News Feed Discussions Having second thoughts! Input please.

  • Having second thoughts! Input please.

    Posted by gretarae on May 19, 2016 at 4:30 pm

    I am scheduled for my ventral/incisional/midline repair…retromuscular with polypropylene mesh and a modified component separation next week!! A big operation which I expect to be extremely painful!

    Alas, a rescheduled consult with a plastic surgeon here, he suggested that he thinks a primary repair with some biologic mesh or even vicryl (?) might allow this defect to try and continue to heal without permanent foreign body. Of course, I love the idea of “trying” this, but I had just gotten my head around the absolute need for mesh in my condition.

    What are the downfalls of attempting this no-mesh/biologic repair….or would you just stick to my plan and do it “permanently” the first time? This process is maddening as every doctor, all highly qualified, is presenting me with an alternative option. Should I cancel this surgery and continue to research more? My supposition is that I am just avoiding the inevitable.
    Losing sleep and ready to move on with my healthy life!

    pszotek replied 7 years, 9 months ago 3 Members · 2 Replies
  • 2 Replies
  • DrEarle

    Member
    May 22, 2016 at 2:27 pm

    Having second thoughts! Input please.

    gretarae – The proper way to decide if/how to repair your hernia is to follow a process that takes in to account your individuality, the surgeon’s perspective and ability, and available technology. 1) Identify your goal. Why do you want it fixed? Normalize abdominal wall contour, relief of symptoms, prevention of it getting worse, scar revision, etc. May be a combination of things. 2) Look at you own medical and surgical history, particularly as it relates to complications, especially infection. 3) Look at the details of the hernia – location and size of defect, and sac. 4) Choose a technique that will most likely obtain your goals (which your surgeon should align with) with the least possible risk. 5) Choose a mesh (or not) that best fits with the technique, and your goals. If you follow this, you will make the best decision you can. Will it be right? Only time will tell.
    A couple more thoughts:
    – There are many types of “component separation” techniques. Make sure you are having one that spares the blood supply coming from the peri-umbilical blood vessels (perforator-sparing). Sparing these blood vessels drastically reduces the risk of skin problems in most studies.
    – If recurrence is your biggest goal, go for a permanent prosthetic that is specifically designed for the technique being used, and strong enough to bridge a gap if needed. There are some mesh products that are simply not strong enough to bridge large gaps, such as Physiomesh. While there is no cut-off number, a basic understanding of what features each mesh has will enable the surgeon to use the most appropriate mesh for a given patient’s hernia repair. Many surgeons don’t have a solid understanding of the mesh products available.

    Hope this helps!

  • pszotek

    Member
    May 19, 2016 at 8:23 pm

    Having second thoughts! Input please.

    Gretarae,

    You describe a pretty common conundrum that patients face with multiple opinions. It will be difficult to tell you which repair you need without a complete history and at least a view of your CT scan. I don’t think either surgeon is completely right or completely wrong. I think that you have to also take into account the techniques being employed. For example, if you are a good surgical candidate and meet all criteria for a low risk of wound complication and the defect is such that you require large repair then I would prefer to perform the repair with polypropylene in the retrorectus space and what I am assuming is a TAR (transversus abdominis release) procedure you are describing as a “modified component separation”. This operation for morbidity and long term outcomes is second to none in a surgeons hands that has a lot of experience with the procedure like all the surgeons on herniatalk. I do not think that the plastic surgeon is incorrect but in my practice it would be exceedingly rare that I would offer a biologic hernia repair in a patient that meets criteria for a more durable repair with synthetic in the retrorectus space. One deciding factor that I would advise you is the technique the plastic surgeon will use to put the biologic in. If he is going to use a retrorectus approach with a biologic then I would not burn that bridge with a biologic at the current time because of the higher recurrence rates and greater morbidity. I hope this makes sense and helps a little bit with your decision. Regardless you should remember that it is impossible to direct you without the entire history of your problem and seeing the images as there are a lot of factors that go into deciding the procedure and mesh that cannot be judged accurately without all the information.

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