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  • management of painful recurrent hernia

    Posted by Joseph on September 4, 2018 at 5:11 pm

    I had open suture repair of an asymptomatic left inguinal hernia 40 years ago in 1978 and open repair with mesh of an asymptomatic right inguinal hernia 20 years ago in 1998. I never had post herniorrhaphy pain after each surgery. However, both were probably associated with post operative wound infections, both presumably superficial. The only change I observed was ascension left testicle with ejaculation. So my situation is not post herniorrhaphy pain but rather a new issue unrelated to the primary repairs.

    14 months ago I lifted something too heavy and most likely tore groin muscles on both sides. After about 4-6 weeks of moderate discomfort, including radiation to left testicle, I initially improved. However, subsequently, starting about 12 weeks after the initial injury, I have had somewhat progressive pinching localized bilateral groin and centralized suprapubic pain and heaviness on the left side without radiation. This is exacerbated by a variety of triggers including prolonged sitting, stooping, tight pants and relieved by sleeping supine, standing and walking. I use wet heat the worst days which is also effective possibly as a counter irritant

    I have been seen by 3 academic surgeons and received a dynamic ultrasound and a supine CT scan. The ultrasound showed a small provokable hernia on the right and a broad based mobile area of weakness on the left without a defect (? Posterior wall deficiency). The supine CT scan was negative for hernia. The 3 surgeons had somewhat different opinions regarding both diagnosis and best treatment strategy. Overall, the consensus was that there was significant groin weakness on both sides and a small hernia on the right. Their recommendations were somewhat different, but included continued watchful surveillance, temporary nerve block followed by ablation. One of the surgeons suggested if nerve block was unsuccessful, an open anterior hernia mesh (prolene hernia system) repair with or without sutures with pragmaticresection of nerves encountered during repair. (He is mature and trained well before TAPP or TEP). I am not sure if the weakness they were referring to is equivalent to the posterior wall deficiency seen in Gilmore sports hernia.

    I have several risk factors for laparoscopic repair including: 1. pharmacologically managed BPH with moderate urinary retention; 2. Low BMI 24-25; 3. previous laparoscopic appendectomy with residual umbilical hernia and diastasis recti.

    1. Given recommendation for nerve block, can you help me to help you determine if the pain is neuropathic or nocioceptive, is there role for Tinel’s test and will nerve block help what I have described.
    2. Given pain out of proportion to physical findings, is there enough diagnostic uncertainty that diagnostic laparoscopy vs dynamic MRI or MRI neurography
    3. Will strengthening a weakened abdominal wall with mesh improve symptoms on the left if there is no true defect

    4.Is type of recurrence relevant: Pubic tubercle recurrence, Internal ring recurrence, Total posterior wall recurrence.

    1. Do I have inguinal inversion R3 or an M3 type hernia
    2. Are the nerves more vulnerable to discrete injury such as stretching or other traumatization with a recurrent abdominal wall injury following previous repair vs primary abdominal wall injury resulting in nerve injury rather than hernia causing my pain
    3. What procedure and what mesh do you recommend, direct open access of pre peritoneal space for TEP. Does my pre existent peri umbilical hernia diastasic recti complicate TEP and make balloon dissection more challenging.
    Joseph replied 5 years, 9 months ago 1 Member · 0 Replies
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