Dr. Twofigh – Chronic Pain

[Chuck]

Dr Twofigh -you are one of the few surgeons in the world that has a large menu of surgical technniques….when you advise your patients about the best way to avoid chronic pain…what do you tell them. I understand every situation is different. And you favor lap surgery in many cases. My impression is the tissue repairs….Shouldice in particular have very high rates of tightness and longterm chronic pain. In you interview with Dr Yunis…you seemed to agree that lichtenstien repairs made up most or your complications work. But i have never met a soul who had a lictenstien that ever complained a peep about them….many were double meshed open. Is it your view that lichtnestein has a lower rate of chronic pain than tissue repairs….and if so …do you regularly perform lichtenstien?

[Chuck]

I guess my question…is lichenstein the overall safest repair in terms of chronic pain and recurrance in your view? I am going to try to set up a consult with you to discuss further…

[MarkT]

Chuck, please stop repeating that Shouldice has very high rates of long-term complications. That is simply FALSE unless you are foolish enough to go to someone who doesn’t know how to do it properly because it is a more complex/nuanced repair.

[drtowfigh]

Every patient has their own set of risk factors and findings and so the best repair is different for each patient.

Thin active male with small inguinal hernia: I would recommend tissue repair.

Thin active male with large inguinal hernia reaching down to his upper scrotum: I would recommend laparoscopic repair with lightweight mesh.

Elderly male with scrotal hernia: I would recommend open repair with mesh.

So, the answer for best repair, in my practice, changes depending on the needs of each patient

[pinto]

Awesome post Dr. T, thanks.

[Watchful]

@drtowfigh

Do some people have a “deep anatomy” which makes Shouldice (and some other tissue repairs) more difficult? If so, is there a way to know in advance using imaging?

Also, how does the size of the hernia affect the difficulty of performing a Shouldice procedure and its outcomes? Does it become a more complex procedure? It’s interesting that the Shouldice Hospital doesn’t reject large hernias for that repair, but most others do.

Your ability to use all these types of repairs is extremely rare. In the vast majority of cases, the patient essentially picks the type of repair by picking the surgeon, which is obviously far from ideal.

[drtowfigh]

With larger hernias, there is a wider gap and more thinned tissues. So, trying to pull all that together will result in higher tension at the suture line than for smaller hernias. That tension can result in chronic pain, as you’re in a constant state of trying to tear it apart. So, I assume there would be less chronic pain with a mesh based repair in these situations.

[Watchful]

@drtowfigh

Thanks for the response. My understanding (or maybe just wishful thinking) was that the Shouldice procedure reconstructs the area in a more clever way which largely avoids this tension thanks to the 4 layer repair, plus relaxing incisions if needed. I think I get what you’re saying, though, if there isn’t enough tissue to work with.

[Watchful]

I think an important question is what you can do to resolve chronic pain after tissue repair. If it’s caused by nerve damage, then neurectomy is an option. However, if it is caused by pressure on an area of excessive tension, then what do you do?

I heard of a case of chronic pain after a Shouldice repair where a surgeon recommended doing a lap mesh procedure as a possible solution with the goal of reducing the pressure on the Shouldice repair.

[William Bryant]

That would make sense I think Watchful. Don’t some surgeons do both as a combined repair in some cases?

I do think time will bring improvement. Baris had surgery again very soon after and said he probably should have waited. I suppose it’s not easy to wait though.

[MarkT]

It would be nice to get more information on ‘tension’ because there seems to be a multivariate spectrum of how it manifests (short vs. long-term, unnoticeable vs. problematic, etc.).

At the low end, there is clearly normal, temporary, non-problematic tension associated with a tissue repair that is either unnoticeable or that resolves over the short-term. This would describe my case, as I had (and continue to have) absolutely *zero* noticeable ‘tension’ following unremarkable recoveries from either of my Shouldice repairs many years ago.

At the high end, it seems we can get to chronic, problematic tension, perhaps due to issues associated with a large hernia (as Dr. Towfigh stated above), maybe also due to poor/insufficient tissue quality regardless of hernia size? Perhaps even just a poorly performed repair? In addition to ensuring a tissue repair is suitable for a particular case, is this perhaps yet another reason to avoid getting a tissue repair (especially a more complex one like Shouldice) from a non-expert surgeon?

Shouldice Hospital generally describes tension is normal and that it resolves, so I wonder at what point tension is too high, tissue quality is so poor or strained, etc. that such adaptation is simply not possible?

From Shouldice Hospital’s website:

“…The reality is that tension is not the enemy of hernia repair as it exists naturally throughout the abdominal wall. All hernia repairs by their nature involve realigning tension within the abdominal wall by repairing the tear or weakness in the muscle. The key is what happens to that tension over time.

Natural tissue techniques can put immediate, but minimal, tension on the muscles and surrounding tissues as they are drawn to repair the hernia, but this mild discomfort subsides quickly as the tissues stretch and compensate in the natural healing process through muscular adaptation so well described by physiologists and seen in weight lifters. Thereafter, only the strengthened natural tissue abdominal wall remains…”

https://www.shouldice.com/hernias-explained/ (click on sub-heading of ‘The Myth of ‘Tension’ in Hernia Repair’ – this is just an excerpt of what is written there).

[Watchful]

Right, but things get really uncertain with all these factors of hernia size, type of anatomy, tissue quality, body mass, and age. It’s not good that it gets iffy when you venture outside the realm of pretty ideal cases. For some reason, at Shouldice, they focus only on body mass as a criterion.

You mentioned the skill of the surgeon. There is an interview with Dr. Burul who was a very experienced surgeon when he joined Shouldice, and he was the chief surgeon there for a while. He said that it took him a year and half after he joined to feel comfortable with performing the Shouldice procedure on different hernias. He didn’t stay long there, by the way, and went to some other hospitals.

• This reply was modified 3 months, 2 weeks ago by Watchful.

[Oceanic]

Does anyone know what’s considered a normal time frame for tension resolution. My right side feels pretty good already but my left side is a lot tighter by comparison.

[sensei_305]

why does it always feel like the left side is the problematic one.

[Watchful]

Who knows, but more than two weeks seems very possible. You’re still quite close to your surgery…

In what way does the tightness show up? What do you feel, and during what activity?

Any changes in the pain while standing up or walking (when not using the lifting trick)?

Shortly after surgery it’s like you’re in a fog of war and don’t know what’s just a fairly normal part of healing, and what may become persistent (hopefully nothing in that category). New symptoms can appear later on as well (again, hopefully not in your case).

[Oceanic]

Hi Watchful, I’ve read from more than one person the tension can take a month or longer more to dissapate. May say muhc betetr at the 6 week point.

The tightness just creates a pulling sensation and it seems to come from the area under the incision where the repair was done and then it extends towards my thigh and down the groin. This only happens when standing and walking and is fairly similar to a few days ago, if I wedge some socks under my testicles to hike them up I can walk a lot more comfortably and for further.

As I’ve said I’m hoping it’s just a case of the muscle/tissue needs to remodel and stretch or that Dr. Conze is right and it will resolve when the swelling subsides, although my right side the swelling has gone down a fair bit but the left side not so much.

The right side does feel a little tight too but it doesnt really cause any discomfort when walking

Did your tension sort itself out or still feeling some tightness?

• This reply was modified 3 months, 2 weeks ago by Oceanic.

[sensei_305]

In my case I don’t feel pulling on my inguinal area, I do feel it on my umbilical where I had a repair done with sutures same day mesh was implanted for inguinal crap. What I feel is actually pushing when I sit. Feels like if a balloon wanted to pop out of my pelvic area where mesh was. Not sure if anyone else has experienced this, nevertheless I am flying back to Seattle mid July to have revision surgery and sort out wtf is going on with me. Surgeons are too quick to send you to pain management for some shots that will do absolutely nothing once they have made their money.

[Watchful]

Tightness sensation wasn’t the issue that I was dealing with right after surgery. I was developing severe pain after a few minutes of standing or walking, and the method I shared with you helped me with that. What has happened since then is a long story, and I don’t want you to assume that you will go through something similar, particularly since it sounds like our symptoms have been a bit different.

[Oceanic]

Watchful I’m sorry to hear it’s been a rough ride for you, how are you doing now and how far out from surgery are you? Can you walk for a reasonable distance yet?

I was in severe pain walking the first few days but its been calming down more and more, I still odont have unlimited range though and will have to stop due to pain eventually, a few km maybe, I then need to sit down, let the pressure ease off and I can go again for a short distance.

[Watchful]

@oceanic

It has been a rough ride, unfortunately. I’m about 7 months out from surgery.

Currently, I don’t have trouble with walking. However, I do have trouble when sitting – pressure builds up gradually which leads to discomfort and then pain. I didn’t have this in the early months of recovery. I have no idea what’s causing it – scar tissue, tension of the repair, who knows… It doesn’t feel like a recurrence. I also have some other symptoms which are classic nerve injury symptoms, but I think that’s just an added bonus rather than the root cause of everything.

[sensei_305]

Exactly what I feel when I sit. Can also feel the pressure after sexual intercourse. Sorry for being explict but yeah. Its exactly as you describe it. A gradual build up like a balloon filling up. I guess we will find oit what is the root cause on my revision surgery this summer. Back to Seattle I go.

[Good intentions]

I have had a recent experience that might give you guys some ideas. I recently had some persistent discomfort around the area of the original hernia and scrap of mesh that remains after mesh removal. This was after several days of long walks and hikes and some somewhat strenuous physical work. It seemed like a nerve problem since there was some referred pain that seemed to originate from the mesh scrap area.

I decided to try doing more and heavier weight lifting and more pushups on the thought that the pain was from a small irritated spot on the nerves in the area and that stressing/straining/stretching the abdominal wall might pull the damaged spot to a new smoother area where it could heal. It seems to have worked.

So, maybe try some things that are counterintuitive.

[Good intentions]

Here is an interesting description of all of the mechanisms that occur when abdominal pressure is increased and the muscles are activated. There are more than I had realized. I would imagine that the disrupted tissues from any type of repair need to be worked in order for new collagen to form/align correctly and to resist the natural tightening of the scar tissue. It seems like a balance between too much and too little, in order to get the complete and correct healing process.

https://worldsurgeryforum.net/2017/07/surgical-anatomy-of-inguinal-canal.html

[sensei_305]

whats up brother @good-intentions long time no see… Was actually chatting with Dr.Billing a little while ago. In short, I was supposed to go back and have right side mesh removed as we had spoken back in January. I ended up going with Eduardo Parra-Davila here in West Palm beach since my insurance takes him. He removed right side mesh plus the left over small piece Dr.Billing had left behind on left side. I felt great days post surgery and boom sure enough.. The annoying burning/ discomfort in belly button is back. Right side mesh removal 100% pain free. Left side however well each morning when I wake up its pretty painful. Soreness like, when sitting for a while also tend to feel a bit of pressure. I had a CT scan done last week and waiting on Dr.Parra to review to rule out a recurrence or whatever is going on. I know I have about 50-60 pounds to lose so that is not helping my case. Good to see you are still active here in the forum.

[Good intentions]

sensei I was wondering about your second surgery. It’s good to hear that other surgeons are getting involved in the mesh removal business but, of course, also bad to hear.

Are you saying that everything was good after the first left removal until the second right removal? It reads like you’re saying that the left side felt good until the right side was removed.

Not trying to defend Dr. Billing just trying to understand overall. Dr. Parra-Davila is a new name in mesh removal. Good luck going forward. My views on hernia repair keep evolving. The latest is that TREPP makes a lot of sense.

https://www.palmbeachdigitalsurgeryinstitute.com/find-a-doctor/detail/eduardo-parra-davila-1609864925

Good luck and stay in touch.

[sensei_305]

Sent you DM @good-intentions

[Watchful]

Thanks, GI. I do try a large variety of exercises as well as hot compresses and massages of the area.

[Herniated]

Watchful, if you have not already done so, perhaps it is time for a physical exam/blood work/imaging to rule out other potential issues (e.g. infection, tumor, bleeding)?

[Watchful]

Herniated – thanks, but my symptoms aren’t consistent with any of those things. My surgeon wasn’t surprised by my symptoms during my follow-ups with him – they are evidently quite used to seeing these in some cases.

If I wanted to look further into it with imaging or other methods, I would need to fly somewhere to a specialist with the right expertise and experience. There are very few of them, and none in my area. I’ll probably do that in a few months if I see no improvement.

[sensei_305]

@ watchful, would like to hear more about your symptoms, perhaps we have some things in common. Send me a DM if you like.

[pinto]

Watchful, I’m glad your doc is on top of it and sorry to hear you’re in some rough spots. Amazing this relatively ignored part of our body can wreck so much havoc on us. Hopefully you’ve seen the worst of it and daylight just around the corner. I’m pullin’ for ya.

[NFG12]

No matter what we do hernia surgery is a quick fix, do it lap bilateral 10,000 dollars! Hernias don’t usually hurt as a surgeon said to me once it’s a money maker, same as gallbladder surgery, supposed to be harmless but my buddy ears this or that and has to use the bathroom! He said Gallbladder and Hernia surgeryare money grabs, which they are only 1% have to be treated as an emergency! Remember this yall the groin is the most complex part of the our anatomy!

[NFG12]

Also he was honest said kud yea a hernia can be the Suze of a tomato it doesn’t hurt but cause of the appearance or if your a weightlifter etc. I know the ins and outs with Dr. Towfigh, Dr. Belyansky, Dr. Chen,Dr. Dr. Ramshaw, Dr. Jacobs, Dr. Yunis. My life for turned upside down at 25 for oh there’s a Lil indirect etc I wouldn’t of know it with accidentally finding it on an ultrasound. Do your research etc Dr. Janzyck been doing Robotics before Towfigh and Belyansky not saying nothing bad but he’s the pioneer with his partner Dr. Iacco. Research do your thing and wish the best but there is light at the end of the tunnel!!!

[Watchful]

Thanks, Pinto. I’m staying optimistic. Luckily, I manage reasonably well most of the time even with these annoying symptoms.

[pinto]

You’re welcome, Watchful. You’re a great citizen here and so I’m sure you’re handling things as best as one could. Just a few years ago when I got an IH for the first time, I was so shocked. Never heard of ’em before except for the cautions heard about lifting things. I think Chuck has expressed the angst felt best of all so I won’t try. 😀 You keep positive, fella.

[Oceanic]

@watchful

I have sent you a PM rather than take this thread off topic

[Author]

Posts