Hernia Recurrance

[William Bryant]

Oh dear. It just doesn’t seem to be overly confident with many/any surgeon or surgeries type.

Although I’d be inclined to go with Dr Kang.

Good luck everyone

[Jack2021]

Hi Oceanic,

Really sorry to hear about this. Apologies if I missed it in the thread, but have you spoken to Dr Conze about this yet and if so, what did he think?

I’m guessing he’d want to do his own ultrasound to assess you before giving a definitive opinion, which obviously isn’t particularly convenient with him being in Germany.

If you haven’t already, I’d look to email Dr Conze some of the ultrasound imaging if you can and then run through over the phone what he thinks are the possible scenarios, including potential outcomes/risks, if it definitely is a recurrence. I’d write down in advance what you think the scenarios could be, to make sure you cover everything with him.

I’d also check with Dr Conze re whether he would charge you again if the repair has failed, should you decide to go back to him for treatment.

Another option, albeit long haul, would be to contact Dr Kang. From memory, I think he’s previously said that his repair is suitable for tissue repair recurrences.

More of a long shot, but I think good to cover all options, you could also try to contact Dr Ralph Lorenz to ask if a Desarda repair could be an option.

Best of luck and please keep us posted,

Jack

[Good intentions]

If you’ve had no pain and the surgeon thinks that they can repair the “recurrence” (added a comment near the end) a calculation of the odds seems to suggest going back to Dr. Conze.

Avoidance of recurrence is still the number one thing on the minds of surgeons that do hernia repair. Chronic pain and mesh complications are secondary, out of mind. It’s just the way things are. (still) Your case would lead the typical surgeon to recommend mesh even more strongly because of the recurrence, if it is a recurrence. But the odds of mesh problems are still there.

If you watch that video I posted and the others that show up on the side-bar you might be shocked at how they talk about “what they thought was working X years ago turned out to be incorrect”. There is sitll a lot of experimentation going on. SAGES just released a bunch of new videos and this is even more apparent.

You were satisified for 16 months. The new hernia is small and only uncomfortable. I’d go back to Dr. Conze.

I would also get more information on the new hernia. Is it really a “recurrence”, a failure of one of the repairs, or is it a new hernia in the same location? If it’s a new hernia then the two original surgeries might not really be failures. Dr. Conze can probably explain in detail what he thinks occurred. Might help you make your decision.

Of course, you’ll want to consider also if your activities put unexpected strain on the area. It’s not a simple mesh or no mesh decision.

And finally, remember that I am very biased, as somebody who had a terrible laparoscopic mesh implantation experience. All of the boxes were checked for an excellent result – surgeon, method, and material – yet the mesh was removed three years later.

Good luck.

[Oceanic]

Thanks GI for the detailed response I appreciate it, the direct hernia is definitely in the same area but obviously I don’t know if it’s a new one or a failure of the past repair.

I’m just concerned after Dr.Towfighs advice that a second open repair should never be attempted but I know Dr. Conze would likely do this as he definitely doesn’t do laparoscopic procedures.

I’m just so sick of the whole situation I hoped I might at least get 10 years from the repair or hopefully it saw me out, I’m 55. I am still frankly terrified of laparoscopic surgery, I think if I had that and it went badly wrong and left me in chronic pain I’d likely call it a day.

• This reply was modified 2 months ago by  Oceanic.

[Good intentions]

I don’t think that there are hard and fast “rules” to go by.

You’re in a tough situation. The odds have not changed. Dr. Towfigh has described one risk, nerve damage,. The mesh risk has been well described also, even by the professionals like the Editor of Hernia.

You’re basic dilemma is comparing what Dr. Towfigh said, below, to mesh risks. And I think that Dr. Towfigh’s comment is focused on recurrence, not mesh-caused chronic pain.

Dr. Towfigh : “Going back in open, after prior open repair, is asking for trouble. There are nerves that risk being injured as they are already involved in scar tissue.”

Another question you might ask is – will this surgeon be around to help if I have mesh problems? That is the other aspect that doesn’t get attention. If you do decide to go for lap mesh ask them directly. If they avoid the issue, move on to the next surgeon. I hate to be the bad news guy but Pain Clinics and Mesh Removal are real businesses that have grown dramatically in the last few years. You might try contacting Dr. Krpata to see if he has an opinion.

Again, I hate to keep posting these kinds of videos, below. But this one is from a very well-known clinic, The Cleveland Clinic. It involves Dr. Krpata. If I had to choose lap mesh I’d probably try to have Dr. Krpata do it. He’s seen real cases and deals with them. He should have insights on how to aovid problems. Or he might just agree that it’s a gamble and nobody knows how to avoid problems. But he should be there for you until resolution of any problems is achieved.

She was fine for seven months after implantation, then wasn’t. 2019 was not that long ago.

https://my.clevelandclinic.org/patient-stories/383-woman-relieved-from-chronic-groin-pain-after-hernia-mesh-is-removed

my.clevelandclinic.org

Woman Relieved from Chronic Groin Pain After Hernia Mesh is Removed

Discover how Jody Lynn, finally got relief from a complication related to her hernia surgery after traveling to Cleveland Clinic and meeting with Dr. David Krpata.

[Watchful]

As far as I know, Dr. Krpata doesn’t do laparoscopic or robotic surgery.

I asked multiple surgeons who do both open and lap about what to do after Shouldice recurrence. They all said lap. Even my Shouldice Hospital surgeon (who doesn’t do lap) said lap. Not that I trust him much after what happened with my surgery.

One big problem with the situation is that you can’t be sure that the symptoms are caused by the recurrence. They could be caused by the Shouldice repair. In that case, you can end up repairing the hernia laparoscopically, but still suffering from the symptoms plus adding whatever issues you get from the lap surgery (hopefully none, but as we know from all the papers we read, the incidence of problems with that procedure is far from negligible).

There are no easy answers, unfortunately. It’s a crapshoot. My inclination would be to do nothing as long as the symptoms aren’t too bad, and the hernia size is stable.

[Good intentions]

My point about Dr. Krpata was that he runs a pain clinic focused on hernia pain. He has probably seen and considered all of the typical problems from hernia repair. He is not avoiding the issues and might have insights that a typical surgeon would not. He could probably answer the question about performing pure tissue surgery again.

And, before mesh repairs were promoted as the be-all end-all repair I am pretty sure that pure tissue repair after a pure tissue repair was the common method for a recurrence. Because mesh did not exist. Somewhere out there is a surgeon who can imagine, or who has studied, what they did before mesh took over the hernia repair field. I doubt that there is any reliable data about the efficacy of mesh or pure tissue repairs after a recurrence from a pure tissue repair. But there might be old data, pre-mesh, probably in better researched studies than today’s, about the best method of repair after a pure tissue recurrence.

For what it’s worth, I still get occasional pain from the remaining piece of mesh in my groin. And there is still a bump there, which is, I think, the ball of mesh, nerves, vessels, and stuff left behind. But, so far, it has always resolved after a day or two. If your bump is not getting bigger I would wait, as Watchful suggests. If you start getting other signs of canal intrusion like testicular torsion then reconsider.

Good luck.

[Watchful]

I actually asked him this question, and he said fix the recurrence with mesh.

It’s true that in the old days tissue repair was used to repair tissue repair recurrences. However, even primary tissue repair results were fairly poor on average, and recurrence repairs did even worse. There were good reasons for the fast adoption of mesh – it wasn’t primarily driven by some corporate conspiracy, at least not for inguinal hernia applications.

The Shouldice Hospital was one of very few places that reported very low recurrence rates with tissue repair. They reported higher recurrence rates after recurrent hernia repair, but still reasonable. They never studied properly their chronic pain rates. Not sure how well recurrences were studied either – they don’t really follow up with their patients. Also, they don’t consider hernias without a bulge to be real, so if it’s just seen in imaging, they ignore it. Oceanic’s case wouldn’t be considered a recurrence in their official stance, which is ridiculous. These days, when asking about what to do for recurrence, even they say lap mesh, or at least that’s what they said in my case.

I’m not a fan of any of these surgeries – they’re problematic in way too many cases based on the research papers and the individual cases that I’m familiar with, which is the reason I believe in watchful waiting when possible. It’s even trickier with recurrences. You can’t keep going back in again and again without repercussions, so you need something that would minimize the risk of recurring.

[Good intentions]

Actually, from a different perspective – Dr. Conze is considered an expert in hernia repair. Why did he not recommend a mesh repair after the “failed” modified (what was the modification?) Shouldice repair? Is he one surgeon among thousands with this opinion?

It might be that he is aware of a specific weakness of his method and knows how to fix it.

And, to add complexity, we’re still referring to all mesh types and procedures as “mesh”. Recurrences should be repaired with “mesh”. Which one, which method, after a pure tissue recurrence? PHS, TREPP, Onflex, Progrip, Insightra, plain old Bard “gold standard” mesh … pick one.

Sorry Oceanic, this probably doesn’t make your decision easier. But there might be some clues that will help.

[Good intentions]

When did you ask? And did you ask specifically about repairs after Shouldice procedure recurrences? I have a faint feeling of competition in the discussion. I have not proposed a conspiracy, or collusion, regarding corporate influence promoting mesh. Just a focus on a profitable business venture and the efforts to keep the revenue flowing. It might look like a conspiracy in my descriptions but it’s really just large corporations with a common interest. And the corporate money controls the discussion and research.

I had a thought about these multilayer repairs and recurrence. Each interface between layers offers a place to form a pocket in to which abdominal contents could be projected. This could form an uncomfortable bump, but due to the layered structure the contents are stopped before they get in to the inguinal canal. It’s been my impression that any deviation from a solid repair that results in discomfort is often called a “recurrence”. But is it really? Or is it some new phenomenon that is actually “safer” than a recurrence but still uncomfortable. Remember that the common scary fact used to influence hernia patients is incarceration and possible death or emergency room visits. Is a “recurrence” after Shouldice as likely to incarcerate?

Besides that, if it’s not a true recurrence then maybe a reoperation without mesh is a rational choice. Much of what you see in the hernia repair field is an attempt to make things black and white – hernias all need surgery, mesh is the best repair for the majority of hernias, any recurrence should be repaired with mesh, etc. The world just does not work that way. It’s worth exploring the in-between situations.

Anyway, even though Oceanic is in the U.K. I would guess that Dr. Krpata would converse with him as he did for you, Watchful. It is definitely difficult to put all of this extra effort in to fixing what was supposed to be fixed by the surgeon but sometimes you’ll get lucky and find somebody with answers. As I did when I was able to reach Dr. Billing after several attempts.

There’s nothing to lose by trying. Otherwise you’re just another patient on the conveyor belt.

[Oceanic]

Hi Watchful thanks for the advice, I’ve been pain and trouble free and only recently I’ve been getting some aching and mild testicle pain when seated so I’m fairly sure the recurrence is what’s now causing the discomfort, at the moment the hernia is only 1cm x 1cm according to the Ultrasound, would it not be better to get it fixed now whilst small as they inevitability become larger which then makes the surgery more complicated. One surgeon I spoke to said it’s small enough to be stitched up or even a small piece of mesh the size of a quarter putting over it after the stitching. I’m worried full laproscopic surgery for a 1cm hernia is overkill as I know they’ll cover both sides with a huge piece of mesh.

[Watchful]

Not sure if it will inevitably get bigger since the area around it may be stronger than normal thanks to the repair. It’s certainly a concern, but inevitable may be too strong. Maybe wait and see if this actually happens or not. It’s typically a gradual, not sudden process. Also, if you go with lap mesh eventually, it won’t really matter if you let the hernia grow or not by waiting.

You can’t go back in again and again safely. The risks of chronic pain and blood supply damage (even risking your testicle) increase. It’s very important to get it right the first time. Since that didn’t happen for you the first time, you really need to get it right (that is a good repair) the second time if you decide to treat it. Lap will give you a good repair that will last without going back into an already operated area. All these hernia surgeries are risky, but this is probably less risky than going open again to do a questionable repair which may lead to further surgeries.

Like I said, my approach would be watchful waiting as long as the symptoms don’t bother you too much and the hernia size is stable. Even if you ultimately need to have surgery again, at least you won yourself some more time without living with the potentially bad repercussions of another surgery. If your quality of life is pretty good right now, don’t risk it would be my advice.

• This reply was modified 2 months ago by  Watchful.

[Oceanic]

GI, I’m in the UK so Dr. K is not really an option, thanks for the advice

[ed]

have you tried any of the facebook hernia forums. specifoally the one called Inguinal Hernia support Uk GB

[Good intentions]

Could you give some details on the past tissue repair? One year is not long. I tried to look at your Timeline but when I click on what looks like a description I get taken to a completely different thread. The new forum is still terrible for learning what people have experienced in the past. I saw an extract that said double Shouldice but can’t figure out who did it. Have you talked to the surgeon that did the first repair?

The type of hernia and type of recurrence are important. One of the big problems today is that all mesh types are called “mesh” and all laparoscopy methods are called “minimally invasive”. And Shouldice is used to describe anything that is “Shouldice-like”. Even the professionals that try to do studies on past results can’t really tell what is what.

If you do decide to get a mesh implant (that might be what really terrifies Oceanic Dr. Towfigh) be aware that the latest fad is the absorbable synthetic mesh. “Short-term results look good!, let’s go with it”.

https://youtu.be/gUfI2bDwC7w?feature=shared

[Oceanic]

It was 16 Months ago and I had a direct and indirect modified Shouldice repair done by Dr. Conze, there is now a small 1cm direct hernia on the same side, it causes some discomfort sitting in the car or an office chair but I’m ok walking or laying down

[drtowfigh]

Going back in open, after prior open repair, is asking for trouble. There are nerves that risk being injured as they are already involved in scar tissue.

Laparoscopic repair would be safer and more effective. Not sure why laparoscopic surgery scares you. If done by a specialist, it would be the best option.

[Oceanic]

Thank you Dr for the reply, all the people on this forum that seemed to have got totally destroyed by hernia surgery seemed to have had laparoscopic, I’m also in the uk and can’t seem to find many experts in this procedure, the surgeon in Germany who did the original surgery 16 months ago would opt to go open again, I’m so unsure of what to do now. Thanks