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1 Week Post Removal and Pathology Report
My experience so far, 1 week out from inguinial mesh removal.
. I’ve felt like I have been in the hands of people who really know what they are doing at Cleveland Clinic and with Dr. Krpata.
. The pain of explantation has been way less than implantation- I could not leave the couch for three days after implantation, and trying to simply breathe left me in tears and agony. Compared to that the pain I have had this week has been low, mostly a general burning and aching.
. The doctor said the bottom of the mesh had curled up. The pathology report states: “Foreign materials with chronic inflammation and multinucleated giant cells.” Not sure if that is normal for all mesh or if the pathology report alone would be cause for explantation. Any thoughts on what the report really means?
. Overall I am extremely relieved that I went ahead and got it out, but am withholding final judgement, hoping things continue to heal up in the next weeks and months. -
19 Replies
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How are you doing now?
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Yes I’ve read reports that say high volume surgeon is probably best option. And I suppose that is across all methods and practices.
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depends on who you ask and what study you look at and how it’s removed. i think the bulk of studies show lap is actually lower for chronic pain and, given a surgeon who is experienced with the robot, less difficult to remove. openly placed mesh is a bit precarious because of all of the nerves involved, both in terms of the mesh potentially adhering to those nerves and other critical structures, and in the case of removal having to get around those nerves and other structures to get to the mesh. which also could arguably explain some studies showing higher rates of chronic pain. i am guessing lap vs open are roughly equal though when all things are considered. finding a surgeon who is comfortable with one or the other will likely result in very similar rates of pain and similar rates of mesh removal success.
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From what I’ve been reading recently it seems open is better than lap, yet lap seems to be the surgery that gets ‘pushed’. It sounds more up to date, easier etc, smaller incisions and quicker recovery time. But it seems it has more risk of chronic pain. And it seems more difficult to remove.
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Makes sense. Thanks, GI.
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I miswrote above. An indirect hernia would be evidenced by abdominal contents squeezing through the deep ring inside the spermatic cord casing, the parietal peritoneum (I think). Not beside it, but inside it.
Anyway, I think that you can imagine that with the peritoneum peeled back to the deep ring you would be able to see any extra space around the cord itself, that might provide room for material to squeeze in, Fat or omentum or intestine. I have images captured during the surgery, I might go back and see if I can identify anything. They’re pretty bloody though and I don’t really know what I’m looking at.
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I was trying to make that point in my two posts. He said that he saw an indirect hernia when he had the peritoneum down and was removing the mesh. But afterward there was no indication of a hernia.
From what I’ve read about indirect hernias, defining them is often a matter of degree. How much stuff is squeezing through next to the spermatic cord? Or, how much extra space is there around the spermatic cord? That would be the “hernia”, the extra space that stuff might squeeze through.
My takeaway is that the ring was visibly stretched but nothing substantial was happening there. Once the peritoneum was stitched up and healed he could not see a depression that would indicate a hernia. So, I just take extra care to avoid pressure-causing activities. So far it seems to be working. Nothing extra seems to be moving down in to the canal with either of my cords.
Compare the above to descriptions of direct hernias. Oftentimes they are just called posterior wall weaknesses.
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Hi GI,
So that’s your surgical report? Suggests there are indirect hernias after removal on both sides? I had thought you said there were no hernias after removal and you haven’t had any recurrence yet.
Thanks
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GI, Thanks for that report. It sounds like the right side had more worrisome adhesions, but the left side still had a lot of inflammation (and contraction).
It’s hard to imagine why someone would choose lap hernia surgery unless there is a significant chance that not getting one would harm one’s health.
Also, thanks to Herminius for sharing your report.
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Above, when I say that he did not see an indirect hernia before opening the peritoneum, I meant when he went back in to do the left side he said that both groins were examined and no hernia was seen on either side. Even though he had said he saw an indirect hernia when he took the right side out. I did have some small bowel attached to the right side port area though.
Just completing the observation. I was so happy to get the mesh out that I wasn’t and still am not too worried about an indirect hernia. The mesh was worse.
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Here are the basics, at the bottom. It’s interesting that he does not see an indirect hernia when the peritoneum is closed, on first viewing, but after he opens it up and removes the mesh he apparently sees an indirect hernia. Not sure how that works, maybe it means that the internal ring is enlarged.
The left side went smoothly so I haven’t included the Procedure notes. The mesh that came out was smaller than what went in, but I think that he meant inches, not cm, in his description. I have the pictures and they are next to what looks like a 6 inch ruler for scale and they are about 2 x 5 inches. The piece started as 6 x 6.
I had been exercising more after the right side had been removed so that might have caused some of the edema. I had been considering leaving the left side in (still trying to believe that the mesh implantation alone wasn’t the problem, that maybe a mistake had been made and the left would be okay) but after exercising, the left side was now the worst side, compared to what had been the worst, the right side.
Any typos are mine. I had to retype from an image of his notes.
Right side, where the original direct hernia was.
“Findings: The right groin was densely adherent to surrounding tissues. I was able to remove about 90% of the mesh. I left some mesh laying over the iliac vessels and near the spermatic cord. The left side looked normal and not explored. The colon and small bowel were normal.
Procedure:
…The left groin was examined and looked normal with no hernia. The right groin looked normal too, but we agreed to explore the right groin because of his pain and to remove the mesh. I dissected the mesh off the anterior and lateral wall of the groin. It was densely adherent to the tissues, more than expected. I then went medially and dissected the mesh down to Cooper’s ligament. I removed the mesh in this area. I dissected up to the cord and freed as much as I felt comfortable doing. The cord structures and major vessels going into the groin were carefully protected and I left some mesh there. The spermatic cord and vessels were dissected of the mesh. The epigastric artery was adherent to the mesh and I was not able to preserve it. I ligated it with ligaclips. The excised mesh was removed through the 12mm trocar in three pieces. There was an indirect inguinal hernia but it was small. The area was irrigated. There was no evidence of intestinal injury.
…”Left side:
“Findings: The tissue was edematous. Essentially, all of the mesh was removed from the left groin. He has a small indirect inguinal hernia. This was not repaired. The dissection was tedious due to the inflammation and the contraction of the mesh to the tissues of the abdominal wall. A 2×5 cm piece was removed.”
Herminius, let me know if you’d like me or others to start new Topics instead of adding to yours.
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GI, would you be willing to post your pathology report? I remember it being said at some point that your peritoneum, your muscle and the mesh had all fused together. This may have come from Chuck, so could have been his interpretation.
It almost sounds like getting the mesh off the muscle may be easier than getting it off the vessels that it covers. Is the damage to the muscles and peritoneum temporary?
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Thanks Herminius. My inferior epigastric artery couldn’t be saved either. I suppose that the lack of blood supply to the areas it supplied could have caused some of my longer term healing soreness. The body’s other supply lines will grow in to provide new supply over time, as I understand things. Something to be aware of if you have some pain. It should resolve, although I can’t find much about it on the old internet. Lots about where it goes and how it gets damaged. Not much about the effects on the body of removal or damage.
Good luck. Hopefully your original symptoms don’t come back.
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From the Surgical Report:
“No evidence of hernia recurrence. The lateral portion of the mesh was folded from the inferior up towards the middle space of Retzius.. used cautery to take it away from muscle… gonadal vessels, which were completely freed from the mesh and preserved… dissected the mesh off from both medial and lateral sides coming on the inferior epigastric vessels. We were able to take the mesh safely away from them, but we did have to clip the inferior epigastric artery both proximally and distally. The vas deferens was also preserved and the mesh was dissected away from the iliac artery and iliac vein, and then finally taken off from the pubis as well as Cooper’s. Once this dissection was complete, the mesh was removed in its entirety. -
Also when inflammation is present, the amount of it correlates to the size of the source of the inflammation ie the mesh? I am assuming all things equal, as if one is allergic to a substance things can go quickly south with just a small amount…
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Some researchers seem to think that scar tissue forms around static foreign bodies. In particular I remember the discussion in a paper for a 3d mesh for inguinal hernia where the mesh is implanted but otherwise free to move within a certain space. It was found that no scar tissue formed around the mesh, which I assume meant there was less inflammation as well…
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The paper linked by Dr. Towfigh is interesting in that it suggests that either there is no such thing as “mesh reaction” (it’s all just common foreign body response) or that all mesh implant patients suffer from mesh reaction, just to differing degrees of discomfort.
What is left out the “mesh reaction” discussion is the subject of what causes the reaction. Is it just the presence of the material itself? If the mesh was unraveled and implanted as a ball of fibers would it cause the same reaction? Or is it the movement or lack of movement of the mesh as the body moves around it. All Prolene sutures should cause a “mesh reaction”. The Shouldice procedure done with Prolene should have a line of mesh reaction. The depth of research in to the problem seems not deep at all. Observations and RCT’s but nobody, besides Bendavid, seems to be looking for root cause.
Good luck with recovery Herminius. Can you share more of the surgery notes? Any observations about nerves or vessels or the original indirect hernia would be interesting.
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Ah, ok thanks for the answer about the pathology report!
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Congratulations.
And yes, that is typical pathology for any foreign body removed for any reason.
We published on this here: https://pubmed.ncbi.nlm.nih.gov/30772445/
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