Open repair techniques with mesh
07/10/2023 at 1:46 am #36197SNParticipant
I am curious on how many open repair techniques there are with mesh and how they differ. Is Lichtenstein the most popular and more favorable?
07/10/2023 at 2:40 am #36198
Lichtenstein is the most common. It’s open anterior mesh placement. There are open posterior (preperitoneal) mesh techniques (Kugel, TIPP, TREPP), but they are much less commonly practiced, and more difficult. As to what’s better, who knows… You can look up some studies comparing them.
07/10/2023 at 12:02 pm #36201
Dr. Towfigh said that the plug is the most used repair method in the world. Apparently it is very easy and fast to do.
Here is a paper from 2014 by one of the participants in the HerniaSurge mission, the Guidelines. He reports some details about three open methods; Lichtenstein, plug-and-patch, and the Prolene Hernia System (PHS). Four years later the plug was the only mesh product that the Group did not give a firm recommendation to. Ten chapters are under revision in the Guidelines. There might be something useful in the new version of the Guidelines, if you can wait.
Sorry, this probably does not help your decision-making. But it is the reality of the situation. 2014 is when I had the laparoscopic TEP procedure to repair my unilateral hernia. It’s easy to see why the surgeon chose it, it is highly recommended. But the results for me were terrible.
MINI REVIEW article
Front. Surg., 20 June 2014
Sec. Visceral Surgery
Volume 1 – 2014 | https://doi.org/10.3389/fsurg.2014.00020
Tailored approach in inguinal hernia repair – decision tree based on the guidelines
imageFerdinand Köckerling* and imageChristine Schug-Pass
Department of Surgery, Centre for Minimally Invasive Surgery, Vivantes Hospital Berlin, Academic Teaching Hospital of Charité Medical School, Berlin, Germany
“The endoscopic procedures TEP and TAPP and the open techniques Lichtenstein, Plug and Patch, and PHS currently represent the gold standard in inguinal hernia repair recommended in the guidelines of the European Hernia Society, the International Endohernia Society, and the European Association of Endoscopic Surgery. Eighty-two percent of experienced hernia surgeons use the “tailored approach,” the differentiated use of the several inguinal hernia repair techniques depending on the findings of the patient, trying to minimize the risks.
07/10/2023 at 12:17 pm #36202
I mis-wrote above. Dr. Towfigh said “best seller”, not most popular.
Sorry SN, I know that you’re trying to find a clear path forward. Keep working at it, something will make sense to you eventually. Her comment seems strong enough to at least knock one option off your list. Some small help.
Yup, agree that plug meshes should be off the market and the main reason they aren’t being pulled is because it would look like they are admitting it is a poor design. Also, plug mesh still seems to be among the best sellers, if you can believe it.
07/10/2023 at 3:17 pm #36205
Since the perfix plug is being discussed I’d like to chime in with some personal experience that supports the view that it is a poor option.
I was assured it was the gold standard during my initial repair and trusted the surgeon putting it in. Quick, easy, and reliable. My repair failed within 2 years and I had to have removal surgery. It was found that the plug had hardened and contracted. This allowed the original hernia defect to recur. Another aspect of the failure was that the onlay mesh (patch), in the surgical install instructions, is never specified by the manufacturer that it must be secured with sutures. My onlay mesh was simply placed on the floor of the inguinal canal and during revision was found flapping like a flag in the wind, superficial, and entwined with my ilioinguinal nerve.
The failure and subsequent removal of this poorly designed mesh has destroyed my life. Murdered me in a sense.
07/10/2023 at 3:42 pm #36206
07/10/2023 at 5:00 pm #36207
I’m a good part of a year past removal. Doing terrible actually. Although from what I’ve gleaned from here there’s still hope that things will heal more. I’m trying to remain positive and deal with this one day at a time. I did see significant improvements after removal. Unfortunately, it seems I’ve hit a baseline where I improved after removal but not enough to get back to normal life. 24/7 pain at a lesser degree, ongoing neuropathy, inability to return to any gainful employment, pain with extended activity, pain with sitting for certain lengths of time. I’m doing my best to remain as active and healthy as possible but every day is a struggle.
Don’t want to get into too much detail regarding surgeons and procedures due to ongoing litigation but yeah, the perfix plug failed in such a way that it destroyed me.
07/10/2023 at 6:24 pm #36208
Could a neurectomy help in your case?
We have a lot of common symptoms, although mine seem less severe. In my case it was caused by tissue repair (Shouldice); no mesh or plug.
I decided to give it at least a year until exploring what can be done. I’m leery of undergoing additional surgery because of the risk of making things worse. A neurectomy of some kind may make sense, but not sure. Other than that, I don’t know what can be done. For example, if scar tissue is causing some of this, can they remove it without creating even more scar tissue?
I’m also hoping for improvement with time. So far, my experience has been that the intensity of the symptoms varies from time to time, and perhaps the non-pain neuropathic symptoms improved, but the pain actually worsened a bit with time, and became more frequent. The tissues keep “remolding” for months and maybe longer, and it feels like the symptoms also change somewhat with that process. I don’t know when that process ends, and I don’t know what to expect in the long run. I would say that my symptoms are moderate – not severe, but not mild either. I’ve been able to function, but the pain and discomfort definitely take their toll on me.
07/10/2023 at 6:27 pm #36209David MParticipant
Was your only mesh not sutured on either side? One of the questions I have about Lichtenstein is with regard to the medial suturing. Laterally the mesh is sutured to the inguinal ligament, which seems adequate, but I can not get a clear imaginative picture of the suturing medially. The muscles and tendon types there do not seem substantial enough to not tear in the videos
The other thing that I wonder about is that the spermatic cord is just laid back on top of the mesh in a lictenstein.
How big was the onlay mesh in your plug and patch when it went in? Is it similar to the Lichtenstein mesh?
07/10/2023 at 9:57 pm #36215
Sorry to hear that herniacomps. Terrible. Hope you improve. Good Intentions may have some advice as in the body heals and keeps trying to heal.
Have you been told nerve ablation or neurectomy may help?
Personally I’d give it time if you can and also some people have said if they kept relatively active it reduced symptoms – hard to do if pain is caused though. Good luck
07/11/2023 at 5:20 am #36217
Thanks all. Yes neurectomy. When I consulted multiple surgeons regarding removal, some of the lesser specialized ones wanted to barrel ahead with triple neurectomy and just tear everything out. Butcher me. What ended up happening was we went in with the intent to preserve all nerves if possible. The plug had no major nerve involvement but the onlay removal also required resection of the presumed ilioinguinal nerve trunk that had adhered to the mesh itself. Bad luck on how it all settled. No avoiding it. So I’ve already had what was deemed a selective neurectomy already. I continue to work with multiple specialists and manage my pain, as best as possible, through healthy life style and medication.
I’m fearful to go back in or pursue any further form of neurectomy or ablation due to the unpredictable and injurious nature of it all. Between a rock and a hard place.
07/11/2023 at 7:31 am #36218
I suppose if you can bear and manage the pain, although you should not have to, you could wait to see if it got better and if not then have neurectomy.
07/11/2023 at 7:31 am #36219
I’m sure Good Intentions will have some sound advice re time and healing etc
07/11/2023 at 9:12 am #36222
Here is the Topic I created about healing from mesh removal. It’s been a long slow process for me. Over five years and I’m finally feeling like I’m at a stable 90% of where I was before mesh implantation. You’ll find posts from a year or two ago where I said something similar but this time feels more solid. Of course, the worry now is that if things have been changing could I have a recurrence? I’m not going to worry too much about it, I’m just going to enjoy these moments of good health while I can.
Good luck herniacomps. I kind of hate to wish for it, because things shouldn’t be this way, but I hope that you get a huge settlement. And I hope that all of the other people after you get huge settlements. So that, finally, the financial aspects of selling bad products drives them from the market.
07/11/2023 at 10:36 am #36223
There are many nerve branches in that anterior area. It’s easy to harm them directly or indirectly while performing surgery there, particularly when it’s a reoperation where it’s even harder to see them because of scar tissue. Also, there’s all the other tissue damage that can cause nociceptive pain.
I’m not an expert on triple neurectomy, so I don’t know how invasive or risky it is. The studies I’ve seen show that in the large majority of cases there’s significant pain relief. Those nerves in the anterior area are all sensory other than the genital nerve branch which innervates the cremaster. If my condition was severe, I would definitely explore that option further. I wouldn’t be quick to pull the trigger, but I would definitely look into it.
What medication are you taking? Pregabalin (Lyrica)?
07/12/2023 at 5:39 am #36246
My understanding, and the way it was explained to me, is that triple neurectomy is used as a catch all approach in dealing with complications and mitigating pain. Some surgeons want to do just that, leave the offending mesh, and hope you can move on through life with a numb groin. That’s what my original operating surgeon suggested and I was simply astounded that was his only offer. Others will take the mesh out and perform the triple neurectomy as a prophylactic measure to head off any possible post op nociceptive or neuropathic pain. Avoiding repeat customers, you, back in their office complaining that the surgery failed. My understanding is the risks involved with TN are things like continued or unresolved pain, testicular atrophy, abdominal distension and atrophy among others. I’d rather live for another 50 years without that. I think the best approach, and what others here seem to agree with, is to go in with the goal of removing the offending mesh and preserve all nerves if possible. I expect a surgeon to be surgical rather than having them scorch the earth so to speak.
So now I still have post op pain, but I have to view it as a win because its more manageable and less than before. I take what’s considered a low dose of gabapentin, and have just started a complementary course of duloxetine that seems to help tremendously. Despite the difficulties I’ve endured these past 2 years I think the human body is an amazing machine that will always seek to heal itself. I had a competent surgeon put everything back as close as possible to the way it’s supposed to be and now I’ll have to wait. My groin has been through 3 surgeries in my life and I’m tired of being cut up. Having pieces of me removed is traumatic. Taking more of me is just something I cant stomach.
07/12/2023 at 6:10 am #36247
I’m not a triple neurectomy expert, but from what I learned about it there aren’t significant issues when it’s done distally from where the nerves become sensory-only. You do get numbness, but that’s preferred to pain. You don’t get atrophy when cutting sensory nerves with no motor function. The question in my mind is whether there’s a way to make sure a painful neuroma doesn’t form on the cut nerves.
I totally understand not wanting another surgery. I suggested it since you said you’re doing terribly, can’t work, etc. If you’re doing reasonably well with medication, then it’s a different calculation. It sounds like you’re getting the right combination of nerve pain medication. There’s also pregabalin which is somewhat similar to gabapentin.
Have you noticed any significant side effects with these drugs?
07/12/2023 at 6:22 am #36248
I wouldn’t say the side effects are too bad. When starting medication of course it takes time for the body to adjust but once you’re stabilized on a dose things clear up. My doc is also conservative with treatment so we keep the dosages low relative to what the daily limits are. Only take what is needed. Periodically I’ll taper down just to see where my actual baseline is in recovery. Taking meds forever is not my goal and doing so can mask your actual progress.
Typical side effects though. Sporadic drowsiness, brain fog, etc. but nothing extreme that I’ve found that outweighs the benefits I receive. It allows me to function somewhat like a human again.
07/12/2023 at 4:59 pm #36255
That’s good to know – thanks. I hope you improve while these drugs keep the symptoms under control.
My feeling is that the body can heal certain things, but not others, so a lot depends on the exact damage you have. I guess that’s actually obvious. For example, a nerve that got a bit injured, stretched, or moved may heal with time (possibly a long time). However, if the nerve is caught in scar tissue, a stitch, or mesh, it’s a different situation. Not sure how that can be resolved other than through some invasive means.
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