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Laparoscopic or Open Approach
After 10 months of pain, and visits to orthopedic surgeons, neurosurgeons, gastroenterologists, etc. I am still without a diagnosis. Based on what I have read, I began to wonder if I have an occult hernia. I have now been to see 2 hernia surgeons that are within a 3 hour drive of home. I have a small, palpable bulge in the right groin, and terrible pain, but nothing shows on the CT. The ultrasound showed a ‘small cystic-lesion’ in the inguinal area. No one has ordered an MRI with/without Valsalva (no one knows what I mean when I ask for it).
Both surgeons are saying they will do exploratory surgery. Dr. #1 uses the extraperitoneal, laparoscopic approach (which I like), but he says his success rate is 60-70% (30-40% recurrence), and he wants to put mesh on all openings, even if no hernia is found? Is his recurrence rate typical?? I only have pain on my right side, but Dr. #1 wants to explore and use mesh on the left side as well. Dr. #2 uses the OPEN approach (not laparoscopic, which I’d prefer), and says he only has a 1% recurrence rate, however, he said, “My concern of course remains that even if we do find and repair a hernia, discovered at the time of surgery, will it relieve your discomfort?” .
I am confused about what is best. My insurance won’t pay for me to come to CA, or I’d try to make the cross-country flight (though sitting that long would be extremely painful). Dr. Towfigh, do you ever operate on the East coast? If faced with the 2 options above, which would YOU chose? Or do you have any further advice?
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16 Replies
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Laparoscopic or Open Approach
Awesome post. I hope others can relate.
Your symptoms may be due to a hidden hernia. It is more common among women and can be debilitating. It is not uncommon for the examination to be less than expected among men with hernias. However, your imaging should show the hernia.
I am happy to review your films. You would have to submit an online consultation via my website http://www.beverlyhillsherniacenter.com
Once you have a diagnosis via imaging, then perhaps you can use that as armamentarium to seek surgical cure.
That said, lateral thigh pain is typically not a symptom related to an inguinal hernia.
I hope I can help.
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Laparoscopic or Open Approach
Dear Dr. Towfigh,
I went to see Dr. Goodyear on your recommendation. He bases his opinion solely on physical exam and the REPORT (he REFUSED to look at any of my films, as he says he is not a radiologist) . Because the CT and MRI reports did not say I had a hernia, and because he said he could not feel one when I pressed my groin area, he told me that I do NOT have a hernia, so there is nothing he can do. He suggested that I see an orthopedic surgeon, that it is probably a hip issue, but I’ve seen 4 orthopedic surgeons who all say it is NOT my hip. I’ve had nerve conduction studies, MRI, CT and ultrasound (the ultrasound reported “a small cystic lesion” – which doesn’t make much sense) but nothing showed on the other tests.
I was previously teaching full-time at a community college, and in my free time hiking, bicycling and kayaking…very active for my age (55). It will be one year in a few weeks that I’ve been disabled by pain in my right groin…it is an every day pain…it doesn’t come and go. Usually lowest in the morning, and worsens as the day goes on (with activity..which is limited to short walks). I also have odd sensations in my right outer thigh when I put weight on that leg as I bend…it feels like the muscle is quivering.
Did you say there would be an option for me to send my films out to you to review, before I consider buying a plane ticket and hotel room in Beverly Hills? I realize I would have to pay out of pocket. I’ve been to all the specialists in my home town (neurosurgeon, orthopedic, gynecologist, gastroenterologist, etc.). If Dr. Goodyear is right that this is not a hernia, I don’t know what else to do, as all the above mentioned specialists have not figured out the cause of this very localized pain.
I appreciate your helping so many with hernias (and was encouraged to read the good report from lkpittman). Thank you for taking the time to read this.
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Laparoscopic or Open Approach
Great questions. I thought, or at least hoped, that after the initial repair my pain would be gone. I now know that some of the original pain was nerve related and after the repair, I had nerve pain as well. I was told that there was no guarantee that the repair would fix my pain because there seems to be a correlation between pre op pain and post op pain, but I didn’t see any other option. The repair did help the pain initially, it became more of a pulling pain. Now that I have had the neurectomy, the tingling and burning pain are gone. I am hoping mesh removal will help because there is pain right where the tacks and mesh can be seen on MRI, almost like trigger points when pressed on. In my case, I am hoping pure tissue repair proves to be better. That is what I will have when the mesh is removed, the Dr. said he would not put another mesh in me after all the pain issues I have had. It is very difficult to understand and after many conversations, that is how I best describe it. Hope this helps!
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Laparoscopic or Open Approach
I am so sorry to hear all that you have been through and am praying that Dr. Belyansky will be able to help you. I am confused about hernia repair at this point. You said you had severe pain “from the hernia” to begin with , but that AFTER the initial surgery you were NOT better. In one of Dr. Towfigh’s replies to me I think she said IF you have a hernia and it is repaired, the hernia-related pain should be gone. Do you know WHY your initial repair did NOT help your pain? Do you think it was because of the mesh, and that open tissue repair is a better way to go? I know you are a patient, not a doctor, but you’ve had a lot of experience by now! I thought “once I get hernia surgery, I’ll be back to normal, but now I’m rather afraid I could be worse.
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Laparoscopic or Open Approach
Dr Goodyear is great and he should be able to discuss the benefits of open tissue repair vs mesh repair.
Others in NE include Dr Gina Adrales in NH and add Sharon Bachman in MD. Both also have an interest in female surgery.Whichever surgeon you see, please let them know about herniatalk.
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Laparoscopic or Open Approach
You are in excellent hands with Dr Belyansky.
Please let us know what he finds in your operation and what he ends up doing. -
Laparoscopic or Open Approach
Yes, the constant pain is very difficult to deal with, but I refuse to give up. I am 49 years old and have lots of living left to do! I had my original femoral hernia repair done by a general surgeon, in Virginia Beach, whom I liked very much. I was having severe pain with the hernia and possible nerve involvement, so I think I should have pursued a hernia specialist to start with- hind sight is 20/20! Since the original repair, I have still been in severe pain, but the pain was a little better right after and the pain now is somewhat different. Dr. Belyansky performed a triple neurecromy, which helped with the burning, tingling pain, but did not resolve the sharp pain in my groin and around my pubic bone. I am now scheduled for open tissue repair of the hernia and lap mesh removal (before surgery we did discuss the possibility of mesh removal if neurecfomy did not resolve the pain, but thought we would start small). Mesh removal will be a much more difficult surgery, especially as far as recovery goes. Ready for the 2 year ordeal to be over!
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Laparoscopic or Open Approach
Eller642,
Thank you very much for the recommendation of surgeons in Annapolis. I will go check it out…has Dr. Belyansky corrected your hernia? If so, did he do it laparoscopically? I’m trying to remember which type of hernia you had…was it inguinal or femoral? Again, thank you for taking the time to write to me. Constant pain is hard to deal with, isn’t it?!
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Laparoscopic or Open Approach
I don’t know how close Annapolis, MD is for you, but there is Dr. Adrian Park and Dr. Igor Belyansky, who is director of the Abdominal Wall Reconstruction Program at Anne Arundel Medical Center. I am currently seeing Dr. Belyansky for problems with a hernia repair and he is great. Very knowledgable about hernias and problems with hernia repair and nerve issues as well. He is also the nicest and most caring doctor I have ever been to see. He was fellowship trained at The Hernia Center at Carolina’s Medical Center. He comes highly recommended from the director there. After seeing many doctors for my problem, I feel like the solution is with Dr. Belyansky. I truly appreciate all of the help and advice offered by Dr. Towfigh and wish that she wasn’t so far away from Va. Wishing you well!
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Laparoscopic or Open Approach
Thank you for clarifying the mesh issue, I really appreciate you! From what I’ve read, Dr. Goodyear uses the Prolene Mesh System and open repair. However, when I see him on July 2nd, I will make sure to ask what he plans to use in me – a very thin female. I know the pain I have now, but I would hate to have even more pain (from mesh or nerve damage?) after hernia surgery. Don’t suppose you have any surgeons in the Northeast to recommend?
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Laparoscopic or Open Approach
– in thin patients and in the average female, I do not recommend mesh repair, unless perhaps it’s lightweight and placed laparoscopically. The risk if mesh-related pain in this subset is higher than average. A tissue repair done in open fashion should be considered
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Laparoscopic or Open Approach
Dr. Towfigh,
Thank you for your reply. if you have time, could you please clarify your last statement, where you say, “I would shy away from any mesh, unless it is a lightweight mesh or you are a heavy built person.” I thought mesh was the main method used to repair hernias…what would be the better option? Please help me understand. I am not ‘heavy built’, but am a very small person, and since this pain began, I’ve lost considerable weight…I’m under 100 pounds now.
I did look at the AHS website, and see many surgeons listed in my state; it doesn’t give much info about them, so I suppose I would just need to start making phone calls and ask the questions you suggested. When I called the doctor’s office I had asked if he dealt with occult, or hidden, hernias in women, and the staff member did not know what I was talking about. But, he is listed on the AHS site and is less than 2 hours away, so I’ve got an appointment scheduled. He prefers open repair, but I was under the impression he uses mesh. What would be a good question to ask him about that? THANKS again for the time you devote to this site and all of us who are suffering.
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Laparoscopic or Open Approach
The American Hernia Society website is a great first start. Ask the offices you call about the doctor’s experience and interest in hernias, especially hidden hernias among women. If they are not aware of it, then perhaps you should move on. If they have done over 500 or so inguinal hernias laparoscopically, that is a good start for you.
As for the ultrasound, there are no cystic lesions that typically occur in the inguinal region. More commonly, these are hernias. A specialist can examine you and help determine the cause of your pain and provide treatment. Your symptoms are very much consistent with a hernia. Another possibility could be a hip problem, such as a labral tear. That gives the pain with external rotation.
Lastly, an open repair is a perfectly sound option, as long as they also look for a femoral hernia and can repair a femoral hernia via open fashion. I would shy away from any mesh, unless it is a lightweight mesh or you are a heavy built person.
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Laparoscopic or Open Approach
Hi! I think you can start by searching for a surgeon at the American hernia society AHS website.
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Laparoscopic or Open Approach
Dr Towfigh,
Thank you for your helpful reply. I’m wondering how I would go about finding a surgeon who has “done at least 250 (and some say 500-750) laparoscopic inguinal hernias.” The hernia surgeon I saw at Johns Hopkins said he had a 60-70% success rate (his nurse told me that meant 30-40% recur)…that does not sound good to me. The other surgeon, who uses the open approach said he has less than 1% recur. From what you wrote, it seems perhaps this second option is better.
I would LIKE to find a surgeon who HAS the experience (250 or more) and can do it laparoscopically, but don’t have any idea how to find such a person (in PA, NJ, MD or DE). What are the main drawbacks to open surgery…longer healing time, more post-op pain, etc? (Neither Dr. is even SURE that I have a hernia, and if so if it is femoral or inguinal). The laparoscopic surgeon should see both areas easily…is the same true for open?
The groin pain makes it difficult to sit straight up (can recline); the other movement that is almost impossible, is to rotate my thigh (as when trying to look at sole of foot, or cross legs)…that sends pain off the chart. Is this consistent with hernia, or not?
I’m attaching 1 view from my Ultrasound (I was lying down); it was described by the radiologist as a “small inguinal cystic lesion” whatever that might mean.
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Laparoscopic or Open Approach
I’ve mentioned these before in these posts, and I hope this discussion board can be a tool to spread this information to others, including your physicians:
1. If you have a bulge on exam already, then imaging is not necessary. You have a diagnosis. Imaging rarely offers anything more than confuse the sutuation, such a as the radiologist saying it’s negative.
2. If a CT scan is negative for a hernia, and there is clinical evidence for a hernia (suggestive by story and by exam), then either a) the CT scan is misinterpreted (commonly), or b) you must seek a more sensitive test, such as MRI. In JAMA Surgery, my paper will be out soon that discusses the different imaging modalities and their use to determine hernias.
3. Laparoscopic surgery should only be performed by a specialist who has at least 250 (and some say 500-750) laparoscopic inguinal hernias in their experience. Otherwise, the recurrence rate and complications may be too high. So, do not choose laparoscopic surgery just because It sounds better; in some cases and with most surgeons, open repair is safer and with better outcomes.
4. If no hernia is found, do not undergo hernia repair or mesh placement. You cannot become better. And you may be subjecting yourself to risks. (Perhaps you misunderstood your surgeon: if on one side a hernia is noted, mesh is always placed to cover that hernia and those around it on the same side. That is standard.)
5. If you have a hernia and hernia-related pain, then repair will cure you. In women, the hernia may be small and the findings minimal. However, the associated pain may be severe and repair will help you. Most do not yet appreciate this among women.
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