Non Mesh Repair Questions

[Jnomesh]

Thank you dr. Kang for your input and offering a different and welcome point of view!!!

[drkang]

I totally agree with your assessment of mesh hernia repair.
I myself have seen many patients suffering from mesh pain as a surgeon, although I have not experienced it directly as a patient.
In addition, I have repeatedly experienced how difficult it is to remove mesh and how dangerous it is because the inserted meshes have been terribly clogged between many important structures including the muscles, vessels and nerves and so on, through about 40 mesh removal procedures. (I remove only the inserted mesh with open hernia repair)
It seems rather strange that not everyone who has undergone mesh operation experiences chronic pain.

I think that the recurrence rate of tissue repair and the incidence of its chronic pain are over-exggerated
Clearly, there are tissue repair methods, such as shoulder repair, that you mentioned, which have a lower recurrence rate than mesh repair.

The frequency of chronic postsurgical pain of such tissue repair is, as a matter of fact, lower than mesh repair.
Although tissue repair has the potential to cause nerve injury, it cannot produce mechanical pain caused by the mesh itself.
And the possibility of nerve injury can be minimized in the tissue repair as it is performed under direct vision, as can be seen by common sense.

In addition, nerve injury or nerve irritation in mesh repair can occur after a period of time after surgery due to time-consuming mesh folding, mesh migration and mesh contraction, etc, which does not happen in tissue repair.
In this way, the possibility of pain due to nerve injury is much higher in mesh repair than tissue repair, besides mechanical pain by mesh itself

Nevertheless, some surgeons claim that tissue repair also has as many problems as mesh repair
I think the reason is to defend their position in performing mesh repair with possible obvious complication.
Most of them simply cite what they say without a deep understanding and experience of tissue repair.
I think through this repeated quotation process they build up exaggerated figures that are favorable to them and that they wish it to be.
This is clearly wrong and very unfair to mislead the patients’ decision.

What is really sad is that there are fewer surgeons who can do tissue repair, and younger surgeons only have to learn about mesh repair.
If this time runs a little longer, even this controversy disappears, and mesh repair may be the only surgical option for inguinal hernia repair.
When mesh complication is considered serious, it will be a tragedy for future hernia patients.

In this sense, the role of few surgeons, including Shouldice hospitals, who strive to demonstrate the benefits of tissue repair, should be very important and encouraged.
I am ready to play such a role though it is very small.
For my brief introduction, I have performed more than 6,000 my own non-mesh tissue repair treatments so far and have had a recurrence rate of 0.5% and a mild chronic pain incidence less than 2%.
All my procedure is done under local anesthesia with 3-4cm skin incision and takes only 20 minutes.

Thank you for your passion for non mesh repair!

[Jnomesh]

Thank you again for your reply and offering a different perspective. It is very refreshing.
So im guessing that where you described the nerves going isn’t where I’m feeling the issues. It seems like maybe it is the lateral femoral cutaneous nerve location. Maybe when the mesh folded it aggrebatedbthis nerve and then she the mesh was removed it is still aggravated. The area is like 3 inches below the ASIS and slightly to the left. A slight rigging issue when walking and burning when sitting. I guess time will tell.
on another note Mesh for hernia repair in the US has become so prevelent that there aren’t other options offered.
when I went for my hernia repairs never ever was a pure tissue option offered so I can make an informed decision. Never ever were the risks-however small-of mesh explained to me. Never ever did the surgeon say if something went wrong with the mesh they didn’t know how or couldn’t remove it. It really is troubling. I know of after searching relentlessly of three surgeons in the US-that’s right 3! Who specialize in non mesh repairs-out of probably 100,000 surgeons who perform this procedure. It’s just wrong.
The shoukdice hospital in Canada reports that there recurrence rate is less than 1%!!!
and even less then that for chronic pain.
so why do surgeons in the US keep quoting high recurrence rates??!!! One doctor on this site said he believes recurrence rates with tissue repairs are 100% if you were to follow the patient throughout there lives. What a nonsensical statement.
bottom line is patients need more options when it comes to hernia repairs. The bias towards mesh is so out of whack that if someone doesn’t want this procedure they either have to travel or travel out of the United States to get this procedure or to roll the dice that a surgeon who doesn’t routinely do tissue repairs will do a good one.
i recently found a surgeon in LI NY who is from the shouldice clinic and has performed over 650 surgeries using this method. But I had to search like crazy to even know he existed. We need an operation similar to the shouldice clinic here in the states. A place where only pure tissues are done by highly skilled and trained surgeons. A pure tissue repair with less than a 1% recurrence and pain VS the gold standard of mesh with a 3% recurrence rate and possible debilitating pain due to a plastic foreign material that can reek havoc in the groin. With chronic pain rates that are reported as high as 20-30%. Dr. Towfigh what’s going on here? Something isn’t right. There needs to be at the very least a balance.
Again patients need alternatives and options.

[drkang]

Hi, Jnomesh.

External iliac vessels(artery and vein) and common femoral vessel share the same continuing vessel trunks with only different names depending on the anatomical position.
So external iliac vessels are named when they run under the inguinal canal and the next part are called (common) femoral vessels(artery and vein)

I respect Dr Towfigh’s view and experience concerning non mesh hernia repair, even though mine are quite different from hers.
It seems to be true that the experience and result are different or sometimes even contradictory from surgeon to surgeon.

Thank you!

[Jnomesh]

Understood. Thank you

[drtowfigh]

Dr. Belyansky is the best person to answer those questions. Examination is key to helping you get the correct answer. Reoperative groins and the symptoms that come with them can be very very complicated. Whatever I tell you may lead you in the wrong direction.

[Jnomesh]

Hi dr. Towfigh-thank you for your reply. I had my mesh removed by dr. Belyanski due to my mesh folding over and curling up into a ball and becoming as he described it “rock hard”. He was amazing and was able to detect on a cat scan I had done in March that the mesh was defective and bent and even worse when he got in there. He was able to remove 90% of it except for a little in the illiac vein and artery.

I suffered two issues before mesh removal: extreme heaviness and a swollen feeling medially and then a sort of stiffness feeling more laterally front thigh like 2-3″ below the ASIS (almost seems like maybe where the LFCN is ) and when sitting caused extreme burning in thigh and groin. No burning when walking or being upright only sitting.Since mesh removal almost at the 6 week mark that heaviness feeling medially is gone. However the funky tight feeling in the upper thigh is there on and off and sitting is still uncomfortable but much better than before the mesh was removed. I requested no new mesh to be put in if there were any hernias upon removal. So I was wondering:
1) could the discomfort I mentioned especially when sitting be coming from the little bit of mesh left on the illiac vein and illiac artery are these structures near the area I indicated? (2-3 inches below the ASIS)
2) when I met with dr. Belyanski 5 days post surgery he mentioned that there was slight weakeness in the femoral area and that I could be at risk for a femoral hernia down the road. He told me he couldn’t reinforce that area with sutures Bc it was to vascular. So since I have had such a nightmare experience with mesh I got kind of nervous with this news and wanted to do some research on femoral hernias and how they are repaired without mesh in case I do get one. I am a male-thin 5’8″ 145-150lbs. I’m hoping I won’t ever get one!
3) in the operative report it states there was weakeness in the internal inguinal ring and he sutured the area with absorbable sutures by bringing down the internal oblique muscle to the illiopubic tract. Just curious how long it takes for this suture repair in your opinion to fully heal? I don’t want to risk reinjuring it and am willing to be patient just looking for a time frame.
Thanks for any input you can offer. I had to travel out of state for the surgery and it isn’t always easy to contact the surgeon to ask questions

[drtowfigh]

Dear Jnomesh,

Some thoughts about your post:

The outcome from femoral hernia repair is poor for non-mesh tissue repairs. The reason is because, unlike the common inguinal hernias, the femoral hernia is not flanked by muscle. It is flanked by thick taut ligaments. They have “no give.” Tissue repair used to be done, and history has taught us that the ouctomes are poor and chronic pain is a very real problem with it.

It think Dr. Shouldice described the best tissue repair for femoral hernias. I have performed it, and it works well for thin and small build patients (usually women). Simple suture repair does not work in most situations and can result in a lot of pain in the area. Being in such a particular anatomic region, even open mesh repair is no longer considered efficacious enough for femoral hernias. The gold standard is now laparoscopic mesh repair, based on a large study focused on this type of rare hernia.

Though rare for both sexes, femoral hernias are more common in women and can be seen among men. The question is: did you have a true femoral hernia (deep with content) or did you have a wide femoral space notable only on exploration?

With regard to exercise: all studies show that the majority of exercises are protective of hernias, do not increase abdominal pressure, and in some cases can reduce the size and/or symptoms of hernias. Since femoral hernias are not lined by muscle, exercise does not affect its progression or symptomatology.

Lastly, you asked about the mesh left on your vessels. It is common practice to do so, for safety reasons. If your mesh was removed because you had a true mesh reaction, then I do not leave any mesh at all, because even the slight amount may cause pain. Symptoms down your leg may be due to a) femoral hernia, b) nerve pain, and/or c) retained mesh. Your surgeon is very qualified to assess the pain for you and help you figure out why you have the pain down your leg.

You may notice that this forum will have contradicting information. Do not be afraid of this. It is something we are very used to in medicine, as it is not a black and white field and information is always in flux. Also, with surgery, outcome and experience can be different from surgeon to surgeon.

[drtowfigh]

Dear rcl0223,

Very good questions about nerve damage and chronic pain with mesh vs with tissue non-mesh repair. It is a myth that non-mesh repair has lower chronic pain or nerve damage risk. The best study on this was also the first to study such an issue. It clearly shows a significant chronic pain risk with non-mesh tissue repair. See attached. Note that this study was done during an era where most of the surgeons were skilled in non-mesh tissue repair. Everyone was focused on reducing hernia recurrence back then (hence the advent of mesh repairs) and that was the main outcome that was measured. Pain was assumed to be part of the profile of hernia surgery. But once hernia recurrence was a lesser issue (due to use of mesh), then the importance of and interest in chronic pain increased.

Today, the outcome numbers quoted for non-mesh tissue repairs are all over the place. The reason may be that the recurrence and pain/nerve injury rate is very much a factor of the surgeon’s technique and experience. Each surgeon and institute has their own data. For example, recurrence rate may be between 0.5% and 15%. Chronic pain may be between 1% and 20%. The outcomes from tissue repair are no longer as predictable as the more standardized mesh technique.

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Attachments:

[Jnomesh]

Again thanks for the prompt reply!! I am 5 weeks out from having a large mesh removed so I am probably still healing from that 3 1/2 procedure.
i appreciate the work you are doing in offering an alternative to hernia mesh repair, as this is causing many problems to many people here in the US and other countries. I only wish that we had similar options in the US.
one last question
I know you don’t use mesh but maybe you can help me with a anatomical question: my surgeon was able to get 90% of the mesh out but had to leave some small amounts of mesh on the illiac vein and illiac artery.
im wondering if these two structures are near the upper thigh where I have some burning when sitting. I’m thinking that maybe when I sit and compress the area that maybe the mesh fragments is compressing these two structures and resulting in the burning sensation. But again I have no idea where exactly these two structures are although I think i read somewhere that one of these turns into the femoral artery which I know is in the leg-thus my question.
thanks again!

[drkang]

In Korea, everything is fast, so I am also accustomed to it. (joking!)

It is somewhat difficult also for me to give you correct answers to all of your questions, because I don’t have perfect knowledge or experience.
So I am afraid that there could be some incorrect answer.

1) As far as I know, the wound strength reaches maximal point in 6 weeks after operation, which is about 80% of preinjury level.
So I usually recommend my patient to return to full nornal activity including exercise in 3 weeks after repair, as our musle has surplus strength to ordinary activity.
You can find some reference at the following address. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174176/

2) I am afraid that I have no idea about US hernia surgeons.

3) I do two different type of operation respectively, according to the type of inguinal hernia – indirect or direct.
For indirect inguinal hernia, I just close the hernia opening. It is somewhat similar to Marcy operation.
And for direct hernia, my technique is a bit similar to Shouldice in one aspect, and to Desarda in another aspect, but as a whole, it is done with much smaller incision and much stronger than those two operations, I think.

4) For femoral hernia, I just close the hernia opening with continuous nonabsorbable suture as I told you before, which is very simple procedure.

5) I think any suture material is OK for inguinal hernia. It depends on surgeon’s preference. But for femoral or umbilical or epigastric hernia, of which hernia opening is very tight and dense, non-absorbable suture material must be used.

6) I don’t think the symptoms you have now are not related to femoral hernia. The symptoms of femoral hernia are buldging(which is like cystic ball) and sometimes pain. I don’t know of any other symptoms besides.

7) Sorry, I don’t know about stem cell therapy or tissue regeneration. But I think that kind of treatment is not necessary, as tissue repair can show excellent result if it is done properly.

8) As I told you at previous answer, I don’t think there is anything to help you in the matter of femoral hernia thing. But one good news is that femoral hernia seldom occur in men. Actually so far I had just one male femoral hernia patient who is US citizen. It is just one out of more than 10,000 hernia repairs. And another good news is, as I told you, non mesh femoral hernia repair is very simple and secure.
Don’t worry too much about femoral hernia occurence.

Thank you!

[Jnomesh]

Thanks doctor for your prompt response that is awesome and much appreciated. While I have your ear I thought I’d throw a few more questions your way:
1)how long does it usually take for a non tissue repair with absorbable sutures for a inguinal hernia to fully heal? I’ve read at 6 months the area should be about 75% healed and at a year 100%.
does this seem accurate?
The reason I ask is because when I had my mesh removed laparoscopically 5 weeks ago the surgeon reinforced the indirect space which had weakness by bringing the internal oblique muscle down to the illiopubic tract and stitched with absorbable sutures. So I am just curious how long will that area take to heal and how long should I be extra careful as to not risk reinjuring the area?
2)Also do you have any contact with or know iof any surgeons in the US that specialize in pure tissue repairs?
3)also what technique do you use to repair inguinal hernias (shouldice, bassini, Mccvey, desarda etc
4) and what technique do you use to repair femoral hernias
5) what are the pros and cons of absorbable and non absorbable sutures
6) i know you mentioned that femoral hernias are less prevalent and thus you have done less of these repairs but what are the symptoms patients usually present with a femoral hernia outside of an y obvious bulge? I have some burning in my upper thigh right about where the bio bone ball and socket is-sometimes there is slight burning that radiates around to my lower back. Both of these are only brought on when I sit not when I walk.
7) are you aware of any advances in the area of hernia repair: stem cell therapy or tissue regeneration?
8) is there anything that can be done to make a hernia area that is weak (but no hernia present) stronger such as prolotherapy or PRP therapy. My surgeon noted I had some weakness in the femoral area and was wondering if there are some things I can do to strengthen the area?
Thanks again-look forward to hearing back from you!

[drkang]

Hi, Jnomesh.

I don’t think there is any exercise to prevent hernias, though many people want to know about it.
Because muscular tissues consisting of hernia openings usually are not used actively during physical exercise.
So it’s very difficult to strengthen those muscles.
Furthermore, femoral canal, through which femoral hernia comes out, consists of ligamentous tissue which is very tight and fixed.
So it cannot be strengthened by any exercise at all.
Umbilial hernia and epigastric hernia also have hard and tight ligamentous hernia openings.
On the contrary, many exercises which increase intraabdominal pressure contribute to hernia development.

Regarding diet, balanced nutrition is recommendable.
As you know, food which increases intraabdominal fat is bad for hernia.

I don’t think non mesh femoral hernia repair will compromise inguinal area.
The repair is not done at inguinal area, but at femoral area.

Thank you!

[Jnomesh]

Thanks for your reply. 6 years ago I had a laparoscopic mesh repair for what turned out to be both a direct and indirect hernia. I had issues post surgery and starting last Feb debilitating pain. It turned out the mesh had curled up into a rock hard ball and I had the mesh removed (robotic assisted laparoscopically). He was able t remove about 90% of the mesh with some having to be left in the illiac vein and illiac artery.
he said there was no direct hernia (scar tissue filled in the area) and no indirect hernia but some weakeness in the indirect space which was sutured with absorbable sutures.
my question is the surgeon said the was slight weakeness in the femoral area and he could not reinforce this with sutures while he was in there Bc there area is very vascular and didn’t want to risk any bleeding (he was in there laparoscopically ).
He said in the future i am at risk for a possible femoral hernia. So I am just trying to be procactive and have a plan should I develop a femoral hernia . and have a surgeon in the US who has experience treating femoral hernias with no mesh
so a few questions:
are there any steps I can take in regards to nutrition, diet and excercise or any others steps proactive or preventative to increase the odds that I don’t have a femoral hernia down the line?
also when you repair a femoral hernia with out mesh is there risk or likelihood that the inguinal area is compromised?
thank you for your input?

[drkang]

Non mesh femoral hernia repair is much easier than non mesh inguinal hernia repair.
After small incision and treating the hernia sac, the hernia opening is closed securely by continuous non-absorbable suture.
All procedure is done under local anesthesia, and it takes about 15 minutes.
Femoral hernia is relatively uncommon, so I have just about 20 cases experience.
No recurrence so far.
Thank you!

[Jnomesh]

Hi. Dr. Kang. Just curious about tissue (non mesh) repair for femoral hernias. What technique do you use and are the results (low recurrence) the same for inguinal repairs?

[drkang]

I thank you to enable me to chime in this discussion. I am a 62 year old hernia surgeon in S. Korea.

If we talk about car driving, we can say there are some fearful dangers. Nonetheless we usually drive our cars without accident. If we talk about the risks of hernia repair, we can say all kind of fearful and dangerous possibilities. But we need to talk about it, based on real experience and results rather than on theoretical possibilities which make us confused.

As you know well, there are some surgeons who prefer mesh repair and others non mesh tissue repair. I myself am one of those who strongly assert that inguinal hernia must be repaired without using mesh.

The reason is that mesh repair problems currently take place in reality (even in this forum we can find some who suffer from mesh complications). Contrastingly risks of tissue repair are discussed mostly on theoretical basis. It’s like we say car-driving is dangerous. For your reference I talk to you I have no accident in more than 30 years driving.

Another reason why I prefer non mesh hernia repair is that no mesh tissue repair, if done properly, can show even lower recurrence rate than mesh repair. Actually I have performed more than 5,000 no mesh inguinal hernia repairs for the past 4 years and the actual recurrence rate so far is about 0.5%.

It is not a wrong decision that you don’t go through mesh repair. I strongly recommend that you find a good surgeon who does non mesh repair properly.

Thank you!

[rcl0223]

Thanks for the replies, Dr. Towfigh. Can you provide percentages as they tie to recurrence rates and the chances of nerve damage in open, non-mesh repairs? I’m still weighing my options on which direction to take (lap mesh, vs. open non-mesh). The surgeon I met with stated the recurrence rate for non-mesh repair, bassini technique, is around 10%, and chronic pain percentage around 5-7%. It would be great if you could share these numbers to justify going one way or the other. And again, if you had a healthy, 33 year old male come in for hernia surgery, which route you would recommend for long term quality of life?

Other surgeons can feel free to chime in as well.

Thanks!

[drtowfigh]

– There is a real risk of direct nerve injury with tissue repairs. Mostly, due to direct injury (cut, burn) or entrapment in the sutures. With mesh repair, there is the added risk of mesh-related injury to the nerve, such as erosion, entrapment, yet most surgeons don’t manipulate the nerves as much during a mesh repair, as it is not necessary. To think that there is no risk of nerve injury with non-mesh repair is not factual.

– Similar to open procedure, the risk of nerve injury from laparoscopic repair is due to direct injury (cutting, burning) or mesh-related injury. That said, the risk of mesh-related nerve injury is limited to direct mesh impingement or erosion, which are quite rare.

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hello Dr. Towfigh – a couple of questions to add to this thread:

– I understand that the risk of recurrence is greater with a non-mesh repair but are you also saying that the risk of nerve injury is greater with a tissue repair than it is with mesh? If so, is this because of the physical stitching required vs placing of mesh?

– In terms of chronic pain, what are the most likely causes with a laparoscopic mesh repair? Is it the mesh itself or are there other ways in which this procedure can injure nerves?

Thank you!