Jack
Forum Replies Created
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Also, it looks like they use robotic for “complex” inguinals (maybe these are recurrences with prior lap mesh?), but for primary inguinals, what some surgeons call “bread and butter”, they use straight sticks lapp techniques.
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Very sorry for your continued suffering from the surgery, heart goes out to you:(
Did you have tissue repair of bilateral inguinal hernias by this doctor?
Have you been able to talk with any other surgeon who can tell what went wrong?
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Congratulations on making a decision Mike, hats off to you for traveling to Korea for your health, and best wishes for a good operation and speedy recovery with Dr Kang.
I’m 50 and fit/active. I’m wary of mesh, like most on this board it seems, and have investigated Shouldice Hospital. My hernias are bilateral, which with Shouldice seems like a lot of cutting, and two chances at pain, that’s the only reason I’m considering getting it done laparoscopically.
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Good points Mike M, especially the walking on eggshells part.
Out of curiosity which type of procedure do you think you’ll get?
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I’ve seen a few docs say if it’s not bothering you you can wait. And Fitzgibbons has published studies showing strangulation risk is extremely low but most watchful waiting people eventually get the surgery as the hernia becomes more painful as the years go by. I’ve been very anxious, as I’m sure people on the board can relate, as there is a not trivial chance of pain or complications. I think I’m going to keep a journal of how it feels, ie how much it hurts or interferes and maybe that can guide me, rather than looking down and seeing the noticeable bump and assuming it needs to be fixed soon.
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Dr Chen was talking about with laparoscopic. My understanding is he uses progrip mesh which is self fixating so he doesn’t need to tack. But his message is don’t use too many tacks and the only truly safe place to put one is Coopers ligament. I think this is an area where best practices have improved with laparoscopic surgery, the good drs know now not to use several tacks all over the place.
I am curious about metal vs dissolvable tacks. Dr Towfigh, are you out there;)? Maybe people who use metal just do it because they’ve always done it? Or maybe there’s a better reason like it holds better? I think one of Dr Towfigh’s shows says she often doesn’t fixate but sometimes (big hernias or direct?) you have to in which case she uses metal. And then there is this other famous surgeon who says metal tacks should be taken off market. So I’m confused.
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I have not had any surgery yet
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This is such a great list, you really did your homework. Obviously only an issue for males, but is resecting the cremasteric muscle, per the Shouldice Hospital technique really a cause of sagging down there? I gather it’s done to give the surgeon a better view of other possible hernias. I wonder what the impact on patient is as it seems like many who modify the a Shouldice technique (like the surgeon you went to) leave this out.
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This seems like a logical way of looking at it. It does seem like pain can happen though with pure tissue. On Google there are some negative (from a pain perspective, who cares about the food) reviews of Shouldice as well as some of the “modified Shouldice” docs in the USA. I’m not a doc, so just a guess but maybe pain from a tissue repair comes from scar tissue hitting nerves? Or a nerve accidentally sutured? Or the “tension”. I do think the pain, based on a few reviews, can be more than just discomfort. And there’s the issue of there’s so few tissue repairs compared to mesh. If there were 800k tissue repairs every year in the USA there would probably be a lot of people online upset about them too?
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Yes I think you’re right Watchful, that Shouldice Hospital takes on bigger hernias, their main restriction I think is body mass.
And I’d be very interested what a top hernia surgeon achieves for chronic pain and other complications in his/her series. There’s a guy who seems very well respected, many of his lectures are on YouTube, named David Chen of UCLA and he says the goal of hernia surgeons should be to get recurrence and pain to .5%, because it can never be zero. But what does a doctor at his level actually achieve today? Does/can he even know given our multipayor health system where beyond the 2 week checkup most patients probably don’t report back to their surgeon?
People on this board, what does your mesh using surgeon say his/her pain rate is?
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I agree with MarkT’s comments. There are many studies that compare Shouldice to other repair procedures, but they don’t use cases performed by the Shouldice hospital, which has high volume and high quality control, and therefore the studies may be flawed. I think this is true for the meta studies Dr Hanniford cited on the recent Hernia Talk Live where he said mesh techniques performed better than Shouldice for pain. I wish Shouldice Hospital would publish (if they even have?) their own data on chronic pain, using what most researchers in the US deem pain, ie any pain more than three months post surgery. In another Hernia Talk live episode Dr Spencer of Shouldice Hospital says they are studying it and he thinks by the modern definition (ie inclusive of what doctors used to call post surgery discomfort and not only truly debilitating pain) he thought Shouldice’s pain rate was about 5 percent (which he suggested was better than mesh). There don’t seem to be good numbers. I do think the study from three countries in Europe in 2018 by Kockering and Koch that Good Intentions posted here is probably pretty good in that high number of cases, and probably many/most of the Shouldice cases performed in Germany where there are a handful of high volume Shouldice experts (including one of the two lead authors). And this study basically said in terms of pain and recurrence Shouldice and TAPP/TEP were equal. If that is true than Shouldice technique (for a person who qualifies based on bmi and size of defect) seems less about pain and more about eliminating the really awful (and probably low probability) mesh complications that require explant, ruin a patient’s quality of life.
Thoughts? Dr Towfigh? Would love to have doctors weigh in rather than us laypeople.
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Personally I think the other study that you linked to, published by Kockering and Koch in 2018 that compares Shouldice to other methods is more informative. It is a much larger sample size, was done at a time when laparoscopic was better known, and looks at patient populations on an apples to apples basis (ie similar age, bmi, etc).
I would be very curious what Dr Towfigh, an honest to goodness expert, thinks.
To a layman the studies, particularly the better one in 2018 show a) the results for Shouldice vs Tapp and Tep are not statistically different; b) ongoing pain can be an unfortunate side effect with Shouldice too, it is not a risk free operation either.
That said, you make a good point in other posts that Shouldice does not close a door, while the laparoscopic techniques do. And these studies are at only a 1-2 year follow-up. There doesn’t seem to be good data on how mesh ages over decades, people just say “surgical mesh has been used for decades” and leave it at that.
Any thoughts from our Moderator?
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Well, mesh methods are the established ones, that’s the reality in North America and Europe, mesh are the overwhelming majority of procedures. Personally I wish there was more choice and less of a “default” to mesh, but if you want good tissue repair it’s relatively few surgeons who really have the training and volumes to do it properly. Surgeons tend to be biased on which method is best, they all seem to feel their method is best even though most don’t seem to have a great insight into what their patient results are measured even a year post-op (at least not in the USA). That’s why I like this study, because it has real numbers.
Again, I think your point about Shouldice not closing a door is a really good one. I don’t think the risk of chronic pain with a Shouldice repair is zero. This study shows that and one of the authors when he was on Hernia Talk live said his pain rate with Shouldice (which is most of his practice) is 2 percent. That we don’t hear more about this could be due to the bad cases not being as horrific as the mesh bad cases. It’s also due to the fact that there are relatively few Shouldice operations performed a year. All that said, my gut tells me it’s maybe the better option. But I’m not sure it’s a slam dunk.
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If you’re talking about the last two statements in the “results” section of the abstract, those are comparing Shouldice to Lichtenstein. The results “did not identify any difference” between Shouldice vs TAP and vs TEP in terms of one year follow up outcomes.
Frankly I would have loved if Shouldice tested as much better than the laparoscopic techniques, that would make decisions about surgery for me personally much easier!
I think you make a good point about Shouldice not closing a door the way the mesh (especially Lap) techniques do, everyone says if something goes very wrong mesh removal is awful surgery.
I’m less suspicious of bias in a study like this. A Koch (who was interviewed on Hernia Talk Live) is one of the two lead authors and has most of his practice doing pure tissue repairs and speaks at Hernia conferences around the world (including one in Colorado this week) about Shouldice. I would not be surprised if hundreds of his personal cases were part of the Shouldice group data. The other lead author, Kockerling, looks like a laparoscopic/mesh surgeon.
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This is an interesting paper, because it’s a good sized sample and tries to look at “apples to apples” (ie patients with similar age and bmi and other characteristics) comparisons of Shouldice vs the various mesh methods. At least one of the paper’s authors is a high volume, expert Shouldice practitioner. My reading is that after one year the pain for Shouldice vs TEP or TAPP is not significantly different. Do you have a different read?