UhOh!
Forum Replies Created
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quote Good intentions:I know that my hernia had what seem to be the classic signs of a direct hernia – a peaked bump medial to the groin when standing, that disappears when lying down. I haven’t see a clear explanation of what, exactly, is stretching or tearing and/or why a bump forms there. I assume though that the “tear” extends across or in to the inguinal canal. The image of a round hole is probably incorrect, it’s probably a longitudinal or oblong defect. Some of the omentum and intestine is pressing directly outward, visibly, and some is pressing in to the canal, where the spermatic cord is. While I was trying to live with my hernia, at times my right testicle would get pretty screwed up as the spermatic cord got pinched.The diagrams I’ve seen, which I think are pretty overgeneralized, seem to suggest that a hole forms in the posterior part of the canal, something (fat or bowel) then pushes into the canal from the back side, and then sort of slides down and out the external ring.
The diagrams I’ve seen are always depicted with intestine in them, but I thought that a significant percentage were just fat, though I cannot seem to find a reliable stat on that.
I don’t really get testicular pain, just some muscle cramping above the defect, closer to my hip joint. Feels like a minor muscle ache, which I’m assuming is because there’s some kind of tear along that muscle and the discomfort is referring upwards.
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Not to hijack this thread, but a related question: Is it true that ease of manual reducibility and tendency to spontaneous self-reduce upon lying supine can determine the type (between direct and indirect) and if so, how accurate are these indicators?
I, too, am curious about this, and have a similar “plan” to the OP (as far as whether/when to seek repair), though it has more to do with the propensity of indirect hernias to eventually become incarcerated.
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What do I want less than plastic mesh inserted into my groin? Estrogen-secreting mesh would probably top that list for me…
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Thank you, Dr. Kang! Your input is always appreciated, as is your knowledge.
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Interesting, thanks. I tend to doubt I have a significant risk of the extension of the peritoneum by the hernia itself would be great enough to cause a thinning; mine just isn’t that big. My concern was more about whether rubbing against other surfaces would cause that but your hypothesis makes sense.
Also interesting about the degradation seen upon mesh removal. Is that primarily on lap repairs, done from the inside, where the peritoneum has the opportunity to stick to the mesh (vs. open repair where mesh sits atop/in between muscle and that is the surface most likely to adhere to the mesh?
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quote Good intentions:In broad terms, the statement is saying that all mesh products are the same. There are many many alternative designs, but somehow the “expert” witnesses were not able to make that clear.
The irony is that Bard markets its “alternative” design, the 3D shape, explicitly. 3D Max is the alternative, feasible design for flat mesh.
It’s one of the barriers to understanding why one out of six people will probably have chronic pain from mesh repair. Bard put a lot of time, money, and effort in to developing 3D Max as a “better”, different, product. Without understanding why these failures occur they just allow them to continue happening. Letting the courts classify all mesh products in to one broad category is not helping anyone, except Bard.
p.s. I don’t mean to seem argumentative. I’m just stating what I see. It’s a missed opportunity. Bard has a financial obligation to their shareholders to win these cases. But if they lose, the obligation turns to making a making a better product to avoid similar losses, which requires understanding the failures. It’s the great strength and weakness of our free market economy. Money drives progress.
I think it’s a little difficult to fully understand the failures given the large, and largely uncontrollable, variable of having different surgeons with different techniques and skill levels.
Whether mesh has a place inside the human body is irrelevant if the pain in question could just as easily be caused by how much mesh the surgeon used, what technique it was inserted with and how it was attached.
And if the pendulum swings back in favor of tissue repairs then perhaps companies like Bard will begin developing “special” Hernia sutures that have new and unique properties to them.
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quote drkang:Hi UhOh!
That is an intriguing question you made.
As you mentioned, most patients that we treat are a mostly homogenous group. If our numbers are statistically significant, I believe it is possible it may be due to ethnic differences.
But rather than Koreans having genetic tendency of indirect hernia, I believe there is higher possibility that Westerners are more susceptible to direct hernia. Reason is, Koreans have a lower prevalence rate of inguinal hernia than that of you Americans. And from my personal experience of surgeries, I have noticed that tissue of many Westerners are slightly softer than that of Oriental people. While indirect types of inguinal hernia are more affected by hereditary anatomical factors, direct types have more relation to the strength of tissue. Therefore, if my above mentioned observation is correct, there is higher possibility of direct type inguinal hernia for Western people.
Bear in mind that I am not saying this with proper or accurate reference, but it is my personal opinion on your interesting inquiry.Very interesting. Potential genetic causes of differing tissue strength aside, it would be interesting to know what other lifestyle differences might be contributing factors. Perhaps the way westerners do (or do not…) exercise, or the vastly different diets across cultures…
If statistically validated, it sounds like there could perhaps be some interesting guidelines for lifestyle changes that lead to better health beyond direct hernia occurrence/recurrence in westerners.
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I don’t think it’s that simple. Just developing a better design than the one you developed previously is called progress, and “well, we didn’t have that design back then” is a perfectly reasonable defense. I think that you’d have to show that a reasonable alternative design existed at the time of the injury.
The problem would come if a better design existed in theory, but had been scrapped due to cost, for example. Device companies have to continue attempting improvements, though, if for no other reason than patents have a limited shelf life and it’s important to bring out the “next” thing before the current one’s IP protections expire.
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quote drkang:Hi Jimbohen,
[SIZE=12px][FONT=arial]In the majority of textbooks on hernia, the ratio of indirect and direct hernia for an adult man is 2:1. From the statistics that I collected for adult males, the ratio is 2006 to 646 men, making it approximately 3:1. Thus, my ratio of direct inguinal hernia is not higher but rather lower than that written in text books. I’’m not sure if my numbers have statistical meaning. But if it does, I think it might be due to racial differences.
I’m guessing you see a more homogeneous patient population than a surgeon here in the US might, right? That makes me wonder: Is the difference racial/ethnic (in that Koreans are more genetically predisposed to an indirect hernia) OR cultural (fewer Koreans spend their lives sedentary only to wake up one day and decide to do something stupid like attempt to lift the refrigerator, meaning a lower rate of direct hernia)?
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Nice, looks well-written and, more importantly, well-researched.
Very interesting information about Chevron for two reasons:
1. When the oil industry takes a more morally-defensible position than the medical industry, you know there’s a big problem…
2. Because the oil industry never takes a morally-defensible position for altruistic purposes, meaning the scientists and lawyers at Chevron clearly saw potential liability that the medical industry seemingly missed.
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quote Good intentions:Thank you Dr. Kang, that is a very nice compliment from a man of your expertise. I try to only write about things that I feel I understand, but am certainly learning as I go, and starting from almost nothing.
My thoughts about going back in time with the mesh repairs are based on what I thought were promising early results that drove people to consider the tension-free repair as superior. But your video is very timely in showing how that thought process might be wrong. It is an excellent educational presentation. Thank you for supplying it.
I can’t imagine that the big organizations behind the hernia repair industry would let people go back to non-mesh repairs. The large institutions resist change, if they are benefiting, no matter who or how many people get harmed. It will take time and constant pressure to get things to change, I think.
How expensive is hernia mesh? If patients are starting to insist on a non-mesh repairs, is it out of the realm of possibility for the same device/pharma companies to develop “new” and “special” sutures that cost the same (and therefore provide the same opportunity financially)?
I would imagine the pushback will come largely from doctors who don’t see the ROI in taking a long time to teach/learn to do something the right way vs taking a short time to teach/learn a “good enough” way. All of this helps make the case for why hernia repair should be the domain of specialists vs general surgeons.
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Isn’t one of the surgeon contributors here in Indy?
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Dr. Kang: Very interesting and insightful, particularly the idea of looking at direct and indirect hernias as two separate conditions. Has anyone ever documented the failure rates of various repair techniques broken down by direct vs. indirect hernias? It sounds like mesh solved the wrong problem; that of differentiating one type of hernia from another preoperatively and choosing the repair technique accordingly (or perhaps it was a desire to “streamline” things and have one fewer procedure to teach surgeons in training).
Among others, this is a big part of why I would insist on imaging prior to seeking surgical repair if/when I decide to go that route. If different repair techniques are best suited to different types of hernias, I’d want to know the type before choosing a surgeon.
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A few thoughts, I’m sure others will have more:
How many different procedures (tissue repair vs. mesh; lap vs. open) do you do and how do you determine which to use?
If you primarily perform mesh repairs, what kind do you use, and how much?
How many repairs of each type have you done this past year?
Do you allow residents to participate in your operations, and to what extent?
What’s your recurrence rate?
Do you do imaging in advance to plan for the surgery and choose the appropriate procedure? -
Curious whether weightlifting underwear would be a potential remedy for daily wear, and if it would provide the right kind of compression?
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quote drtowfigh:It’s hard to different clinically between most direct and indirect hernias unless that are large.
Sports hernias and direct hernias are different entitities. One does not evolve into another.
Sports hernias are tears. If the tear is large enough, things can bulge through and hence the hernia. Luckily, most do not get that big.
So a stretching/thinning/slackening of some of the abdominal wall muscles, absent a tear, could lead to a true hernia, but would never constitute a sports hernia?
Regarding the difference between direct and indirect, are you saying that in reality one cannot go by those “difference between” infographics found in various places online? The one that struck me was the supposed difference upon lying down (indirect must be manually reduced, direct self-reduces automatically) and standing up (indirect reappears higher than before, then drops, while direct reappears in exact same place). Sounds like it might not be quite that simple?
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quote Physiqz:It is great that you mentioned your powerlifting background. I am actually a competitive powerlifter and experienced the same imbalance issues that ultimately, I believe, led to my sports hernia. Muscular imbalances seem to play a very large, if not the largest, role in developing the injury.
I also have another hypothesis, which you may be in a great position to comment on: I think that, for any lifters with a weak area of the lower abdominal wall, the use of a lifting belt has the potential to actually increase the likelihood of developing a hernia. Using the belt properly, one creates more intraabdominal pressure than would naturally occur (even with a valsalva). However, the groin area doesn’t have the belt to brace against, so the tissue alone has to withstand that pressure increase.
I used a belt up until about two years ago, when I first realized I probably had a hernia. Since then, that’s been a no-go.
Also curious what exercises you’d recommend for someone wanting to even out that imbalance. I’ve taken a look through the guide on your site, but am a little lost, since I’m not injured to the point I can no longer lift without pain and need to essentially come back from zero. I still lift 3x/week and am squatting 1.5-1.75x bodyweight (which has always been on the heavier side for me, with or without belt or hernia), so my activities aren’t limited. I just want to avoid it getting any worse and keep everything as strong as possible.
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Just clicked the link: It think you may well find a bias towards mesh among the attendees if the focus is endoscopic surgery. Aren’t virtually all endoscopic/laparoscopic hernia repairs done with mesh? Perhaps there are a greater number of surgeons doing open repairs that are actually doing more tissue repairs?
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Are general surgeons properly incentivized to develop this type of specialty? With an increase in the number of doctors that are hospital/health system employees (vs. in private practice), and increasingly restrictive health insurance plans, it becomes a “take it or leave it” for patients.
As a general surgeon, I’m not sure that the ROI is there for learning these techniques so long as the belief is that the avoidance of mesh is about “patient preference” vs. better outcomes (at which point there will be an increasing interest in it).
Personally, this is why I’ve declined to do anything about the hernia I have: It’s not particularly bothersome, it’s unlikely to become an emergency overnight and I doubt that waiting will make it more difficult to treat if/when I do. Any potential damage from a mesh repair, however, is far harder to undo.
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quote Physiqz:I actually just recently spoke with Dr. Goldstein of “The Hernia Institute” in New York and he told me that several of his patients that presented sports hernia symptoms in-fact has an indirect inguinal hernia–which is a “real” herniation. In this case, a small bugle will present itself–though not always palpable from the outside of the body like your case.
It is great that you mentioned your powerlifting background. I am actually a competitive powerlifter and experienced the same imbalance issues that ultimately, I believe, led to my sports hernia. Muscular imbalances seem to play a very large, if not the largest, role in developing the injury.
At this point, if I had to guess (and it’s truly a guess), I would guess that what started as a sports hernia eventually progressed to a direct hernia, because I didn’t recognize the signs and kept lifting through it. However it sounds as though anything with a very visible bulge is a true hernia of some type.
I am guessing direct because the bulge always, immediately, and automatically completely reduces upon laying down, with no manual reduction necessary. However I’m sure one of the docs can correct me if I am mistaken; I’m going by what a number of “difference between direct and indirect” charts show.
I would also guess direct since the only discomfort I ever feel is muscular (vs. nerve/testicle) and if I manually reduce it while standing, then push all the air out of my abdomen/hold lower abdominals taut it stays in. However unlike an indirect (I think) it doesn’t stay in on its own for a time, then pop back out; it’s consistently visible unless I lay down or reduce with finger.
Who knows… Will have proper surgical diagnosis at some point.