MarkT
Forum Replies Created
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I would go to Shouldice first…then probably Dr. Sbayi…then I would do more homework on the U.S. and European options.
Shouldice has the history and track record. Even the ‘new’ surgeons there are going to very quickly gain more experience with the repair than virtually any external surgeon whose practise is not primarily focused on that repair…and they will have been trained ‘from the source’.
Dr. Sbayi was at Shouldice for a year, where he learned the repair and performed many hundreds of them…and he has performed many hundreds since then. AFAIK, he remains quite faithful to the method too. In North America, that is about as close to “Shouldice, but outside of Shouldice” as you are going to get.
For any other option, I would want to know where that surgeon learned the repair, how many they have done to date, the volume/frequency they still do, what they modify (if anything), and hopefully some patient outcome data including how they track it.
While it is almost certain that it is not necessary to average 50 repairs a month to become sufficiently proficient so as to provide the best chance at an ‘optimal’ outcome, we also don’t really know what level of volume/frequency is necessary to achieve comparable results. At minimum, I would want someone who has done a lot of them and who continues to do a lot of them…a relative handful per year is not going to cut it, IMHO.
I’m still amazed at how much discussion revolves around the cremaster…I just don’t get it…in fact, I think it is almost a ridiculous focal point when there are many other risks associated with the surgery to which no one is devoting nearly as much discussion…some of which are more likely to occue and/or are much more debilitating.
Do yourselves a favour and contact Shouldice…ask for a list of risks and their approximate likelihoods…ask about cremaster function and why loss of reflex or descended testicle is very uncommon despite the resection…I suspect many of you will probably stop obsessing about the cremaster if you do so 😉
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Peter, I’m so sorry to hear that a reliable solution has not been identified and I can only try to empathize with your frustration and resignation.
The flip side is that I know what it takes to perform at an elite level, and I know from your many posts how much time and effort you have put into deeply understanding your situation and looking for a solution…so I can’t help but respectfully wonder if the psychological toll this has taken on you over these 2.5 years is behind the feelings of having no fight left in you. I believe that you are stronger than you might understandably feel at this moment…
If you don’t mind sharing more info, how did Dr. Krpata frame the surgery? His being unsure if you would get better may not be surprising, given your unique situation…but did he give *some* indication of what improvement he believes could result? Did he frame the surgery as being a reasonably good idea or did you get the impression it was a ‘hail Mary’ type of option?
Beyond normal risks associated with surgery, did he identify specific risks beyond potentially losing a testicle? Not to downplay that (who wants to lose a testicle??), but it does strike me as a *relatively* trivial one given the context of your current situation, no?
Anyway, I am certainly not pushing you towards more surgery…but am wondering more about how the pros/cons were framed by Dr. Krpata and how you weighed them, and whether it *might* be worth reconsidering to give yourself the chance at improving in some way. As always, thanks for sharing.
-Mark
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Sounds like you are healing normally.
If you had a ‘typical’ inguinal hernia and uneventful surgery, then it should be virtually impossible to damage the repair via normal daily activities like walking, household chores, etc.
If you are two weeks out without any problems, then you would likely not have any restriction on activity at this point and pain tolerance will be your natural limitation…unless you are doing something unusual like very heavy lifting, more extreme sports, etc., which might warrant waiting a bit longer and perhaps checking in with your surgeon.
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I pulled a copy of the paper. It is a relatively brief editorial opinion, rather than a formal study.
Worth noting the author (Joseph E. Fischer) was at Harvard since 1970 and passed away just last year. He was quite a prolific researcher: https://en.wikipedia.org/wiki/Josef_E._Fischer
He notes that ‘fads’ exist in surgery and that some procedures have become the norm without a whole lot of evidence behind them, sometimes simply because some ‘important’ person championed them…and he believes this to apply to hernia repair.
When he was a resident (mid-late 60’s?), the Cooper’s Ligament repair (Anson-McVay repair) was the standard being taught…although he was not sure why, because while it was purported to prevent femoral hernias, such hernias made up only ~1% of male hernias. He said that a few years later, when he was doing more surgeries, “…I noticed that there was more postoperative pain with the Cooper’s ligament repair, so I started doing the conventional repair but with special attention to the transversalis fascia. It was not the Shouldice type of repair, of which all of us were aware, which in its classic execution demands that one cut through the transversalis fascia and then reef it up, repairing it, but we did in fact tighten up the transversalis fascia, resulting in increased strength of the repair. I also noted that there was less pain with this transversalis fascia repair, paying special attention to the inguinal ligament and the conjoined tendon, and I observed few recurrences and noted very little pain.” (p.620)
He goes on to say that recurrence became the primary outcome consideration of most hernia surgeons, despite recurrence rates of 4%-6% and pain rates between 2%-4%, both of which he deemed to be ‘satisfactory’.
He states that a ‘cottage industry’ of mesh repair then developed, with numerous post-grad courses teaching various repairs with various meshes. His friend (Arthur Gilbert) developed the plug and patch, and there was Kugel, Lichtenstein, and variations on the plug and patch…with surgeons being happy to believe that recurrence rates would drop.
But he then saw many patients who had post-op pain, given that much of his practise was dealing with problem cases of patients from other surgeons. Inguinodynia (chronic pain) was an issue for many, though he noted it was often very hard for him and other surgeons to determine if patients had real chronic pain or purported to have it because they were seeking legal recourse.
He claims that most hernia surgeons denied there was such things as inguinodynia at the time. He disputes this and says there were simply too many cases for them to all be bogus and that many patients indeed had life-altering pain. He therefore questions why there was a movement to introduce mesh to reduce an already ‘acceptable’ recurrence rate, given the terrible chronic pain that resulted for a small but significant number of mesh repair patients.
What he finds particularly interesting is that while most surgeons denied that inguinodynia exists, they still took great steps to prevent it via neurectomy. He also suggests that chronic pain can result from “osteitis pubis from permanent sutures in the pubic bone, cord entrapment, and sutures catching the cord or the genitofemoral nerve” (p.620).
He then does a bit of a literature review, but there is just too much info to summarize it all here. A couple of studies found that chronic pain was a bigger concern than recurrence and that neurectomy reduced chronic pain (despite others, like Lichtenstein, claiming inguinodynia does not exist and that all nerves should be preserved).
He criticizes one study that found neurectomy to not be effective, stating they didn’t perform what he believed to be the right excision, which would be “the isolation of all 3 nerves, dissecting it as far back as one can laterally, tying it off with 6-0 Prolene, touching the end of the nerve with phenol and alcohol, and then burying it in the muscle” (p.621).
He feels that there is a ‘steep learning curve’ for doing a good neurectomy that many surgeons are simply not willing to overcome.
After the lit review, he says “…whatever the incidence, there is a small but significant group of patients who undergo a mesh repair who are seriously inconvenienced by the amount of pain in both the near and remote postoperative periods” (p.622).
He maintains that a 6% (max) recurrence rate is worthwhile to accept in order to avoid the small, but significant number of cases of debilitating chronic pain that has a major impact on quality of life and even results is some mesh repair patients being suicidal (we have at least one on this forum).
He says that his preferred (tissue) repair method is no longer readily taught and most surgeons today would not even understand it.
The big takeaway in his discussion: “…there is no question in my mind that patients will be better off if we abandon mesh repairs with or without neurectomy and return to an old-fashioned transversalis type of repair, taking care to reef up the transversalis, and to doing a careful repair of the conjoined tendon and Poupart’s ligament, somewhat along the lines of the Shouldice Hospital repair” (p. 623)
That is a pretty strong statement.
He notes “…there is now a considerable body of patients, numbering in the thousands, who report inguinodynia to a US Food and Drug Administration (FDA) database, and it is only increasing…The inguinodynia database that the companies allegedly collect is imperfect, and companies keep asking for the piece of mesh that was removed from the hernia site, examining it for defects. I think this is a sham. It is not a deficit in the mesh that gets these patients into trouble, it is the inflammatory response of the 3 nerves to whatever kind of mesh is inserted, and adherence to the mesh and/or the inflammation around the mesh is what causes the inguinodynia, which I think is a miserable disease” (p.623).
His parting words are that “recurrence of a hernia is not the most terrible thing in the world. It can be repaired. But patients are not miserable and do not take narcotics, they can go about their ordinary business, and the pain is relieved by simple medications, and if it is not tolerated, these patients can undergo repair of the reoccurrence. It is time that we stop creating inguinodynia in inguinal herniorrhaphy. The public health problem of herniorrhaphy in 5% of the adult male population in this country undergoing mesh repairs will sooner or later create an enormous problem” (p.623).
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Be sure to get solid travel/health insurance too, where the purpose of your travel is approved up front by the insurer (to avoid a claim possibly being denied after the fact).
The chance of serious complication might be very low…but getting stuck in a foreign country, with no insurance, and requiring an extended hospital stay and/or additional medical services…definitely don’t want to deal with that!
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A tissue repair for femoral hernias was developed at Shouldice and it is described in this paper:
Shouldice, E. B. (2003). The Shouldice repair for groin hernias. Surgical Clinics of North America 83(5), 1163-87. https://doi.org/10.1016/S0039-6109(03)00121-X
I pulled a copy of the article, since the abstract does not give much info. This paper is almost 20 years old and I have no idea what (if anything) may have changed. Also, per the Shouldice website, they do use mesh in some cases. After a lengthy description of their inguinal repair, this is what is written about their femoral repair:
“Although initially mesh was used to try to decrease the recurrence rates, in 1984 Dr. Alexander, of our institution, introduced a pure tissue repair that is now one of the methods used for correction of femoral hernias when the inguinal ligament is intact. This repair, called the complete groin repair, also includes an inguinal exploration and repair of any other defect identified at that time.
Complete groin repair technique for femoral hernia
Dissection is performed in the same manner as for all groin hernias, including division of the transversalis fascia to allow a clear view of Cooper’s ligament. Reduction of the herniated mass is facilitated by complete exposure and splitting of the posterior wall of the canal and dissection below the inguinal ligament, freeing the hernia. A sac is not always present in femoral hernias; fat alone is identified in 7.3% of our male patients and 4.4% of our female patients with primary femoral hernias. Once the femoral orifice is cleared of the hernial mass, permanent interrupted sutures (Fig. 10) are passed initially through the defect from below and through Cooper’s ligament then carried anteriorly and superficially through the inguinal ligament and iliopubic tract in wide loops. These sutures are placed about one centimeter apart closing off the defect and covering the area from the pubic tubercle to the femoral vein. These are left untied but clamped together with hemostats, with the free ends extending inferiorly toward the thigh. The repair then proceeds as with an inguinal hernia repair. The second line of suture, however, interlocks with the previously placed interrupted sutures across the femoral defect. Upon completion of the third and fourth lines of the Shouldice repair, the interrupted sutures are drawn up and tied, thus pulling the Shouldice repair toward Cooper’s ligament. Sometimes, to avoid tension the tissues may not be completely opposed; however, in these situations the sutures appear to act in a similar manner to a mesh repair closure of the defect.”
Again, I have no idea if this remains the way they do the repair or if it has been modified since this was written. I would certainly contact Shouldice with any questions.
Monika, I went to Shouldice for inguinal repairs (30yrs for one side, 17yrs for the other). Both seem to have been flawless…no issues since then. I believe Mike M and Pinto both had inguinal repairs performed recently by Dr. Kang and they speak highly of their experiences as well.
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You should hear back rather quickly if you email them, probably before the end of the following day.
I think you are overseas? They have an int’l toll-free # as well. They might ask you to create an account on the website and submit their medical questionnaire to get detailed info.
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Shouldice method is used to repair femoral hernias and the Shouldice Hospital has done many thousands of them. They note on their site that mesh may be used for these repairs though, depending upon the nature of the defect, tissue quality, etc.
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AFAIK, ultrasound is generally fine for detecting regular hernias and is the common first option…but MRI has been shown to be superior for detecting hidden/occult hernias.
I think the usual order of imaging would be ultrasound, then CT if ultrasound is inconclusive, then MRI…in part because of cost, speed, and technical expertise to perform and interpret.
Dr. Towfigh has published research in this domain:
https://pubmed.ncbi.nlm.nih.gov/25141884/
https://pubmed.ncbi.nlm.nih.gov/30368312/ -
Hi Peter – in a previous post, you mentioned the possibility of additional surgery to restore at least some function, but that you were afraid to consider it (which is quite understandable).
Did you ever explore that further and find out what (if anything) could be possible? Has any other surgeon suggested a course of action?
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If it is returning to almost flat, and you have no other change in symptoms (pain, or anything else mentioned above), then it seems unlikely that there is any incarceration or cause for concern…maybe just some swelling?
That is just my non-professional opinion though, so I would suggest checking in with your doc if you think anything has significantly changed.
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If your hernia is able to be reduced, then it is (by definition) not incarcerated. It doesn’t have to be reducible on its own when lying down…if it can be manually pushed back in (gently!), it is still considered reducible.
Often, it will reduce passively by lying down…sometimes people can reduce it themselves with gentle manipulation…sometimes the help of their doctor or surgeon might be needed to reduce it.
You may or may not have any pain with an incarcerated hernia. Pain is a possible symptom, but not a necessary one…and even a reducible hernia could be associated with some pain either right away or over time.
If you suspect incarceration, you should seek prompt medical attention to confirm, as it could be a medical emergency. Incarceration can also lead to strangulation (where blood flow is restricted or cut-off, or where there is organ obstruction), which is indeed a medical emergency. Symptoms can include more severe pain, swelling, and/or tenderness; nausea, vomiting, chills, sweats, etc.
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@mikem
I am very glad you had such a positive experience with Dr. Kang and you have done the community a great service with your detailed posts.
I think we might quibble over the cremaster concerns and maybe recovery time, but these discussions are very productive and highlighting another reliable tissue repair option is a wonderful thing.
Aside from the way he differentially treats direct and indirect hernias, which itself is quite interesting, I’m particularly intrigued by his assertions that using mesh is *always* avoided in inguinal repairs regardless of patient characteristics (age, weight, etc.), hernia size and complexity, and even tissue quality…all of which goes even further than what Shouldice would maintain.
I wish we could have some direct discussion and debate between surgeons. Wouldn’t it be fascinating to have a top Shouldice surgeon sit down with Dr. Kang for a congenial chat? Two guys who have done many thousands of tissue repairs, who both strongly believe tissue > mesh, who could offer deep insight into why they do things they way they do, and who could question each other on the merits of their respective approaches?
I know he keeps his own data, but I really hope Dr. Kang takes steps to have his work formally studied and published. If his overall approach and repair methods are indeed this good, that is the path to getting his message out there and eventually having his methods taught. I’m dismayed that there is not more than one Shouldice Hospital out there…and perhaps there should be more than one Gibbeum Hospital too!
Thanks for taking the time to document your experience.
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You still need to check on that before travelling.
Quite often, standard travel and emergency medical insurance is meant cover unforeseen situations and emergencies…but you have a pre-existing condition (the hernia), are seeking elective (non-emergency) surgery. That represents an entirely different risk to the insurer vs. someone just going on a normal vacation. You want to be sure that the nature of your trip does not void coverage and that you are covered for post-op complication or a botched surgery.
Remember, these ‘point and click’ policies are not fully underwritten up front…only when a claim is filed does the insurer really take a close look…and they will typically do whatever is reasonably possible to avoid paying out.
It is also worth finding out how quickly they do pay out…i.e., do you need to cover expenses yourself and will be reimbursed later when (if) they approve your claim?
Again, the risk of complications might be very low and everything probably goes just fine…but it could be an extremely costly and stressful situation to be overseas, dealing with post-op complications, and then find out you have to cover costs yourself for a while or that your costs are not being covered at all. Best to be prepared!
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Hi Peter,
I’m glad to hear that you have been speaking with people like Drs. Yunis, Meyers, etc. It is really disheartening to hear how ‘crazy’ Dr. Brown’s plan was when others critique it…but that dynamic could actually help to identify a good course of action for you.
I don’t know how feasible this would be…but what about assembling a group of specialists to provide feedback on various treatment plans? Even if they won’t formally collaborate and compare notes, you could do this on an individual level.
If Dr. Meyers (and a couple more) would at least put their proposed treatment/surgical plan ‘on paper’, you can send it around to whoever is willing to look at it (along with your imaging, medical records, etc.) to solicit expert feedback.
Let’s say you end up with three different surgeons who each provide you with a somewhat detailed plan of what they would do to try and correct or improve your situation…then you get them to critique each other’s proposals…then you add a few more specialist to the mix, who might not be willing/able to operate themselves, but whose expertise might yield additional feedback on those three plans.
Thus, you would end up with a half-dozen or so opinions on each of the three treatment options to help you compile a list of pros/cons as you try to make a decision.
Seems that might work better than everyone working in isolation? I would even offer to pay people a consulting fee of some sort for their time to participate in this idea. So if Yunis won’t operate, maybe he will spend an hour or two with you, going over the three plans from other surgeons, for example.
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Hi Dr. Kang,
I am happy to provide info when I find it…of course, I am not a surgeon and do not understand all of the details, so your response is very valuable for learning more 🙂
Your comments also reinforce the idea that the skill and experience of the surgeon may be the most important variables for patients to consider, especially with complex tissue repairs. The relatively low complication, recurrence, and pain rates that your patients (and Shouldice Hospital patients) enjoy is almost certainly due in large part to those factors.
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You’ll have to thank Mike M for that last reply 😉
As for me, I did indeed go to Shouldice Hospital…two inguinal repairs…one side was 30yrs ago, the other 18yrs ago. Both repairs were problem-free, with no chronic pain or any limitations on physical activity since then.
Memory is hazy, but one of them was trouble-free in terms of not having much pain and being easily reducible right up until the date of the repair, while I had some discomfort develop with the other one in the time leading up to surgery…some pain and it would take a bit longer to reduce when lying down, if I recall.
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@emuboy2000 – I appreciate you taking the time to respond and expand upon your decision. I had not seen your previous posts, so this has been helpful. BTW, I was not doubting that you actually lived near Shouldice, in case that was not clear…I mean that I perceived the decision to go to Korea as dubious, given that you live near Shouldice.
Clearly the added context of being Korean and still having ties to Korea, is very relevant. Further, having a hidden/occult hernia is *extremely* relevant to your position and the criticism that Shouldice will not rely on imaging and will only operate on a palpable hernia (and I share that critical viewpoint – I think imaging clearly has much to offer – its flaws should just be recognized).
I understand the points you make about the longer stay, staples, and the ‘always having done it this way’. I think Shouldice should indeed modernize some of its procedures and policies, including updating the hospital and beds, considering alternative closing methods, and offering an option to not stay for several days. Personally, these are not enough of a ‘negative’ (and the stay is positive in some ways) to sway a decision when the procedure and outcome should be the priorities, but I understand each person will have their own thoughts about that.
I find “The problem with Shouldice” blog to be riddled with problems. Virtually every criticism and point raised by that surgeon has little (if anything) to do with patient outcomes and typically doesn’t even consider the patient perspective. She talks about the ‘fairness’ of Shouldice being able to cherry pick patients, being grandfathered into the OHIP system as a private hospital, that she would be bored doing the same thing every day, etc…it’s all valid criticism of the SYSTEM, but near-irrelevant from a patient perspective.
In any case, thank you for expanding upon your previous post. Your decision makes more sense to me now. I don’t want to appear to be a “Shouldice shill” either…I had good experiences there, recognize what they could update or do better, and I am very pleased to see Dr. Kang being another tissue repair option. If you do go, I hope you will post about your experiences the way Mike M has done.
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@emuboy2000
Personally, I think that is crazy to fly to Korea and take on unnecessary risk and expense if you truly live ‘across the street’ from Shouldice, but to each their own.
The main reasons I could see someone choosing Dr. Kang over Shouldice is the inability to choose the surgeon at Shouldice, or because the patient is not Canadian and would need to travel and pay ‘full price’ for their repair anyway…and yet neither of those are mentioned among your concerns.
Making decisions about your health because of things like an ‘if it ain’t broke don’t fix it’ cliché or the antiquated ‘hotel’ strikes me as very shortsighted, as neither is relevant to what SHOULD be your primary concerns: the quality of the repair and your expected outcomes. Why is staying there for several nights an issue if you are willing to fly to Korea???
Not sure why the closure method factors in either. The closure is strong and reliable, yielding a narrow scar that fades with time. They remove the pins before you are discharged…takes a few minutes. Perhaps not ideal, but is that really a concern?
While I do wish they would amend this policy, Shouldice’s reliance on physical exam (which AFAIK all surgeons will do, even if they have imaging) should mainly be a concern only for the small minority of patients who have a hidden/occult (non-palpable) hernia. The Shouldice method makes missing a secondary hernia extremely unlikely too.
Part of the reason for relying on physical exam is that it does remain the easiest and highly reliable way to diagnose a hernia…and because imaging can be poorly done, misread by clinicians or radiologists who are not hernia experts, and can yield false positives (see Dr. Towfigh’s published work for more on those points). Shouldice will tell you they see a number of patients each year who have false positives from imaging.
There is plenty of competition in the space…millions of hernia repairs are performed each year…but if you want a Shouldice repair, you either need to go there, find another surgeon who offers it (and who comparatively performs a fraction of the number of those repairs), or else choose another repair method (and Dr. Kang does indeed seem like a good one).
I don’t think going to Dr. Kang is a bad thing and I’m guessing you will be quite satisfied in the en…it just seems like a rather dubious decision if you are ‘across the street’ from Shouldice and haven’t even cited the main concerns that some have with going there (choice of surgeon being the main one).
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@mikem – I’ve had two repairs for inguinal hernias done at Shouldice Hospital (right side ~30yrs ago, left side ~18yrs ago). I don’t have the surgical notes, but assume the cremaster was cut or reduced, since that is standard practise there. My cremaster reflex functions fine and from what I can tell, both repairs have been flawless…no post-op issues, zero chronic pain to this day, no restriction on lifestyle (swimming, yoga, weight training, etc.), I can’t recall ‘tension’ being an issue during recovery, but it has been a while.
In addition to the three docs you mentioned, there is also Dr. Sbayi @ Stony Brook in NY. He worked at Shouldice for 1yr and continues to perform that repair with many hundreds of them under his belt.
Great news that Stephen is translating Dr. Kang’s book…I’ve been impressed with what I’ve read of him and his work, of course from the experiences of you and others. I hope anyone else here who chooses him will also post about their experiences.