UhOh!
Forum Replies Created
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quote drkang:Yes, dog is right.Of course, in most cases, lying positon is OK for the ultrasonic exmanination for the inguinal hernia. However, standing position makes the exam easier and more precise even if the hernia sac is very small. And it makes the discrimination of the type of hernia easier as well.
Guess I should have asked for standing images, too. Mine is visible enough to get laying down if I perform a valsalva, so I suppose it was deemed unnecessary. Knowing type would be nice, though I’m willing to bet with 95%+ certainty that it’s direct.
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quote drkang:Hi dog,
That is why Desarda technique is one of the ‘one-fits-all’ repairs. Yes, if I were a Desarda doctor, I also would not do the ultrasound examination to diagnose the type of inguinal hernia before operation. As the repair will be the same anyhow. We do the inguinal sonography to check the type of hernia before operation. It shoud be done in standing upright position with Valsalva maneuver.
Out of curiosity, why is standing necessary? I ask because I recently went for an ultrasound but was laying down the entire time. Report was nonspecific about hernia type, but will be sending the images to a radiologist friend for some insights. Important thing was that sac contained fat only; no intestine.
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quote drkang:
Scar tissue has a weaker tensile strength than normal tissue. Hence, I do not believe it is a good idea to use additional absorbable sutures to sacrifice normal tissue and create additional scar tissue.
Thank you for explaining that to me!
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So here’s another question: If there is a legitimate question about tissue quality with a direct hernia, would adding additional absorbable sutures to the surrounding area promote additional scar tissue growth?
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quote drkang:Hi dog!
With frequent mesh complications, the necessity of tissue repair magnifies more and more. Desarda and Shouldice are no doubt big assets in the field of tissue repair, and I believe they are better than any mesh repair methods. But I do not believe that they are the best tissue repair methods with no need of further improvements. I am quite certain that there can be other tissue repair methods that are smaller in scale, simpler, and produce better results; and it is in the direction of type-specific repair.
I agree with Dr. Brown on many parts. However, we are different in the sense that Dr. Brown selects one among existing tissue repair methods in accordance to the individual’s conditions while I designed and am performing my own type-specific repair method that can be executed on all patients regardless of their conditions. Dr. Grischkan’s modified Shouldice method looks like mixing the Shouldice repair and mesh repair. I presume it is a type of mesh repair.
I have not yet presented my techniques to medical society as I had been continuously improving my procedures until several months ago. I am now accumulating my data to submit to a medical journal. It will take some more time. So there is no American doctor doing my procedure yet.
I’ve always been curious about what method(s) Dr. Brown actually uses. He talks about several established methods on his website, but also mentions that surgeons sometimes combine different elements of each, so I’ve often wondered whether he, too, has made extensive modifications, though prefers to simply keep them “in-house” rather than publish/teach them.
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quote drkang:Hi UhOh!,
I completely agree with you. From what I know, the Desarda method is a more suitable method for direct inguinal hernia. If you watch a YouTube video of the Desarda procedure for indirect inguinal hernia, you can see that more than half of the surgical procedure is a process of reinforcing the Hesselbach triangle.
Doctors widely claim that the reason for disregarding the specific type of inguinal hernia and rather repairing the entire inguinal area is to prevent the recurrence of another type of hernia later on. Thus, they claim that if only indirect is repaired, direct hernia can later occur, and vice versa. However, there are not any detailed evidence to support this claim. This is because there were not any opportunities to gain the outcome of type-specific repairs in the first place since all the surgeries were “one-fits-for-all” repairs.
Despite, the key here is not to dispute but to regard the actual results. The recurrence rate of previous “one-fits-for-all” repairs came out to be between 10 – 30% and that of recent mesh repair stand by near upto 10%. How could these numbers be explained?
Perhaps that type-specific repairs could be in fact more helpful in reducing reoperation possibilities. Such questions triggered the beginning of my development of type-specific repair. And the results from my personal experience came in accordance to support the fact that type-specific repair noticeably reduces the recurrence rate. Another merit of type-specific repair is that the extent of surgery is less than half of pervious surgeries. As the extent is reduced, it means less surgery injuries, less aftereffect, and quicker recovery. Each of these merits cannot be disregarded. Thus, “one-fits-for-all” repairs, in order to prevent a slight possibility of what hasn’t occurred yet, operate on unnecessary areas and cause unnecessary injuries to all patients being treated.Another surprising thing to me is that Dr. Desarda, in his reply, mentioned that he made his first and last improvement in operation technique when he operated on his second patient. This is just amazing because it took me 4 years and 11 months to first set my eyes on type-specific tissue repair and develop a final method, which by that time was at the very end of 2017, after operating my 5,000th patient. I have come to a stage where I feel self-satisfied of an almost impeccable method every time I treat a patient. However, that does not mean there will absolutely be no changes in the future. For even for a seemingly tiny improvement, adjustments should be made.
Thank you!
This is why I plan on being very selective in terms of who I seek a repair from (eventually, if necessary), and why I’m insisting on imaging first (which I’ve now scheduled). I care most about a repair type I’m comfortable with, but care just as much that the surgeon is also comfortable doing it!
Out of curiosity, have you had any surgeons from the U.S. come to Korea to learn your method yet? Intercontinental travel isn’t feasible for me at present, and part of the reason I’m waiting is that it seems like more and more doctors are starting to learn new tissue-based repair methods as patient demand grows.
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Thanks for sharing that! I suppose I should have been more specific (as both Dr. Kang and Dr. Brown are) about using “defect-specific” repairs; they are talking about direct vs. indirect (and Dr. Brown also mentions femoral). It appears that Dr. Desarda’s answer is speaking mostly to direct hernias of different shapes, sizes and locations, based on his answer.
His answer doesn’t appear to address indirect hernias in as specific a way as Drs. Kang or Brown (Dr. Kang has his own repair; Dr. Brown referees the Marcy repair). As those doctors explain it (or at least as I understand it), it is an entirely different type of defect, and even if a reinforcement repair like Desarda would patch it up, it still leaves the fundamental problem unsolved.
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quote dog:4. Does it matter what hernia you have for using your method ? This doctor says it is .. https://www.sportshernia.com/no-mesh-hernia-repair/types-important/
OUR TECHNIQUE CAN BE UNIVERSALLY APPLIED TO ALL TYPES OF INGUINAL HERNIA WITHOUT ANY STAGING OR TYPING. SO NO NEED TO CLASSIFY THE HERNIA TO DECIDE FOR THE TYPE OF REPAIR
While this may not be untrue (double negative on purpose), it directly contradicts what both Dr. Kang (on here) and Dr. Brown (on his website) say about the suitability of different repairs to different types of hernias.
Desarda may be the best universally applicable tissue-only repair, but it sounds as though a less invasive, less extensive, surgery can be done when using a defect-specific repair.
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Dr. William Brown’s website also has some good basic descriptions of different pure tissue repairs, and the types of hernias they are best suited for.
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In theory, the insurers are the only ones with even semi-accurate data. Let’s say you have a repair, a recurrence, then chronic pain post-recurrence repair and you saw three different docs for each. All that (likely) stays constant is the insurance, and they know what they’ve been paying for.
You also wouldn’t really need to do patient surveys here; all you need are surgeons who will collect data on cases of recurrence or pain that they are called upon to fix, even if they didn’t do the original repair, in order to know how often this happens.
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I completely agree with the faults in the study. Without a doubt. However, one thing I’ve learned is that the quality of the study design can be dependent on the question being asked.
The study might make perfect sense if (and it’s a big “if”) the question is: How do the results of the most popular heavyweight mesh compare to the results of the most popular lightweight mesh? This way, you are controlling for the surgeons’ experience, and comfort with a particular product, with the assumption that they are unlikely to change products absent a very compelling reason.
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The study design might make sense if the researchers chose the most popular heavy and light weight meshes (holding material and weave type constant). After all, you’ll get the best real world numbers by comparing the the most often used products that allow everything but weight to be held constant.
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quote drkang:It has been a while since I am writing.
In reality, I believe this topic is the key inquiry concerning inguinal hernia repair. The reason being, pure tissue repair in the past had high failure rate, which caused the introduction of mesh repair to be performed worldwide. This resulted into mesh complications. Therefore, if it is possible to find the exact cause of tissue repair failure and develop a new repair method that is reliable not to fail, the risky use of mesh will not be necessary.
The problem here is that it is not easy to identify the reason of failure of tissue repairs. Many would think that research will eventually reveal the cause. However, considering all the variables in research, it is almost impossible realistically to exactly pinpoint the cause. So, the most realistic approach is for a doctor with deep interest in solving the issue to set a hypothesis for the cause of failure and see if it works by performing the method devised on the hypothesis.
Hypotheses for the cause can differ based on the experiences and inspiration of each doctor. Dr. Lichtenstein and those who support his method claim that repair failure is caused by the weakening and tearing of tissue after the repair. Doctors who prefer laparoscopic mesh repair also agree on the tearing of tissue as a cause of failure after the repair and that it is important to implant mesh in the inside of the hernia defect in order to reduce failure rate.
Dr. Desarda seems to agree with doctors that perform mesh repair as well. Except that to avoid mesh complications, the patient¡¯s strip of external oblique aponeurosis is used instead of mesh in his operation.
On the other hand, Dr. Shouldice seemed to have a different opinion. He seemed to believe the insufficient tissue repair methods of the past were the main cause of recurrence. So he developed his own quite meticulous and extensive method.
However, it appears as though the Shouldice hospital carefully selects patients eligible to undergo their repairs. According to posts on this forum, patients who recurred since less than a year ago are not subject to the repair and obese patients are required to lose weight. Patients with early stage inguinal hernia when the bulging is not grossly visible are excluded from the eligible list. At first glance, it may look as though carefully selecting eligible patients is for the better of the patients. However, I also see it as a way to maintain their good surgery outcome. Excluding high-risk patients and selecting only low-risk patients will definitely result in favorable and consistent outcomes. Likewise, frankly speaking, doctors mentioning smoking, collagen deficit, and chronic cough etc. as factors increasing hernia recurrence could be making excuses to defend themselves.
I believe that rather than strictly and selectively performing surgery on patients in accordance to the various problems they have, there should be a tissue repair method that will bring successful results to high risk patients as well. Below are what I believe to be the three main problems of existing tissue repair methods that cause high failure rate.
The first problem is performing the same or similar method for both indirect and direct inguinal hernia without distinction.
Second, suture closure is not directly done on the hernia opening.
Third, the hernia sac is not mobilized sufficiently to push it back into its original location.
These three aspects are my personal hypothesis on the cause of tissue repair failure. Therefore, I have developed and am currently in conduct of a new pure tissue repair method where the hernia sac is sufficiently mobilized to restore it back into its original location, specific methods ideal for each direct and indirect type is used, and suture closure is directly done on the hernia opening. For the whole time, I haven¡¯t selected patients relatively ¡°safe¡± to treat nor rejected patients with high risk factors to perform my method on. From my experience until now, I can say that the various high risk factors have little to no influence like taking from or adding a cup of water to a fully filled bath tub.
Factors that are considered high risk are in fact mere aspects of life to many people. Rather than demanding patients to modify their life to the surgery, it is necessary to develop the surgical method to cover the way one¡¯s lifestyle is. Accordingly, an ideal tissue repair should be able to give successful results consistently despite whatever risk factor that the patient may hold.
Thus, I believe the essential reason for tissue repair failure is because existing methods are not impeccable.
I always like reading your explanations for things on here! It sounds as though the first and second problems may be related; a one-size-fits-all approach would not account for the need to close different types of defects (a tear in the case of direct, and a widening of the interior ring in the case of indirect). Using a single approach would also have to presuppose that the damaged tissue itself will not be repairable and there is a need to use the body’s other tissue to “compensate.”
The first part of your hypothesis, about use of a single tissue repair method for all surgeries leading to higher failure rates, should (theoretically) be testable through a retrospective study, assuming the surgery notes from each patient specified the nature of the hernia (direct or indirect) and gave at least some description of the technique used.
Perhaps the high overall failure rate would be broken down into a very low rate when the technique was appropriate for the hernia type, and an astronomical rate when an inappropriate technique was used. The good news is that it would seem this type of study could be organized with minimal notes from each surgery, and could offer some useful findings even if there was not sufficient information in those notes to speak to problems two and three above.
I’m going to try and get ultrasound imaging of mine done in the coming weeks and it will be interesting to see how that impacts my decision as to whether or not to seek a repair, and a surgeon’s suggestion of one technique over another.
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I also wonder whether pre-surgical workflows matter more than are given credit for. Both Shouldice and Dr. Kang, for example, seem to see high volumes of hernia repair patients and have established workflows seemingly nonexistent elsewhere.
The first time I heard of Shouldice was in business school; it was the subject of a case study used in an operations class. While their procedure seems quite effective, I’d be willing to bet that the pre-surgical workflows have something to do with why nobody else can replicate their low recurrence rate when using the same technique.
And then there’s Dr. Kang. While not discounting the improvements he seems to have made to pure tissue repair techniques, a big part of his innovation would seem to be workflow-related. The addition of US imaging as a precursor to every single surgery allows a defect-specific procedure (and incision location) to be selected in advance and, I would imagine, minimize the need to improvise during surgery to account for unanticipated findings.Another thought: Is it possible that pre-surgical workflows have a greater impact on the outcome than they’re given credit for?
[USER=”2019″]drkang[/USER] can certainly weigh in, though not sure if any Shouldice docs here to comment.
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quote drtowfigh:The original Shouldice repair was described with stainless steel suture. Most of us do not use that anymore. At the Shouldice hospital, they still use stainless steel because it’s cheaper—that’s what they told me. They make their own sutures in the back room. I saw their technicians do so. They have a limited stipend provided by the government Lee patient so they have a lot of cost cutting steps. Suture is one of them.
The reason why tissue repairs fail is often because of the quality of the tissue being sewn. Most with inguinal hernias have a collagen deficit. Sewing collagen deficient tissue together is less sturdy than healthy tissue.
Is there a way to address a collagen deficit through medical management or dietary changes either prior to, or directly after, surgery? Would seem to be an interesting study; half the patients randomly assigned to address the collagen deficit, the other half not, and see the results of pure tissue repairs.
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quote dog:I am just wonder if stainless steel sutures or any nylon sutures can have similar effect on inflammation like we are all here against mesh …it is foreign to body with unknown long term effect [h=2]DESARDA technique using just dissoluble sutures and that is working ok ..WHY ?[/h]
While I’m not a doctor (and don’t even play one on TV!) I do know that surgical-grade steel has a very long history of implantation in the human body.
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Oh, and to your other, nicely detailed, point, I have no illusions of “self-healing.” I only care to keep it as small and minimally symptomatic as long as possible while still keeping the other 99.5% of my body physically fit. Though I imagine that strengthening the surrounding muscular structures couldn’t hurt.
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Thanks. I’m not entirely sure what impacts the mechanics of the kettlebell swing have and where. I do know that unlike the squat, I’m not taking a breath deep into my belly and holding it the entire rep. The end of the swing doesn’t worry me, since I don’t think it’s particularly abrupt, it was more about the hip explosivity used to initiate. As I understand it, the purpose of the workout is to use one’s body to control the weight as momentum takes over and tries to send it into the stratosphere.
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Interesting, didn’t realize that technique actually removed muscle from elsewhere for repair (vs sewing together previously unconnected tissue).
One clarification: by “sac material” I meant the excised peritoneum creating the sac, not its actual contents. Based on what Dr. Kang has said about this material thickening over time, it sounds like this is what millions of years of. Human evolution came up with prior to modern surgery…
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One thing I believe has been mentioned here, by Dr. Kang, if I recall, is a mismatch of defect toe and repair type. Some are suited to direct, others to indirect. For example, a repair designed for direct not only would seem to have more cutting and sewing, but would fail to address the problem of a dialated internal ring.
That’s part of what’s seemed to informed his preoperative workflows (US imaging as standard, selection off repair type prior to surgery) and then size/location of incision.