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Recurrent hernia repair of complex hernia
Hello,
Having significant difficulty finding a hernia surgeon in the tri-state area who I feel comfortable/confident repairing a recurrent inguinal hernia that was initially repaired with the Prolene Hernia System! One surgeon insisted on performing a prophylactic neurectomy rather than a pragmatic one, if necessary, claiming that numbness is better than inguinodynia, although I never experienced groin pain from the original repair and the literature is equivocal regarding the efficacy and long term outcomes of this procedure! Another claimed that because I didn’t experience chronic pain from the original repair I wouldn’t from the second repair, which isn’t factual! When I asked another surgeon the percentage of his patients experiencing CHRONIC post surgical inguinal surgical repair, he responded ” All patients experience pain after surgery,” thereby evading my specific question entirely, but inadvertently answering it! Another showed a video of the surgical procedure in their waiting room and provided a question and answer sheet, but did did not provide any meaningful opportunity to ask additional questions during the consult, and had a medical student, not a resident or fellow, examin me without my permission! Another expressed an aggressive hostile attitude and response when I needed to cancel a scheduled surgery (a date that he “pushed” on me, and that I provided weeks of notice prior to cancellation) due to severe sequalae from an infection! This raised serious questions relating to his lack of empathy, the reason for his grossly inappropriate reaction (he was being paid cash only for the completion of the surgery), and that IF this was his response to a legitimate cancellation, raised questions regarding his level of response and accessibility IF I was to experience any post surgical issues relating to the surgery he performed?
In addition, several surgeons insisted on performing a TAPP due to the scar tissue in the anterior plane from the Prolene Hernia System, and that TAPP would provide much better visualization and repair, completely negating a TEP repair. Others indicated they would ONLY perform a TEP but would need a CT Scan, although I provided them with a well detailed MRI abdomen/Pelvis of the hernia (I discussed this issue with the chief of radiology who confirmed that the MRI was very clear, accurate and sufficient and I did not require being exposed to ionizing radiation from a CT scan). Another surgeon claimed that due to comorbidities, another open anterior surgical repair, Lichtenstein, would be best to avoid any complications from general anesthesia and indicated that in “his hands” a recurrence would be approximately 5%, which does not comply with the literature findings.
Questions: Although a laproscopic surgical repair would be preferable, can a second open repair be performed IF the scar tissue in the anterior plane is carefully dissected and the ilioinguinal nerves carefully preserved, resulting in a significantly decreased risk of a third recurrence and low risk of inguinodynia (chronic groin pain)? If so, I would appreciate feedback regarding surgeons in the Tri-state area who you would recommend to perform this procedure but also possess appropriate levels of collaboration, communication and empathy?
What is the protocol for conversion to either a TAPP of open repair IF during a TEP the surgeon is unable to complete the intervention due to excessive scar tissue?
Why is the TEP performed under local anesthesia (a field block with sedation) in certain European countries, but not in the US?
Thank you for your time and attention to this extremely frustrating situation.
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4 Replies
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Just curiosity, but how do you know that you have a recurrence? Pain, a lump, material where it’s not supposed to be? And why did you call it a complex hernia? The PHS is used for typical inguinal hernias.
Also, just an opinion, but I don’t think that Dr. Towfigh can tell you why the other surgeons had their opinions. It’s the chaotic nature of hernia repair today. A big complicated mess of materials and methods. None seemingly better than others. The one that’s been called the worst, the plug, is the most popular. I think that most surgeons just learn one method and that’s what they do.
Basically, what Dr. Towfigh suggested was that you should choose a TAPP surgeon. The advice about trusting your surgeon only seems valid if you choose the right one. You trusted the one that did the PHS and now, apparently, you have a recurrence.
Good luck. You seem aware of the various pitfalls. You’re about ready to just create a checklist and use a process of elimination to choose one.
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Thanks for your message. Seems you have a recurrent hernia after PHS mesh. That is an anteriorly placed mesh, but there is a posterior component. In my experience, it is much easier and less complicated to deal with these PHS recurrences from a posterior approach. Usually, that is a TAPP, either lap or robotic, as the TEP is hard to do when there is mesh scarring the extraperitoneal (EP) space. I do not see any benefit from another anterior approach: the nerves are all at risk of injury, the ilioinguinal nerve is almost never salvageable, and neurectomy is commonly indicated to prevent injury related pain. Also, there is higher risk of affecting the vasculature to the spermatic cord in males.
The tristate area refers to NY/NJ/CT. There are many many surgeons there who can help you, many of whom I have interviewed on HerniaTalk LIVE. My recommendation is pick one who you trust and can answer your questions and don’t tell them what to do. Forcing a surgeon to work outside of their own decision making is asking for problems.
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Hello Dr. Towfigh,
I greatly appreciate your feedback.
Fyi, two highly reputable hernia surgeons indicated that they would ONLY perform a TEP, not a TAPP! Their clinical rationale for the TEP was that it was less invasive than TAPP, especially considering my older age and medical comorbidities. However, one indicated that he would consider performing a Lichtenstein, stating in his “hands” he would carefully dissect the scar tissue in the anterior plane, with a very low risk of injury to the ilioinguinal nerves, recurrence or inguinodyna.
Another highly regarded hernia surgeon offered a TAPP, but indicating that “if” I was a “member of his family”, he would prefer performing an open repair!
At my age, my major concern is the potential side effects and sequalae of general anesthesia, [POCD, POD and urinary retention], as well as having a third recurrence and chronic post surgical pain syndrome, which I did not experience after my original PHS repair many years ago.. Based on the feedback from several hernia surgeons I consulted, there isn’t much difference in rates of recurrence between another open repair versus a TAPP or TEPP, but that levels of inguinodyna are decreased with a posterior repair.
I would appreciate your impression about the statement made by one of these surgeons that because I didn’t experience inguinodynia after my initial PHS repair that I wouldn’t after a second repair?
Thank you for again.
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It will probably help your decison-making to fully understand the Prolene Hernia System. When complete you will have a piece of mesh between the peritoneum and the abdominal wall, like a TAPP or TEP procedure, connected to a piece of mesh in the inguinal canal, like a Lichtenstein procedure.
You also need to fully understand what yoru surgeon meant by “recurrence”. Literally, it means that the same hernia that was present before has come back. But, I think that the word is sometimes used if any type of hernia appears after a hernia repair.
If the hernia has recurred around the mesh that was placed before then some or all of the mesh will probably need to be removed. If it’s a new hernia in a different place then the solution will be different.
Here’s an image of the PHS, and a description of the method of placement.
https://cobalt.pipelinemedical.com/Product/Detail/system-hernia-medium-prolene-3-cm-34571
cobalt.pipelinemedical.com
Systems: Prolene Hernia System, Medium, 3 cm | Pipeline Medical
The PROLENE™ (Polypropylene) Hernia System is a sterile, pre-shaped, three dimensional device constructed of an onlay patch connected by a mesh cylind
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