Just had open mesh

[Jnomesh]

Never heard that before. Maybe a misunderstanding.

[jzinckgra]

Had my 3 week post-op visit yesterday. All went well. Still a bit of pain, but starting to cycle again this week. One question: Surgeon told me that even with mesh, hernia’s continue to grow in size. I may have misunderstood what he said, but is this true? Why wouldn’t everyone do Shouldice and use tissue to close the hole if the mesh wasn’t supposed to stop the hole from growing?

[Good intentions]

quote jzinckgra:

Turns out the mesh from the lapro repair extended over to the side of the new repair. The Dr. questioned why my larpro surgeon used such a large (4×6″) patch for what was a pretty small hernia.

Had I gone back to the lapro surgeon, would he have also been challenged by needing to remove and/or make room for the new patch on the right side?

Since the Onstep procedure does extend down to the pubic symphysis I guess it does make sense. Both procedures go deep and toward the midline.

What is kind of surprising is that Dr. Reinhorn was not aware of the trend toward implanting the biggest piece of mesh that will fit, for laparoscopic mesh implantation. He should have seen “laparoscopic mesh” and thought “there’s going to be mesh in my way”. He should not have been surprised because that’s been “state-of-the-art” for many years.

The surgeon who implanted the mesh that I later had removed actually overlapped the two pieces at the midline by about a 1/4 inch. I don’t know if it’s in the “Guidelines” to do that but I guess that he was planning for shrinkage. If you had gone back to your same surgeon he probably would have just laid it down as close as possible, maybe even overlapping it. That’s how the lap procedure works, just lay it down, close things up, and let whatever happens happen.

He does not report any fixation, so it’s still possible that it moved.

“The mesh extended lateral to the internal ring,deep to the Coope/s ligament and to the midline. CO2 was then evacuated under direct visualization as the trocars were removed. The mesh maintained good position and trocar sites were hemostaiic.” ”

Whatever the reason, good luck.

[jzinckgra]

quote Good intentions:

Yes, there is something off with the overall description. Either the original mesh was placed incorrectly or moved immediately, or it moved quite a distance before it was “incorporated”, or it migrated over a longer time, or jzinckgra actually had a bilateral mesh placement. The notes from the first surgery would tell something. Without those it’s a mystery.

Here is a snippet from my left side lapro surgery:

“The mesh was then inserted via the umbilical trocar and positioned in the left inguinofemoral region to completely cover the direct,indirect and fenrcral spaces widely. The mesh extended lateral to the internal ring,deep to the Coope/s ligament and to the midline. CO2 was then evacuated under direct visualization as the trocars were removed. The mesh maintained good position and trocar sites were hemostaiic.”

Based on the position over to the midline, I am not surprised it got in the way of the right side mesh.

[jzinckgra]

quote kaspa:

I’m trying to understand this and hope I won’t say something too ignorant.

As I understand, JZ had a laparoscopic repair of left inguinal hernia and now had an open one for right hernia. When suturing at 2 points in Cooper ligament, one point included previous left mesh.

So the question here is, wouldn’t previous doctor wish to have a bilateral repair, something not too difficult by laparoscopy, perhaps as prophylaxis for right side?

A month or so after lapro on left side was done I started getting right side pain with bulge. I assumed another hernia. Doc said no. I went to two other docs, including Dr. Goodyear who also said no hernia felt. CT scan did show fat hernia but since docs couldn’t feel it they wouldn’t do surgery. Fast forward three years and I had hernia on right side which was just patched.
i dont think patch from lapro moved. I read surgery report and can post here, but ultimately that patch which was 5.5″ in length was placed lengthwise across abdomen and extending to the midline. Whether this was oriented incorrectly I don’t know, but it’s not hard to understand why recent right side open surgery ran into the other patch. I have follow up appt with Dr for recent surgery and I will ask more about what he encountered during surgery

[Good intentions]

Yes, there is something off with the overall description. Either the original mesh was placed incorrectly or moved immediately, or it moved quite a distance before it was “incorporated”, or it migrated over a longer time, or jzinckgra actually had a bilateral mesh placement. The notes from the first surgery would tell something. Without those it’s a mystery.

[kaspa]

I’m trying to understand this and hope I won’t say something too ignorant.

As I understand, JZ had a laparoscopic repair of left inguinal hernia and now had an open one for right hernia. When suturing at 2 points in Cooper ligament, one point included previous left mesh.

So the question here is, wouldn’t previous doctor wish to have a bilateral repair, something not too difficult by laparoscopy, perhaps as prophylaxis for right side?

[jzinckgra]

In my report, Dr says he used two sutures to hold mesh in place. It states “…and 14 x 11mesh placed in place and sutured to the Cooper ligament in two places, one of which incorporated the previous mesh.” Am I to infer one of the sutures was actually placed between the new and old mesh? Or that both sutures are in the Copper’s ligament?

[jzinckgra]

quote scaredtodeath:

How is your pain level from the procedure

Getting better. Day 6. Pain is mostly from the incision now and less of the deep pain.

[scaredtodeath]

How is your pain level from the procedure

[jzinckgra]

quote Good intentions:

[USER=”1438″]jzinckgra[/USER] I saw your post of today that contained the records. Apparently it’s been removed or unapproved for some reason, since I saw it this morning.

But I noticed that the records implied that the new hernia was on the same side, the right, as the old one. It might just have been a typo in your medical procedure notes, my medical notes had significant errors also, with metal tacks mentioned, which were not seen by MRI or found during later mesh removal, and also referring to me as “she” in one instance.

Anyway, if you can get the records from your first surgery that would help you understand why the mesh was there, possibly. I still think it’s possible that you had bilateral repair, but just did not realize it.

Hi,

Here is the report again. I edited the last post too many times and it got flagged for spam. To answer your question about same side repair, I realize the surgery report below doesn’t specify, but when he refers to the fact there was mesh on the right side, one would assume this is the side of the previous patch. This is NOT the case. 1st hernia was left side, 2nd and most recent is right. Following the report, I have a few questions.

PREOPERATIVE DIAGNOSIS: Right inguinal hernia.
POSTOPERATIVE DIAGNOSIS: Right inguinal hemia.
PROCEDURE PERFORMED: Right inguinal hernia repair.
ANESTHESIA:Total intravenous anesthesia.

Us r: LP593 6/25/2019

INDICATIONS: . This is a 46-year-old male with symptomatic right inguinal hernia after previous laparoscopic repair. He understands the risks of surgery including bleeding, infection, recurrent hernia, chronic pain and informed consent was obtained.

OPERATIVE FINDINGS: There is an indirect right inguinal hernia repaired with a 14x 11mesh. There was mesh from the previous surgery extending to Hesselbach triangle and cue to the anterior abdominal wall. I had to excise some dense peritoneal adhesions
to the anterior abdominal wall and repair the peritoneum in order to facilitate the insertion of 14
x 11 mesh.

PROCEDURE IN DETAIL: After anesthesia was administered, local anesthetic was given after prep and drape. The preperitoneal dissection space was entered in the usual fashion and preperitoneal dissection was carried by first taking down the indirect sac, passed the bifurcation, spermatic vessels and vas deferens. The direct space was socked in from adhesions and I ended up opening the peritoneum and dividing the peritoneum leaving some of the anterior abdominal wall until I could create a pocket for the mesh. I then closed the peritoneum with running 3-0 Vicryl. Hemostasis was obtained with electrocautery and 14 x 11mesh placed in place and sutured to the Cooper ligament in two places, one of which incorporated the previous mesh. I then closed the external oblique and Scarpa with 3-0 Vicryl and 4-0 Vicryl for skin.
Steri-Strips and dressings were applied. Sponge, needle, and instruments counts were correct. At the end of the case, the patient tolerated the procedure well and taken to Recovery.

Questions:
1. I’m am thin (6’1″, 155lbs) guy so thinking the left side lapro which used a 6″ long patch was placed across abdo, so that explains why it extended over to right side triangle. Agree?

2. Is removal of adhesions, presumably from last surgery common?

3. Report said he had to repair the peritoneum. Is this above and beyond what’s usually done for IH? I believe he had to do it due to adhesions.

4. I’m an avid cyclist and go to the gym and was told to not do both for 3 wks as opposed to std 2 wks he usually advises. Could I do stationary bike and/or stair stepper lightly starting next wk? I forgot to ask Dr. I don’t want to screw up the surgery and think I overdid 3yrs ago too soon after first hernia, so just asking….

[Good intentions]

[USER=”1438″]jzinckgra[/USER] I saw your post of today that contained the records. Apparently it’s been removed or unapproved for some reason, since I saw it this morning.

But I noticed that the records implied that the new hernia was on the same side, the right, as the old one. It might just have been a typo in your medical procedure notes, my medical notes had significant errors also, with metal tacks mentioned, which were not seen by MRI or found during later mesh removal, and also referring to me as “she” in one instance.

Anyway, if you can get the records from your first surgery that would help you understand why the mesh was there, possibly. I still think it’s possible that you had bilateral repair, but just did not realize it.

[jzinckgra]

To clarify, I did not have repair of recurrent hernia. The left side was patched three years ago using lapro. I got a new hernia on right side and this one was patched last week using open mesh.

[Good intentions]

[USER=”1438″]jzinckgra[/USER] My notification did not work the first time.

jzinck, do you have a copy of your medical records? They would be worth examining. Actually Dr. Reinhorn probably should have examined them also, but I think that some doctors just work with whatever they find once they get in there.

All patients should get copies of their medical records so that they can be as informed as possible if problems occur.

[Good intentions]

quote drtowfigh:

Interesting that you had a recurrent hernia repaired in anterior open fashion after laparoscopic surgery (that is standard) BUT they chose a repair technique that involved the same posterior space as the laparoscopic repair (not as standard, but I’ve seen it done).

What do you think Dr. Reinhorn did to make space for the Onflex device? And how do you think the mesh from one side got over to the other? That is quite a distance. Did it migrate or was it improperly placed?

Or did jzinckgra actually get a prophylactic placement on the right side also and was unaware?

@jzinckgra

[USER=”935″]drtowfigh[/USER]

[drtowfigh]

Interesting that you had a recurrent hernia repaired in anterior open fashion after laparoscopic surgery (that is standard) BUT they chose a repair technique that involved the same posterior space as the laparoscopic repair (not as standard, but I’ve seen it done).

[Good intentions]

It’s called Onstep, and Bard makes a device for it called Onflex. You can search those names and find a lot about it.

[Good intentions]

Onstep is another new method of mesh placement, introduced to the market with little long-term data. Bard is the device maker behind Onstep. They’ve branded their mesh as “Onflex”.

https://journals.sagepub.com/doi/full/10.1177/1457496914529930

http://ugeskriftet.dk/files/b5467_onstep_repair_of_inguinal_hernias.pdf

https://www.crbard.com/davol/en-US/products/OnFlex-Mesh

https://www.hindawi.com/journals/srp/2016/6935167/

[scaredtodeath]

I think the missing link her is that DOctor does the one step procedure… I don’t know the details of the procedure but the mesh is placed posterior via an open procedure

[Jnomesh]

I agree-it’s weird that he encountered the lapro mesh from the other side when he entered via open method. Since lapro is fork behind the muscle and the open repair is from the front you’d think this wouldn’t be possible.
id ask him what type of mesh was used. The only thing I can think of there are some types of mesh that are implanted openly but have 2 flaps -one goes behind the muscle and one in front-so maybe this is where he encounter some of the mesh form the lapro repair.