[KC]

@william I use black silk only at the deep inguinal reconstruction. And this way of reconstruction is almost tensionless.
I use prolene in Shouldice operation.
Black silk has a merit of grasping tissue which is ususally disadvantageous in surgery. But in my operation I need to hold the medial end of spermatic fascia of the deep inguinal ring tightly to pull that back to lateral abdominal wall. In this situation, silk is convenient. My operation picture will help you understand that

[KC]

thanks to Jack2021 for kind comment.
my operation time is 72 +- 15 minutes.
now a days, i use only two Black silk 1-0 sutures.
my incision is about 5 cm +- 0.5
I changed my operation technique very recently, so My cases need a long term follow up data and need more cases to convince the effectiveness. my report confirms only that there is no early recurrence and Post-herniorrhaphy pain is fair. actually my individual experience says much better.

[KC]

@ watchful : it is about 4 cm distance from the medial margin of the deep inguinal ring to the pubic tubercle. so 6cm size and 4 finger wide deep inguinal ring means that it is very large that the medial margin of the deep inguinal ring is almost approached to the pubic tubercle. In my case usually very long duration hernia with omentum packed case was like that. and also usually hernia presented from earlier life. in these cases I suffered no problem to close the defect, because the deep inguinal ring is only displaced. it is not worned out. my job is repositioning the medial margin to it’s original position.

[KC]

@ pinto ; I am very sorry that I cannot explain well in metaphor cause my English is very poor. but please imagin that the shutter is open a little for a passage of spermatic cord when there is no hernia. and when hernia develops the shutter is open in one direction due to the protrusion of the hernia sac. usually the two lateral pillar is not move much. In human anatomy one lateral pillar is inguinal ligament and another is thick musculofascial tissues. Bassini and Marcy operation is approximating these two pillars together closing the door itself. My modification is pull up close the opening after reduction of the hernia sac.
above explain is for the indirect inguinal hernia. direct hernia is protruding out from the weakened shutter door it self.

[KC]

@ pinto, From 2003 to 2017 i performed PHS herniorraphy in about 50% and 3D patch herniorrhaphy in about 30% and TEEP about 20%, and annual inguinal herniorrhaphy number is about 70-80 cases. From 2019 I use mesh only in TEEP cases when patients wanted that or in femoral or obturator hernia cases, annually under 7 cases. all other cases with indirect inguinal hernia, I perform with the Modified Marcy operation. and in direct inguinal hernia cases, I perform Shouldice operation with two layers suture only or TEEP. In direct hernia, I scrutinize the deep inguinal ring. and if i find out small peritoneal sac popping out a little like a tongue at the deep inguinal ring, I perform deep inguinal ring modification simultaneously. 2018 is a transitional period of above.

[KC]

And to drtowfigh, i want to comment that I have operated my modification technique not to children but to adult male indirect inguinal hernia. the size of the deep inguinal ring is not a matter, but the definite weakening or defect is important to scrutinize the posterior wall.

[KC]

Dear watchful and Pinto. I am very glad and welcome to talk about this subject with anyone, but I do not know how Dr Kang do his practice and have no information of his data. I respect Dr Marcy as a surgeon who first emphasized deep inguinal ring modification. and my key Idea added to him is that moving medial margin of the deep inguinal ring to the lateral direction. In large indirect hernia you can easily find that the medial margin of the deep inguinal ring with inferior epigastric vessels is encroached medially making the inguinal canal shortened. in this situation, Marcy operation is not so different from Bassini operation.
my technique is not so tricky compared to Marcy operation, If you are to do Marcy operation you should detach the internal spermatic fascia from the vas and testicular vessels. If you do not do this, it’s not true Marcy operation. I think this procedure is most important and my modification is only small but “much different” modification that suturing this medial margin to the upper lateral abdominal wall horizontally. My modification has an effect of pulling the medial margin of deep inguinal ring more laterally, which makes the deep inguinal ring repositioned under the thick internal oblique abdominal muscle and lengthening the inguinal cannal increasing the obliquity of the inguinal cord structure. So there can be possible chance of damaging the spermatic cord during the procedure detaching the internal spermatic fascia from the spermatic cord, but not during the suture of medial margin to the lateral abdominal wall.

[KC]

Dear Watchful
I have no data camparing both method. I only suggest that my modification can be at least equal to Marcy operation theoretically.
There are reports concluding High recurrence rate with Marcy operaion.
I hope some surgeon get to be interested in this idea when they try tissue repair.

[KC]

Imagin that you are infront of shutter door, which is open half. How will you close the shutter door. Will you close the shutter door approximating two lateral pillars or drawing down the shutter? Marcy operation is closing the shutter approximating two lateral pillars, and my modification is drawing down the shutter.

[KC]

dear William Bryant, I am practicing at the Ewha womans univsersity hospital and a surgeon practicing kidney transplatation and also adult hernia. if you have read my article, you will know that I repair the posterior wall of Pantaloon hernia with Shouldice operation in classic two layer method. if you tightly occlude the deep inguinal ring I think that two layer Shouldice repair is enough

[KC]

I am the author of above mentioned journal “Novel modification of Marcy operation for indirect inguinal hernia reconstituting deep inguinal ring shutter action”
My modification is applied to all cases of adult indirect inguinal hernia no matter how large is the deep inguinal ring. and actually it’s detail is much different from old Marcy operation.
any question I appreciate, I would like to answer in detail about my practice.