[John Fortem]

Hello everyone!

Sorry for the long absence. I am writing here today to let you know that I no longer have the hernia. I had it repaired by Dr. Koch of course, and I feel great! It’s amazing… I didn’t expect the outcome to be this good. I mean I had my fears and I was a bit skeptic about the procedure. It’s been a little over a month now since I had the operation. I am like 99% recovered and it’s almost as if I never had a hernia in the first place. I have fully restored function in the groin, I have no pain or discomfort, and the incision is almost invisible which is something I found particularly interesting! For you see, Dr. Koch used a surgical glue to seal the wound, and believe it or not… it’s made by Ethicon! The same Ethicon that makes meshes that people so often complain about (and often rightfully so). So what this tells me is that 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.

There are a lot of things to be said about the operation. I might have to come back here more than once to fill you guys in on all the details. I want to keep this come-back post short. And of course, if any of you are considering traveling to Germany for the operation, or you just have general questions about my hernia surgery, feel free to send me a private message and I will try to reply promptly.

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 fidel18:

[USER=”2662″]John Fortem[/USER], i just have questions for you. When the hernia or intestines of your brother slipped down to the scrotum, was he still able to bring it, meaning intestine, back by hand or when lying down or it was already permanently lodged in the scrotum? Since it started slipping down to his scrotum, how many years did he wait before surgery? I have a right inguinal hernia and I notice it is starting to go down to my scrotum. I can still press it back even if Im standing or lying down. My fear is it will get worse and get entangled with the other matters in my scrotum. Thank you.

Sorry for the late reply! I haven’t been to the forum in a long while. That’s called a retractable hernia. No, his hernia was not retractable. Not after it had gone down into the scrotum. And he has told me that he can’t recall ever being able to push it back in or that it would retract back into place on its own when laying down. So, no!

He had it for about 10 years in total. He had started having pain in the groin from abdominal pressure for the last 2 years, so the pain started in year 8. I would approximate that it started to slide down about 1 year before that. So the order of events would be something like this:

Year 0: hernia started to bulge out
Year 7: hernia started going down to the scrotum
Year 8: hernia is in the scrotum and groin pain starts to develop
Year 10: hernia is operated on

It’s been nearly 4 months now and he is feeling good 90% of the time and has no symptoms of pain, but he sometimes feels some sort of discomfort. I don’t know what to make of it. But the 4 absorbable sutures should all be absorbed by now and everything is held in by the 2 permanent sutures. He still has that thing that looks like a hydrocele. His discomfort might as well be coming from this area. He still doesn’t know what exactly this is.

I myself will be visiting Dr. Koch very soon for my own surgery. I am looking forward to it and to have this done, but at the same time I am starting to feel nervous about it. I know I will have to do it sooner or later, and it’s better to have it done sooner.

[John Fortem]

quote Baris:

Thats probarbly correct yes but the main reason for cutting the cremester muscle is not for actually reaching the repair itself.. its due to the fact that if its not cut and resuspended in the repair it damages the repair in the future. Both dr muschaweck and and dr koch have been to the shouldice clinic to observe operations and understand the technique.
The chief surgeon here has been operating here for 41 years on just hernias

What I have read before is that the cremaster muscle is dissected in order to prevent the testicle from sliding up and sort of force opening the repair site unwillingly if you understand what I mean. But I have no date to support this.

But does this apply to all kinds of inguinal hernias? I mean does it even apply to scrotal hernias where the intestine has gone down to the scrotum? I think this is what Dr. Koch meant, that in this particular case he has to get past the cremaster muscle to get to the intestine and properly put it back into place. But I guess if your hernia is only superficial, i.e. it has not gone down tot he scrotum, then he may not need to do anything about your cremaster muscle. This is my own interpretation, not his words exactly.

I don’t know about Dr. Muschaweck, I can only tell you what Dr. Koch has told me in person, that is: he himself has been to the Shouldice clinic a number of times and has even published some research papers together with some of the doctors there or are finishing up a new paper (I don’t recall exactly which it was).

I think 41 years is a lifetime of dedication to a single topic or profession, but even 12 years of experience speaks volumes compared to maybe 1 to 2 years of experience by your general surgeon available at your local hospital. I am only speaking about what is available for me at home. And of course they all use meshes here. I rather have my cremaster muscle cut than have a mesh implant.

[John Fortem]

Dr. Koch is a good friend with Dr. Muschaweck and he has met with Dr. Desarda at his clinic in India. He had great things to say about them both. But he was not a fan of the one-size-fits-all in regards to the Desarda method. In fact, he insisted that the majority of inguinal hernias in men are of the indirect type and are the result of bad ring closure during development.

[John Fortem]

In regards to cremaster muscle… it was “split” according to Dr. Koch. My understanding is that it was sliced but not dissected away. The cremaster muscle stands in the way, you have to get past it somehow to pull the herniated intestine back into place. The easiest way to do so would be to dissect it, which if I am not mistaken is the standard procedure in the original Shouldice technique. But with Dr. Koch everything is about preservation and conservative approach, so he makes a smaller cut in it, just enough so he can grab hold of the intestine and pull it back up. It is likely more time consuming but Dr. Koch has had hundreds of patients to practice on so he can probably do it blind-folded. I think he said he does around 300 to 400 operations per year. If memory serves me right, he has been doing hernia surgeries for the last 12 years… you do the math.

[John Fortem]

In regards to the stabbing pain I described earlier, he has been experiencing this for about a year before the surgery. I’m not sure what to make of it, but if it’s been there before the surgery, I think it’s unlikely to be caused (or worsened) by the hernia surgery itself. It may not be related to the hernia at all.

My brother has been diagnosed with discus hernia. This diagnosis was discussed with Dr. Koch and made possible thanks to Dr. Koch because my brother has been having back problems for some time now and he was refused an MRI scan back at home. On the day of the first visit, after explaining the back problem, Dr. Koch called his colleague Dr. Boris who operates his own radiologist office at the same medical center and my brother was offered an MRI scan which later confirmed his suspicion that he did without doubt have a herniated disc.

So if any of you are in need for an MRI scan, just know that these services are also offered at the same medical center. There are in fact a dozen of different private practitioners that all collaborate and operate under the same roof.

If we go back to the hernia itself, my brother has had his hernia for about 10 years, and I think he said that it only became problematic (symptomatic) during the past 4 years which is when it slipped down into the scrotum. Like I said, it’s difficult to say what pain symptoms were caused by his bad back and which ones were caused by his hernia. But I think it’s reasonable to say that his hernia related pain was no more than 4 on a scale of 10. Judging by the number of complaints I hear from him… hehe… I would say it’s likely a 2 out of 10 now, and that’s only on the bad days, on good days it’s closer to 0.

It all depends on what condition you are in when you go in for the surgery, and what other health issues you have. But I would say the sooner you treat your hearnia while it is still not symptomatic, the better the chances of success are and that you will not have any chronic pain.

[John Fortem]

quote Chaunce1234:

Dr Andreas Koch in Germany (unsure of location)

He is based in Cottbus, east Germany.

[John Fortem]

What happened? What did it feel like? Did you feel like something snapped? Do you have a visible bulge now? What are the issues you have since? What did the doctors you met tell you?

[John Fortem]

After meeting Dr. Koch in person and after he successfully treated my brother’s hernia, I can warmly recommend him.

Feel free to ask me any questions you may have.

[John Fortem]

quote UhOh!:

Isn’t it premature to discuss repair types without knowing for certain the hernia type (direct vs. indirect)? Based on what Drs. Kang and Brown say about repair types, it sounds as though the majority of non-mesh techniques are best suited to direct hernias. At the same time, I’ve seen multiple sources suggest that the majority of hernias reaching the scrotum are indirect…

Certainly! The more you know, the better! I had the opportunity to talk about the Desarda technique with Dr. Koch and he basically confirmed what people here on the forum are saying about Desarda technique in regards to hernia type, that is: it is not a one-size-fits-all technique, and it certainly is not a very good option for indirect hernias. So if you have indirect hernia, then the Desarda technique may not be your best option.

If you ask Dr. Desarda himself, he will tell you that it does work for both types of hernias. It may work for both types of hernias, but you may not have the best possible outcome if you have one or the other type of hernia. You also have to take into consideration many factors. It may be very successful technique for both types of hernias, but only if performed by the hands of its creator, Dr. Desarda himself.

1. Hernias reaching the scrotum, otherwise known as scrotal hernias, are indirect hernias.
2. Desarda technique is best suited for direct hernias.
3. My brother had his indirect (scrotal) hernia repaired without a mesh by Dr. Koch.

[John Fortem]

Like with any new invention, it will take time to perfect it. This is all the more reason to be cautious about robot assisted surgery.

“Things that are complex are not useful, things that are useful are simple.”
~ Mikhail Kalashnikov

[John Fortem]

While robot assisted surgery is an important evolutionary step in surgery, in case of hernia surgery it adds no significant value. As Good Intentions noted, it just makes the operation easier for the surgeon, ti adds accuracy and precision to the work.

I would say that in general robot assisted surgery (RAS) has an advantage over traditional video laparoscopy (VL). But laparoscopy along with robot assisted surgery is inferior to open surgery (OS) in case of hernia surgery.

RAS > VL < OS

How to know when to remove a mesh? I think you will know the answer to that question if you start having complications from the mesh implant. This can result from foreign body reject, inflammation and mesh shrinkage and adhesion to soft tissues. These complications will also depend on a number of factors, among the most important I think is at what layer of the abdominal wall the mesh is inserted.

[John Fortem]

I understand your concern da Vinci. It’s good that you are doing your own research. The sparks or arcs are avoidable though… by not doing a robotic surgery. Is there any particular reason why you prefer laparoscopic or robotic surgery?

[John Fortem]

I read an interesting article yesterday regarding chronic post operative inguinal pain (CPIP). You may want to read it.

https://www.degruyter.com/view/j/iss…-2017-0017.xml

Two of the predictors for chronic pain appear to be pre-operative and post-operative inguinal pain. Females also seem to be more predisposed to chronic pain. It contains a lot of interesting discussions about chronic pain. It was published in 2017, so it’s very recent, and it is a systematic overview.

The question of whether or not the use of a mesh can reduce the risk of chronic pain compared to suture repair is inconclusive.

“The use of mesh seems to reduce the risk of CPIP compared to suture repair. Many trials have investigated the question whether lightweight meshes (LWM) may reduce the risk of CPIP. The interpretation of these studies is difficult due to the large variety of mesh materials and mesh properties such as weight, pore size, tensile strength, weaving pattern, and elasticity.”

The conclusion states:

“The avoidance of chronic pain is a primary concern in inguinal hernia repair and may be considered the most important clinical outcome. This problem preceded modern mesh-based techniques; however, as recurrence rates have decreased, pain has become the more prevalent and important complication. Understanding the causative mechanisms and risk factors of inguinodynia help to prevent, diagnose, and treat this condition. Groin pain, especially in the absence of a bulge, often needs interdisciplinary diagnostics and no operation. Detailed diagnostics, meticulous operative technique with profound knowledge of the anatomy, proper nerve identification and handling, optimization of prosthetic materials, and careful fixation are of utmost importance. Further research on how to avoid CPIP and explore the effectiveness of treating it is necessary.”

This is interesting. Because when you read the statements of mesh promoters, they will all almost unanimously say that meshes have helped reduce recurrence rates down to practically zero. I agree with this author though that recurrence should not be the primary clinical outcome measure, while chronic pain should.

The author is Dr. Reinpold of Hernia Centre Hamburg-Wilhelmsburg. He does hernia surgeries both with and without the use meshes. You can read more about this doctor and the center here:

https://www.leading-medicine-guide.com/en/Specialist-Hernia-Surgery-Hamburg-Dr-Reinpold

[John Fortem]

quote Jnomesh:

I’m addition look into non mesh repairs-they will be harder to find but they are out there.
understand that with mesh they put in a pretty big piece which is standard-bigger for laparoscopic Repairs (5”x7”) which seems out of whack for a small hernia like yours but is standard procedure.
also understand that mesh is permanent and not meant to come out-there is no “do-over”. Another thing to think about if you should have post op pain you will never know for sure if it is do to the mesh itself or Bc you had preoperative.
so research the hell out of both procedures and ideally meet with a Couple of surgeons for both mesh (open/lapro) and non mesh repairs whichever route you decide to take make sure the surgeon is a hernia specialist-this means probably looking outside of a general surgeon.

I can also confirm that a large piece of mesh is used in case of laparoscopic or robot assisted repair. I was watching some surgeon from India yesterday on YouTube, and he was also explaining that you have to make sure the mesh is larger than the hole. It kind of struck a cord with me. Because I was watching a Canadian documentary a few weeks ago about mesh implants, and in that documentary the activists of some British anti-mesh group were emphasizing exactly this: the mesh is larger than it has to be to cover the hole. They have to make it large for obvious reasons. Such as making sure they can fasten it properly and also give it some slack as the mesh will ultimately start to shrink eventually.

Mesh is really a bad invention if you ask me. It has no business being inside the human body. It doesn’t matter what kind or type it is, they are all more or less the same, and it’s not natural. I am even skeptical against the absorbable meshes that are up and coming. It’s incredible how infested this idea of using a mesh for hernia repairs is in the world today. If we are to use some kind of mesh in the body, we have to be absolutely certain that it is 100% compatible and thoroughly tested in the human body. Ideally, we should use a material that is as natural as our own tissues.

[John Fortem]

So da Vinci is good for implantation and explantation of meshes? And even superior for explantation than traditional laparoscopy? Regardless of da Vinci model? I believe Xi is the latest generation of this system, gen 4. I supposed it doesn’t have to be this latest system? This is the only one that has specific wording about general (hernia) surgery in the FDA document.

[John Fortem]

quote dog:

Great Business ..one inserted it…Second remove it ..You see every one has job! Well …Will you trust surgeon who created mess in the first place to undo it? I wouldn’t

True and true…

[John Fortem]

quote Davinciproblems:

I am referencing handling and manipulating mesh

Ah yes, I see your point now. That is true… I think. It has not been cleared for implantation or explanation of a surgical mesh specifically. It is kind of assumed that it is OK… I think. But yes, it is not worded in the text. Perhaps [USER=”935″]drtowfigh[/USER] can tell you something about that?

[John Fortem]

quote Davinciproblems:

From my research, the instruments are cleared for handling soft tissue only. Do you have the clearances for handling other materials?

A hernia repair is a soft tissue repair. I’m not sure what you’re getting at?

From dvuro (da Vinci urology) website:
http://www.dvuro.com/technology.php

“The PK Dissecting Forceps may only be used on soft tissue. Do not use it on cartilage, bone or hard objects. Doing so may damage the instrument or make it impossible to remove from the cannula.”

“The Harmonic ACE Curved Shears Instrument is designed to be used in conjunction with both the da Vinci System (S and Si models) and a compatible Ethicon Endo-Surgery Generator and Hand Piece. It is intended for soft tissue incisions when bleeding control and minimal thermal injury are desired. This instrument may only be used on soft tissue. Do not use it on cartilage, bone or hard objects. Doing so may damage the instrument or make it impossible to remove from the cannula.”

Again, this text passage describes how or when not to use the different instruments (of a certain da Vinci model) in urologic procedures.

“Each quarter this page will highlight the use of da Vinci advanced technology in different urologic procedures. The highlight will include an opinion from a surgeon currently using the system and technology. If you are looking for additional information on the use of the technology, please visit the da Vinci Online Community.”

What kind of surgery do you need? And what robot system and model do you plan on using?

What kind of da Vinci problem do you have Mr./Mrs. da Vinci problems? Are you a surgeon or a patient?

[John Fortem]

On the same topic, “Intuitive Surgical wins FDA nod for inguinal hernia repairs with da Vinci Xi”

https://www.massdevice.com/intuitive…s-da-vinci-xi/

And here is the FDA document, dated 2017:

https://www.accessdata.fda.gov/cdrh_…17/K170713.pdf

Similarly, here is the indication for use:

“The Intuitive Surgical Endoscopic Instrument Control System (da Vinci Surgical System, Model lS4000) is intended to assist in the accurate control of Intuitive Surgical Endoscopic Instruments including rigid endoscopes, blunt and sharp endoscopic dissectors,scissors, scalpels, forceps/pick-ups, needle holders, endoscopic retractors, electrocautery and accessories for endoscopic manipulation of tissue, including grasping, cutting, blunt and sharp dissection, approximation, ligation, electrocautery, suturing, and delivery and placement of microwave and cryogenic ablation probes and accessories, during urologic surgical procedures, general laparoscopic surgical procedures, gynecologic laparoscopic surgical procedures, general thoracoscopic surgical procedures and thoracoscopically-assisted cardiotomy procedures. The system can also be employed with adjunctive mediastinotomy to perform coronary anastomosis during cardiac revascularization. The system is indicated for adult and pediatric use. It is intended to be used by trained physicians in an operating room environment in accordance with the representative, specific procedures set forth in the Professional Instructions for Use.”

Note how it says “urologic surgical procedures, general laparoscopic surgical procedures”. Well guess what? Hernia surgery falls under general surgical procedures. Also note that this document relates to model lS4000. So it may or may not be applicable to model SP999 indicated in the previous document. You be the judge of that.

Generally speaking though, I would not go for a laparoscopic operation of an inguinal hernia, be it robot assisted or traditional video laparoscopy. I rather put my trust in the hands of an experienced, traditional surgeon with a lot of experience, than hyped up high tech gadgets like surgical robots, plastic meshes and all that sort of thing. That’s just how I see things.

I see that there is a lot more interest in the business side of things than the medical side of things, you know in helping people get better. Which by the way should be the number one priority for any surgeon, physician or doctor. If I have a hernia, I need medical help, I need someone to help me treat it, someone who puts my well being at the front. I am not interested in filling someone’s pocket with money just for the sake of it. If you work in this field, or any kind of profession really, money should not be your first priority, you need to have passion for the job first and foremost and have people’s well being as your first priority. But in the society that we live in, that we have built, everyone is chasing the dollars, the yens, and the euros, etc. It’s a pretty cold, insensitive, unfair and unjust world that we live in. Everyone has only their own best interest in mind.

But to answer your question directly, yes, the da Vinci robotic system has been approved for general surgery procedures, including hernia surgeries. But apparently only certain models have been approved for that, as indicated in the document above. So it’s good that you do your own homework and make sure the robotic system that will be used in your operation has been approved for that type of procedure. You may also find that the same system has been approved by government or federal agencies in one part of the world but not in other parts of the world, just like with medicine. So while a system may not have been approved for one type of operation by the US regulatory agencies, it doesn’t necessarily mean it is not safe to use in that particular way. It may, or may not, have been approved in a different country, on a different continent, for the same type of operation. Regulatory approval may be under way in the US.

Don’t get too hanged up on the da Vinci. It is the best recognized and most widespread system, with about 4400 systems rolled out worldwide, and about 43000 trained surgeons. But there are many more competitors up and coming now. Some of the most notable are TransEnterix and CMR Surgical. Some of them may or may not be approved for hernia surgery. Some of them may be more or less beneficial for hernia surgery. Who knows?