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quote DrBrown:

Dear UhOh!
If the hernia can be identified on physical examination, then there is no need for an imaging test.
Ultrasound results depend on the expertise of the technician.
Best wishes
Bill Brown MD

Thank you. I should add that the reason I requested the test was to help me decide how immediately to pursue treatment. The thing I cared most about was sac content, and mine was shown to contain only fatty tissue, hence not rushing for surgery.

A friend in radiology cautioned me about operator dependance for US and therefore I wanted it for my own knowledge, not for a treating physician to rely on.

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There’s also the issue that, plastic surgeons and cosmetic dermatologists aside, physicians are by and large terrible at sales and marketing. It’s just not something taught as part of their training, and isn’t second nature to most. It probably never occurs to those who still do tissue repairs to “market” such and tap into the growing demand for such procedures. The idea of “customers” not only wanting something they consider second best but actually marketing that, is a foreign concept. Then again there’s a reason I’m a marketing consultant, not a physician…

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quote drtowfigh:

I don’t agree that for the watchful waiting patient that can be risky. Quite the opposite. That is exactly what I would recommend for the watchful waiting patient.

I am a surgeon who believes that the hernia hole can decrease in size with certain changes in activities, lifestyle. We have seen the same on followup imaging. Remember that in the case of indirect inguinal hernias, the hole is always there for the round ligament (females) or spermatic coed (makes). It’s enlargement of the hole that makes a hernia a clinical diagnosis.

Do you see reductions in hole size for both direct and indirect, or only indirect?

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For what it’s worth, I went for a consult last fall with Dr. Wilson Hartz at Northwestern Surgical Associates* and he said he could do it, did it for many years, would do it if requested, but probably hasn’t done one in about three years. However he said that he prefers mesh and tends to use it because it’s the standard of care and offers more consistent results (i.e. issues of tissue quality).

Personally, I don’t think it’s right to push a surgeon to use a procedure other than that they consider best, because it’s not really setting either of us up for success, but perhaps worth a consult? Only other info I have is that he told me he uses a Bassini repair for indirect, and a McVay for direct. Not sure his preferred anesthesia regimen; we didn’t discuss.

I seem to recall Dr. Towfigh mentioning a surgeon in WI, at MCW, I believe, who does non-mesh repairs.

Most surgeons don’t seem to bother with US imaging if they can confirm a hernia on physical exam (I still asked another doc for imaging order and had it done).

*Sees patients/does surgery at Northwestern Memorial, but different group for insurance/billing purposes.

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quote DrBrown:

Dear Jnomesh.
If I had a hernia, I would love to repair it myself. Unfortunately, I am not as flexible was I used to be.
Your best bet to find a local surgeon is find a surgeon who was trained before mesh was available. So he/she would have to be in their late fifties or sixties. Write out your list of questions so that you do not forgot anything. Take someone with you, under the stress of the office visit you will forget half of what the surgeon tells you. Do not hesitate to record your visit.
Everyone is welcome to come to Calfornia. I have operated on patient’s from every state except Minnesota and Iowa. So they will get a discount.
Best wishes.
Bill Brown MD

[USER=”2580″]DrBrown[/USER] , looking at your CV, it looks like you did some training in the Midwest; do you by chance know of surgeons in the Chicago area who regularly do pure tissue repairs? So far the best I’ve gotten is one who said, essentially: “I can do them, I did them exclusively for years, but the last time I did one was about three years ago.”

I’d prefer someone who does them regularly, but more so, I want to go to a surgeon who believes in the technique (asking a surgeon to do something they don’t personally believe in, even if I think it’s right for me, is setting us both up for failure, in my opinion).

Thanks.

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quote DrEarle:

The problem with anonymous surveys is there is no connection to what the patient had done. There are also rules about this with regards to human subjects research. there are also rules however with regards to quality improvement, which are generally exempt from HIPAA, but because of a general misunderstanding of this, rarely used if even possible. A single/integrated medical record is the answer to accurate outcomes data for hernia repair, and indeed all of health care. “Medicare for all” is doomed to fail. Current payment system doesn’t have accurate outcomes data.

Not sure what Rand Paul is worried about. Seems like there is some sort of agenda there. I don’t know what, but something doesn’t quite add up.

I’m still curious, why wouldn’t you get good, or at least better, data by treating recurrence and chronic post-repair pain as separate conditions, allowing doctors to report their occurrence as they would any other condition?

Regarding Sen. Paul, here’s a purely speculative hypothesis: It seems that most of the initial negative mesh publicity, and resulting lawsuits, stem from vaginal mesh (as I understand it, a similar product, used in a different way). Prior to entering politics, his father was also a physician, an old-school OBGYN, if I recall. Perhaps he developed, and instilled in his son, an aversion to mesh based on his practice in that area?

Again, entirely speculative, and not based on any knowledge or facts other than both father and son being doctors and the types of medicine they practiced.

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quote DrEarle:

Actually, even getting data from billing databases using ICD and CPT codes is very difficult. And it’s impossible to get good data. A single.integrated medical record would allow us to get good, real world data. I respectfully disagree with the notion that medical device manufacturers dictate surgical procedures. That is generally the last thing in a surgeon’s mind when seeing a patient. And mesh choices are often dictated by hospital administrators, without, and even ignoring surgeon input. I have seen this first hand. Finally, the sutures are made out of material very similar to mesh, and I have seen plenty long term problems from suture repair in my career. Not as many as mesh, but that’s because the numbers for suture repair are lower. If 90% of groin hernias were repaired with permanent sutures, we would certainly see more problems from this. Some technique related, some anatomic related, some infection related, some related to foreign body reaction to the suture material, and some related to recurrence. And that is exactly why we need long term outcome data. By the way, I know a surgeon that had their inguinal hernia repaired at Shouldice, and ultimately had a good long term outcome, but the experience there was terrible, and there has never been a follow-up survey or contact of any kind from Shouldice. I am not advocating for or against Shouldice Clinic, but anyone claiming near perfection simply is not telling the truth. From their website: “Our 99% lifetime success rate for repairing primary inguinal hernias sets the gold standard.” This type of statement is no better than a mesh company saying the same thing about mesh repair. Nobody is perfect, but we could all be honest.

By the way, this is a very good discussion, and I appreciate you all taking the time to respond.

To clarify, my thinking about new ICD codes (or some other method of recognizing and recording this as a separate condition) was that it would allow any physicians who treat patients suffering to report numbers in an attempt to quantify the size of the problem without patients having to return to their original surgeon or respond to any survey.

And I did not mean to imply that surgeons were in the pocket of device makers, far from it. However, we know that the industry will attempt to wield whatever influence it can, and, to your point, I think hospital and insurance administrators may be more “impressionable” (unlike doctors, they aren’t the ultimate fiduciary).

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quote Jnomesh:

Thanks uhoh. I think your post illustrated my initial post. Those who are experts at non mesh repairs like dr. Kang would most likely think and say absorbable mesh is not necessary to use along with a pure tissue repair Bc they are experts in this type of surgery and deem it uneccessary. Surgeons who are experts at mesh repairs would most likely say absorbable mesh is inadequate and permanent mesh should be the gold standard.
The problem lies in that there are very very very few surgeons in the US that do non mesh repairs and on top of that are expertise in pure tissue repairs- meaning people wanting a natural repair will have to either travel out of state or out of country for what back in the day would be a routine non mesh repair. Many people won’t do this endeavor either because of travel or cost or both.
on top of that most surgeons except for a few (I count maybe 5 surgeons in the US who only do non mesh repairs) day they will do a pure tissue repair but that there will be a high recurrence chance-I believe they say this Bc they just aren’t confident that there repair will hold Bc they just don’t do many if any of this type of repairz
Thats why I think a pure tissue repair with absorbable mesh may be the great compromise for s large number of people who don’t want mesh but also can’t travel to one of the few surgeons who do non mesh repairs.
For the surgeon who says I can do a pure tissue repair but there will be a high recurrence rate maybe this rate will come down greatly if a absorbable mesh is used in addition to the natural repair.
This may also be a option for people who have had their mesh removed like me, who even though there were no hernias upon removal the area is surely weakened and if I ever re-herniate and don’t want mesh but a natural repair may not hold Bc of the weakened tissue maybe a absorbable mesh on top of the non mesh repair may be an answer.
Could be the great compromise!
ofcourse more data needs to come in on absorbable mesh (for me would be more if a chronic pain question then recurrence rates)
but im more curious if there are contraindications to a absorbable mesh on top of a pure tissue repair?

What I think absorbable mesh will offer is for those who use and believe in pure tissue repairs to be able to do less extensive repairs, with less damage to healthy tissue. This would also likely make it easier to teach the method to surgical residents.

And, while this shouldn’t be a factor for doctors or patients, the fact is that it will have the support (instead of opposition) from device companies. One less hurdle to overcome.

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quote Jnomesh:

Hi Dog. Seems pain rate is significantly less with absorbable mesh. They still worry about recurrence with absorbable mesh that’s why I think it would be interesting to examine a pure tissue repair to close the hole and then a absorbable mesh to further reinforce the area to help it heal fully during the first year of healing ( a time period researchers note is imperative as the area gets stronger and this is the time period a lot of recurrences happen-within the first year) then by the end of that year the mesh will be fully or hopefully fully absorbed or disintegrate fully.
would love to hear some of the surgeons weigh in.

I recall asking Dr. Kang about exactly this not that long ago (I’m sure the thread isn’t buried too deep). His opinion is that the mesh is unnecessary if the tissue repair is done properly.

The study, as I recall, found that absorbable mesh was not a good one-for-one substitute for traditional mesh in direct hernia repair and had a high recurrence rate (probably due to lack of defect closure).

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quote DrEarle:

Good intentions – Excellent comment regarding outcomes data. You stated there are “few metrics, despite close to one million surgeries per year”. Hernia repair, like health care in general, is complex. Not complicated, but complex. Therefore, by definition we cannot control it, but we can manage it. But we can only manage it if we have real world feedback (data) from the output of the system, in this case hernia repair outcomes. Only then can we get some really smart people to analyze the data, and gradually improve our application of hernia repair methods to those most likely to benefit. This can be accomplished. However, we need a single medical record (not single payer) to do it. The PPACA required electronic records, but inadvertently created a multi-billion dollar industry who’s own interests are well above those of the public. Not only would this allow continuous practice improvement, it would allow the type of post-market surveillance of hernia mesh (along with all other devices and drugs) we so desperately need.

My question has always been: Why is follow-up data from the repairing surgeon necessary to quantify this “pretty well” (if not perfectly)?

Let’s assume two things are true enough to impact results: That people unhappy with the outcome of surgery will often go to another doctor to correct the problem, and surgeons (like all of us!) are biased towards the success of their methods and will have alternate explanations for the pain some experience.

Given this, and the difficulty of follow-ups even absent these factors, why not track all post-surgical complications (pain, recurrence) in hernia repair patients as its own, separate condition? A few new ICD codes would help classify the different complications, but now you have a way of tracking results, even when someone goes to another doctor and the original treating physician is unaware.

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quote DrEarle:

There’s always more than one side of a story. Here’s an interesting perspective of the Shouldice Clinic from a Canadian Surgeon.

https://canadianfemalesurgeon.wordpress.com/2015/05/19/the-problem-with-shouldice-or-the-most-dangerous-phrase-in-the-english-language-weve-always-done-it-this-way/

“this blog comes from my own professional opinion as a general surgeon/hernia fixer and defender of evidence based medicine and socialized healthcare, discussions with many patients who have gone or are considering going to the Shouldice clinic, going to a talk some years back given by a surgeon who worked there, and the Shouldice clinic website.”

I read through this, and the problem is that she melds three largely separate issues in ways that make it difficult to consider each individually. As I see it, she is saying:

1. Mesh is best and should be the repair of choice.

2. The problem with the Shouldice repair is the unwillingness of its namesake clinic to evolve it along with the rest of medical science.

3. Socialized medicine is better and Shouldice is cost-inefficient.

I think that the first is highly debatable, and is, indeed, debated by medical professionals far more qualified to render an opinion than I am.

The second is perhaps the most interesting and poses very important questions regardless of where one stands on mesh vs. non-mesh. It certainly seems as though there is merit to this argument, and that improvements to non-mesh surgery could be made.

The final argument is a political one, and (in my opinion) doesn’t belong in a discussion of what the “best” way to repair a hernia is. Governments and insurance companies can enter the arena on that one, but I don’t particularly want that to be the basis of physicians’ decisions on what is “best.”

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Nor is it typical of the egos that sometimes make their way into surgery (and other academic/scientific fields); one would expect the motivations to be having the method bearing one’s name become as widely used as possible, with the least amount of friction around new user adoption. Of course, that can leave one looking foolish, too (see: Millikan).

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I think what you say about type-specific vs. one-size-fits-all is even more true with a “pseudo-recurrence” for another important reason: the term “pseudo-recurrence” (hernia of another type discovered later) suggests that the two surgeries would be done at different times (vs. true pantaloon, when they’d supposedly be done simultaneously). That would seem to also imply one would have the chance to recover completely from the first surgery before even discovering the second hernia.

The insurance issue may well be exclusive to the US, and the new emphasis on outcome-based reimbursements. The idea that the provider is reimbursed based on the success of their care (vs. simply the price tag of the services) is good in theory, but leaves many potential problems and misalignments of incentives. If the discovery later of a second hernia (different type) is considered a recurrence (particularly when preoperative imaging isn’t used) then surgeons are incentivized to perform a catch-all repair, instead of the most appropriate repair.

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I think an even more practical question regarding “pseudo-recurrence” patients is: What is ultimately going to cause less pain and fewer potential complications, a one-size-fits-all repair that requires excessive cutting and sewing, or two defect-specific surgeries, with very limited scopes, conducted at different times?

Absent an obvious pantaloon, I’d almost certainly opt for the latter.

Then, of course, there is the growing issue of reimbursements: If insurance companies consider the development of a second type of hernia on the same side a “recurrence” then that could put reimbursements in jeopardy. Completely backwards set of incentives for surgeons, but these are the times we live in…

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Yes, that’s exactly what I meant when referring to “type-specific repair” and “defect-specific scope.” I do understand that, particularly for direct hernias, the type-specific repair methods are new, but my hypothesis was that the challenge, for most surgeons, is not figuring out how to do such a repair, it is altering how they fundamentally think of hernias.

From your description, it sounds as though very similar principles of defect repair exist in authentic Bassini and McVay to your repair (and a surgeon experienced with the former could learn the latter fairly easily), BUT the main challenge is convincing surgeons to apply those principles to what is, essentially, a new problem: Until now, those principles were applied to creating maximal reinforcement to an anatomical area, instead of applying them to repair of a very specific deficiency. Behavior change is much harder than learning new skills. The patient’s goal of having their hernia repaired is the same, but the surgeon’s goal, in terms of what the final anatomy should look like, is different between the two.

My way of thinking about this also stems from my professional work, in product marketing, which often involves developing different stories around one product/capability intended for different audiences. It’s easy for me to do as a consultant, but notoriously difficult for people to do when they’ve only thought about the product they’re selling in one way. I recognize that how a surgeon interprets any of this will differ than how I do, as each profession comes with its own way of thinking about pretty much everything.

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quote Baris:

Thats true aswell but if i had an indirect hernia and no defect in the direct area would imaging techniques show how prone the muscle is to rupture? Or would it allow the surgeon to confirm that the area is strong enough to not even need to check the fascia and just repair the ring in case of an indirect hernia? How would an ultrasound intepret this?

Now you’re asking questions I would have to make up answers to 🙂

However, what I will say, and this is a personal opinion/preference ONLY: If the ultrasound didn’t reveal anything, I personally would only want that which was confirmed by imaging to be repaired, and in the least destructive way possible. If something else should rupture at a future date, fine, I’ll deal with it then. But I’m not one to do more extensive surgery over a “maybe” in this type of situation.

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quote Baris:

Hi dr kang,
in relation to imaging none of my hernias were present on the imaging but felt when touched. How would the surgeon know how big to make the insicion to see the whole inguinal floor? When i asked the surgeon at shouldice he very quicklly dismissed imaging techniques for hernias. In my case for instance i was shocked to find out that the surgeon cuts all the way down to the pubic tubercile. However i was glad it was done that way as on my left side i had both a direct and indirect hernia. My left side had been operated on before twice and it was totally missed. Now coming back to choosing specific types of repairs for the type of hernia, if the surgeon didnt intent to cut the whole muscle and do a one big repair (fit for both direct and indirect) how would he have found the second defect that was present on my left side. I asked about this ( to the surgeon at the shouldice clinic) and was frustrated it had been missed before. He said that they deliberately restructure the whole floor as one of the main reasons being is that in 13-14% of surgeries they perform there is a secondary hernia present which is missed by most other surgeons. I then asked what if there wasnt a secondary hernia and it was just an indirect isnt that pointless that the tissue is cut away? I was then told what if when i arrived i had an indirect but that area (where direct hernias appear) was still intact but very weak? How would i have known? How would the surgeon of known? Wouldnt it increase the likelihood of me having a reoccurence and then more surgery to then correct the direct hernia? Leading to more pain invasion and scarring? In a way thats why i believe in the shouldice technique the idea is to go in once and do the utmost to minimuze the risk to the lowest stage possible by repairing the whole area to a high standard to minimize future issues and strengthen the tissue as a whole, especially incase its still intact but prone to rupture. That is why i think the reoccurence rates are very low as every possibility is assesed and repair is done not just to fix but also to prevent.
So in a way yes its more cutting away and maybe slight more invasion but i do believe it cuts out any possibilities of being a short term resolution and rather being a long term solution, thus why they do a one repair fit for all and have amazing statistics. The only reason i say this is because i had two previous surgeries and i think everyone will agree that youd rather have one ‘supposedly invasive’ surgery rather than many little ones to correct eachother.
This is why i belive the clinic/technique does a repair which addresses both direct and indirect regardless of the type of inguinal hernia you have.

i hope i have made sense :)))
Regards
Baris

But wouldn’t all of those questions be answered in advance if imaging were done by a technician with hernia expertise? Part of the problem is how operator-dependent ultrasound imaging is and how much variance there seems to be in expertise among technicians specific to hernias.

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[USER=”2019″]drkang[/USER] thanks for that very detailed (yet very understandable!) description of McVay vs. authentic Bassini vs. corrupt Bassini. That at least some some US surgeons seem to recognize the need to use different repair techniques for different hernia types is reassuring, but it tells me something else, too, that’s completely wrong with the way the vast majority of surgeons approach hernia repair.

While your methods sound more effective than what the majority of non-mesh surgeons do, and I don’t want to diminish that in the slightest, it sounds as though your results are attributable in large part to one thing that has nothing to do with surgery itself: the use of preoperative imaging. Like you, it seems that experienced surgeons recognize, on some level, the need for a type-specific repair. What they DO NOT recognize, is the need for a defect-specific scope of repair.

That preoperative imaging means that not only does the surgeon know the type of hernia, they know exactly where the defect is and don’t need to do any extra cutting in order to get a visual on the entire anatomy. While I think I understand the merits of your specific techniques over authentic Bassini, McVay or Marcey, it sounds as though veteran surgeons familiar with these techniques could achieve similar results as you if they used preoperative imaging to not only select a repair suitable to the type of hernia, but also limit the scope of the repair to the actual defect, no?

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Ah, I now have a better understanding! I didn’t realize that the “authentic” involved cutting that which was not already torn.

This is quite interesting to compare with what a veteran (probably about 70 years old) surgeon told me when I sought a consultation and discussed tissue repairs (since he’s old enough to have actually learned them). I asked which technique he used, and he told me Bassini (assuming the “corrupt” and not “authentic”) for an indirect, and McVay for direct. I’m not sure the reasoning, but at least he seems to recognize that different repairs are somewhat better suited to different types. Though some of what he said conflicts with info I’ve seen elsewhere (notably Dr. Brown’s repair descriptions).

He also said that, in his opinion, the high ligation repair was sufficient for indirect, but that he’s come to do mesh repairs in keeping with the standard of care. I’m assuming he was referring to the Marcey, as I seem to recall you saying that a true high ligation doesn’t involve narrowing the internal ring, and is only applicable to children.

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quote Good intentions:

Here’s an interesting article about the early years of a surgeon’s career. One sentence seems especially relevant. The “standard of care” is the phrase that you’ll see often when looking at why mesh is used. The device makers have managed to make mesh implantation the standard. Which just means that everybody is doing it, whether it’s the best or not. You can’t get in trouble if you’re doing what everyone else is doing.

“Case Selection. Young surgeons need to be constantly reminded to do what is safe, proven, simple, and accepted as the community standard of care. Those heroic procedures done as a resident will get you in trouble more often than not outside a tertiary care center.”

https://jamanetwork.com/journals/jamasurgery/fullarticle/508661

This is absolutely all true, in my opinion. BUT, young surgeons learning and following the “standard of care” (because they don’t have enough experience to know if/when to deviate) does not exempt them from approaching it with skepticism or experienced surgeons from constantly learning. Should a resident approaching their second ever hernia repair attempt a Desarda based on reading about it in a manual (when the attending probably only knows mesh repairs)? Absolutely not. But that same resident should allow their cumulative knowledge and experience begin steering them towards seeking training in a more effective alternative (or developing one) as they continue on in their career.