[kaspa]

Thanks for the advice, but it simply disappeared so I couldn’t copy it. I had already published it and was editing. I think the other instance was same thing. It’s not very practical to write posts in wordpad, then paste. That wasn’t any spam at all, so I thought I’d have it published fast at least.

[kaspa]

I hope she can do it as soon as possible. I understand she must be very busy. What I don’t understand is why I have a post flagged as spam for the second time.

[kaspa]

When will my post flagged as spam be revised and published?

[kaspa]

Dr. Conze does Shouldice, Desarda, and mesh repairs (Lichtenstein, TIPP and laparoscopic, this one seldom done).

It’s quite amazing being very good in 5 different techniques, but he claims the center did 25,000 repairs in 20 years.

I presume sports hernia, not considered above, is done by Dr. Muschaweck.

He does “tailored surgery”, which is mesh-free 60-70% of the time.

That’s good you have a nice experience.

But I’m not very sure you make an appointment for a mesh-free repair and don’t leave clinic with a mesh decided it’s best when you’re open.

[kaspa]

Patient, the downside of any hernia repair is recurrence. Tissue repair is the best option IMO. I think Dr. Kang was a wise choice for his large background in non-mesh local anesthetic hernia repair.

[kaspa]

I spent a lot of time writing a post and when I finished it it was flagged as spam! So we must wait until it’s revised by someone… This is my second time.

[kaspa]

Quite small and almost invisible. 3.5cm right? I can see you won a cool Korean ruler 🙂

[kaspa]

Great. Can you offer some more details. Is your hernia direct or indirect. Right or left. How’s the incision scar.

[kaspa]

quote John Fortem:

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

Not agreeing is fine.

quote John Fortem:

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

Me neither.

quote John Fortem:

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

Wherever. But I think so, UK.

quote John Fortem:

And “they” refers to Shouldice Clinic…

Well, “they” refers to Rolls.

quote John Fortem:

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?

It’s a good comparison indeed. They’re both perfectionists. The comparison isn’t perfect though. If I could buy a Rolls-Royce, I’m sure I could buy the best possible car according to my wishes and I’m sure I wouldn’t be disappointed.

When I choose an hernia surgeon, unfortunately I can never be that sure. I’m never sure they’re doing the best. So many people complain after hernia repair and that’s quite concerning. Shouldice is no exception.

About cars, Audi engineers are very perfectionist for sure, but when they tell you the best cylinder you can have in an engine is made by Audi, not by Rolls, you’re free to take it or not.

As you know virtually every surgeon in every corner of the world will repair groin hernias with a mesh. If you choose not to have mesh, which is very wise in my opinion, you don’t have many choices. Shouldice Clinic, Desarda Clinic in India, Desarda Center in US, Dr. Kang in Korea, Biohernia in Europe.

You see you don’t have much to choose from. And, whatever your option you need a lot of money.

If you ask me to name the best, I wouldn’t name Biohernia. Perhaps a lot of people would agree with me.

quote John Fortem:

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.

He’s the brain. No need to put other people a surgeon needs here, that changes nothing. Yes, he can be as perfectionist as you like. That’s your judgement. Each brain in Shouldice needs other people, too.

As for money, I think that people who can afford any of 5 options named above will likely be able to afford any of them. Not the same with cars. Distance can be a problem for people who don’t like long travel, like me.

quote John Fortem:

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?

I like history very much. But history won’t help a lot here. According to Dr. Kang, in North America they imported a corrupt version of Bassini. I can’t tell, but Dr. Kang is perhaps right. Anyway, it’s no big deal.

What we can perhaps learn from history is that hernia repair improvement stopped with mesh repair. I believe Shouldice could now be obsolete if industry didn’t introduce mesh.

quote John Fortem:

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%.

Sure, no guarantees as I told before. There are many people who did mesh repairs and are doing fine. But I wouldn’t ever do a mesh repair unless I really had to. We’re now in the philosophical realm. We’re discussing ideas and people are free to make their choices.

quote John Fortem:

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.

I’d like to have all details, too. But when you don’t have all details you must make judgements with the details you have and I think we have enough of them.

quote John Fortem:

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 never told anyone to chose a surgeon or a clinic. I said people in Shouldice are perfectionist and that a single surgeon will have a tough work discrediting that team.

quote John Fortem:

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.

I think you did a good decision based on your premise. But your premise doesn’t lead to Dr. Koch only. Your feedback is quite valuable in a forum like this. Feedback is the best you can offer, indeed.

[kaspa]

quote John Fortem:

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.

I’m still reading your post, but this part needs a comment now. 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’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. You’re happy with your repair, and I appreciate that. But many people here are still making decisions. 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. 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.

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

[kaspa]

I’m trying to understand this and hope I won’t say something too ignorant.

As I understand, JZ had a laparoscopic repair of left inguinal hernia and now had an open one for right hernia. When suturing at 2 points in Cooper ligament, one point included previous left mesh.

So the question here is, wouldn’t previous doctor wish to have a bilateral repair, something not too difficult by laparoscopy, perhaps as prophylaxis for right side?

[kaspa]

I’m a late comer on this truly interesting topic.

Healing a hernia without surgery is quite a philosophical questions these days of mesh-era.

I think in future, when mesh-era is gone and surgeons invest in research on hernia physiology again, they’ll find subtle details that will allow them to treat an hernia without surgery, perhaps direct hernias first.

Don’t ask me to substantiate this too much, but I believe hernia sac will be the key. A defect in the wall isn’t enough, that’s why a congenital indirect hernia can show up only decades later. There must be additional factors which are random events, like hernia sac formation.

If you asked a doctor 50 years ago if it would be possible treating a peptic ulcer without surgery he’d think you were nuts. Yet, today most such ulcers are treated with potent antacids and sometimes antibiotics, too. Thanks to understanding pathophysiology of peptic ulcer.

[kaspa]

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

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

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.

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

[I couldn’t edit and this jumped to next page, that’s why I repeat previous post]

[kaspa]

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

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

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.

[kaspa]

Hi, Best. I think Lomeprazol won’t damage your esophagus.

Dr. Kang is able to repairing both direct and indirect inguinal hernia. I’m not sure about sports, but he may be able to repair it or at least advise you on best options.

I hope Dr. Kang will come here soon.

[kaspa]

I always appreciate reading Dr. Kang’s opinion. There aren’t many experts in inguinal hernia like him, unfortunately.

I think the most important part in his statement above is that most doctors do a lot of repair techniques which they think it’s better in each case in stead of doing a single technique, or two at most for direct and indirect. That way that’s much more difficult that they are experts in any technique and thus have small rates of complications (we can add that most surgeons do a lot of surgeries and only some hernia repairs, which makes that more important).

When I searched for hernia surgeons in Europe I found one that could use more than 7 or 8 techniques with training in centers worldwide. Too much technocracy for me and I discarded him right away (later I even learned that training in Shouldice Clinic consists in watching a few surgeries without touching anything).

Also, I’m not very sure that most surgeons are aware that high ligation is mandatory in indirect hernia repair…

[kaspa]

Bestoption , perhaps you should ask that to your GP. He’ll probably ask for an endoscopy, if need, or simply prescribe medication, IMO. Anyway this is not the best forum to discuss that.

I have discovered something interesting since my hernia appeared 4 months ago. I use to have some epigastric pain from time to time, most often after meals. It’s happened a few times in the past 10 or more years. Sometimes it’s quite intense and I even went to an emergency department once and they thought that was some kind of gastritis and gave me omeprazol IV without any benefit.

Recently that happened after breakfast and it was so intense I thought I had to go to ED again, but it disappeared after some 30 minutes.

Later I found that that this epigastric pain is related to my hernia and it completely disappears if I reduce my hernia.

It’s interesting not only to see this is related to hernia, but also how meals seem to influence hernia’s tension.

Also, it’s interesting to have had that episodic pain for more than 10 years before hernia appeared. I think this can mean that something in my inguinal area was wrong long before hernia appeared.

By the way, this is the only symptom of my hernia so far (apart from bulging of course).

[kaspa]

In Dr. Desarda’s he only tells about Prolene in his website “Operation technique”.

I also checked amazon.com and it seems Dr. Desarda published a new book available in paperback or kindle. In “Look inside”, if one searches “Prolene” it happens 3 times (pp. 86, 89, 90). If one searches “absorbable”, it happens 11 times (between pages 7-75). But one can’t access the pages, so I don’t know the context.

In his article in Hernia (2006), Dr. Desarda only tells about Polypropylene interrupted sutures, but in fig. 2 legend, he mentions “continuous absorbable sutures” (an error?).

[kaspa]

In his article in BMC Surgery, Dr. Desarda only tells about Ethilon or Prolene sutures, both non-absorbable.

Shouldice Clinic also use non-absorbable suture (in stainless steel!).

It’s worrisome that some doctors choose to use absorbable sutures when standard is non-absorbable.

[kaspa]

Happy to know about that and hope it will all run finely.

Perhaps you might tell us who’s the surgeon as there are so few doing only no-mesh repairs.