Brief Answer:
Standard care depends upon the type of hernia as explained below

Detailed Answer:
Hi.
Thanks for your query and an elucidate history.
To recapitulate: Male/73 - Type II Diabetic - chronic constipation - colonoscopies clear - wants to know standard care as there is difference of opinion - Hernia repair 25 years with mesh - needs hernia repair again - two surgeon have said different ways of repair - as explained above...

My thoughts:
- Diabetes has to be well under control.
- Constipation should be relieved well as this is an obvious cause of recurrence of hernia and whichever way the repair is done, it can cause problems.
- It is very important to know whether the hernia is a direct one or an indirect type. To have proper clinical evaluation and examination to know the size of the sac, diameter of the neck, like position of the mesh inside and the amount of fibrosis
- Your willingness about the cord-clamp meaning the cord going to the testicle can be cut, tied and separated so that the repair becomes full-proof. This is one part that can be considered only if you are willing and not a must.
- All these points considered together makes the repair successful.
- If this is a large necked hernia, without any adhesion of intestine and/or omentum to the sac, laparoscopic repair with extraperitoneal placement of dual mesh is the best procedure.
- If this is of indirect type with long sac, then preferable is an open approach. This enable to see the defect, the mesh, the opening- neck of the sac, whether there are any contents as a part of the sac called as sliding hernia, proper return of such contents back to peritoneal cavity, proper fixation of the mesh, the tissues and so on.

Please discuss these issues with your Surgeon, who knows/does both types of surgeries. If I can know these details, I can assist you further.
Please let me know id any high resolution ultrasonography, CT or MRI have been done to know the details of hernia. I think this is very important point as the reports add-on for the proper planning of surgery. If not done, insist for pre-operative assessment.

I hope this answer helps you in decision making, best option of surgery and best outcome.
Please feel free to ask for further relevant queries if you feel that there is a gap of communication.

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Brief Answer:
I hope this helps and clears your doubts.

Detailed Answer:
Hi.
Thanks for your appreciation.
Dual mesh has as the name suggests two different surfaces. The inner surface does not allow the internal organs to get attached to the mesh in the healing process while the out surface which is placed against the abdominal wall gives strength to the defect to close off the hernia. This is used when laparoscopic procedure of hernia repair is done.
Ethicon is the name of the company which produces such meshes and is famous worldwide for the best quality of the mesh which we use frequently, they are the best.
As explained earlier, a good pre-operative assessment by clinical examination, high resolution ultrasonography/MRI can give a 3-D image in mind of a Surgeon as to how to proceed, which procedure or combination of procedures would benefit the patient the most. And this is important in your case as this is re-surgery as all the normal anatomy would be distorted.
Such cases are always a challange on opening up and the experience of the Surgeon is most helpful for on-the-spot decision. No standard procedure can be charted as every case will be different after the previous surgery has been done.
I hope this answer clears your doubts, please feel free to ask for further relevant queries if you feel that there is a gap of communication.

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Brief Answer:
as explained in details.

Detailed Answer:
Thanks for your appreciation again.
Open surgery usually dose not need dual mesh unless and until there is sliding hernia, meaning when colon or urinary bladder is a part of the sac of hernia. This too is the diagnosis-on-table-on opening.
CT scan too is a great investigations and you will have to insist on studying the hernia too.
Constipation has to be investigated and treated successfully for the success of hernia repair; there should not be obstruction to the urinary flow by enlarged prostate or any such reasons, there should not be having chronic cough.
These are pre-requisite of successful hernia surgery. As also important is normal hemoglobin and serum protein values, particularly albumin.

I hope this answers your query and adds on for best outcome of surgery.
I am practicing in XXXXXXX Accept new patients, we have different system here.

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Brief Answer:
No barium - request to study hernia site too.

Detailed Answer:
Barium can not be used in CT scan as it gives artifacts.
Please request them to scan for the abdominal wall and the hernia site too. This may give a valuable information that can be useful for planning a successful surgery.

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Brief Answer:
With X-rays - not possible with CAT Scan

Detailed Answer:
Very true.
When Barium is used for Upper GI series X-rays are used to see the reports.
Barium with CAT scan is not done as it gives disturbed images called artefacts.
CAT Scan needs iodine based contrast material.
I hope this clears your doubts.

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Brief Answer:
As discussed in details below.

Detailed Answer:
Hi.
Thanks for your feedback.
As suspected in previous discussion and as advised, you have got colon in hernia sac. If the inner mesh is a dual mesh then organs may not get attached to it as this is why it is specially made for.
And your Surgeon will be more bothered about this situation.
With or without barium- I was wondering why would you be interested to know about this.
All the best, discuss in details with your Surgeon and make sure about the possible course of actions that he may take and give the feedback.

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Brief Answer:
as explained in details.

Detailed Answer:
Most welcome.
I can understand your apprehension if you have about this. The Surgeon too are similarly bothered and hence will not do any mistake.
Since there is colon in the hernial sac, the dissection is going to be difficult one and the Surgeon has to take an extra efforts to mobilize the whole thing so that the bowel is replaced well to the abdominal cavity.
If the tissues at the most internal side can be approximated without any tension the plain mesh can be safely placed above the approximated first layer which separated the mesh from the colon. and further closure completes herniorrhaphy.
In some cases the first layer can not be approximated well, it is here the dual mesh with non-sticky side placed towards the abdominal cavity is placed. This ensures that the internal organ is saved and placed safely without any chance to get adherent to the abdominal wall causing further complications later on.

I hope this answer helps you, please feel free to ask more if you feel that there is a gap of communication.

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Brief Answer:
Follow the Surgeon's advise

Detailed Answer:
No, I do not agree for a reason. GI Doctor is not a Surgical specialist and would not really know the implication as good as the Surgeon.
Follow what your Surgeon say - the one really operates and faces the difficulties.
Please give feedback about what the Surgeon say.

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Brief Answer:
as explained in details.

Detailed Answer:

Approximation means getting the two borders of the wound together and stitch them together to close the defect. Since the two edges can be at some distance, they may come close to each other without being needed to stretch the sheet of tissues; it is at this time that we may have to give tension releasing incision at a distance if possible so that the opposing ends are brought together and stitched together.

I hope this clears your doubts.
Attend the marriage and get an appointment accordingly when you are free.
Avoid constipation and upper respiratory tract infection that gives coughing.
Avoid the foods that cause constipation or stomach upset of any sort. If the hernia remains in reduced position all the time except when you are straining, routine activities can be conducted. Try to keep the hernia in reduced position, which I understand is difficult but possible.

Please get your Hemoglobin and Serum proteins tested, and if on lower borders of the range or less than normal, you need to get this corrected as you will be getting appointment for Surgery, say after 2 months from now, and after the marriage of your niece.

I hope this answer helps, please feel free to communicate further if you have any other doubts.

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Brief Answer:
Hi.

Detailed Answer:
Hi.
When one sleeps, the hernia contents return back to the abdomen as one is lying down hence there is no bulge in the morning on getting up, once the persons gets up, the hernia contents starts sagging down the weakest portion that is hernia opening and slowly accommodate the available space in the well formed sac of hernia, which in your case is up to the scrotum. Hence largest at the end of the day.
4-6 weeks booking:
Really do not know why so. May be they have the list ready and have limited allotted time in OT. Or may be a system wherein the Doctor and the patients gets very good length of time to have proper preparations for the successful
surgery. Good for you since you can attend your niece's marriage.

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