Thunder Rose
Forum Replies Created
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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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I was concerned with minimizing swelling so I wanted papain and bromelain. I ate a lot of papaya and pineapple the week before and week after surgery, but you can also buy these as supplements. I prefer getting them from the whole foods.
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Inguinal is a groin hernia. What you describe sounds like an incisional hernia.
I have a friend doing well with DNRS, that could help pre-operatively.
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The article you linked to cites 4 recurrences vs. 1 recurrence: that isn’t a lot of data. Have you found any similar studies? I’m swayed by the research showing that the recurrence rates for the Shouldice repair are correlated with a surgeon’s experience with the repair, so I’m inclined to trust Yunis if he says he can do a strong repair without resecting the cremaster.
I believe Dr. Reinhorn in Massachusetts prefers doing Nyhus repairs. He wasn’t taking out-of-state patients last summer but perhaps that’s changed. Towfigh and Yunis both perform Nyhus repairs but I don’t know their algorithm for who gets one.
My reason for not wanting stainless steel was concern over it breaking. I’ve worked with 32 gauge stainless steel doing beading projects with my kids so I know from personal experience with the material how easily it snaps and breaks apart. I benefitted from another patient sharing their notes on a large number of surgeons (that’s how I have data on the cremaster) and he had notes about Muschaweck preferring Prolene. I liked that Towfigh and Yunis both use Prolene and that it is known for ease of removal if there were a need to do so. I didn’t want Polybutester (used by Grischkan) as it’s polyester and hence more inflammation-inducing. The YouTube videos of Drs. Sue and Peter Jones doing Shouldice repairs use Prolene (you can see the color is blue on the periphery of the view although it looks more purple where it’s over flesh) and we were impressed with their technique.
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Regarding exercise: I had a large direct inguinal hernia for more than 5 years of watchful waiting. Most exercise was indeed fine: running, x-country skiing, swimming, downhill skiing, dancing, road biking and stationary biking, figure skating, and hiking.
Mine finally worsened last summer and I do think it was in part due to a change in exercise as well as having waited so long. HIIT (esp. squats and lunges) is not recommended. I also started doing longer trail runs (7 miles+ with lots of hills) and single-track mountain biking with lots of hills.
So yes my experience is that most forms of exercise are fine.
Regarding the cremaster muscle, it wasn’t relevant to my anatomy, but my understanding is that Yunis works around it but Brown prefers to “shave” it. Shouldice it’s optional to take it but Sbayi always takes it. Kang and Muschaweck don’t take it.
I’m very happy with my Shouldice repair from Yunis. I wouldn’t go to Brown because I wouldn’t want a Desarada repair on top of my Shouldice repair. The Desarda repair is destructive of non-injured tissues in order to create the flap of External Oblique Aponeurosis to use as a patch.
Anterior is toward the front of your body, posterior is toward the back. The posterior-placed mesh (laparoscopic or robotic) is much larger than the mesh used in the anterior repair, and typically covers the direct, indirect, and femoral spaces. It’s also usually a contoured mesh and the procedures are less studied than anterior-placed mesh. Anterior mesh is in the inguinal canal, so it’s in the same space as the spermatic cord and the ilioinguinal and genital branch nerves. I’d choose Nyhus if I were to have mesh– posterior-placed mesh from an open, anterior repair — as it’s a smaller mesh with the benefits of being in the posterior space.
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I was reading the preview chapters of “The SAGES Manual of Groin Pain” (Towfigh is one of the editors) and I saw “snapping iliopsoas tendon” listed as one of the causes of groin pain in the chapter “Groin Pain: An Overview of the Broad Differential Diagnosis”. Did you end up getting a diagnosis?
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Please don’t give up. I think you’ve read about the SH patient — the wife on the runner’s blog — who went to Meyers after Brown and had a lot of improvement. Grischkan does Desarda reversals so that’s another potential option. I went to Yunis and he did amazing work with me — he’s also a vascular surgeon and I believe his work is world class but he works with insurance and for me at least was fairly affordable. He does revisions and Nyhus repairs but I’m not sure what he does for SH.
I’ve been reading Atul Gawande’s books about surgery and medicine — the early ones (Complications and Better) — and he talks about how slow the system is to recognize bad doctors, or doctors who were once good but become bad due to psychiatric problems or alcoholism or drug abuse or illness or whatever. It really really sucks. I think you are doing a great service by telling your story.
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One caveat is if you think you’re reacting to the suture material on the posterior wall (in this case silk which is much more inflammatory than Prolene). If that’s the case then you probably do want that removed, and most likely they’d need to place a mesh. In your shoes I’d want a Nyhus repair with polypropylene mesh. But given my experience and the preferential use of “tension” tissue repairs for low BMI dancers I’d doubt that the tension itself is the problem.
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Hi Peter,
I hope you’re getting more answers from Drs. Zoland and Meyers.I think your questions about the closing of the External Oblique Aponeurosis get into complexity of the anatomy of the inguinal canal. My understanding is that the modern Shouldice or Bassini uses the external oblique aponeurosis just anterior to the inguinal ligament, but still on the inferior wall, as part of the reconstruction of the posterior wall of the canal after the cutting of the tranversalis fascia. This is not part of the closing of the E.O.A., which forms the anterior wall, and is typically done with an absorbable suture (mine was Vicryl).
However, the Desarada procedure uses a flap of that E.O.A. from the anterior wall to reinforce the repair on the posterior wall. In order to do this, the flap of muscle must be freed, i.e. they cut into the muscle medial to the canal to create the flap that is then pulled posteriorly into the canal. My understanding is that Brown does this or something similar to reinforce his repair.
Again I hope you are getting the help and advice you need from the surgeons you’re talking to. But my informed guess is that the Bassini repair on the posterior wall should not be reversed, instead it’s the Desarda or Halsted reinforcement that involves cutting into muscle and relocating it to a different area of the anatomy. For the male anatomy there is the additional complication of muscle that should be anterior to the spermatic cord now being relocated posterior to the cord. There are people on this forum who have gone through Desarda reversals with some improvement.
I have 4 lines of Prolene reconstructing my posterior wall by connecting the superior wall (transverse abdominus, transversalis arch, internal oblique) to the inferior wall (inguinal ligament, external oblique aponeurosis). Today I’m 2 days short of 2 months out from surgery and in the past week I’ve cross-country skied, downhill skied, and jogged, all without pain. With the complexity of your repair I wonder if the reversal will ultimately be the Desarda/Halsted “reinforcement” and whatever else he did to address the sports hernia, and not the posterior wall reconstruction of the inguinal canal.
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Anesthesia: I don’t know the specific meds. At the surgical center I first signed a paper where the two main options were General Anesthesia or Monitored Anesthesia Care (MAC, i.e. IVCS) and I only signed permission for MAC. Then I spoke to the anesthesiologist and finally to the anesthesia nurse. If you want to know the specific meds you could try calling Sarasota Physicians Surgical Center. I shadowed a pulmonologist during an endoscopy under IVCS years ago so I felt like I knew what I was agreeing to. Apparently typical patients are awake but then have amnesia, but they told me afterwards that I was atypical and snored through my procedure.
Yunis did not recommend PT. For the days immediately following the procedure he recommended walking rather than biking (in contrast to Shouldice Hospital). I followed the advice reported in reviews of the German surgeons like Wiese and Koch and tried to do a lot of walking immediately.
Regarding mesh I was pretty confident mine wasn’t femoral so I wasn’t too concerned Yunis would place mesh. His office has separate paperwork to sign allowing a tissue repair and not permitting mesh placement so I think one can go in confident mesh will not be placed unless the patient has given specific permission. My understanding is Yunis does not use polyester mesh like Parietex Progrip and does use Polypropylene mesh (smaller flat for Nyhus, Bard 3D Max for laparoscopic).
Sbayi surprisingly offered lots of different mesh and honors patient request for mesh material– we discussed Ovitex, “thicker biologics”, and Phasix synthetic absorbable. With Sbayi we discussed a “complete blow-out” of the inguinal canal floor and using G.A. or relaxing incision first before turning to mesh. I believe Yunis was more confident indicating he can do a Shouldice for inguinal defect of any size.
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TBH my husband did all the cooking, cleaning, and managing kids for a week. Walking, hiking, even getting in and out of a car repeatedly for hours while going birding at a state park was fine but I didn’t want the kids bumping me (I have very active 7-year-old twin boys). I was doing computer work (designing catalog layouts) (while on vacation) starting the day after my operation, but only in bursts of thirty minutes on, thirty minutes off, and against doctor’s orders to wait until day three to return to office work.
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Hi Eu, Answering your questions one by one:
1. How big was your incision?
— Yunis told me ahead of time it would be larger, but it’s only 6 cm (just under 2.5 inches). I am extremely fine-boned so my best guess is he adjusted the incision to my frame.
2. How long have you experienced post-op pain and what meds did you use for it?
— I did not fill my prescription for pain meds (I think it was a codeine with acetaminophen). I used the maximum dose of over the counter Tylenol and Ibuprofen for about a week, and then a lower dose for another week. I walked two miles the evening after my surgery and two to three miles including uphill hiking every day after that. I had some bloating after the surgery and some swelling with a healing ridge. Superficially I only had one small bruise about an inch across and then a second one-inch bruise appeared three days post-op.
We stayed 8 days in Florida for a bit of vacation so I had an in-person follow-up and they did comment that many patients have much worse bruising and swelling, and larger incisions, than what I experienced.
I have been doing some light jogging starting at 2.5 weeks post-operatively. I think everyone’s pain tolerance is different, and my bulge had grown so large and bothersome that the nuisance of a healing surgical wound was immediately an improvement for me over the hernia.
3. If you experienced nausea and bloating prior to the surgery (I have a low-grade nausea and bloating over the last month or so), do you still have it?
I didn’t have nausea, but I did have a feeling of needing to lie down to reduce the bulge and my ascending colon would feel bloated and gassy. Every digestive complaint I had before the operation (mainly sluggishness) has been resolved. My bulge had grown to roughly tennis-ball sized and my defect turned out to be direct.
For me, the decision to go to Yunis was predicated on confirmation I would only receive a Shouldice repair, not a Desarda, independent of my defect type (direct vs. indirect).
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I found the six-sided box model to be very helpful for gaining a rough understanding of the inguinal canal:
https://en.wikipedia.org/wiki/Inguinal_canal#Walls
I also found watching YouTube videos of Shouldice Repairs to be very helpful for visualizing the surgery:
a more recent 2-layer Shouldice:
https://www.youtube.com/watch?v=DWW-ohDn8zsan older 4-layer Shouldice:
https://www.youtube.com/watch?v=NIJaYVmLzO8 -
I don’t have direct experience with this, but my understanding is that with a laparoscopic recurrence you’ll have an open repair the second time (avoids scar tissue). (My uncle had a laparoscopic mesh inguinal repair which rapidly failed followed by open mesh repair that has held). However, if you’re having the mesh removed then the laparoscopically placed mesh should be removed laparoscopically.
If you’re looking for an expert in recurrent hernias and potentially a tissue repair, I just had an open Shouldice repair from Dr. Yunis in Sarasota for my inguinal hernia. My recovery has been very good (2.5 weeks out today. I was walking 2-3 miles/day starting the evening after surgery).
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I almost went to Dr. Brown when I thought my inguinal hernia was indirect, as he’s one of the only surgeons in the U.S. advertising a Marcy repair for indirect inguinal hernias. It’s ironic that this attracts those of us seeking a minimally invasive repair. Dr. Brown did impressively correctly predict that my hernia was direct based on a photograph of the bulge. At that point he described to me his operation as a Shouldice repair reinforced with the external oblique aponeurosis either with overlap (Halsted) or immobilization (Desarda). This extra “reinforcement” doesn’t line up with any published accounts of the Shouldice repair that I’ve seen, and I suspect accounts for the slow recoveries I’ve seen reported even by satisfied patients of his. That was my first post on this forum — asking if this was normal to add to the Shouldice (https://herniatalk.com/forums/topic/shouldice-reinforced-with-desarda/)
I’m grateful to PeterC for sharing his experience. I’m also grateful that this week I had a Shouldice repair and my recovery has been unbelievably easy. I think I started this journey wanting a pure tissue surgeon, but now I suspect that the surgeons who can be choosy about which patients get a tissue repair and only do a tissue repair when appropriate are able to keep their tissue repairs minimally invasive.
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Dr. Towfigh: you wrote that in the Shouldice repair “Classically, the cremasteric muscle and genital nerve branch are resected” and Dr. Spencer Netto confirms in this interview that is the standard of practice at Shouldice Hospital. But in this interview you indicate your Shouldice repair differs from the classical repair in that you do not resect the cremasteric muscle. Do you also not resect the genital nerve branch of the genitofemoral nerve? It would be helpful to understand whether to seek a surgeon who preserves all nerves or if the genital nerve branch of the genitofemoral nerve is an exception to the preference against neurectomy.
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Hey how did this go? I am struggling to find a US option but would probably go with Kang or Shouldice if travel were possible.
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Dr. Reinhorn is a big fan of the Nyhus repair. Since your mesh is large for an open repair that’s probably what you have. With the Nyhus repair the mesh is in the posterior space normally accessed in a laparoscopic or robotic repair. It seems likely your PCP hasn’t encountered this type of repair before and may be misinterpreting what she felt.
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My understanding is none of the nerves were cut and I have no reason to think otherwise.
One surgeon who told me he would transect the genital branch nerve told me it would take 6-24 months to grow back and I would have numbness. I have nothing like this. Another surgeon told me he would transect both the genital branch and the ilioinguinal nerves. My understanding is Yunis does not take nerves in a primary repair.
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I hear you Osler, but the surgeons cutting the round ligament are also the surgeons who aren’t cutting the cremasteric muscle and are avoiding cutting the nerves — i.e. these are the conservative, minimalist versions of the Shouldice repair and they’re still cutting the round ligament. It is not clear to me whether anyone even offers a Shouldice without transecting the round ligament. Are you finding options, mesh or no-mesh, where the round ligament is preserved?