Thunder Rose
Forum Replies Created
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I apologize– I don’t mean to denigrate Kang and I don’t fully understand his method(s). I do find it frustrating that someone would pass up highly skilled surgeons in the US and be so dismissive of their techniques simply because Kang is touting a repair that is supposedly so superior. Comparing the Sue and Peter Jones 2-layer Shouldice on YouTube to the old school 4-layer Shouldice video on YouTube from BioHernia, my view is that the 4-layer Shouldice takes more time and more skill. I feel better about having the 4-layer, but to each his/her own.
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Also: there’s plenty of research showing that highly experienced hernia surgeons can achieve low recurrence rates with tissue repairs.
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I was walking 2-3 miles each day starting the day of surgery. I’ve read reviews of Wiese with folks walking ~5 miles right away. I didn’t start running again until 2.5 weeks after surgery. My memory is that Yunis discouraged biking initially (in contradiction to the practice at Shouldice Hospital) and also discouraged squats or dead lifts. I waited until about the 2 month mark for downhill skiing and squats.
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The external oblique aponeurosis (EOA) is cut in both Shouldice and Desarda. It’s the anterior wall of the canal: it is cut to gain access to the inguinal canal in both repairs. See my response to William above for why I’m against the Desarda repair.
Unlike a general surgeon, Yunis is only doing hernia repair: “relatively few” Shouldice and Desarda is still a high raw number of tissue repairs annually.
I had to practice cognitive flexibility to accept that Yunis preferred Desarda repairs. I was focussed on achieving the end result — an out-patient, conscious-sedation, Prolene 4-line 2-running-suture Shouldice repair — that I wanted, and ultimately determined that with Yunis I could have my desired outcome.
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William, I suggest watching the surgical videos for both Desarda and Shouldice on YouTube and considering the 6-sided-box model of the inguinal canal. Being able to visualize the repairs helps a lot. The Posterior and Anterior (back and front) walls are opposite each other, the Inferior and Superior (floor and roof) walls are opposite each other.
The hernia sac comes through a defect or enlarged ring on the Posterior Wall – the back wall. In Shouldice the faulty Posterior wall is first cut and then rebuilt using the structures on either side of the Posterior Wall (from the Inferior and Superior walls, the floor and roof of the box, where they are adjacent to the Posterior wall) to create the “double-breasting” like a fancy jacket.
The Desarda Repair takes the Anterior wall, that is the FRONT wall or opposite side of the box, the External Oblique Aponeurosis, cuts it into a giant flap and pulls it underneath the Spermatic cord and everything else that passes through the canal, and then stitches that to the BACK wall to make a flap that functions like a flat mesh would.
I believe surgeons like Desarda repairs for the same reason they like mesh: it’s a big flap that is easy to fix in place and cover a defect. It’s an easy to teach repair.
Yes, both repairs cut into healthy tissue. Shouldice is a clever bit of double breasting using structures immediately adjacent to the defect. Desarda is borrowing tissue from the top of the box and tacking it onto the bottom of the box, creating a mesh-like tissue repair.
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I was influenced by the idea that for the majority of people it’s not reaction to the mesh itself but badly placed mesh that causes the problems, hence mesh plugs and system meshes causing issues with such frequency. I extended that thinking to even the flat meshes bunching/migrating over time: perhaps there’s no such thing as well-placed mesh. It’s the quick, easy, literally band-aid-like solution, but not a good choice for an enduring pain-free repair.
Yes, there’s a large body of material in my Shouldice repair’s four lines of running sutures. Prolene sutures are used internally throughout medicine without the level of issues we see with Polypropylene mesh, which leads me to think the problems primarily arise from the form (mesh) not the material (polypro).
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I didn’t research this.
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I love that I’m getting called out for personal biases. I made crafts a few years ago with my kids using a similar gauge of stainless steel to what they use at Shouldice Hospital (32 or 34 gauge): tiny posable beaded animals using seed beads. Here’s a link that’s very similar https://stuwahacreations.com/2014/08/20/how-to-make-tiny-beaded-geckos/. They lasted a few weeks and my kids played with them and eventually that wire snapped with not much bending back forth. So I have an image of those tiny bifurcated gecko bodies with tiny sharp metal points jabbing out their middles that I cannot forget.
I also think Grischkan made a comment to me about the stainless steel sutures snapping as a reason why he uses polyester sutures despite having close ties to Shouldice Hospital.
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Yes I’m still happy with my repair. I live in Wyoming and since my repair have done nearly two full ski seasons (Alpine and Nordic) and quite a bit of running, hiking, and biking. I don’t have any pain with exercise.
Very rarely when at rest I get a twinge or brief ache of scar tissue pain at or near the surface of my skin, but I don’t have any pain deeper down at the site of the repair in the inguinal canal.
Sorry, I don’t feel qualified to give more specific critique of the Desarda repair. I suggest watching the YouTube video of Desarda himself demonstrating the technique. My memory is that it gave me the willies watching him pull tissue under the spermatic cord that should have been over it.
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I never talked to Peterson. I piggybacked on another HerniaTalk user’s research in ruling him out (that was privately shared with me). The info I received was that he uses individual sutures instead of running lines, and I knew I wanted running lines.
I don’t have informed opinions on mesh removal, but my uninformed opinion is that it’s a more specialized surgery than a tissue repair, and I’d be more willing to spend the money to see someone like Towfigh to have a chance of getting my health back without the solution being worse than the problem.
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Hey Chuck: Wiese vs. Koch: I know that Wiese uses Prolene for his Shouldice repairs because of this thread: https://herniatalk.com/forums/topic/my-meshless-hernia-repair-in-germany/ I’m not clear if Koch uses Prolene or Stainless.
I almost went to Wiese because I had to make a family trip to Ulm in spring 2020. I was going to have my hernia surgery before flying home from Frankfurt. Then COVID hit and I cancelled my surgery. My hernia became much worse in Summer 2020 and that’s when I found HerniaTalk and did a lot more research.
So there’s some random geographical bias in my mentioning Wiese. I sent BioHernia better-informed questions in fall 2020 for both Koch and Wiese but I didn’t get any answers, just a response from Nahom that he realized I still couldn’t get into Germany at that time on a US passport. These are the questions I sent Nahom, copied from my email:
…is it possible to ask Dr. Wiese or Dr. Koch some questions about the particulars of their repairs? I’ve come to understand that not all Shouldice repairs are equivalent. For instance,
1. Do you transect the genital branch of the genitofemoral nerve routinely? Do you identify and protect the ilioinguinal nerve or is it transected?
2. Do you transect the round ligament routinely?
3. Do you ligate and resect the hernia sac routinely? In what circumstances would you do so?
4. Does your Shouldice repair always include 4 lines of sutures on the posterior wall (2 sutures each reversed to make 4 lines total) or do you place 2 lines on the posterior wall? Which structures are being sutured together in the reconstruction on the posterior wall?
5. What kind of suture material do you use for the posterior wall reconstruction? For the closing of the external oblique aponeurosis? For the skin closure?Also, is it possible to request a Shouldice and not a Desarda repair, or is it up to the surgeon to select the repair type during the operation?
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Watchful: you’re correct: I made an error above. Sbayi uses conscious sedation, though my notes show he told me that he “may introduce general aneasthesia to let muscles relax” although I believe he said that’s rare.
As you say Yunis prefers GA but allows for patients to choose MAC. I was able to choose at a private conversation with the anesthesiologist immediately pre-op at the facility.
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Hi Monika, I was interested in a Marcy repair until a surgeon said my hernia was most likely Direct (based on its shape and size). It did turn out to be a Direct Hernia.
Have you found a surgeon who will do a Marcy repair for an adult without reinforcing with Desarda? I suppose Kang does.
Watching YouTube videos of the Desarda repair ended any interest I might have had. It doesn’t make sense to me anatomically, and I think I was influenced by comments Towfigh has made about not doing Desarda repairs and the absence of evidence for the procedure. I only went to Yunis given reassurance that he would honor my choice not to have a Desarda repair.
I haven’t been thinking much about hernia repairs for over a year. I have not been following new research and opinions on these repair options.
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Hi Debbie, Sbayi uses metal sutures and insisted on General Anesthesia. I decided I wanted Prolene and Monitored Anesthesia Care (MAC) / Conscious Sedation. Yunis uses Prolene and offered MAC in an outpatient surgical facility instead of a hospital setting. I could have had the same (Prolene Shouldice repair w/MAC in outpatient facility) from Dr. Wiese in Germany and probably would have gone that route if not for COVID. Yunis was out of network for my insurance but the facility and anesthesia were in-network: it wound up being less money out of pocket even than the flat rate for Wiese, so it worked out in my favor.
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I read Kang’s website in depth last summer. I am not swayed. Science requires replication and independent verification. Have you taken the time to watch videos of these surgeries? If you have the stomach for it I highly recommend it.
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Yes he offers two methods: a Marcy repair for indirect and a 2-layer Shouldice for direct. But he calls it a Kang repair and claims it’s different? If you look into what he’s suturing I don’t see any significant difference except for some very cute comic strips.
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What is it that makes you think Kang Repair is so worthy of replication? I see him as having hired excellent marketers, but I don’t see that to be correlated with being a great surgeon. There are other surgeons offering a tailored approach (Towfigh, Yunis, Muschaweck, Wiese). I see Kang and Muschaweck both obfuscating the details of their two-layer repairs while using their branding to sell their procedures as unique, when they’re in fact not functionally different from the other two-layer Shouldice and Bassini repairs being offered by various surgeons through the E.U., U.K, and U.S. — surgeons with strong enough word-of-mouth followings that they don’t need to invest in expensive marketing strategies.
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I don’t think Brown, Yunis, Grischkan, and Kang are the only surgeons offering 2-layer Shouldice. I do think many are calling it Bassini.
I strongly considered Grischkan but ultimately did not feel comfortable with his use of polyester suture material. Similarly Brown uses highly inflammatory silk sutures. I was more concerned about choice of suture material rather than the volume of material.
For me the healing at the subcuticular wound closure was much more bothersome than the internal suturing, where I have never noticed any significant change of sensation. I would rather have a one-and-done surgery than endure another surgical wound.
I can see how that’s an argument for the smaller incision offered by Kang. But I don’t think it’s a straight up smaller-is-better metric — a too short incision could result in increased bruising/internal bleeding, i.e. more trauma at the surgical site. I feel confident that Yunis is doing the smallest incision that reasonably balances those negative effects. Since my incision was only 6 cm, I do think he’s to some extent adjusting incision length to body type.
I’m just over 6 months since surgery now and still very happy with my repair.
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Hey Dave, my repair is 4 lines of Prolene on the posterior wall (formed by 2 running sutures), what’s commonly referred to as a 4-layer Shouldice. I wanted the 4-layer repair to reduce likelihood of recurrence. The incision length was roughly 6 cm (just under 2.5 inches). I think I was told it would be 3.5 inches so it was shorter than I expected. Good luck!
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Hey AJ9000! I’ve been reflecting that my surgery with Dr. Yunis and recovery were particularly easy because we live at over 7000 ft. in Wyoming, so sea-level in Sarasota was akin to a hyperbaric chamber. It’s good to hear you also had a good experience (most likely without that elevation benefit)!
We flew home on day 6. I kept up with the highest recommended dose of Tylenol and ibuprofen for the first week or so to prevent pain escalation.
I hope your return to the gym goes well!