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Mesh Removal? Meshoma? Tumor?
Hello,
I think a meshoma from plug is compressing femoral nerve / artery. Here are the operation notes…
Not sure if any doctos see these threads or if anyone can add anything based on these notes:
Technique:
External oblique fascia was exposed and divided. Cord was mobilized at the pubic tubercle and an indirect hernia was found. There was no direct component. The hernia sac was dissected free, ligated at its base; it contained no bowel. It was reduced into the internal canal. The hernia defect itself was relatively small; however, he was too active to justify tissue only repair, so I opted for a medium plug and patch system. The plug was put in place and the inner leaflets were sewn to the borders of the internal ring. The external leaflet was allowed to expand in the preperitoneal space. The only patch was then placed and a new internal ring was created with the obdurated arms of the patch and the patch was then extended medially over the pubic tubercle and laid flat. Cord was returned to the canal. External oblique fascia was closed over the cord….
Thanks
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6 Replies
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See:
“The Millikan modified mesh-plug hernioplasty.”
He published a case series in 2003 and again in 2008. Instead of deploying the plug in the traditional manner, the outer leaflets of the plug are deployed through the hernia defect and pulled back like a pre peritoneal patch in the pre peritoneal space. The idea being you get the benefits of a pre peritoneal patch without all that mesh back there to create complications.
I think there are several concerns that are unique to this approach, which potentially we’re not considered by operators who continue to build upon it.
The first is that the plug is shaped like a pleated shuttlecock. It’s outer leaflets have pleats and waves and we’re not designed to lay flat in the pre peritoneal space. As a result it may not adhere flat to the wall well due to the memory effect of the material.
The second issue is that the size of the overlap is actually very small in comparison to a real pre peritoneal patch. This results in less strength. More so as surgeons select even smaller plugs as in your case for this method. The size of the overlap of the outer leaflet is likely very small.
However if everything is done as the original author published, it shouldn’t be an issue because of all of the other components of the repair adding additional strength… However there are some nuances here.
The small size and pleaded nature of those outer leaflets make it less likely that it’s going to flatly adhere well to the abdominal wall in the pre peritoneal space. Even if the interleaflets are anchored well with non-absorbable sutures those outer wavey petals can ball up, even invert like an umbrella turned inside out in the pre peritoneal space. The result is a mass of scar tissue interfering with everything nearby.
Another big consideration is the fact that the outer leaflets are designed to have a memory effect to hold a cone shape. When the outer leaflets are pulled back in the pre peritoneal space, they are being brought under tension. The entire configuration is now spring loaded and attempting to push itself deeper. If absorbable sutures are used, or if the anchor point fails earily in recovery the whole thing is going to want to ‘walk’ deeper.
Think of a barbed foxtail seed working deeper into your sock as you walk.
I suspect as scar tissue incorporates into the 3D nature of the plug deployed like this, these forces increase if not well adheared to the abdominal wall.
It is very possible you could have mass effect on the structures you mentioned related to the above. If you do it should be relatively apparent on CT or MRI imaging.
You haven’t told us anything about your symptoms but start locally and get imaging.
Then seek the opinion if experts. And opinions can varry widely. Some world experts on this topic have the approach that you can’t tell where pain is coming from with mesh and that all of it needs to be removed. They will explore your groin from both sides in an attempt to exclude all causes of pain in one very invasive surgery. Another expert listening to your symptoms and looking at your imaging may decide that you have a problem related to a meshoma compressing those structures you mentioned and may offer you a more targeted approach.
Having traveled the country and spoken with most of the big names that come up in these discussions, I would offer a +1 for Dr. Towfigh. She is exptional and her skill set may be particularly wellsuited to the problem you describe.
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This sounds like it is likely the Bard Perfix plug and patch, in size medium.
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Here is one type of plug and patch. Where your surgeon wrote”only” he probably meant “onlay”.
“The only patch was then placed and a new internal ring was created with the obdurated arms of the patch ”
https://www.bd.com/assets/documents/pdh/initial/perfix-light-plug-technique-guide.pdf
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The plug and patch is the only system that the mesh-supported “study” groups recommended avoiding. The description your surgeon wrote suggests that yours was one of the more complex plug and patch systems.
I will link this Topic to your other one so that people know more about your issue.
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