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What causes a pure-tissue hernia repair to fail? And how?

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  • What causes a pure-tissue hernia repair to fail? And how?

    What is it the actual failure mechanism of a pure-tissue hernia repair that causes it to fail? What is the weak point of the repair? Aren't the muscles just being sewn back together, so wouldn't the muscle regrow to itself and combined with scar tissue hold it together?

    Does the muscle tear? Does the tissue itself rip or tear?

    Do the sutures pop or come undone? Is that why Shouldice (supposedly) uses stainless-steel sutures?

    Does the standard plastic suture eventually degrade and fail, causing the original hernia opening to return?

    Is it because of an unsatisfactory repair or lack of practice of the surgeon?


    I am trying to better understand the mechanism of failure for pure-tissue hernia repairs, but I haven't found a great resource online that explains it.

  • #2
    You can edit out "supposedly". I just had a chat with the Shouldice hospital and they do indeed use stainless steel sutures.

    I cannot comment on your other questions because I do not know, it's something I am trying to understand myself.

    Comment


    • #3
      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.

      Thatís part of whatís seemed to informed his preoperative workflows (US imaging as standard, selection off repair type prior to surgery) and then size/location of incision.

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      • #4
        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 DESARDA technique using just dissoluble sutures and that is working ok ..WHY ?

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        • #5
          Originally posted by dog View Post
          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 DESARDA technique using just dissoluble sutures and that is working ok ..WHY ?
          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.

          Comment


          • #6
            dog UhOh!

            I'd be very curious to hear the official reason from Shouldice as to why they use stainless steel sutures, though I suspect it's because of biocompatibility, and perhaps the strength contributes to their very high success rates.

            My understanding is that many metals (stainless steel, titanium, gold, etc) are highly biocompatible and inert in the human body, which is why they are often chosen for stents, staples, pins, sutures, and other permanent implants or scaffolds.

            I do wonder if, over time, plastic sutures or plastic meshes would degrade, perhaps that would contribute to hernia recurrence if that is the case. Who knows?

            As for the Desarda repair using absorbable sutures, I suspect it's because the strip of muscle used in the repair just integrates back into the muscle as part of the healing process. But that would also be an interesting question for a Desarda practitioner to answer.

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            • #7
              Hi chaunce,

              i believe the reason they use it is like you said, its biocompatible and strong. When i requested surgery they also said that i had to wait one year after previous surgery as this is the time it takes for the muscle to fully repair from being cut and sewn together and therefore i believe this may be another reason for using these sutures. It keeps the repair in its strongest form up until ffull recovery/ healing.

              in terms of the desarda repair, is it still suitable for patients that are big in size? And how succesful is it? Just curious as my previous surgeon said he wouldnt opt to use it as its designed for Ďsmall framed skinny peopleí.



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              • #8
                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 itís cheaperóthatís 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.
                #ItsNotJustAHernia
                www.BeverlyHillsHerniaCenter.com

                Comment


                • #9
                  Originally posted by drtowfigh View Post
                  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 itís cheaperóthatís 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.

                  Comment


                  • #10
                    Originally posted by UhOh! View Post

                    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.
                    Also Is it possible to use biodegradable mesh to reinforce collagen ?

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                    • #11
                      Also Dr Brawn told me that thank to drtowfigh he using a lot of her natural pain inflammation cooling supplements after surgery !

                      Comment


                      • #12
                        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?

                        drkang can certainly weigh in, though not sure if any Shouldice docs here to comment.

                        Comment


                        • #13
                          I certainly think so. The shouldice surgeon stated that preparation was as important as on the day of the surgery. A whole load of diatery changes were given to ensure your prepared for surgery in the best way possible. I had a shouldice procedure (absorbable sutures) before and i went in their weighing 107kg. When i requested surgery at the shouldice clinic after reoccurence they told me to come in at a maximum of 89kg or theres a big chance id be sent back home. When i asked them why and that i had the surgery weighing 107kg, they said that it allows them to complete a better repair as fat around muscle tissue contributes to a weaker outcome and finish. It also ensures a less painful and better recovery i was told.
                          So when thinking about it even a simple change in a pre surgical procedure contributes to a better outcome.

                          Comment


                          • #14
                            Originally posted by drtowfigh View Post
                            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 itís cheaperóthatís 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.
                            Interesting, thank you for this information drtowfigh

                            The next obvious question then is; how can patients increase the quality of their own tissue and/or collagen? Does exercise, healthy diet, and weight loss into a healthy BMI range achieve this?

                            As Baris mentions the Shouldice clinic is known to routinely suggest diets and weight loss to patients who are overweight before they will do a surgery, so perhaps there is some validity to a dietary approach. I suppose the question then becomes is if the successful outcome is then dependent on maintaining that weight loss, and if weight gain alone would contribute to recurrence?

                            In my mind I think of a lean cut of steak versus a marbled fatty steak, I wonder if that is is basically reflective of what the muscle tissues resembles of a lean vs obese patient.

                            Comment


                            • #15
                              While treating me, Dr. Towfigh has figured out that I have a collagen disorder. I havenít been to a rheumatologist for an official diagnosis, but may do that in the future. I have had multiple recurrent hernias and tissue repairs fail and have other symptoms suggestive of a collagen disorder, so Dr. Towfigh has treated me as she would someone with a diagnosed collagen problem. I have certainly asked what I can be doing to improve my collagen and quality of my tissues and the answer so far has been nothing. I donít know of any supplements that have been proven to help with this type of problem. I am taking a collagen supplement, not sure if it helps with this sort of issue but I figured it canít hurt. Maybe Iíll have nice skin and nails from it! Haha. A person with a true collagen disorder does not do well with pure tissue repairs because our tissues are weak and do not heal like healthy tissue and peritoneum. I am not over weight so that has not contributed to my problem. I would like to know the answer to the question, as well, if weight gain alone contributes to recurrence. If anyone knows of diet and exercise that help improve collagen I would love to hear it! I am having ultrasound therapy from PT for now to help with healing from surgery and reduce scar tissue. Figured that canít hurt either. I am open to any advice and suggestions since I am slow to heal and seem to have an unusual amount of swelling for a long time after surgery.

                              Comment

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