[John Fortem]

quote Km8888:

Yup, same side. My brother also had a hernia operation on the right side as an infant.
I also remember having “episodes” of strong, sharp pain in the right lower groin area while playing soccer as a kid (ages 7-12) that would go away in 2-5 minutes, similar to cramps, but always on the right side. Those went away during my teenage years. I don’t know if it was gaining weight, or not playing soccer as often after I moved to the US.

I lost a lot of weight over the last year and significantly increased my physical activity, including doing squats with weight at the gym, and squat-jumps without weights on my lunch breaks.
I believe this is what put me over the edge and brought back the hernia, or worsened it to where I now have symptoms and a bulge I can feel whenever I stand for more than 30 seconds.

I have a consultation scheduled for August 20th with Dr. Brown, who I now see actually posts on this forum, so hopefully sometime soon I can get the hernia repaired without mesh and it’s associated side-effects and dangers.

That’s interesting. My brother also had a hernia, also on the right side. Yeah, I know I also gained some excess belly fat in my early 20s. As I recall I was 23 when I got my hernia. I used to train and compete in athletics from when I was 14 years old up until I was 19 years old. So I was definitely less physically active in the years that preceded my hernia formation.

Although, according to some studies the risk of developing a hernia is higher in people who are physically active such as athletes than in sedentary and obese people. They suggest that the fat somewhat acts as padding that suppresses herniation. I’m not sure what to make of that… but I am pretty sure that if athletes are more likely to develop a hernia then it is not because they lift heavy weights, but because they have poor form and body mechanics. It is a common misconception, almost a universal one, that hernias form by lifting heavy weights. That’s a myth! The best recipe for hernia formation is asymmetric overload in the lower abdomen/groin area, especially in a person who already has a weakness there from birth.

I have read great things about Dr. Brown. I think he is one of few surgeons in the US who does mesh free repairs. It’s a smart move finding a surgeon that fits your criteria and not prolonging the inevitable, you should not wait any more than you have to, especially if you already have bad symptoms from your hernia. I wish you good luck with everything and I hope you will get well soon!

[John Fortem]

quote Km8888:

Interesting… I’ve always been able to clench like I’m performing a kegel, and have my right testicle ascend upwards. Now I have a right inguinal hernia.

On the same side, right? This is a sign of weakness, and it’s likely that you were born this way, with inguinal ring not properly closed off. And as we age, the risk of developing a hernia in this area only grows bigger. Especially if you are not even aware of your weakness.

I am convinced that doing certain exercises can aggravate the already weakened tissue and cause a hernia. I know what finally caused my tissue to give in and cause a bulge (which I later learned is called a hernia). I was doing an asymmetrical stretch of my abdomen and legs. At one point I just felt instant pain in the right side of my groin, it felt like a tear, like quickly pulling up a zipper. I could instantly see and feel a small bulge, less than an inch in diameter underneath the skin. It was painful in the beginning, as the hole was still small and the pressure was high. I asked Dr. Google what it was, and that’s when I learned it’s a hernia. I never went to a doctor for this until later in life when I decided to take care of it. Like most men I presume, I didn’t feel comfortable having a doctor examine my junk. I just dealt with it on my own for about 8 years. I had it repaired 2 months ago, without a mesh and without cutting the cremaster muscle.

If you have a hernia, I would recommend having it repaired. Don’t play the waiting game, even if it’s asymptomatic. You will have to do it sooner or later, and sooner is much better. Just make sure you do it as naturally as possible for best possible outcome. First and foremost, that means doing it without a mesh, at the hands of an highly experienced surgeon.

[John Fortem]

quote kaspa:

About your aggressiveness to me, it seems inadequate to the forum, so any dialogue is finished now.

I am not being aggressive, I just don’t agree with you.

quote kaspa:

I don’t mean people who drive Rolls, of course (I thought that was clear). I mean people who plan and build a Rolls Royce.

I can see that now. I’m sorry, but English is not my first language.

quote kaspa:

I’m talking about engineering. What it has to do with hernia surgery? Well, I wouldn’t like an engineer to repair my hernia. I’m talking about perfectionism and yes here they share that with people from Shouldice Clinic.

And “here” is?… at the Rolls Royce factory? UK?

quote kaspa:

Shouldice Clinic is a reference in inguinal hernia. They’re a highly trained team who only do that and they’re as paranoid as people in Rolls Royce. So, one single doctor, however good he or she can be, will have a hard time formulating a sound argument they’re wrong. If they say something is important, chances are more than 99% it is.

And “they” refers to Shouldice Clinic…

So let me get this straight…

1. You equate Shouldice Clinic (surgeons!) to Rolls Royce (engineers!). (You made that comparison, not me. I never suggested you would want an engineer to repair your hernia, I thought you were talking about car drivers, not car engineers.)

2. You like Rolls Royce for its perfectionism. Therefore, you align your preference in surgeons to your car/engineering preference. (Shoot for the stars! I get that, and I don’t blame you for wanting the best.)

I can finally see what Rolls Royce has to do with hernia surgery. Perfectionism! Like I said, I don’t blame you for wanting the best. But don’t ask me to agree that Shouldice Clinic is the best. Especially not on the basis of one single patient report of bad outcome and at the expense of one surgeon’s private clinic. And we have not even filled in the missing details of this patient report, or heard the other party (surgeon).

By the way, I don’t think that Audi engineers are any less of perfectionists than Rolls Royce engineers. If we are going to compare things, then we should make sure to compare apples to apples and oranges to oranges. Both groups are perfectionists, simply because they are engineers. It’s in their nature. In order to become an engineer you have to be more interested in things, and less interested in people. In order to become a doctor (of medicine), you have to be more interested in people than things. And I don’t think Dr. Koch is any less competent, any less skillful or any less interested in people than any one of the surgeons that work at the Shouldice Clinic. I don’t understand why someone would even question that. Based on a single case report?

Why do we even trust the Shouldice Clinic so much? Are they really above everyone else? Are they really the top authority when it comes to hernia surgery?

quote kaspa:

So, one single doctor, however good he or she can be, will have a hard time formulating a sound argument they’re wrong. If they say something is important, chances are more than 99% it is.

You have to understand that Dr. Koch clinic is not a one-man shop. You can’t do surgery without a team of people. I don’t think he is any less of a perfectionist than the surgeons who work at the Shouldice Clinic.

I think the Shouldice Clinic is a good option for people who live close to it or who can afford the treatment at this clinic. Not many people do. But honestly, I think the Shouldice Clinic is glorified too much. That’s not without reason of course. It has played an important roll in pushing back against the “mesh empire”. It is still influential that way.

The name “Shouldice” is one of the main selling points for the Shouldice Clinic, along with its low recurrence rate. To the point that people avoid other clinics unless they use the “original” Shouldice technique. But remember, Shouldice would be nothing without Bassini. Which serves as an excellent example of that single doctor who went against the establishment at the time and paved the way for what later became known as the Shouldice technique, and fast forward a few years and you have the Shouldice Clinic. Was Bassini wrong?… did he make a sound argument for his technique? Why didn’t other surgeons pick it up until after his death?

quote kaspa:

You’re happy with your repair, and I appreciate that. But many people here are still making decisions.

I understand that. But suggesting that the outcome is much better if they receive the original Shouldice treatment at the Shouldice Clinic is not doing them a favor. So what? We should all travel to Canada and have it done at the Shouldice Clinic? That’s just silly, and not everyone will be able to afford that, and even if they did, it does not guarantee a positive outcome. There are no guarantees in surgery. At best there are some statistics and there is probability. Let me know when the recurrence rate at the Shouldice Clinic drops down to 0%.

quote kaspa:

It seems clear that Baris case was perhaps complex (not that sure), but it’s a surgeon’s task to explain that to patient (before surgery) and even reject it if they feel incapable to repair it. I’m sure surgeon already had a lot of info from Baris even before they met.

We still don’t have all the details, and if you want to be the judge you better gather as many details as possible, and you have to hear out both parties.

A surgeon cannot know what the eye can’t see, and neither does the patient. Some things are only understood in the middle of a process as you are doing it. Which is why my brother and Dr. Koch agreed to decide on surgical technique and suture material intraoperatively. Yes, my brother had his hernia repaired by Dr. Koch as well, and his hernia went all the way down to scrotum, but he is fine now.

quote kaspa:

No one feels much comfortable about Baris case, as you can understand. For people who are deciding, all experiences are worth the same, and it’s good yours is positive.

Agreed! But they should be uncomfortable for the right reasons. Not that I want them to feel uncomfortable of course… and I have given them more than one reason to feel comfortable about going to Dr. Koch.

I have said it before, but I don’t mind repeating it again. What really made my decision easy is when I read about a number of cases of mesh repair where one surgeon would put the mesh in but refused to take it out because of the difficulty of such operation, so the patient would travel to a different surgeon to have the mesh taken out. I can assure you that Dr. Koch is not one of these clowns who put the mesh in and then refuse to take it out or redo the surgery. Mr. Baris reported himself that Dr. Koch worked on him more than once. In fact Dr. Koch is one of the surgeons in Europe that people come to visit when they want the mesh to be removed. During my visit in fact, he had one such difficult case of mesh removal, where he had to transport the patient to a university hospital in a different city so he could remove the mesh. I know because he told me so, and he was late for my checkup. He had been gone for almost entire day.

Look! I am not Dr. Koch’s lawyer. If it makes people feel better, more comfortable, knowing that they received the “original” Shouldice treatment and they can afford it, then by all means, have them travel to Canada to get it done at the Shouldice Clinic.

[John Fortem]

quote DrBrown:

The cremasteric muscle does not have to be cut during hernia repair. I agree that the shouldice clinic advises cutting the muscle, but I do not feel that cutting is necessary.
Regards
Bill Brown MD

As someone who had an inguinal hernia repair done 2 months ago, I can agree on that. I had the “fake” (as some patients on this forum will suggest) Shouldice repair done in Germany, without steel sutures, without a mesh and without cutting the musculus cremaster. I’m a male in my 30s and I train 5 times a week (strength and conditioning), and I have not once had a problem with my testicle migrating up into the abdomen. And let me tell you, I should know what that feels like, because as a young teenager I used to play ping pong with that thing, my testicle would slide up into my abdomen and drop back out as if it was nothing! It’s only later in life that I got my hernia and that I learned that this is not exactly normal and something to consult a doctor about. It’s not something to laugh about and have fun with, that only aggravates the condition.

The take home message here is two-fold:

1. Cutting the cremaster muscle contributes nothing in preventing hernia recurrence. If anything, it should be cut long before a hernia develops in the first place… which doesn’t help someone who already has a hernia, and when the repair is done right there is no reason to cut the muscle if you’re a skillful surgeon. I would argue that if the cremaster muscle contributes to hernia formation at all, then it does so in the very early years in life, and in cases where the internal inguinal ring is not properly closed (which is the primarily what we have in indirect hernia cases in males).

2. Migrating or traveling testicle is an early warning sign. It’s a sign that this person may develop hernia later in life and therefore it should be taken seriously. I strongly believe that if insightful and knowledgeable advice is given at this early stage, it may help someone prevent hernia development later in life, or at very least postpone it. Like many ailments, hernia develops cumulatively. But clinically, it only becomes a “hernia” once it’s too late to prevent it. That’s all the more reason to catch the early warning signs. After all, prevention is the best medicine! And finally, of course, if we ask the Shouldice clinic, any young person that presents with a traveling testicle should have the cremaster muscle cut… just in case! It tells you something about the medical community and especially the Shouldice clinic. But who knows, at this stage, cremaster cutting may even be effective.

Disclosure:
I am not a doctor. I am just an average John. I know just enough about the topic to get by. And then there is my own personal experience of course, which gives me some insights that average doctors don’t have. Then finally, there is that thing called common sense… which sadly is no longer as common as one might think.

[John Fortem]

quote UhOh!:

But isn’t that an anatomical feature exclusive to men? Is there a female equivalent? Otherwise, wouldn’t apply to the OP.

Exactly! That’s anatomical feature in men. I wouldn’t know what the equivalent female version of that is, but the only reason that’s even brought up in discussions is because inguinal hernias are primarily a male problem. Primarily! But apparently women can also get inguinal hernias, but it’s far less common then in men. I can see now that the poster did report having an inguinal hernia, I didn’t see that at first or neglected that fact (lost in details).

I did a quick web search and found some interesting information:

“The cremaster develops to its full extent only in males; in females it is represented by only a few muscle loops.”

“In female humans, the cremaster muscle is smaller and is found on the round ligament.”

So as it turns out, women also have the cremaster muscle and while it’s anatomically or even physiologically different then in men, it’s situated in roughly the same area.

[John Fortem]

Spot on! Recurrence is often used as the primary outcome measure in these statistical studies of hernias. When what they should be using is as primary outcome measure is pain and other long term complications. Of course, reinforced concrete is much stronger than just concrete alone! But should you ever have complications from bad reinforcement and decide you want to get those rebars out of your concrete… well… good luck getting that out without damaging the concrete.

Don’t look only at the recurrence rates. That’s the trick! You have to look closely at other factors and take them into account.

I could also have done my hernia surgery for free in my home town like most people that live here. But the surgeon I met could not even tell me what kind of mesh would be installed in my body or what material it was made of. So much for “discussing” the “options” with my surgeon.

I have a relative who had a hernia repair with mesh, open surgery, and he told me he never had any issues with it. He did his several years ago and he is in his 60s. But why play dice? You need to know what the risks are if things go wrong. This is something that upsets many people who had mesh repair that are now against mesh repairs. They were never told of the disabling complications that can arise from mesh implants.

I went out of country for my surgery. And what really made my decision easy is when I read about cases where one surgeon would put the mesh in and refuse to take it out. There was one woman from my own town who got mesh implant for urinary incontinence, and she had to seek help out of country to get that thing out. The first surgeon refused simply because the procedure was too risky? Dear God! So I knew right then what I had to do.

[John Fortem]

quote jzinckgra:

I’ll spare you my long story, but yes, I had lapro mesh repair in June 2016 for left side IH. Two weeks later, started feeling and seeing right side issue. Drs all said no hernia, CT scan showed otherwise. Didn’t do anything about it then cause it sorta went away for over 2 yrs until this yr. Started getting dragging feeling, bulge, some pain in right side. Ended up getting open mesh procedure two weeks ago to fix it. Oddly and somewhat frustrating to say, I’ve had pain again on left side and hoping I don’t have recurrent one. These hernias are a PITA. In case you’re wondering why I went open vs lapro 2nd go-around was because I heard recovery time and pain levels were slightly less with open procedure. I can tell you for me, that was not the case. While the open wasn’t/isn’t terrible, I have more pain during recovery mostly due to the 1.5″ incision at 2 wks post-op then I did with lapro.

I did open surgery but without mesh. It’s been almost 2 months now since I had it fixed, and I have no pain or discomfort. I had it for about 8 years.

My reasoning in the beginning was to do minimally invasive laparoscopic surgery. But as I continued to do my research and learned about the possible complications of mesh implants, I started steering away from both meshes and laparoscopic surgery. I quickly realized then that if I want to do this “my way” I will have to travel abroad. I did look at different “absorbable” mesh options, but I finally decided that it was a futile approach and an experimental product, so I decided to go all-out open surgery and not hold back.

What I wanted to achieve by minimally invasive surgery, and what is often advertised as being the pros of this type of surgery is that it causes less pain because the incisions are smaller (but there are more of them) and that recovery time is shorter.

I decided to throw out all this fancy technology (meshes that “disappear” and surgery without cuts or pain…) and listen to that little voice in my head that told me to go with open surgery, without mesh. “As God intended” if you will… or as it was traditionally done for centuries. Surgery is surgery, is surgery.

I honestly think that open surgery is frowned open more than once, for no good reason, especially in the West where access to advanced technology like laparascopic equipment or even the robotic surgery equipment is more easily accessible. Now let me tell you about this latest cool thing called mesh… dear God!

My incision is just about 4 cm. That’s closer to 1.6 inches. Sure, I did have some pain. It’s surgery! You know the saying, no pain, no gain? I believe that applies here as well. But I was not dying of pain. I did take 12 tablets (6 small ones and 6 bigger ones) of painkillers for the first 3 days, as prescribed by the surgeon. After the first 2 to 3 days I was told to only take them on a need-to basis. I didn’t really have to take them the first 3 days either, it was not that much pain really. I never took the opioid, this one very strong tablet I received.

The way I see things now, I would never trade in open surgery for laparoscopic one, not even robotic surgery. Laparoscopic and robotic surgery come with their own unique set of limitations and issues. And have this in mind! Just because the incision holes are small to an external observer (patient for example) does not mean that a lot of cutting is not going on on the inside and that a lot of difficult cuts and suturing is not performed. Quite the contrary!

So why not make your surgeon’s job much easier by allowing him or her to cut you open so they can properly see and reach in and fix you right up the first time, and improve the outcome of your surgery? Fear? Everything you want is on the other side of fear!

Anyway! Those are my reasons for going with open surgery, and of course part of the reason is that I wanted to do the mesh free, suture repair. To me, that’s the only reason to ever do open surgery anyway. If I wanted a mesh repair I would be indifferent about the access mode. Mesh is mesh, is mesh. Mesh does not become less of a mesh by doing open surgery. I don’t buy that. Sure, having easy access and good view might help you install the mesh correctly, more so than laparoscopically, but if you already have a patient open up right in front of you and everything is so easy to see and reach then you should have a very good reason for installing a mesh in the first place. I believe meshes should be reserved only for very extreme cases, and of course in laparoscopic surgery due to the very nature of that kind of surgery with restricted access, bad view and all that follows with it.

[John Fortem]

quote Hiway40blues:

Hi-my first post here. I had an IH open-with-mesh repair last Fall (October) on my right abdomen. I decided on ‘open’ for various reasons, including a strong fear of general anesthesia. Anyway it went well, still have occasional tenderness, etc., but I’m back to my usual routine, including lots of walking/hiking. In December I started getting pains in my left side, and in January a bulge appeared there. I was very upset and disappointed: I got myself through the first surgery by telling myself -‘get it repaired and get on with your life’. Now I have to ‘psych’ myself up to go through it all again. Out of curiosity, has this happened to many people here? After getting an IH repair, did you develop one on the opposite side? I wonder if it was there all the time, and nobody noticed it because there wan’t a bulge there.

I had open surgery without mesh, but with general anesthesia.

Getting a hernia repaired and getting on with your life is the right attitude. I wish I had done mine years ago.

My hernia was on the right side as well. While I don’t have a hernia on my left side, I will tell you this! I have read that hernias can migrate from one side to the other, and I have witnessed this on myself.

To put things in perspective, I had my hernia for about 8 years, and during the first 2 to 3 years I had it disappear on the right side and appear on the left side at least 3 times. My hernia was reducible where it goes back into the abdomen when I lay down on my back during sleep, and I would simply notice in the morning when I go to the bathroom that the hernia is on the “wrong” side. Whenever it was on the wrong side it would feel very uncomfortable, as if pushing on the wall so it can pop out. Thankfully, it would move back to its normal location in the days that followed. It’s been probably about 5 years since the last time it appeared on the left side, the “wrong” side. Ever since, it has been on the right side. And now it’s fixed, for good, I hope.

It’s been almost 2 months now since I got it repaired and I have no problems with the left side and there is no sign of bulging or discomfort there. So I don’t think I will get a second hernia on the left side anytime soon. But since I did have a bulge or a migrating hernia there, I might have a weak spot there that may become compromised later on in life. But I will cross that bridge when I come to it, and I know now how to deal with it. It’s much better to deal with your problems as soon as possible than to play the waiting game and procastinate.

My point is that while you may not have a bulge on the opposite side, it’s quite possible that you have a weak spot there as well if you already know you have or have had bulge/hernia on one side.

[John Fortem]

What kind of hernia do you have?

I don’t know what this “long lasting local “numbing” anesthesia that lasts several days” is. You could ask (the other doctor) what this is.

As for painkillers, I think I used 2 x 6 tablets, 6 smaller ones and 6 bigger ones. I received several blisters of both types and 1 which I think was a strong opiate for severe pain, which I never used. I didn’t really have to use the others either, but I took them as I was told to take them at least for the first 2 to 3 days after surgery. Sure, I did have some pain after surgery, but it was not something I could not tolerate. If you can tolerate the pain, there is no need for painkillers really.

For the record, I’m a male in my 30s and I had open inguinal hernia surgery without mesh, and I had it done under general anesthesia. For me, having general anesthesia was just like falling asleep and then waking up and wondering when I would go in for surgery, only to be told that it’s all done. So it was like nothing. You don’t know what you’re made of unless you go find out. I also never had any surgery before, this was the first time for me, and I honestly would rather do it again under general anesthesia than having to watch and listen to the doctors working on me. I had no adverse effects from the anesthesia.

As for cutting… well, something will have to be cut if you’re going in for surgery. If you want to limit the amount of cutting then the minimally invasive, laparoscopic approach is probably the way to go. However, that nearly always entails mesh repair. In other words, if you want no-mesh repair, then you have to do open surgery. If you want minimally invasive i.e. laparoscopic repair, then you have to get a mesh. Dr. Towfigh is to my knowledge the only surgeon who offers laparoscopic repairs without mesh. There may be others, but she’s the only one I know of.

As for pain as a result of suturing, that’s only the case when suturing is done in a way that causes tension, i.e. tugging and tearing on the tissue. There is more than one way to make incisions and suture tissues together. These are the surgical techniques that are so often discussed on these forums. So here is an important question you can ask the surgeon/doctor, what type of surgical technique he or she uses.

[John Fortem]

Wow! Another happy end I see. Good luck dog!

[John Fortem]

quote kaspa:

I appreciate very much Fortem’s reports and am happy he’s doing well.

Thank you! It’s been close to 2 months now. The scar is even less visible now and the “sausage” underneath the skin (along the incision line) is almost completely gone now. The absorbable sutures are likely more than 50% dissolved by now and I still don’t have any signs of reccurance.

quote kaspa:

However, Bari’s case can’t be disregarded and there seems to have been not much dialogue there.

Let me add that any type of “alternative repair” is better than the “one size fits all” approach done world-over using meshes. Be it Shouldice, “not so much original Shouldice”… whatever! I have said what I think about the “originality” of these different techniques.

As for this particular case, first of all, I really hope that this person gets the help he needs and deserves. As I recall, the operation at Shouldice clinic is already done with by now. I hope he will report back about the results. If you want to be scientific and objective about this then you want to make sure to document the Shouldice side of the story here. It’s one thing to talk loudly about this and that, how one doctor is doing it wrong and the others would never dare to… but let’s see some results please.

Now, the very first thing that came to my mind while reading Bari’s report is the number of hernias he had. Did he in fact have 2 hernias? Two indirect hernias? As I recall he even had a third one? I posted these questions before and I am still waiting for answers. Also, did the hernias go all the way down to the scrotum?

Sadly, this strikes me as a difficult case, and yes, Dr. Koch does do mesh repairs where he finds that it is inevitable or in other words where he does not feel confident to do it without mesh. And yes, surgeons will sometimes go against what was discussed previously with the patient. A bad surgeon will do that irregardless of what the patient wants. A good surgeon will only do that when the current situation forces his hand to do so and he sees no other option, other than aborting the operation. Look! When the patient is breathing through the laryngeal mask and his abdomen is cut open, he has nothing to say about what is to be done. His life is in the hands of the surgeon! Now, if the patient is so paranoid that he does not want a mesh implant under any circumstances then this should be agreed upon beforehand. Then the surgeon can just close him up and send him off to a different surgeon or whoever the patient thinks will fix his problem his way… the “original” Shouldice clinic or whatever.

It’s not easy being a surgeon! It’s a fine line you have to walk. But when it comes down to following the wishes of the patient, vs. saving the patients life, wishes of the patient have to be put on reserve. First priority becomes saving a life. I understand this is a more dramatic example, but nonetheless, the surgeon has to take charge, not the patient. This is just common sense. Unless of course the patient wants to operate on himself or expressly states that he does not want mesh implants under any circumstances, because the surgeon can then abort the operation if he finds that a mesh must be used.

It also seems that the patient was not patient enough. If the surgeon tells you everything is normal, and you have to wait for the body to heal properly, then you do what you’re told. You don’t immediately start pressing his buttons to do something about it and then complain how the Shouldice clinic has told you how they would never have used mesh and how they would never have done a second or third surgery without allowing at least several months to pass before they re-operate. It becomes apparent here that Dr. Koch was giving in too easily and bending to the wishes of the patient. Sorry to say this! But this is the picture I am seeing here, given what was said previously.

As for Cremaster muscle, Dr. Koch will not cut it unless he has to. The “original” Shouldice repair as done at the Shouldice clinic does that routinely, as a preventive measure, even if the current situation does not call for it. So that’s keeping up with the tradition for you. In my case, Dr. Koch did not cut the muscle. But my hernia was not scrotal. In my brother’s case he did make a cut. But he had waited for it to go down to the scrotum before having it repaired. Same surgeon! Different patients (brothers!)! Different clinical presentations! Different approach!

This is all the more reason for people with hernias to get them fixed as soon as possible! Don’t play the waiting game. I did that for about 8 years. I still had to have it done! In the end, most of us end up getting the surgery, and I think it’s better to do it sooner than later. I was lucky that my hernia was not extensive and did not go down to scrotum.

quote kaspa:

Shouldice Clinic is a reference in inguinal hernia. They’re a highly trained team who only do that and they’re as paranoid as people in Rolls Royce. So, one single doctor, however good he or she can be, will have a hard time formulating a sound argument they’re wrong. If they say something is important, chances are more than 99% it is.

I don’t understand the Rolls Royce reference. Are you saying that people who drive Rolls Royce cars are paranoid? Paranoid about what exactly? And what does this have to do with hernias or surgery? If it makes your mind at ease, Dr. Koch drives a sporty Audi. I’m not sure if that makes him paranoid… by your definition.

Of course, Dr. Koch is highly untrained and he has no team?… that’s just rubbish! If the majority had to decide, then the Bassini technique would never have happened, and since Shouldice technique is derived from Bassini, the Shouldice clinic would never have seen the light of day.

quote kaspa:

They don’t simply follow original Shouldice teachings, hopefully. They even do mesh repairs in selected cases, less than 2% according to them.

Well, of course they don’t! They “only” use steel sutures and cut the Cremaster muscle routinely. And sometimes, they also use mesh. Go figure! For starters, you have to define exactly what the “original” Shouldice technique is.

According to them, yes. In the end, we all believe in what we want to believe in. Humans are biased by nature. Do whatever you think is good for you, and do your own research. But there is no good reason not to get rid of your hernia if you have one, free yourself of this problem and move on with your life.

[John Fortem]

Ah yes! I got it now. Dr. Shouldice was influenced by Dr. Bassini. Here is an excerpt from a book called Textbook of Hernia, published by Springer in 2017, where Dr. Koch is a contributing author. I believe he penned the part about tailored approach and history of hernia repairs. Here we go…

quote :

“The ancient history of inguinal hernia is remarkable with many creative but mostly futile approaches to its treatment. One illustrated and informative resource for the work and workers of that era are the early chapters in Hernia Healers by Stoppa et al. [14,15].

The modern era of inguinal hernia repair began with the works of Bassini [16]. He recognized that the transversalis fascia was the Achilles tendon of the groin, the layer through which hernias develop. He proffered that to correctly repairan inguinal hernia the groin must be dissected layer by layer knowledgably and carefully from the skin into the preperitoneal space. Only then could the muscles, fascial elements, vessels, nerves and vassal structures be identified and preserved. His reconstruction began with the posterior wall opened. After checking for a femoral hernia,he dissected the peritoneal sac to its true neck and ligated it there. He then used a three-layered interrupted suture repair to reconstruct the canal’s posterior wall. His deepest suture line included the lateral edge ofthe rectus muscle, the internal oblique muscle, the tranversus abdominus muscle, and the medial edge of the transversalis fascia. He approximated that four-layer composite to the lateral edge of the transversalis fascia and the inguinal ligament. He replaced the spermatic cord in its normal position and sutured the external oblique aponeurosis to comfortably re-create the obliquity of the canal and the external inguinal ring. In his earlier operations, starting in 1844, Bassini insisted his patients be awakened enough from anaesthesiato perform straining motions to prove that his repair was sound. Bassini’s results for inguinal hernia repair was astounding compared to the poor results of other surgeons of his time. With 90 % personal follow-up of 262 casesover 4 years, his failure rate was less than 3 %. He eventually reported this in a paper entitled, Nuovo metodo operativo per la cura dell’ernia inguinale. While some have noted that Bassini never specifically wrote about the importance of opening the posterior wall, illustrations by his devoted pupil, Catterina, clearly showed that he did open it and that he had described doing so in his own paper, Bassini’s operation for the radical cure of inguinal hernia [17].

Bassini’s true repair was altered and became known as the Modified Bassini Repair/North American Bassini Repair as was its impressive results. Many North American surgeons, influenced by Andrews, did not appreciate the importance of completely reconstructing the canal’s posterior wall. Most simply ligated the peritoneal sac and pulled the transversus arch to the inguinal ligament, frequently under enough tension that a relaxing incision was needed. The short-and long-term result of the Modified Bassini repair was not good. Most failures could be traced to the inability of tissues pulled together under tension to withstand normal intraabdominal forces associated with ordinary bodily functions.

In the early part of the twentieth century severalother suturing techniques were used to approximate the internal oblique and transversus abdominus muscle, with or without the medial flap of the external oblique, to the shelving edge of the inguinal ligament. The “Darn” technique was popular in the UK, Europe and the Far East [18]. Continuous single or double strands of nylon or silk suture that bridged the canal created a mesh-like structure. This technique never gained much interest with American surgeons.

E.E. Shouldice, a Canadian surgeon, revitalized Bassini’s original principals of inguinal hernia repair [19]. Using a local anaestheticShouldice dissected the structures of the groin including opening the posterior wall into the preperitonealspace. Differing from Bassini’s interrupted suture technique, Shouldice used continuous 34-gauge stainless steelwire to reconstruct the posterior wall and repair the hernia. The results of many-thousand repairs at the Shouldice hospitalare impressive. Shouldice championed using local anaesthesiaand insisted on patients ambulating early. His detailed dissection through the double layers of transversalis fascia, along with the contributions of Rives and Stoppa of Franceand Nyhus and Condon in the USA and the earlier work of Henry and Cheatle helped set the stage for the eventuality of posterior repairs.”

There is more to read. This is the book:

https://www.amazon.com/Textbook-Hern…/dp/3319430432

[John Fortem]

I’m sorry you had this bad experience Baris. I know it’s of no comfort to you, but it needs to be said that not every operation has the same outcome. We are all unique, and there are many variables that influence the outcome. I think that’s also what makes surgical studies difficult, because you have so many things to consider and measures to compare across, the results easily become diluted and incomprehensible or inconclusive.

Did you say you had triple hernias? Two indirect hernias? Scrotal even? What was the third one?

I had my surgery at the hands of Dr. Koch about 1 month ago now, and I can assure you I am 99% recovered, I have fully restored function in my groin, I have no pain or discomfort. Frankly I can’t believe it ended up being this good. If I knew I would have had it operated on years ago. But I only had one, indirect hernia on the right side. I had it for about 8 years, and if I had not repaired it I think it would have gone down to the scrotum which would have complicated things. So the lesson I learned is that as soon as you recognize that you have a hernia you need to start doing your research and making plans for repair. It should not be postponed. The trouble with postponing is that you start stacking problems one on top of the other. This is true for all ailments, not just hernias. Problems are meant to be dealt with, the sooner the better.

Dare to ask questions! I knew exactly what type of inguinal hernia I had (indirect), why I had it (congenital), and what type of repair would be done, and I even knew what type of sutures and gauge would be used. I was told all these things by Dr. Koch. But I got many of these details by simply asking him, it’s not something he will tell you unless you ask. Most people will find this level of detail boring or even frightening, and while my experience with ordinary general surgeons who don’t specialize in hernia surgery don’t even tell you what type of mesh they will use, Dr. Koch is ready to answer all your questions.

Yes, Dr. Koch uses a modified Shouldice repair. But I knew that before I even came to Germany. Because I knew what the so called “original” or genuine Shouldice entailed, because I did my research beforehand. Using steel wire for suturing? Are we still living in the 18th century? I am glad that Dr. Koch uses a combination of absorbable and non-absorbable synthetic sutures. And why would he cut the cremaster muscle unless he needs to? Just because the Shouldice clinic dictates so? Because the inventor of the technique – Dr. Earle Shouldice – who lived in the 20th century used a steel wire and used to cut the cremaster muscle? The technique used should be fluid, not a static teaching from the previous century, just so you can say that you are staying in touch with the tradition.

What I liked the most about Dr. Koch is that he is approachable, he listens and adapts to your specific needs. There is nothing worse than blindly following the teachings of an old school just for the sake of preserving the tradition. Be water! As Bruce Lee would have put it. Formless! Shapeless! Dr. Koch uses the same principle. Could it be that Dr. Koch is the Bruce Lee of hernia surgeries?

All the major and minor hernia repair techniques are improvements or modifications of one or the other. You have McVay, Desarda, Shouldice, Bassini… I don’t recall now what order these came in, but I am pretty sure the “original Shouldice” borrows from some other technique, and that’s alright, that’s how it should be. Borrow freely what you find useful. That’s the only way to a better way. How does that old saying go… all artists borrow, the best ones steal?

Losing fat prior to surgery is always a good idea, if you can manage, regardless of type of repair or even type of surgery being done. I started doing strength training and conditioning 2 months prior to my surgery.

As I recall I got 10 big wound dressings in my goodie bag. On day 2 after the surgery I could hardly get out of the bed on my own and stand up straight. I walked like a robot. I did not have much pain, but I was feeling very stiff and my abdominal muscles were tense and I even had episodes of twitching. That’s because it was sutured in. Dr. Koch told me that this is normal and that the muscle needs to remodel itself, and so it did. I estimate that for each day that went by I was feeling 9% better. So right about day 10 I was nearly 100% recovered and I was feeling like myself again. I thought to myself this is amazing… Dr. Koch has accurately assessed how many wound dressings I would need. From that point on I saw nothing but improvements.

Right around the end of week 3 I reactivated my gym membership and started doing some light cardio workouts. After week 4 I started doing some weight lifting. I could not wait to start hitting that gym again, and I am dead serious about exercising now. I have never exercised this much in my whole life. I exercise 5 times a week with 2 days off during weekend. I am nearing the end of week 7 now and I am doing squats and pull ups, something I could never do before. I have never been a fat guy. I used to compete in athletics for a local club, I did that for 7 years, I trained karate for 3 years, I gave tennis a shot, among other things. I am what you would you might call a normal guy, just a little bit over the “normal” limit if you look at the BMI or waistline. My hernia is/was mainly congenital, but having a sedentary job did not make things better for me and frankly I believe that’s largely what contributed to my hernia (loss of supportive lean muscle).

There are a lot of things to be said about the surgery, but I have nothing but only positive things to say about my experience with Dr. Koch.

I can highly recommend Dr. Koch to anyone looking for…

1. A surgeon who listens and tailors the surgery to your wishes and needs.
2. A highly skilled hernia surgeon with special training in Shouldice repair.
3. Well educated and informed surgeon who keeps in touch with the literature and the hernia field.
4. A surgeon within Europe that does mesh-free hernia repairs.

[John Fortem]

quote pinto:

Thank you. I had it backwards: Here´s an interesting quote:
“Despite statements to the contrary in several textbooks, it is not possible to distinguish a direct from an indirect inguinal hernia by clinical examination, unless the hernia extends to the scrotum (when it must be indirect).” Handbook of Clinical Skills.

I assume that an indirect does not automatically mean it reaches the scrotum but when it does, it must complicate surgery.

Another point of my confusion is that I thought two people can have the same kind of hernia but sourced by congenital cause or weakness later developed in life. In other words, one could get an indirect IH apart from congenital reason. But you seem to say indirect is only traceable to congenital cause. Could you confirm what would be most accurate? Many thanks.

Correct, indirect does not necessarily mean it reaches the scrotum. And yes, scrotal hernias are more difficult to repair.

Are indirect hernias always congenital? I don’t know that for sure, but I am told by Dr. Koch that this is the most common type of hernia in males and it is believed to be congenital in nature. Congenital meaning it’s present at birth. Me and my brother both had the indirect type. That should answer your question about the congenital aspect of it.

[John Fortem]

quote pinto:

You make a lot of sense. The essential point I want to make is that the medical community overwhelming says that IHs cannot be healed other than by surgery. And further some patients pre-surgery who have tried these hernia cure exercises have reported their herniae got worse. So there is big risk in doing physical exercise programs not medically approved (precisely because the reports of exercise failure could be accurate.) If I am mistaken, then I will be happy to learn of the rigorous research data that support these programs or claims. Otherwise, caution should be taken.

The indirect/direct distinction, so far, is most confusing in my study of IH. I might be wrong but my understanding is that apart from the congenital type, the other type can be either indirect or direct, the main difference being that the direct extends down to the scrotum. Any help in puzzling it out will be appreciated.

That’s interesting… you request “rigorous research data” for claims of hernia symptom improvement or cure of hernia through physical exercise. But you don’t put the same requirement on these anecdotal pre-surgery injuries from doing these exercises. Tell me, what rigorous research data do YOU have on patients who got worse by doing physical exercises prior to surgery? And don’t just give me anecdotal viewpoints now.

I think you have overconfidence in the medical community.

Direct hernia: intestine protrudes directly through the abdominal wall. Weakness is in the abdominal muscles.
Indirect hernia: intestine passes through the deep inguinal ring before it protrudes through the abdominal wall. Weakness is primarily in the inguinal canal and I am told that this type of hernia is the most common and is congenital.

[John Fortem]

quote Jnomesh:

Thanks. Definitely a ordeal with mesh removal on top of the two hernia surgeries on each side.
i think it is the other way around indirect hernias are easier to treat-Ive heard the analogy made the a indirect hernia so analogous to a towel preventing a door from closing. Remove the towel and the door closes. This is over simplistic but a indirect hernia is bc of a defect from birth as the small hole that allows ones testicles to drop as a infant stays open to some degree.
direct hernia a hole is manufactured within the muscle where no hole was previously.
ive also heard from most mesh proponents that a direct hernia almost always needs mesh where as a indirect hernia can be done non mesh (of course in reality mesh is used for everything . I’m sure the few non mesh experts out there would say have successs treating both types of repairs without mean.
but you are right a hernia can never be cured without surgery. I think what the author is saying is that they can be managed with some exercises and a support system (truss)
notice he seems to equate the hernia being “fixed “ with it not popping out anymore. Whether a hernia protrudes or not doesn’t really have anything to do whether a hernia is present or not .
ot just means it’s not popping out or protruding enough to be seen. The most important fact is that the hole itself in which the hernia goes through cannot be fixed without surgery.

I’m not so sure about the towel analogy, but you certainly know your hernias, that’s for sure.

Yes, indirect hernia is what I had and Dr. Koch told both me and my brother that these are usually present from birth.

Not really. Technically, you have a hernia if it pokes out. That’s what a “hernia” technically is – a protrusion of intestine through the inner layers of the abdominal wall. So if I lay flat on my back and the hernia retracts then I don’t have a hernia now, do I? Yes, you may still have a “hole” in there. But that’s not what a hernia is. It takes a hole and intestine protrusion to make a “hernia”. If hernias were defined simply as “holes” then all men would technically have hernias, as we all have holes where the testicles dropped down into the scrotum. But in healthy males those holes are not large enough for intestine to protrude through.

Why my hernia used to stay in for days, I can’t say. Was the hole becoming smaller? I can’t say, because I don’t know. But I could go on up to 5 days without being able to see or to sense a protruding intestine. Believe me, I don’t need to see it to know when I have an intestine that wants to pop out. You forgot about the sense of touch. I could literally feel the intestine pressing and pushing whenever it had been tacked in for a long time and it wanted to pop out. I have 8 years of experience dealing with this. This sensation of pressure was most severe in the early beginnings when that hole was still very small, so the intestine would have a hard time pushing out through the hole.

[John Fortem]

quote Jnomesh:

It also may depend on whether the hernia is a direct hernia or a indirect hernia since a direct hernia is due to a actual defect in the muscle itself.
i first had a indirect hernia in my right side which was bothersome but no that bad.
A year later I had what turned out to be two hernias on my left side indirect and direct and both went undiagnosed for 18 months.
before the hernias were finally diagnosed I was sent to PT 2 separate times for a month each and they had me do all sorts of stir including crunches and other at work and it absolutely aggregated my left side.
I know there are probably many variable but I really feel that the direct hernia was a different animal. It really bothered me anytime I did any an work or stomach straining and really bothered me when sitting as well-it was a nightmare

That’s a valid point about direct vs. indirect hernia.

Crunches are one of those exercises that create most abdominal pressure. I would advise against them for anyone who has a hernia that is not retractable when laying down, or anyone who recently had a hernia surgery. Crunches are difficult enough even for healthy people who don’t have a hernia. For all beginners and people who had hernia surgery I would recommend the reverse crunch rather.

[John Fortem]

quote pinto:

[USER=”2813″]GeorgeHirst[/USER], please provide us with the scientific evidence (actual empirical studies) not solely anecdotal evidence for the claim physical exercise reduces the physical gap from which IHs emerge.

You have the right to be skeptical. But you have to understand that this gentlemen is challenging all that we believe in and are taught to be true. It’s a tall order for him to come up with empirical evidence for his claims. To begin with, he would need years of scientific training and the instruments required to do for example imaging studies. It’s not something a regular Joe can fit in his backyard, nor have the expertise to operate it. What we need here is for the scientific community to take up his claims and design a study that can shed some light on the matter. Such study will cost money, and no one wants to finance it.

For comparison, his claim is as repelling as the claim that Earth rotates around the Sun. People got hurt just for uttering those words. As Voltaire would put it: it is dangerous to be right in matters where established men are wrong.

I would love to see some scientific study on the matter. But I have yet to source one, and I am a regular visitor to PubMed (for other reasons).

quote pinto:

Some pre-surgery patients have reported that their physical exercising resulted in enlargement of their IHs. Now I realize their self-reporting are likely unscientific, but their claims are potentially valid.

If they are unscientific, what makes their claims valid?

quote pinto:

Also the medical community widely reports that IHs cannot heal naturally, only by surgery.

I have a hard time accepting a world view where the truth is only what I am told by an authority. With that said, I am not saying that a hernia can or cannot be healed naturally. We need to design a study that will try to answer that question rather than speculating about it. There are a lot of things that the medical community doesn’t have an answer to. How does the medical community explain the fact that I no longer have a hernia on my left side?

quote pinto:

Given the risk of enlargement making the IH worse, it would be foolish to do physical exercise aimed at reducing the IH physical gap–unless of course your claim has wide acceptance medically.

I believe I read somewhere that professional athletes who exercise on a regular basis are more likely to develop a hernias than people who don’t exercise at all. If you already have a hernia, and especially if it’s asymptomatic, I would say that it’s safe to do some easy to moderate exercises without the risk of enlarging the hernia.

In fact, I took up strength training and conditioning about 2 months before my hernia surgery. I saw no worsening of the hernia during this time, but it was not always comfortable to do exercises that involve a lot of lower body motion. Most uncomfortable was running on the treadmill on days when my hernia decided not to come out in the morning. It would literally come out as I was bouncing up and down on the treadmill. It would come out slowly rather than just pop out instantly, but I could feel it and it was no fun at all. Gladly it’s no longer a problem for me. I can even do squats and pull ups and I have yet not teared the repair (a little more than 1 month after surgery). And my repair was done without a mesh, so it is supposedly a weaker repair than the concrete reinforcement bars (plastic mesh) in your groin. I strongly believe that my continued physical exercise has helped me heal after the surgery. Physical exercise can do wonders to the human body, beyond comprehension of modern medicine.

quote pinto:

Aside from empirical research, at least can you name any licensed medical hospitals that offer physical exercise found to reduce IH gaps?

Just because a treatment is offered at a hospital doesn’t mean it’s a good treatment that is backed up by strong scientific evidence. There is more than one hospital in the world claiming to be able to heal any illness or disease simply by offering stem cell therapy. You go figure out if it’s true or false.

[John Fortem]

quote GeorgeHirst:

So many people say that it is impossible, while they sit and do nothing, looking for proof rather than giving it a try for themselves so they can be their own judge.

Spot on! That’s the problem with people in general, not just with people who have a hernia, they much rather talk the talk than walk the walk. Talking is easy, doing the actual work is hard.

quote GeorgeHirst:

Also, thanks for backing me up to being called a snake oil salesman. I have helped thousands of active people get on with their lives through writing my blog and designing the comfort-truss, and I pride myself on that fact. So when I see someone say that it’s very frustrating. I don’t have a blog to sell hernia belts, I sell hernia belts to hopefully help the people who read my blog and watch my videos in the same way that the truss has helped me. Am I an entrepreneur? Yes, I have been my whole life, but I have much better things to do with my time than to talk about hernias if I wasn’t truly in this to help people. I sold a very successful company that I owned for over 10 years because it wasn’t fulfilling to me.

What you are doing is something very unique. It’s what makes your blog unique and what makes you unique. It is quite possibly the first well documented attempt to heal a hernia naturally. It’s an ongoing experiment, and whatever the outcome may be in the long run you are certainly doing the public a great service, and I thank you for that.

Do I think you will be able to completely heal your hernia? Judging by my own experience with migrating hernia, I would say it’s plausible. And judging by the anecdotal evidence you present on the website, it seems like you are making progress.

quote GeorgeHirst:

I would rather help people, and make A LOT less money, than to make a bunch of money doing something that means nothing to me.

I feel the same way. I wish more surgeons and medical device/product manufacturers saw things this way. As I wrote in another thread of mine, “there are needs to be filled and things to be improved upon in the operating room that are not necessarily bad or damaging to the patient, and there is money to be made on these products by the manufacturers and by the surgeons who use them. You just need to use common sense, and stop looking at things solely through the dollar glasses. Don’t be greedy, don’t be evil.”

I made this statement because I have learned that Ethicon makes not only surgical meshes but also surgical glues. I had my hernia surgically repaired by Dr. Koch and he used the surgical glue by Ethicon to seal up the wound. The result is quite impressive! The incision has healed up so nicely, it’s almost invisible. I strongly believe that it is small innovations like this that can have most impact and add up to a bigger whole and benefit the patient the most. Instead of just looking through the dollar glasses and thinking that one size can fit all.

I think that the tailored approach is what sets Dr. Koch and others like him apart from other hernia surgeons. And sadly I must say, they are a minority in the medical field. A lot of the medical world is about numbers and industrialization, treating everyone equally like on a conveyor belt, without much consideration for the unique needs and anatomical variance in each patient. I get the sense that people are becoming more and more like robots, both the patients who are treated as if they are the same model and surgeons who lack the human touch with the world.

quote GeorgeHirst:

Like I say anytime I mention the comfort-truss in my videos: You don’t have to buy the belt I designed. It works for me, but everyone has to find one that works for them and fits their lifestyle. I couldn’t find one that fit my lifestyle, so I had to make it for myself, and now I get to help people by offering it to them.

I can confirm that. I have seen the videos.

[John Fortem]

quote drtowfigh:

I don’t agree that for the watchful waiting patient that can be risky. Quite the opposite. That is exactly what I would recommend for the watchful waiting patient.

I agree with this statement. I would just add that in case of a patient on watchful waiting I would make sure that the exercise regime is easy and conservative, working only with the patient’s own body weight.