[Jack2021]

As lasted from Wikipedia, ‘the cremaster muscle is a thin layer of striated muscle found in the inguinal canal and scrotum between the external and internal layers of spermatic fascia, surrounding the testis and spermatic cord. The cremaster muscle is a paired structure, there being one on each side of the body.’

It’s basically the muscle which causes testicles to retract, so without it, testicles would be swinging around your legs all the time and wouldn’t have their heated regulated for better sperm production etc.

My understanding is that the Shouldice Hospital do cut some of the nerves and the cremaster muscle, which I think they reposition, but Dr Kang doesn’t. A quick google will get you the minutiae.

From my research, ‘if it ain’t broke don’t fix it’ seems to be the best approach to hernia repairs, so personally, I’d prefer a surgeon who leaves the nerves and cremaster muscle alone.

[Jack2021]

It may have changed, but my understanding is that costs are somewhere in the region of £6,500 or so for a single primary hernia repair including consultations with Dr Muschaweck.

I also understand that Dr Conze locates and isolates the nerves during a primary surgery so as not to damage them, but I don’t know how this is done. He also does not cut the cremaster muscle, as per the original Shouldice technique and like Dr Muschaweck, has his own adapted Shouldice method.

[Jack2021]

Thanks for the details. Going from your previous posts, was this with a Desarda repair done in Germany?

How is your recovery so far?

Thanks

[Jack2021]

This study from Turkey in 2008 (including suture images) shows excellent results from a Comparison of Modified Darn Repair and Lichtenstein Repair of Primary Inguinal Hernias, with no recurrences in the darn group over an average follow up time of 56 months, vs 0.6% recurrences in the Lichtenstein group. Post-op complications were 1.9% (darn group) vs 11.7% (mesh group).

What isn’t clear unfortunately, is what the modification is to the darn repair:

https://www.sciencedirect.com/science/article/abs/pii/S0022480407004313?casa_token=3xeOqa-plrgAAAAA:w8tRJejpmV48pZtfvBkdlIcArO2LpVrfS7th3xZ0v-6b7oIDWNcGH3QlH5rN651omlzhchk

[Jack2021]

Many thanks for your reply @drtowfigh, I very much appreciate it.

From the Moloney Darn reports and meta-studies I’ve read, as you say, the majority of more recent studies do tend to be in developing countries, but they do appear to evidence very low recurrence rates and chronic pain rates that are at least on a par with the Shouldice and Lichtenstein repairs.

My understanding from the Moloney Darn repair is that the method specifically aims to minimise tension by not fully tightening the sutures, though it obviously does involve multiple suture points.

I’m finding it very difficult to decide whether to go with ‘watchful waiting’, a Moloney Darn repair in the UK or a Shouldice or Desarda repair in Germany. I appear to be eligible for each option currently according to consultants, as I have a low BMI and am in good shape otherwise. If I went for a non-mesh surgery and each option is available to me, would you recommend one option over the others @drtowfigh and if so, why?

Any thoughts and suggestions from other members would be much appreciated also.

Thanks in advance,

?Jack

[Jack2021]

Hi Jake. I did speak to his secretary, who was very nice but didn’t really know anything about his non-mesh hernia repairs, other than he does do them. I haven’t emailed for further details as I’m currently researching the lesser known Moloney Darn technique and am hoping to hear more about it vs Shouldice and Desarda repairs, from the doctors who kindly reply to some of the posts on here. You can read this other post in the list on the forum homepage.

If you do email Simon Bailly, it would be worth asking:
– How many of these Shouldice repairs does he do each year and is it the same repair as per the Shouldice hospital, or a variation of that?
– Would he recommend this repair over a mesh repair?
– What are his recurrence and long term pain rates and over what timescale are these are based on?
– Does he use permanent or absorbable sutures? I vaguely remember someone mentioning he uses absorbable, though I may he confusing him with someone else. Absorbable sutures tend to be linked with higher rates of recurrence in non-mesh repairs apparently.
– Does he cut the genital nerve and cut/reposition the cremaster muscle, as per the original Shouldice technique? This is apparently done to reduce the risk of recurrence, but appears to be contentious in the opinion of some doctors.

Please do let me know how you get on.

Many thanks,

Jack.

[Jack2021]

Thanks for your reply Good intentions, it’s a very valid point with big businesses so involved in medical supplies and pharmaceuticals.

Re the Moloney darn and other variants of the darn repair technique, they’re clearly more cost effective than a mesh repair, as long as the recurrence rates are pretty equal. If they are as effective or more so than mesh repairs and also carry less risks than those associated with mesh repairs, then surely some reflection by the health care sector is required here.

As we know, the non-mesh techniques which seem to be most effective still leave permanent sutures behind, so there doesn’t appear to be a long term effective repair which leaves no form of foreign body in the patient. Leading on from this, I read a paper by G.E. Moloney from 1961, which came up among the links from the link you kindly posted for me Good intentions, in which Moloney talks about his findings that nylon suture tensile strength reduces significantly after a short period of time (along with its colour and sheen as well!) after being used for hernia repairs. It’s an interesting and concerning article, but I would hope that this has been addressed by now, as it would surely play a big factor in hernia recurrences over time if sutures eventually break under minimal pressure? https://bjssjournals.onlinelibrary.wiley.com/doi/abs/10.1002/bjs.18004821114

It would be great to hear the thoughts of @drtowfigh, @drbrown, @drkang and any of the other doctors/consultants who are members of this forum, regarding suture strength over time and about the Moloney Darn technique, re whether they know or believe it to be an effective method to repair hernias vs the Shouldice, Desarda and Kang techniques.

Many thanks,

Jack

[Jack2021]

Hi Good intentions,

Thanks so much for your reply, much appreciated. I looked on the Cochrane library and found very little.

From your link, assuming that Open Darn Repair and Moloney darn repair are the same technique(???), the meta-analysis from this link (https://link.springer.com/article/10.1007%2Fs10029-019-01892-1) titled ‘Open darn repair vs open mesh repair of inguinal hernia: a systematic review and meta-analysis of randomised and non-randomised studies’ which appears to be based on over 3,000 patients concludes: ‘Our results suggest that open darn repair is comparable with open mesh repair for inguinal hernias. Considering that consequences of mesh complications in inguinal hernia repair, albeit rare, can be significant, open darn repair provides an equally credible alternative to open mesh repair for inguinal hernias. Further studies are required to investigate patient-reported outcomes and to elicit a superior non-mesh technique.’

A link to a Lancet article in 1958 (https://www.sciencedirect.com/science/article/abs/pii/S0140673658910274) states that ‘A personal series of 253 inguinal hernias repaired with
a nylon darn and surveyed more than 5 years after the last operation, with a 76% follow-up, revealed 2 recur-
rences (0.8%).’

I haven’t accessed the full article, as have to pay $35 for it, but this sounds promising!

If it was so effective though, I wonder why it seems to have almost entirely disappeared as a regular option for hernia repair, especially as it would appear to be the most cost effective too.

It would be great to have some insight from the esteemed doctors/consultants/surgeons who frequent this forum, to hear your thoughts and knowledge around this please.

Many thanks,
?Jack?

[Jack2021]

HI Bust3r,
Apologies for the delayed reply. I drafted a long response the other day, but was timed out when I tried to submit it and haven’t had a chance to try again since.

Thanks for your reply, are you in a similar position and looking for a non-mesh repair in the UK?

Re the names you’ve kindly listed:

Emin Carapeti – I ruled out this consultant, rightly or wrongly, due to there being little mention of a specialist interest in hernia repair on the websites he was listed on that I saw. The mention of his having attended the Shouldice hospital didn’t state any training in the technique.
Greg Sadler – oxford hernia clinic – I had’t come across this consultant before and having looked at the website, it appears to advocate mesh repairs.
London Hernia (Largely this is mesh though I think Martin Kurzer may do Desarda or at least a different kind of mesh). – Mr Kurzer kindly exchanged emails with me and has done Desarda repairs, though very few (he was one of the consultants I alluded to in my original post) and he’s an advocate of mesh repairs mainly.
David Nott – I haven’t found much re this consultant, so would need to find more info, though I couldn’t find any details online from an initial search.
Simon Marsh – I’ve not found anything online re this consultant that mentions him doing non-mesh repairs, though that may not be the case.
Aali Sheen – Professor Sheen comes across as a really nice guy and usually offers non-mesh repairs to under 30’s only. He mainly specialises in laparoscopic mesh repairs for older patients.
Simon Bailey – funnily enough I’d found info re Peter Jones before I saw info re Simon Bailey, but I believe Peter retired a while ago now and I was unable to get a response from contact details I found online.

The NHS only consultant who can perform the Desarda repair, is called Duncan Light. He kindly exchanged emails with me and came across very well I thought.

[Jack2021]

Sorry to hear you’ve had a poor follow up experience Pinto. I think the point you raise is a good one, as most people would assume that was a given. I’ll be adding it to my list of questions.

Are you happy to share which country you had/are having this experience in?

[Jack2021]

Hi Scarletville,

I’ve recently joined the forum and not had a chance to search through it fully yet, but like you, I’m UK based and hoping to find a top surgeon who’s experienced in performing non-mesh repairs, in my case, for an inguinal hernia.

Like you, I’ve found details of surgeons in Germany – Dr Ralph Lorenz, Dr Ukrike Muschaweck (who’s operated on many top Premier League footballers), Dr Joachim Conze (who took over from Dr Muschaweck at the Hernia Centre, Munich), Dr Andreas Koch and Dr. Martin Wiese (through Biohernia). Dr Muschaweck ran a UK clinic every month before the pandemic, but isn’t at the moment unfortunately. Her costs seem to be around two and a half to three times more than the others. I know that some of them offer a tailored approach and choose the type of repair during the operation, which I can see the benefits of doing, but I’d like to know for sure that I’d be receiving a tissue repair, rather than find out afterwards that they’d decided to use mesh.

With the pandemic and associated travel issues, plus concerns about follow up appointments, I’m hoping to find a consultant in the UK, though it seems there aren’t many who offer tissue repairs for people over 30, as I’ve only found four so far, despite fairly extensive research. I’ve found some very high profile consultants who’ve operated on numerous elite athletes across a range of sports, but they all seem to use mesh for hernia surgeries.

Of the four I’ve found, from my understanding:
– Simon Bailly apparently practices the Shouldice technique, though I’ve been unable to find out whether he follows the exact same method/a variation, or any information on recurrence rates. I’m going to try and contact him for more information.

– Professor Ernest Schilders, apparently offers a laparoscopic tissue repair. I’ve not come across any research on this technique, so haven’t looked into it further.

– The other two consultants offer Desarda repairs, though both have only done about 10 Desarda procedures each (no recurrences that they’re aware of) and tend to do mesh repairs usually. One of them advocated mesh repairs when I contacted him, though the other said he felt that the Desarda repair was a good equivalent and I felt that he came across very well, so I’m hoping to get a referral to meet him, as he only works through the NHS currently.

I’m guessing with you booking to go to Germany, you weren’t able to find anyone in the UK, or was it more that you weren’t able to find any advocates for non-mesh repairs in the UK who have the experience you’re looking for in performing tissue based repairs?

I’d be grateful for any further information that you or any other members might be able to share about UK consultants offering non-mesh repairs. I’m also very keen to know more about the Desarda technique and how effective it is. I’ve read a number of studies and meta-studies, mainly from Africa/Asia, which appear to evidence excellent outcomes.

Obviously there are numerous studies which advocate mesh repairs, so I’m finding it tricky to evaluate everything I’ve read. Having said that, I’m very clear that I’d prefer to have a non-mesh repair and I want to be confident that the surgeon I choose has an excellent record of successful long-term outcomes.

I may try and post a new thread as well, just in case other people miss this.

Many thanks in advance for any information you or any other members can provide.

Jack