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Dr. Twofigh – Chronic Pain
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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.
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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.
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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.
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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.
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Awesome post Dr. T, thanks.
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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
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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.
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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…
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why does it always feel like the left side is the problematic one.
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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.
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@ watchful, would like to hear more about your symptoms, perhaps we have some things in common. Send me a DM if you like.
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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.
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Sent you DM @good-intentions
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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.
Good luck and stay in touch.
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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.
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