Recurrent pain?

[drtowfigh]

the mesh patches the hole. for inguinal hernias, the hole is fairly small (vs abdominal wall/ventral hernias). as long as the mesh adequately patches the hole, the abdominal contents will not pierce the mesh.
the reason for pain is very complex and needs careful evaluation.

[jzinckgra]

quote jzinckgra:

Recurrent pain?

Dr T,

Does the actual hernia hole heal itself closed? I am trying to understand my recurrent pain. As mentioned in another thread, my surgeon placed the mesh without sutures or tacks. I’ve heard one can get scar tissue, but how could that happen in my case? I undrtdtand that my own tissue is supposed to grow into the mesh and essentially become “one”, so why would I have recurrent pain?

If the hernia hole never really heals itself closed, then I can totally understand the pain as it would seem to suggest the intestinal content is still trying to get through, but is prevented by the mesh. Is this accurate?

HI,

Was following up to my recent questions. thanks.

[jzinckgra]

Recurrent pain?

Dr T,

Does the actual hernia hole heal itself closed? I am trying to understand my recurrent pain. As mentioned in another thread, my surgeon placed the mesh without sutures or tacks. I’ve heard one can get scar tissue, but how could that happen in my case? I undrtdtand that my own tissue is supposed to grow into the mesh and essentially become “one”, so why would I have recurrent pain?

If the hernia hole never really heals itself closed, then I can totally understand the pain as it would seem to suggest the intestinal content is still trying to get through, but is prevented by the mesh. Is this accurate?

[drtowfigh]

Recurrent pain?

To clarify some questions:

– In the US, it is pretty much no longer considered standard to place plain mesh inside the belly, where it can come in contact with intestines, as the mesh may adhese to, or erode into, the intestines. If any mesh is placed inside the belly that can come in contact with intestines, it is coated with an anti-adhesive barrier of some sort, so that it reduces the risk of adhesion and erosion.

– For the typical laparoscopic inguinal hernia repair, the mesh is NOT placed inside the belly, where it can risk sticking into the intestines. It is placed one layer more superficial, so that it sticks to the muscle, where the hernia hole is.

– Hernia content can include anything, though usually it is just fat and not any intestine.

[jzinckgra]

Recurrent pain?

So I went to my GI doc last week and his conclusion is that there is no GI issue, meaning he dones’t think my pain is diverticulitis/losis or IBS. He also had a hernia repair by the same surgeon that did mine and he said many of the symptoms and pain I’ve been having are similar to what he experienced in the past. I didn’t ask if his pains went away, but I’m 2.5 months into this and it’s bothersome. Went skiing yesterday and I could feel the discomfort most of day.

So at this point, I guess my only option is to go back to my surgeon, but what’s he going to be able to do? I feel like I’m stuck with no solution .

[jzinckgra]

Recurrent pain?

In an inguinal hernia, is it the small or large intestine that pokes through?

[MikeL]

Recurrent pain?

I think what it simply means that the mesh may potentially adhere to your internals. However, it is attached to your muscles from inside. You should ask your surgeon what technique he/she used to attach the mesh. Only imaging tests may help to identify mesh current form and position as Dr Towfigh has mentioned. It’s probably still challenge to catch all this mesh information. I am sure that Dr will define special imaging protocol and prefer machine of a higher end. This article briefly describes mesh attachment methods. There are videos on the YouTube that can educate you if you tolerate all this stuff …
https://m.youtube.com/watch?v=TGFtFQ_hY0Q

https://www.facs.org/~/media/files/education/patient%20ed/ventral_hernia.ashx

[jzinckgra]

Recurrent pain?

quote :

Thanks again for your reply. So, for a tension free repair like the one I got, other than the mesh which presumably prevents the intestine from poking through, does the actual hole ever heal over?

Please read this https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477030/

Great article, thanks. Two statements caught my attention:

1. “While the inflammatory response generated by polypropylene contributes to its durability, it also increases adhesion formation when the mesh is used adjacent to the bowel. As a result, polypropylene is rarely used alone in the peritoneal cavity.”

What is meant by “adjacent to bowel?” I thought all patches were placed directly over the bowel, so contact with intestine is assumed is it not?

2. “The inflammatory response to polypropylene also causes the material to contract by 30 to 50%”

Other than blood tests, how would I know I had inflammatory response and potential patch shrinkage? In any case, that is a lot of shrinkage.

My surgical report makes no mention of whether the patch was sutured in place. It was a 10x15cm Bard PP patch. The report says:

“The mesh was then inserted via the umbilical trocar and positioned in the left inguinofemoral region to completely cover the direct,indirect and fenrcral spaces widely. The mesh extended lateral to the internal ring,deep to the Coope/s ligament and to the midline. CO2 was then evacuated under direct visualization as the trocars were removed. The mesh maintained good position and trocar sites were hemostaiic.”

[drtowfigh]

Recurrent pain?

Excellent discussion…

– Imaging is the best way to know if the mesh is flat, especially for laparoscopic mesh. Feeling alone may not be enough.

– Most of the time, we patch the hernia hole in the groin, and we do not close it. The reason is exactly as was described by MikeL. Eventually, the mesh is the cover for the hole, as well as some surrounding tissues. You will not make new muscles to fill in the hole, though that would be a great option in the future of hernia surgery.

– MRI and Ultrasound are good ways to know if there is a unique bowel adhesion to mesh. This may mimic GI symptoms, but is not a common occurrence.

[MikeL]

Recurrent pain?

Thanks again for your reply. So, for a tension free repair like the one I got, other than the mesh which presumably prevents the intestine from poking through, does the actual hole ever heal over?

Please read this https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477030/

[Beenthere]

Recurrent pain?

Sorry to hear about your pain. I had issues that started about 7 weeks after my original hernia surgery and all of my world class experts could not identify what was wrong. It would have helped if they ordered the correct imaging at the time but none did. When I had surgery on my other side for another hernia the doctor found a femoral hernia on the side of the original side plus he removed the first mesh. I am sure this is very rare. Took care of my pain and tightness right away.

Good luck.

[jzinckgra]

Recurrent pain?

quote :

Let me answer your another question that you have asked the Pro by replying to you using other answers tree.
http://www.medtronic.com/us-en/patients/treatments-therapies/hernia-surgery.html
You have tension free repair done laparoscopic way with mesh. It means that your body tissues were not closed/pulled back together. The mesh covered the hole in the groin and attached to the healthy tissue around the defect. The whole idea of mesh is to prevent stress due to tension when two separated muscle edges are pulled and attached together. This old technique may cause another hernia due to another post-op tear. Here is the picture of this “old” technique.
http://hernia.tripod.com/techcomp.html
The drawback is that mesh is an implant that may create other problems such as nerve entrapment, shrinkage and deformation, adhesions, etc… Thus, please do not get wrong that repair under tension is no longer an option. It is applied only under circumstances when it is better than mesh option. Typically, once the muscle are attached together there is no need in mesh anymore.
Balled mesh may be seen on the MRI if done with a special regimen/protocol. Also, doctor does tests on the affected area to confirm the diagnose. Unfortunately, it appears to be not so rear…

I think you identified source of your problem, which is your current level and nature of physical activity. When I was younger I was also doing sport activities on a stressful level (other than ski). My genetics did not allow me to continue my career this way. You are, obviously, the boss of your body. However, let me express few points that may potentially help you. No offence. I just wish you the best. Possibly you are younger than me.

When your body experiences extra load in certain weak location, which is operated area in your case, it tries to absorb it by distributing load to other areas of proximity: oblique muscles, ligament and co-joint tendon, sometimes even adductors, etc… If any of these will be torn due to this activity… First, it will be hard to identify the root cause without surgery. In case of the repair the doctor will decide either to remove the mesh or not, which is complicated thing by itself. (Dr Towfigh has mentioned this several times). All or most defects (torn muscles) would need to be repaired using sutures (under tension) or reattachment techniques without mesh. In some cases tendon release is applied (it will be “cut” from it’s origin…). Recovery from such surgery is painful, indeed. There is much more pain than after lap hernia repair for a longer time. The surgery by itself is not a guarantee to recover 100%. Physical therapy is necessary in such cases and it is done through the pain. It is “unforgettable” and costly experience that, unfortunately, many people go through due to groin injuries, which are right there – near private area. You can search sports hernia forums and sites, and visit different discussion boards to read reviews and opinions.
Another thing that I have learned, this time from my orthopedic surgeon, is when my knee was injured. My doctor has started to ask me some strange questions about my opinion and character and so on… My meniscus was injured and in some cases doctors may fully recover knee by suturing tear under certain clinical circumstances. These circumstances are only discovered during the surgery. However, this reconstruction requires extra recovery time and a lot of discipline and commitment from the patient. Certain moves must be avoided, knee in cast, etc… The doctor explained that if he does not believe that the patient can control emotions and can break recovery protocol then he is not qualified for suture repair. Instead, trimming of meniscus will be done – faster recovery and loss of at least 25% cartilage. For example, for pro athletes 25-35% of saved cartilage may add extra $$$ during career. Someone may else prefer different route. Where I am coming from is that if you neglect signals from your body and the worst thing happens some doctors may even turn you off as a patient. I have never heard of any doctor who wants to see his/her patient back with recurrence. Doctors want to win the battle together with you. They typically have enough business.
One of my friends got abdominal pain and bowel movements after long break between gym exercises while he did not do any surgery at all! His groins and abdominal muscles were soar for almost 1.5 months! His treatment was rest because he was scared enough 🙂

With best wishes

Thanks again for your reply. So, for a tension free repair like the one I got, other than the mesh which presumably prevents the intestine from poking through, does the actual hole ever heal over?

[MikeL]

Recurrent pain?

Let me answer your another question that you have asked the Pro by replying to you using other answers tree.
http://www.medtronic.com/us-en/patients/treatments-therapies/hernia-surgery.html
You have tension free repair done laparoscopic way with mesh. It means that your body tissues were not closed/pulled back together. The mesh covered the hole in the groin and attached to the healthy tissue around the defect. The whole idea of mesh is to prevent stress due to tension when two separated muscle edges are pulled and attached together. This old technique may cause another hernia due to another post-op tear. Here is the picture of this “old” technique.
http://hernia.tripod.com/techcomp.html
The drawback is that mesh is an implant that may create other problems such as nerve entrapment, shrinkage and deformation, adhesions, etc… Thus, please do not get wrong that repair under tension is no longer an option. It is applied only under circumstances when it is better than mesh option. Typically, once the muscle are attached together there is no need in mesh anymore.
Balled mesh may be seen on the MRI if done with a special regimen/protocol. Also, doctor does tests on the affected area to confirm the diagnose. Unfortunately, it appears to be not so rear…

I think you identified source of your problem, which is your current level and nature of physical activity. When I was younger I was also doing sport activities on a stressful level (other than ski). My genetics did not allow me to continue my career this way. You are, obviously, the boss of your body. However, let me express few points that may potentially help you. No offence. I just wish you the best. Possibly you are younger than me.

When your body experiences extra load in certain weak location, which is operated area in your case, it tries to absorb it by distributing load to other areas of proximity: oblique muscles, ligament and co-joint tendon, sometimes even adductors, etc… If any of these will be torn due to this activity… First, it will be hard to identify the root cause without surgery. In case of the repair the doctor will decide either to remove the mesh or not, which is complicated thing by itself. (Dr Towfigh has mentioned this several times). All or most defects (torn muscles) would need to be repaired using sutures (under tension) or reattachment techniques without mesh. In some cases tendon release is applied (it will be “cut” from it’s origin…). Recovery from such surgery is painful, indeed. There is much more pain than after lap hernia repair for a longer time. The surgery by itself is not a guarantee to recover 100%. Physical therapy is necessary in such cases and it is done through the pain. It is “unforgettable” and costly experience that, unfortunately, many people go through due to groin injuries, which are right there – near private area. You can search sports hernia forums and sites, and visit different discussion boards to read reviews and opinions.
Another thing that I have learned, this time from my orthopedic surgeon, is when my knee was injured. My doctor has started to ask me some strange questions about my opinion and character and so on… My meniscus was injured and in some cases doctors may fully recover knee by suturing tear under certain clinical circumstances. These circumstances are only discovered during the surgery. However, this reconstruction requires extra recovery time and a lot of discipline and commitment from the patient. Certain moves must be avoided, knee in cast, etc… The doctor explained that if he does not believe that the patient can control emotions and can break recovery protocol then he is not qualified for suture repair. Instead, trimming of meniscus will be done – faster recovery and loss of at least 25% cartilage. For example, for pro athletes 25-35% of saved cartilage may add extra $$$ during career. Someone may else prefer different route. Where I am coming from is that if you neglect signals from your body and the worst thing happens some doctors may even turn you off as a patient. I have never heard of any doctor who wants to see his/her patient back with recurrence. Doctors want to win the battle together with you. They typically have enough business.
One of my friends got abdominal pain and bowel movements after long break between gym exercises while he did not do any surgery at all! His groins and abdominal muscles were soar for almost 1.5 months! His treatment was rest because he was scared enough 🙂

With best wishes

[jzinckgra]

Recurrent pain?

quote :

This is a complex situation.

IBS is a diagnosis of last resort. If your pain is activity-related, your hernia/hernia repair may be the culprit. If it’s only GI symptoms, then the hernia is less likely a problem. That said, is the mesh confirmed to be flat? Is there any suggestion that the mesh is exposed and causing adhesions to bowel?,

Most of the pain is activity related. Most nights I go to bed and when I lay down I get some mild pain for a bit then doze off. When I awake, I have little to no pain until I start my day walking around, twisting torso, etc. Just today, I took 100mi snowmobile ride and with all the bumps, my abdo region gets jostled all day, getting worse by end of day. This happened last wknd too.

Can a surgeon tell of the mesh is flat by just feeling around? I’ve rubbed the area and felt around many times and I can’t feel anything, but I’m not trained to either, unless it would be really obvious. Since Dr. G appt, which resulted in no recurrent hernia and no hernia on other side, I have not seen my local surgeon. I do have a GI appt this month, but I don’t think it’s GI, but not 100%. Bowels have been pretty normal, but in saying this, if there were any irritation around repaired hernia, would it feel better after bowel movement, with pain coming back minutes later?

One other question. When an inguinal hernia is repaired, the surgeon doesn’t just place the patch directly over the hole then stitch the outside right? Don’t they first suture the inner tissue to close up the hole then place the patch? Many thanks.

[jzinckgra]

Recurrent pain?

quote :

Ogh, no doubt… Most of general surgeons are actually capable to perform groin hernia repair. This is why people typically look for the local general surgeon. However, open repair was developed prior to lap and every single general surgeon must be trained to do this type of surgery in open fashion. You probably never thought about pros and cons relying on the doc. This is what most people would do anyway. Now, going back to your groin pain in the operated area. Here are my 5 cents. If rest and aleve/naproxen (if you are not alergic) will not alleviate pain and you will not feel better in few months I would seek help from a doctor who will be able to separate such possible causes of the pain as damaged nerve, deformed mesh, torn muscles near operated area (sports hernia – often missed by general surgeons), occult hernia. It is very hard to find such specialist. Easy to write, however, only top notch surgeon can do this. You may consider Dr Towfigh services to help you. Good luck with your recovery.

Thanks for your reply. I wish I could take a few months off, but I am way to active to make such commitment. Stupid I know, but I love to ski, snowmobile and workout at the gym. I could try taking a week or so off and see what happens. Come Spring, I am back to cycling and hiking.

[MikeL]

Recurrent pain?

Dr Towfigh, how difficult would it be to catch this possible adhesion to bowel? According to this article MRI may be reliable way to approach such gastro- related issue. https://www.hindawi.com/journals/grp/2016/2631598/
At the same time the researchers claim that adhesions are not cause of a long term pain, which sounds surprising to a non-professional ear. May be these results are primarily correct for ventral hernia mesh repair and should not be extended to other type of hernia? If adhesion is confirmed how complex corrective repair is?

[drtowfigh]

Recurrent pain?

This is a complex situation.

IBS is a diagnosis of last resort. If your pain is activity-related, your hernia/hernia repair may be the culprit. If it’s only GI symptoms, then the hernia is less likely a problem. That said, is the mesh confirmed to be flat? Is there any suggestion that the mesh is exposed and causing adhesions to bowel?,

[MikeL]

Recurrent pain?

Ogh, no doubt… Most of general surgeons are actually capable to perform groin hernia repair. This is why people typically look for the local general surgeon. However, open repair was developed prior to lap and every single general surgeon must be trained to do this type of surgery in open fashion. You probably never thought about pros and cons relying on the doc. This is what most people would do anyway. Now, going back to your groin pain in the operated area. Here are my 5 cents. If rest and aleve/naproxen (if you are not alergic) will not alleviate pain and you will not feel better in few months I would seek help from a doctor who will be able to separate such possible causes of the pain as damaged nerve, deformed mesh, torn muscles near operated area (sports hernia – often missed by general surgeons), occult hernia. It is very hard to find such specialist. Easy to write, however, only top notch surgeon can do this. You may consider Dr Towfigh services to help you. Good luck with your recovery.

[jzinckgra]

Recurrent pain?

Trust me, I wished I had gone to Dr. G. for open repair. My lapro surgeon is considered good in this area, but I never researched how important it is to get a hernia surgeon as opposed to general surgeon.

[MikeL]

Recurrent pain?

Hi, I am not a doctor, however, during my life have had enough muscular injuries including groin… Your dull groin pain (you would need to rule out gastro with a specialist) sounds like muscular. If you have done some more agressive physical activity prior to time when the groin pain started to bother you then it can be tissue in the operated area. Please keep in mind that post surgical physical activities may not look excessive, but… they may be strong enough to cause at least some micro trauma. If it is the case then you may allow this to heal by rest for another 3 months or so unless pain starts to intensify… Btw, why did you go with lap repair when the golden standard is open surgery with lightweight mesh? This was mentioned by Dr Towfigh in this forum. Open repair typically allows better exploratory look and easier to correct if any issue pops up down the road.