preferred option.

I’ve been watchful waiting since, so it’s great to hear about a first hand experience with Dr Conze. I just wish that he wasn’t more than double the price of the other German surgeons, but having worked with Dr Muschaweck in the past, they seem to share a similar price structure.

While it’s important to interrogate the data, there seems to be a lot of unnecessary arguing and overly critical hair-splitting pickiness on the Hernia Talk website these days, which I think will be putting people off from using/posting on the site, which is a shame, as it’s such a fantastic resource. I signposted someone to HT in the hope that they’d post about their tissue repair experience, but they said all the arguing put them off and declined to, so I’m glad you’ve posted your experience and look forward to further updates.

Wishing you a speedy recovery,

Jack