[Jack2021]

Great links to the video and comment Good intentions, thanks.

Here’s a link to the comment – https://www.deepdyve.com/lp/springer-journal/shouldice-hospital-comments-on-shouldice-standard-2020-review-of-JkkEjJj2yQ?key=springer

[Jack2021]

Hi Watchful,

Reassuring that the Shouldice hospital will listen to patient requests for specific surgeons, albeit without promising. I guess you’d have to be politely assertive on arrival that you’d only see whoever you’d enquired about. A longer the list of acceptable surgeons would hopefully raise the odds of getting one.

Thanks for reposting that link, I’d forgotten about that!

Also reassuring to hear about the Canada insurance study re accuracy of recurrence rates, as long as it was fully independent.

It seems to me that unless there’s an increased appetite within the sector to champion and independently monitor long-term hernia outcomes with the different tissue repairs and their modified versions and for individual surgeon results too, to account for varying degrees of skill and expertise, we’ll have to accept what’s most believably evidenced currently and hope we make the right choice.

As some of the doctors I’ve spoken to have told me, they can’t always guarantee their rates of pain and recurrence, because former patients aren’t always contactable, particularly over the long-term and if someone has a bad outcome, they may go to a different doctor, so the original surgeon never finds out that there was an issue. These unknowns may well be factored into success rates for many surgeons who keep their own records.

[Jack2021]

Personally, I’ve found the patient.info site to be a poor resource vs this site, so echoing the points above, credit to @drtowfigh. Please do keep this site going @drtowfigh, it’s such a great resource and hopefully more surgeons with an interest in hernias will join, as I think they too would get a lot out of it that could inform their own practice.

[Jack2021]

Re your point about not being able to select a surgeon at the Shouldice Hospital, Watchful, it would be interesting to know what the hospital’s response would be to an enquiry from a paying patient explaining that they’re travelling a long distance and would like to be treated by either a specific surgeon, or say one of a selection of two or three, if you knew all have great reviews.

Have you tried that to see what they say?

The other point to consider, as noted by one of the posters on the disappeared Mr Sea thread (apologies, I forgot who it was), is that Dr Netto from the Shouldice Hospital stated that their current stats for chronic pain may be significantly higher than stated at perhaps 5%+ and they need to look into this further, or something along those lines.

If correct, could their long term pain rates be linked to cutting the cremaster and nerves? The problem here is that we don’t have a long term study of chronic pain and recurrence of the original Shouldice vs the modified Shouldice (i.e. the version that doesn’t cut the cremaster and nerves and has 4 lines of permanent sutures) and we may never get one, certainly not in time for those of us currently watchful waiting.

I’ve not heard the actual quote from Dr Netto, but if it’s true that their pain stats aren’t accurate, why aren’t they accurate and does it therefore also raise some doubt about their stated recurrence stats too?

[Jack2021]

I agree and hopefully @drtowfigh will be able to have it reinstated.

I checked my history as well and it also said oops, this page is no longer available.

It was such an interesting and valuable thread, so fingers crossed it reappears soon.

If it helps @drtowfigh, Mr Sea started the thread with a write up of his experience with Dr Sbayi.

[Jack2021]

Dr Towfigh also offers a Shouldice repair, following the traditional method I believe, having recently watched her Hernia Talk with Dr Yunis from a couple of years ago, so another potential option for the US list. Please correct me if I’m wrong @drtowfigh.

If I decided to have a Shouldice repair and cost wasn’t an issue, I think I’d currently err towards Dr Joachim Conze in Germany and he uses 4 rows of permanent sutures. I thought Dr Andreas Koch came across well in the Hernia Talk with Dr Towfigh, so if he’d do 4 permanent rows instead of 2 perm/2 resorbable, then he seems a strong option too.

I’m based in the UK, so the distance may bias me somewhat, though I’d also prefer not to have the cremaster and nerves cut, ideally.

[Jack2021]

As Wim said, hep A and B are good to get and the sooner the better, as B can be 2-3 doses spaced apart. Can’t remember re A.

If you haven’t had a BCG jab (TB), then that’s advisable also, along with being up to date with covid and flu jabs.

Check with your GP to make sure you’re up to date with MMR and tetanus and also for costs as some jabs may be free on the NHS, such as hep A, dependent on the GP practice.

I’d ring around travel clinics as well to compare prices as they do vary.

[Jack2021]

Dr Joachim Conze of the Munich Hernia Centre offers a tailored approach based on ultrasounds he conducts himself and what is uncovered during surgery.

He specialises in Shouldice repairs and can do Desarda also.

He used to work with Dr Ulrike Muschaweck at the Munich Hernia centre, I believe, before taking over. Costs appear much higher than Biohernia, similar to Dr Muschaweck’s.

Seems very well renowned. According to the website, he’s Secretary General of the German Hernia Society and on the board of the European Hernia Society.

https://www.hernia-centre.com/medical-team/klaus-joachim-conze.html

[Jack2021]

Simon Bailey in the UK offers Shouldice repairs privately and has done for many years, albeit it isn’t his main specialism.

A google will find his details.

[Jack2021]

Mr Duncan Light, UK NHS, offers Desarda repairs when requested, albeit mainly specialises in lap mesh surgery.

He’s listed on the Desarda website as a surgeon offering the Desarda repair as are many other surgeons from around the world and a google will no doubt bring up additional contact info.

[Jack2021]

Dr Ulrike Muschaweck can be contacted separately also and a quick google will locate contact details.

Dr Muschaweck is well known internationally for treating famous football (soccer) players and is apparently in her 70’s now.

[Jack2021]

Biohernia mainly offer treatment by Dr. Andreas Koch in Cottbus and Dr. Martin Wiese in Frankfurt (both in Germany)

[Jack2021]

Many thanks for your reply to my questions Ezzy, much appreciated!

[Jack2021]

Hi Ezzy,

Thanks for sharing and great to hear you’ve had a positive outcome.

Would you be happy to share:
– Where you had your surgery, who the surgeon was and what the costs were?

– Did you have surgery under general or local anaesthetic and if local, were you awake or heavily sedated?

– Were the sutures used for your repair absorbable or permanent non-absorbable?

– Was it a large hernia?

– You mention it took 6 months to get back to normal activities, so how soon after surgery were you mobile and able to walk around?

– Regarding the 6 months it took for you to get back to normal activities, so other forum members might measure against their own usual activities, what do you class as normal activities?

Many thanks,

Jack

[Jack2021]

Happy New Year @DrTowfigh.

And a Happy New Year to everyone who posts on here.

I really appreciate this forum, I think it’s really important for those of us who want/need to debate, enquire and learn more about all things hernia related.

All the best for 2022 everyone.

[Jack2021]

I agree with your points about UK non-mesh expertise and there actually seems to be very limited specialist non-mesh hernia repair expertise worldwide, sadly.

Re Peter Jones, I tried to contact him, but was unable to, which led me to Simon Bailly, who I believe trained under him, but I’m not 100% on that. I’ve spoken with his secretary, but she knew nothing at all about his non-mesh repairs, other than he does offer them.

I think I was diagnosed around 6 months ago and knew about it a week or so before.

I’m not medically trained, but I think it’s pretty common for the right testicle to hang lower than the left and vice-versa. If it’s not causing any problems or discomfort and they both lift when you tense them, then I probably wouldn’t be overly concerned.

I agree it can be depressing to contemplate the risks of surgery, long term chronic pain and possible recurrence.

Re your possible allergies, you could look into getting hold of some Prolene and taping it to the inside of your forearm for a patch test perhaps. Maybe I should do that too actually! I have a possible nickel or zinc allergy, but I’m not sure which, but that would put me of metal sutures. Again, patch tests could help with that, but obviously it’d still be different when used internally during surgery.

Interesting to hear that your doctor has organised an ultrasound. Is that your GP? My GP’s only prescribe watchful waiting, unless they deem it urgent, by which time there’s a 6-12 month waiting list! Consultants in the UK that I’ve spoken with don’t appear to value doing one, certainly not at consultation stage anyway, but it seems to form a fundamental part of the process in Germany and with Dr Kang. In Germany, the doctors seem to do the ultrasound themselves.

Id be interested to know what the outcome of your ultrasound is if you’d be happy to share?

When you’re frantically researching all this soon after diagnosis, as I did, it’s easy to muddle things up and become overwhelmed with it all. It may not work for you, or you may already be doing it, but I’d recommend making notes re all the key things you want to remember and questions you’d like to ask a consultant when you contact them.

You’re probably already doing this, but I’d also suggest listing each consultant you’re looking into and detailing everything you find out about their approach, so you have a good reference point for all your research, which may influence your decisions. I can’t say I’ve done it perfectly and I’ve updated my questions and notes as I’ve gone along and learned more. I’ve also detailed all the answers I’ve had from speaking with various consultants across the UK and Germany.

It would be easier if we were able to speak to each other, but I don’t think you can send private messages or exchange contact details through this forum.

Failing that, it may not work for you, but I’d recommend blitzing your research, speak to/email some/all of the consultants you’re considering, make your notes and then step away from all this for a bit to come up for air and take a break from it all. Then reflect on everything and see how you feel and what you think then. It may not change anything, but you’ll be more informed and hopefully have a better idea of what you may wish to do and if it’s to go ahead with the operation sooner rather than later, who with. My thinking about consultants has changed throughout my research.

For most of my research re the non-mesh approaches and the non-mesh vs mesh techniques, I used the renowned Cochrane Library website, so I’ve done research on mesh approaches too. I definitely want a non-mesh repair.

Following my research, the options for me are:
1. Watchful waiting, for which there are a growing number of strong arguments. Until this was properly explained to me by a consultant, I thought the sooner I got the operation done the better and thought of it purely as a cost saving initiative in the NHS, but now I realise that’s not the case.

2. Get the operation done asap using a non-mesh technique, so Shouldice, Desarda or Kang appear to be the best options.

Shouldice has the most evidence to support the technique’s success, though consultants seem to have their own variations – which is best? Some of my reading indicates it’s the most invasive/substantial of the non-mesh surgeries. I don’t have a record of where I read this, but it’s in my notes and I think that Dr Kang’s notes on his hospital website states this also.

Desarda has less evidence, but what there is appears to put it on a level with Shouldice, perhaps even edging it somewhat overall.

The Kang repair doesn’t appear to have any published research papers yet to back up all the claims, which do sound excellent. Playing ‘devil’s advocate’ and not meaning to denigrate anything anyone’s said in this forum, in this day and age, can all positive claims and reviews we read online be trusted 100%, particularly when we’re very vulnerable as we search for the perfect fix for our hernia?

Although the Kang repair sounds potentially the best and most minimally invasive repair, with the most attention to detail re its variation in treatment dependent on direct or indirect hernias, some of the recurrence stats quoted appear to vary slightly on different websites (along the lines of 0.16% – 0.88% for recurrence rates, which there could be a justifiable reason for) though they’re still all under 1%, which is extremely low. Kang repairs may be the way forward, though I’d really like to see published research ASAP to evidence it, or not, before I’d consider booking a long haul return for the operation.

Watchful waiting has its appeal!

[Jack2021]

I agree with you Alephy. I stopped all lifting and strenuous activity to begin with, but began to build back up slowly and once told by consultants not to restrict myself, I’ve gone back to normal, more or less.

It makes sense that there’s more discomfort towards the end of the day. Before I lost weight, I would get slight discomfort after sitting upright while working all day.

[Jack2021]

And the Desarda repair is a third option to consider as well isn’t it?

I might be wrong, but I think Pinto may have been referring to Scarletville from the UK, who recently posted about his experience in Germany with regard to ‘local anaesthesia and conscious sedation’ – https://herniatalk.com/forums/topic/german-covid-19-restrictions/

Although not mentioned in that post, I believe Scarletville’s operation was possibly carried out by Dr Ralph Lorenz, one of the German doctors I mentioned to you in another post, William. Dr Lorenz is a member of the European Hernia Society Board and he offers both a modified Shouldice repair or a Desarda repair for his tissue based repairs.

Here’s the set of posts where Scarletville talks about booking in with Dr Lorenz. https://herniatalk.com/forums/topic/dr-js-own-hernia/

I’ve messaged @scarletville to ask if it was Dr Lorenz he saw and how his recovery is going, but he hasn’t replied as yet, but hopefully he will soon.

What do others think about the Desarda repair, as there is an option for this in the UK (and I don’t mean with the consultant in London who in the end referred Scarletville to Dr Lorenz)?

I know there are posts here on HerniaTalk that list issues for some and positives for others re a consultant in the US, but all other research and meta studies I’ve seen, appear to be very favourable with results seemingly on a par with the Shouldice repair.

My experience from contacting a number of consultants across the UK and Germany is that they all know each other pretty well. Some mentioned that the hernia specialist community is relatively small, which is perhaps a concern considering the number of repairs carried out worldwide.

German COVID-19 Restrictions

[Jack2021]

Hi William,

I’ve spoken with two hernia specialists who are/were on the European Hernia Society Board and they said you don’t need to do anything differently or stop doing anything when you have an inguinal hernia, unless it causes you pain/discomfort and that includes lifting, running etc etc.

I haven’t taken that literally as I’d rather not risk it and I believe that heavy lifting while reaching and/or turning is perhaps more likely to be an issue, but that’s my personal opinion.

I go for 3 – 4 mile walks regularly and have done short sprints here and there to test it and have had no ill effects from that.

As I mentioned in my reply to you in the other post (I’ll respond to your reply there asap also), the biggest improvement for me was losing some weight. I’m reasonably slim anyway, but as much as I don’t like to acknowledge it and most people wouldn’t have noticed, I had a bit of a belly.

Losing weight stopped all the discomfort I was experiencing, although it was very minimal and it’s put a bigger spring in my step generally too. Subject to your size, that may be worth considering.

Cheers,

Jack

[Jack2021]

Hi William,

I’m in the UK with a right sided hernia also. I’ve been told mine is inguinal but from my experience, they don’t appear to do ultrasounds as standard here (I was told it wasn’t necessary) so little attention is paid to whether a hernia is direct or indirect. I’d be interested to hear if your experience is different?

Femoral hernias seem to be rarer for men and more common for women, so inguinal hernias are much more common for men. It’s hard to describe and I’m not medically trained, but from my reading, if it appears to be a round lump, that more likely indicates a direct hernia and if the swelling is more diagonal following the line of your groin crease where it meets your thigh, that more likely indicates an indirect hernia. I don’t think this is necessarily guaranteed to be correct, but gives a general indication. There are doctors on here that could no doubt answer this more specifically.

There don’t seem to be many hernia only specialists in the uk and none solely practising non-mesh repairs that I can find. If you come across any more from the ones I mention below or in my other posts, please let me know.

Although I already had a healthy BMI, I managed to lose 7kg quite quickly since diagnosis and it’s definitely had a positive impact regarding pain and urination. I think it’s due to reduced pressure in the stomach area. I didn’t have chronic pain, more occasional dull aches really, but I don’t tend to get that now really. To lose weight, I maintained a healthy diet with plenty of fruit and veg and literally just cut portion sizes down, particularly in the evening and I try to eat my meals within an 8 (ideally) to 10 hour window now. It may not be helpful for everyone but has worked for me and I feel better generally for it.

Waiting is an option. Apparently the risk of hernia incarceration is extremely low to start with if you have a relatively small hernia, though the risk will increase over the years. From my research, some consultants say that if your hernia isn’t significantly impacting physically on your life, then you should consider waiting until it does, rather than having surgery immediately. This is because of the possible, albeit apparently rare risks of surgery complications and also the possibility of long term pain afterwards. Other consultants say that if you have a visible bulge, then it should be operated on, as it will get worse over time and could make the inevitable operation more complicated.

It’s a minefield with many subjective opinions and studies which offer evidence to support both mesh and non-mesh repairs and there are many people who’ve unfortunately had terrible experiences and long term negative outcomes. What most consultants appear to agree on, perhaps not all, is that nobody knows for sure about the possible risks of mesh implantation in the long term.

Meshes are made from different materials, some of which degrade (polyester) and they can move, crease and fold causing complications, more so as they become populated by natural tissue that grows through them over time, making removal complicated. They can be removed but not all surgeons offer the procedure, including those who implant them! Most consultants seem to say that issues with mesh are generally down to the surgeon who implanted them, such as the wrong size mesh was used or it was situated incorrectly and many (perhaps most or all in the UK) surgeons are no longer even taught how to do a non-mesh hernia repair. Mesh is big business for the companies that supply it too.

There are a small number of people who will have a poor reaction to the mesh itself, regardless of how well it is implanted.

You can have a mesh repair if you have a recurrence after non-mesh repair, but it is less likely that you could have a tissue repair following a mesh repair failing.

Unfortunately, despite being classed as major surgery, in the UK at least, hernia’s are seen as an unspecialised operation that all general surgeons can undertake and inexperienced junior surgeons are commonly given them to do for practice.

After reading many studies and meta-studies, my preference is definitely to have a non-mesh repair, either a modified Shouldice repair or a Desarda repair. I’m unsure if one has a benefit over the other. Both leave permanent sutures internally (commonly Prolene which fishing line effectively, but always ask the consultant what they use), but that’s unavoidable and dissolvable sutures appear to dramatically increase the risk of recurrence. There are arguments for both techniques and the Shouldice/modified Shouldice methods are the oldest and most commonly practiced of the two. From my research, both seem to offer similar and sometimes better recurrence rates to mesh repairs, without the added risks from mesh. The key to success with both and no doubt all surgeries, is likely an excellent and well practiced surgeon.

Mesh removal as a specialism appears to be a growing sector, which for me is an added indication that mesh is something I’d rather avoid if possible.

Who was it in the UK that you enquired about non-mesh surgery with that mentioned cutting the nerves?

Ulrike Muschawek who is well known across Europe travels from Germany to London to operate quite regularly I believe (pandemic allowing) through Biohernia and other places which will come up on a google search. She specialises in a modified Shouldice repair and apparently cuts some of the nerves, which is standard from the original Shouldice procedure but argued by some as being unnecessary and detrimental. She’s best known for sports hernia repairs (unrelated to inguinal hernias and is a more minor surgery I believe) and has operated on a few top Premier League footballers in the past. There are some negative reviews around though (but perhaps it’s the same with all surgeons) regarding hernia repairs, including on this forum, related to long term post-op chronic pain. At around £6,500 for a one-side repair, she’s not cheap. I heard that she’s about 70 now, though I couldn’t confirm that. If you have private medical insurance, there aren’t many that she’s registered with and you can’t see her through the NHS.

There are other renowned hernia specialists in Germany, such as Joachim Conze (formerly a business partner of Muschaweck, but they’re not connected anymore) who heads up the Hernia Centre in Munich, Ralph Lorenz of the Hernia Centre in Berlin and Andreas Koch who’s based in Cottbus. There’s a Dr Wiese in Berlin too and there may well be more. Costs are in the region of £2500 – £6,000 for them including accommodation for 2-4 nights.

I don’t think these surgeons cut the nerves or cremaster muscle (Conze doesn’t), but you’d need to check if you contact them. I’d like a surgeon who doesn’t cut them as I’ve not found enough evidence to suggest it’s beneficial and it can seemingly be a cause of long term chronic pain.

I’m also unaware if these surgeons offer the two modified Shouldice/Bassini approaches dependent on direct vs indirect hernias, as Dr Kang does, but I think they all do ultrasounds and tailor their approach subject to what they find during the operation.

Dr Kang’s work looks very interesting too. My concern with having surgery outside the UK is follow ups, both general and also if I were to experience any ongoing issues that might need investigation by the surgeon.

There are some surgeons performing non-mesh surgeries in the UK and if you check some of my earlier posts, you’ll see more of them listed, but they don’t appear to offer non-mesh repairs as a rule. Simon Bailly offers a modified Shouldice, though I think I read somewhere that he uses absorbable sutures, but that may be incorrect. He also offers mesh repairs too and a number of other surgeries. Duncan Light (Education Secretary of the UK Hernia Society) offers the Desarda repair if non-mesh surgery is requested, as well as laparoscopic mesh repairs. He’s NHS only, so you can ask your GP for a referral at no cost.

That’s everything I’ve found so far and I hope it’s helpful for you. Please let me know if you find anything else.

All the best