[MarkT]

There remains great value in this type of paper.

Its purpose is not to suggest what to do about chronic pain, but rather to explain why we don’t have sufficiently useful data and evidence in order to better understand and address the issue. The goal is to motivate change so that obtaining more useful data becomes possible.

I’ve said for some time now that we are unlikely to get ‘great’ data any time soon when trying to evaluate outcomes or compare surgical options, which is not to suggest that it is easy. It’s expensive, time consuming, and there are plenty of other obstacles.

[MarkT]

Any chance you might have strained your groin?

If you have no visible bulge, and an examination doesn’t reveal a palpable hernia or some other problem, then you might inquire about MRI (ideally, dynamic MRI) as it is superior to ultrasound and CT in detecting hidden/occult hernias. Even if it isn’t a recurrence, MRI may be useful in helping to diagnose the problem if an examination yields no good info.

[MarkT]

I’ve had two Shouldice repairs (one on each side), ~10yrs apart, both a long time ago, with no problems immediately after or since. The first few days afterwards are challenging in terms of getting out of bed, bending, etc…but eight days out was much, much better.

If you have a ‘standard’ surgery and recovery experience, then you should be fine to attend a game. Many people are back at work in that timeframe as long as they aren’t doing anything very physically demanding. You won’t be running up any stairs, but you shouldn’t still be experiencing any major limitations that would prevent you from going. Just give yourself more time and avoid any situations where you might be getting jostled around in a crowd of people.

[MarkT]

Chuck, I agree 100% with Watchful…don’t put the cart before the horse…diagnosis is the priority.

A hernia can still be palpable if there is no visible bulge…so a physical exam is the first step. If you already had a physical exam that did not find anything, then imaging is the way to go.

Get a dynamic MRI done. It is likely your best option to nail down a diagnosis (whether it is a hernia or something else) which will then inform a course of action.

Ruminating about the past, talking to someone on the phone, contemplating which surgeon to see if you have a hernia recurrence…none of that gives you good information about what you should do next. Get a diagnosis, then go from there.

[MarkT]

Thanks for the detailed posting of your experience, Watchful.

I’ve posted mine many times, but of course they are going back many years and we have wondered what has and has not changed. My main contribution at this point is anecdotal in confirming that both of my repairs were flawless with zero post-op complications or restrictions on activity to date, one side done 30 years ago, the other side almost 20 years ago.

Interesting to note the variation in procedure regarding the cremaster and sutures…that is something we have talked about a lot here, especially the latter.

With the sutures, did they say if they have shifted to exclusively using prolene now? Is it simply the surgeon’s choice? Or something the patient can request? Maybe all new surgeons can/must use prolene, but the older ones still use steel? If it is a complete shift, that would be a *very* new development (certainly within the past 1-2 years, AFAIK).

I also wonder what data or other motivation has informed their decision to deviate from always resecting the cremaster…and how they make that decision for each surgery (indirect vs. direct? other hernia or patient characteristics? surgeon preference? patient request?).

It does sound like you had a rather unusual short-term post-op experience. I do recall a fair bit of variation when I was there. The first time, one other guy was also my age (18/19) and he was on a stationary bike the next day, while a couple of other patients (much older) struggled to walk to the dining room and skipped ‘exercises’. The vast majority of us were in between…no issues walking slowly, but not exactly motivated to hop on the bike right away either. One of the older guys had a notably rougher time.

Your experience of the cohort model being problematic during recovery is notable and not something I had previously considered. I experienced it as a reassuring ‘we are all in this together’ type of thing, both before and after surgery…but my short-term recovery also aligned with that of most others, while yours negatively deviated from them. That is something that warrants more study and there should be additional supports in place to not only aid in the recovery itself, but also to address the potential *additional* anxiety from seeing others fare better.

I would like to see the facility upgraded…sounds like not a lot has changed with the ORs and the rest of it looked much the same when I visited around this time last year.

The patient experience is very important, but the end result is ultimately what matters most, so I hope you will continue to post updates throughout your recovery and in the months that follow. Going forward, I hope all goes smoothly and you end up with a problem-free, enduring repair.

[MarkT]

I really hate this site sometimes…type up a detailed reply, but it times out and requires login again, with the entire post gone.

I give up…the short of my reply, from memory:

The follow-up time convention seems confusing…what does “36-6 months” mean…36 hours to 6 months or counting backwards from 36 months to 6 months? In one spot they talk about follow up 1 week, 4 weeks…six months…and each year post-op. They mention MRI at 3 and 6 months…ultrasound over the long-term…They could do a much better job of clearly summarizing all follow-up protocols in one spot. The table provided does a weak job of that.

They claim ZERO adverse events beyond three seromas…ZERO infection, recurrence, chronic pain, and even ‘discomfort’. Impressive…and hard to believe.

The video (not part of the study) cites a sub-20min. repair time under local, and yet the study notes a mean repair time closer to an hour even for the single hernias…is that because the recurrence repairs are a different procedure?

I’m curious to know what that springy little flower looks (and feels) like over the longer term? What about the flat mesh portion?

Maybe I’m naive, but some of the figures concern me…Figure 6 shows two 40mm plugs with about that same distance between them, surrounded quite a bit of flat mesh. What is that going to look and feel like years down the road?

I hope there will be longer-term data and (importantly) replication studies.

[MarkT]

Hydrolyzed collagen is typically the form you get in all the health/supplement stores, though there are different types and sources.

There is a summary of some research below from someone whose work I enjoy that suggest some potential benefits. The wilder claims out there typically have very little (if any) good research to back them up…lots of anecdotal stories and hypotheticals.

https://www.foundmyfitness.com/topics/collagen

[MarkT]

I strongly disagree.

Things like communication and payment schedule are indeed relevant from a ‘patient satisfaction’ perspective, but they have virtually nothing to do with the quality of repair you can expect.

What is most important to you, getting the best surgeon and best repair possible or…other things?

Unless you have good evidence to support the idea that frequency/volume might lead to being “overconfident, sloppy, and make mistakes”, there is no good reason to believe that is the case. Evidence-based decision-making is the better path, IMHO.

I agree with Good Intentions…I’ll go further and say that you consistently seem negative, adversarial, and even condescending at times. That is partly what I’m unsurprised that you have yet to find any option that meets your standards.

There is also a strange focus on very unlikely events…I would never choose a a hospital over a speciality clinic because of the *highly* unlikely event that something not only goes wrong, but goes so wrong that being at a more comprehensively equipped hospital would be beneficial. Further, some speciality clinics (like Shouldice Hospital) are responsible in that regard and will refer certain ‘at-risk’ patients to a hospital (this was done with my father). Also, some specialists operate at their clinic, but also have hospital privileges and will do repairs at the hospital if they feel it is better equipped to serve a particular patient.

[MarkT]

Hi Peter – coincidentally, I was just thinking about you this weekend and wondering if anything more had come of your discussions with specialists. I was going to tag you in a post, but I didn’t want to pry…

I understand not wishing to go through the emotional toll of a lawsuit…but perhaps it is worth exploring for the sake of your future? With a strong case, the likelihood of a settlement is probably high, as such cases very often will not make it to court, especially if insurance is involved…they will typically try to negotiate a settlement to avoid the cost of litigation.

Settlement funds could provide a nest egg to help offset current and future lost earnings, help cover health/rehab expenses, and perhaps innovations in treatment/surgery may even materialize that will then be more within financial reach as a result. I would at least reach out to an experienced litigator in this space and go from there.

Only you and Dr. Krpata can really know best, but I still wonder if it isn’t worth taking the risks associated with another surgery to see what he might do for you. Even a ‘partial success’ might be better than the status quo?

In any case, your situation (and that of some others) indeed serves as a valuable warning to not take ‘routine’ surgery lightly…and that even when we do our best to find an expert with a good track record, and we don’t do anything ‘wrong’ ourselves, that things can turn out badly (extremely badly in your case).

I wish that I had more to offer than empathy, encouragement, and throwing out some ideas…I’m glad that you are not alone and have your family for support. There are literally thousands of people out there who have experienced horrible trauma (military veterans, accident and abuse victims, etc.) and with much time and work so many find some purpose and direction, so I wish for you to maintain hope and enlist the help of people who can guide you on that difficult path.

[MarkT]

Perhaps Dr. Towfigh can chime in, as she was part of a group who have published papers on imaging and their work suggested that MRI was far superior to CT or US at diagnosing *hidden/occult* hernias (i.e. those with no bulge and that are not palpable upon physical examination).

AFAIK, she still recommends dynamic MRI in such cases, but perhaps dynamic US is adequate? I think their published studies looked at standard MRI and US (not dynamic) but I’m not 100% sure, so perhaps she will comment further.

[MarkT]

@andy2023; @ajm222

It has been quite a while, so I can’t recall it too vividly…anything flexing the core generated a bit of pain (getting out of bed, rolling over in bed, sudden movements), but it was momentary. You deal with that by propping yourself up on your elbows and relying much more on your arms to manoeuvre, to get up and sit/lay down, etc. You quickly realize how much you use your core for so many movements and I remember my triceps getting a good workout!

About the ‘worst’ thing that can happen is sneezing, which gives you a nice jolt of pain for a few moments, but it passes…and virtually nothing you can do will damage the repair.

It might have felt a little tight, but I wonder how much of that was the pins they used to help seal the incision (they essentially folded up the skin and pinned it), which made for a strong closure with a narrow scar. It felt good when those came out. I’m also not sure if they still use that method.

I did not need any assistance to get up or to do anything. If I recall, I took Tylenol at the recommended intervals and I never felt that I needed anything more than that. It was as much pre-emptive as ‘necessary’, I think.

Classifying pain even on a 1-10 is hard. I’ve never experienced ‘horrible’ pain in my life that I would think falls in the 8+ range…so maybe a 5-6? The first few days were a little challenging, but pain was momentary and never terrible. The pain also guided what I could do because I would get a pang of momentary pain if anything was too much/too quick.

It really can vary between people though. On one end of the scale, one guy was gently riding a stationary bike the day after his surgery (that was certainly more than I was willing to attempt). On the opposite end, an older guy had difficulty even walking and had a meal the next day in his room while everyone else had little problem walking to the dining hall.

They strongly encourage (almost force) you to move after surgery…from turning over in bed periodically to walking at least up and down the hall several times per day (if not outside, weather permitting), to partaking in their ‘exercise program’. I think that really helps with avoiding stiffness that contributes to pain.

You can find some more info by googling ‘shouldice exercise’…from hospital recommendations to patient experiences…and even some videos of people’s experiences and the exercises they were doing post-op.

[MarkT]

@cdnguy – there might be a thread on here with more detailed info, but if you tag stephen or drkang (just put the ‘@’ in front of those usernames), you will probably get a response from Stephen.

Stephen works with Dr. Kang and helps with non-Korean patients…I think he is translating Dr. Kang’s work into English too.

[MarkT]

@cdnguy – there is some info on the hospital’s site:

http://gibbeum.com/whykr/Why-and-What-Kang-Repair.php

[MarkT]

That is quite the false equivalency to respond with “none of us know the real statistics”.

I know that you are smarter than that.

[MarkT]

So I’m an outlier, a rare problem-free, back-to-normal case after two separate surgeries, and the ‘at least minor issues’ rate is hovering somewhere close to 100%?

I think perceptions of reality are being badly skewed by non-representational sources like this forum, doctor review sites, anecdote, etc.

I would suggest that the reason you haven’t heard of more cases like mine is because people with unremarkable experiences tend not to seek out opportunities to share those unremarkable experiences.

Also, the bad cases, however rare, tend to be what stand out and remains salient in our mind.

[MarkT]

“…have yet to find anyone with a tissue repair who is back 100 to normal”

Really?

[MarkT]

GI, maybe you have come across this somewhere…

There was some mention recently of an institution considering amendments to its surgical training program, including more attention to tissue repairs ‘in part due to the desires of its young surgical students’ or something to that effect. I’m almost positive this was somewhere in Europe, but for the life of me I can’t recall where I read it and it doesn’t seem to be in any of the articles I’ve saved.

All I remember is that this was more of a side note in the discussion rather than the focal point of the article, which unfortunately makes it harder to find…but it was good to know that there was some desire for institutional training rather than having to seek it out later.

[MarkT]

I don’t believe it too uncommon for free fixes?

I know that Shouldice Hospital waves physician/surgery fees in cases of a confirmed recurrence…”Hernia repair for a lifetime. Guaranteed” is also stated on its website.

I can’t recall who posted it, but someone else mentioned the same was true of their surgeon.

[MarkT]

Surgeons do not get paid to participate on forums…any time they give to us here, or through the HerniaTalk videos, etc. is on their own free time and we should be appreciative, IMHO.

Per the link near the top of my previous post, Dr. Sbayi completed his graduate surgical training at Seton Hall University in NJ (search his name, then click on the Education tab). He also spent over 1.5 years at Shouldice Hospital, where he went through their internal training program to learn the Shouldice repair and where he performed many hundreds of that repair.

I can’t emphasize enough that we must put the bad reports that we read into proper context…the few negative suture-related cases need to be weighed against the *hundreds of thousands* of repairs where there have been no such issues. If you do a search, you will find that there are also cases where people have experienced problems with a variety of suture materials including Prolene, silk, nylon, and natural gut…these cases are extremely rare too.

It is important to avoid assigning too much weight to such unlikely adverse events. There are many other risks that carry higher probabilities to worry about. Your last paragraph is quite right when you say “…but even that is uncertain”. We indeed have no certainty…we can just take steps to try and reduce the risks as much as possible. So far, the best way we know how to do that with hernia repairs is to select a well-trained hernia specialist who continues to perform a high number of the type of repair that we have chosen.

(Also keep in mind that Dr. Kang not speaking English is completely irrelevant to his skill/experience – the hospital accommodates foreign patients and we have a few people on this forum who have gone there and encountered very little difficulty with the language barrier – at least one of them made a very detailed thread about their experience before and after).

[MarkT]

I can’t speak to Dr. Sbayi’s reasons for leaving Stony Brook…but it seems illogical to assume he was fired, as the hospital continues to list his name on their website and there is no disciplinary action noted on the NY state website (https://www.nydoctorprofile.com/NYPublic/). Also, while he completed his general medical school education outside the USA, his graduate surgical training was completed in the USA (the same link will verify). He could have a very good reason for choosing to leave (e.g., relocation, opening his own clinic, family/personal reasons, etc.)

What I do know is that he also received training at the Shouldice Hospital, performed many hundreds of the repair while there, and he continues to offer it. Despite him longer working at Shouldice, at least one senior surgeon there has publicly recommended him to patients in the U.S. who wanted a U.S.-based option. IMHO, that is a good endorsement, considering that it would have been equally easy to just say something like ‘we can only endorse our own surgeons who work in our hospital’.

IMHO, it short sighted to not come to Canada because of the gov’t and Trudeau. They have *no* relevancy to your search for a quality hernia repair. Don’t let politics cloud your decision, as nothing changes for you as a patient if a different gov’t is in place here. Also, focusing on the ability to sue a doctor seems to be unproductive…you are better served to look for the best care, not the easiest route to sue in the unlikely event that something not only goes wrong, but goes *so* wrong that a lawsuit would be warranted.

Shouldice Hospital does use stainless steel sutures; however, that has not been identified as a problem in the literature. They have done *hundreds of thousands* of repairs with those sutures over many decades and AFAIK there is no good evidence from any reputable source that this is something that ought to be avoided. Having said that, if suture material remains a concern, then by all means consider a U.S.- or Europe-based option, where Prolene sutures are the norm.

There is a valid concern of not being able to choose your surgeon at Shouldice…however, it is worth noting the hospital’s training program and how that might compare to external options offering the same repair:

“All staff surgeons, regardless of their prior experience, are required to complete an extensive introductory training period, during which time they learn our specialized repair technique that requires the use of mesh in less than 2% of all cases. First, they must assist a Shouldice surgical team for at least 50 operations before they are permitted to perform the Shouldice Repair. As this gold-standard technique can take even an experienced surgeon several months to master, each of our surgeons must further complete up to 100 supervised operations under the watchful eye of a senior staff surgeon before being approved as the leader of a surgical team.”

Think about those numbers…within a matter of months, a ‘new’ Shouldice surgeon will be more experienced with that specific repair than the vast majority of external surgeons who do not exclusively offer that repair too.

If it seems that I push that hospital, it is mainly because I believe in the repair and that I believe it is difficult to replicate the training and experience/volume elsewhere (and I’ve had two flawless repairs there myself that have held up for many years now). I don’t see it as perfect…there are things I would like to see studied more or changed at Shouldice Hospital.

There are some external options (mainly in Europe) who perform what is likely a ‘high enough’ number of Shouldice repairs to be comparable in skill/expertise, although many perform some modification of the original repair that has been less studied (AFAIK, such modifications typically pertain to not touching the cremaster muscle and/or using two or three continuous suture lines instead of the standard four).

As for Dr. Kang, who I would strongly consider too (particularly given your location), perhaps you already know his hospital website which has contact info and fee estimates for international patients: http://gibbeum.com/abroad/From-abroad.php

If you are finding flaws/concerns with everyone mentioned on this site, then you are likely to find some with ANY surgeon you consider. My best advice remains to seek a high-volume hernia specialist…and to put any negative reviews or concerns you identify into the context of their overall numbers. When you read 5-10 bad reviews, but that surgeon has been practising for many years and has done a very large number of repairs, some bad outcomes and reviews are statistically expected, because there is no such thing as a 100% success rate over a long follow-up period, even for the ‘best’ surgeons offering the ‘best’ repair options.

Good luck – I hope this information is helpful and that you will find an option that puts your mind at ease and that yields a flawless outcome for you.