Recurrent Sportsman’s Hernia (Inguinal disruption)

[GaleW]

Hi to anyone who can help me,
I am a 40 year old overweight female who had Laparoscopic TEP surgery some 5 years ago from the expert hands of Professor Sheen.
My diagnosis at the time from the dynamic US was weakness but no discernible hernia. Professor Sheen decided on that basis to operate (although he warned there was no guarantee it would sort the crazy pain I was suffering) and the pain disappeared entirely. I walked out of hospital after surgery feeling better than when I had gone in.
Thank you Professor Sheen.
Fast forward 5 years and my pains have returned, I am unable to do anything physical (I go to work and sit in my chair the entire day and at home I lie on the couch) Any work I do do puts me completely out of action in extreme pain. I tried to contact Professor Sheen but he is on emergency leave and as I cannot wait, I decided to see a different consultant (recommended by Professor Sheen’s secretary)
I have been to see the other consultant and he seems skeptical about the hernia diagnosis, he says it is extremely unlikely to be mesh complications after 5 years and is searching for alternative reasons for the pain. He did send me to dynamic ultrasound and the consultant radiologist admits that what he sees is consistent with what was seen five years ago (which sounds like recurrence) however, just like then, he sees no hernia.
I’d like advice as to how to move forward. It seems that the sportsmans hernia is a hernia that does not properly show up on the ultrasound anyway and is not fully understood in females. This seems to be why other doctors don’t believe my symptoms to be due to hernia (5 years ago I was run around to all sorts of other doctors before seeing Professor Sheen)
Could any of you lovely experts here on the site advise me as to what I am experiencing and my best way forward? Is it mesh complication? Is it recurrent hernia? Do I now need an open surgery to add more mesh or would it be better to go to Korea and have the mesh removed? Everything just seems so murky and I am confused. Thank you in advance for your help.

[Good intentions]

Did the pain return suddenly after a specific action? Or more slowly, like days/weeks/months? Have you been very active over the five years or more sedentary?

Sportsman’s hernias (athletic pubalgia) pain usually happens during activity, not so much afterward. While running or sprinting, for example.

If the pain is the same as before it seems reasonable to suspect that the same nerves are being affected. Not sure how a surgeon would address that since mesh has already been implanted. Mesh is known to shrink over time, so one possibility is that the mesh moved far enough that the previous weakness has been exposed. It is also known to fold and bunch up as it shrinks.

I am not an expert or a surgeon or a doctor but a TAPP procedure to view the abdominal wall from behind, followed by adjustment and/or placement of new mesh seems possible. I can imagine a surgeon recommending that as a possibility.

Just some ideas. Good that you got five pain-free years though. Hopefully the next will last longer. Good luck.

[GaleW]

Thanks for your reply. I dont know of a specific action that caused it (I did carry a heavy item but the pain only started a day or two later). Last time, it was basically any minimal activity that caused pain and extreme weakness and its the same now. I am not particularly sporty but I am an active person and it drives me crazy to have to basically rest the entire time (and have everyone tell me they cant see anything wrong with me

[Good intentions]

I don’t know if this will help you or not but Dr. Sheen seems to run counter to prevailing opinion on treatment of athletic pubalgia. Many surgeons say that they do not use or recommend mesh for its treatment. But there also seems to be some discussion about how to define the problem.

You are in an odd spot, since Dr. Sheen is a firm proponent of mesh. He publishes often about mesh implantations. You might consider getting away from the mesh repair experts and see what an open repair surgeon thinks.

Here is a fairly recent paper by Sheen et al trying to show the efficacy of the TEP mesh procedure compared to open repair.

https://academic.oup.com/bjs/article/106/7/837/6092871

Here is another paper describing an open repair method on young athletes. It has some good diagnostic methods based on where the pain is that might help you understand your condition.

https://kosovajournalofsurgery.net/wp-content/uploads/2023/03/D-Litwin-2-KJS7_merged.pdf

[Good intentions]

Here is a search page about treatment of athletic pubalgia, with fairly recent results. Opinions have changed over the years.

https://scholar.google.com/scholar?hl=en&scisbd=1&as_sdt=0%2C48&q=treatment+pubalgia&btnG=

[drtowfigh]

Sounds like you had an inguinal hernia, maybe direct type and/or a small indirect type , and it was repaired. Pain 5 years later is a hernia recurrence until proven otherwise. A sportsman’s hernia would not act like this. And you would need to be quite athletic to get such injuries.

If I were to see you, I would get a dynamic MRI or review your ultrasound. If the hernia has recurred, then an open repair with mesh or a redo of the mesh repair would be indicated.

[GaleW]

Thank you Dr. Towfigh.
I have just read through the notes again to be certain
This is the first US report

“With a background generalised weakness of the posterior inguinal wall, there are
small focal areas which are slightly more prominent on cough/straining/Valsalva
manoeuvre medial to the deep inferior epigastric vessels on both sides. These
spontaneously reduce at rest.
No inguinal lymphadenopathy seen.
No significant hip joint effusion seen.
Patent femoral vessels.”

However in the report of the operation he wrote

“Diagnosis: Bilateral sports hernia — posterior wall weakness
Operation performed: Bilateral inguinal disruption repair (TEP with glue fixation) 22 June 2018
Main findings: No tears, No indirect defects. direct defect, weakened wall
Planned management: Follow-up in 4-6 Weeks (rehab to commence in first week)”

also in the detailed surgical report he wrote

“Access: Open laparoscopy via insertion of a 10mm blunt port at a horizontal
cut-down incision at the umbilical raphe in sub rectus plane. Balloon
used to create extraperitoneal space, noted coppers ligament during
balloon insufflation. Camera port inserted after balloon deflated and
satisfactory CO2 pneumoperitoneum achieved under vision (preset
maximum pressure 12 mm Hg). Two further ports inserted under
direct vision (5 mm, 3 and 5 cm above symphysis pubis).

Inspection:

 Indirect with small direct components both sides R>L
 No Obturator tears

Procedure: Hernial sacs reduced, L>R. Noted inferior Epigastric vessels
superiorly round ligament of uterus, which was divided. Posterior
wall weakness noted. Created space laterally to accommodate the
mesh. Once hernia reduced, Parietex 15 by 12 cm mesh was place via
the camera port and fixated with Tisseel Glue Spray applicator on
both sides. Small breech of peritoneum on right clipped Sac placed
over mesh prior to deflation under vision.
1 Maxon to 10 mm port site, 3/0 monocryl and glue to skin.”
So after all that, I am unsure as to what I actually had. Maybe you could help me.
The current US read the older US and said he sees the same. I have not yet got the report (it was friday evening)
Thank you again

• This reply was modified 3 months, 2 weeks ago by GaleW.

[Good intentions]

That is unfortunate that his “Main findings:” don’t match his “Inspection:”. Some surgeons cut and paste their reports using parts from past reports.

The thing about mesh implantations though, is that it doesn’t really matter. The mesh will cover the same area, for either direct or indirect hernias. Since you had good results from the first mesh implantation a new surgeon will probably just do the same thing over again.

For what it’s worth, Parietex mesh is a brand name for a series of polyester (PET) meshes. I would guess that he used the Parietex lightweight monofilament flat mesh, since he did use fixation with the Tisseel fibrin glue. The monofilament Parietex is the polyester analog of the common polypropylene flat meshes, which are very commonly used for TEP procedures.

https://www.medtronic.com/covidien/en-us/products/hernia-repair/mesh-products.html

[drtowfigh]

Sounds like my suspicion was right. You had a direct hernia. This was repaired. Now you have a recurrence.

[GaleW]

Is it normal that it doesn’t show up on the dynamic US, neither then nor now?

[NFG12]

Never heard of a sports hernia requiring mesh. It’s when a tendon tears in the pubic bone from kicks like soccer or karate and sometimes heal on there own but I’d see no reason for mesh for a sports hernia, they usually stitch it back together cause it’s not an inguinal, femoral hernia etc. He should’ve never put mesh in for that and yes mesh can cause problems after 5 years, 1 month, 6 months, 10 years etc. I’d get an MRIto see what’s going on and it’ll be the most helpful test to do. These docs we listen to them but research yourself for a smplie tendon tear there’s no reason to put mesh in and that’s the problem your having now. An MRI is best bet and study stuff cause the docs are hard to believe then again even trust anymore especially with hernia repair, wish you the best!

[Good intentions]

It looks like Dr. Sheen used the “sportsman’s hernia” diagnosis as the premise to do surgery. His observations once he got in and could see and poke around were some combination of direct and indirect hernias. In a TEP procedure a large piece of mesh is used to cover both areas.

In sum, he felt confident that surgery would help, and it did. But there was a recurrence. Recurrences are known for laparoscopic mesh implantation, even with large pieces of mesh. 15 x 12 cm = about 6 x 4 3/4 inches.

The large pieces of mesh that have been encapsulated by your body are part of the new decision. Mesh removal could cause new problems. Overall, an open mesh or open pure tissue repair seem to make the most sense. Leave the 5 year old mesh in place if it has not been bothering. Fix the recurrence by another method. The 5 year old mesh is probably tied up with other critical nerves and vessels. It’s how “incorporation” works.

Don’t fret over what has already happened. You’re in a new situation. Listen carefully to the surgeons, take a list of questions with you and don’t commit to anything unless you really understand what is being proposed. You’ve already had one failure by a top well-known expert in the field using the most publicized repair method. Dr. Sheen is one of the HerniaTalk surgeons, listed at the top of the page. Good luck.

[GaleW]

I have just come back from my surgeon, after having both a dynamic ultrasound and an MRI, nothing more than “weakness” can be seen, as such, the surgeon suggests it wouldn’t be prudent to operate as it could make things worse. Instead, he wants to refer me to pain clinic.
I wish I could know if there really is a recurrence. This surgeon (recommended by Professor Sheen dur to him being out of action) is not a hernia specialist.
I dont know if to trust him or to get a second opinion. I could relatively easily hop on a plane to germany if necessary, otherwise to someone in England but I wish I could get more clarity on what I have.
Is there a definitive scan to see the hernia?
Where do I go from here?
It is extremely frustrating and the pain really disables me. Is there any explanation why I should get excruciating pain from it?

[GaleW]

I would really appreciate if someone can help me shed light into my case. I’m suffering on a daily basis and have nowhere to turn to
Thank you

[Good intentions]

Here is an opinion, from a non-expert –

If the pain is the same as before the repair it seems most likely that the defective area is being stressed in the same way. This could be because you’ve had a recurrence as Dr. Towfigh suggested, or because the mesh has come free from the abdominal wall in that defect area and is allowing the stressed area to to be pressurized/distorted again.

Since Dr. Sheen implanted mesh via the TEP procedure, there really are only a few options. Pain treatment, which could involve various pharmaceutical agents. Neurectomy, which has its own hazards. Open exploratory surgery and either a pure tissue repair to tighten the herniated area or a mesh repair to do the same. Mesh on the outside and inside. TAPP (the other laparoscopic method) exploratory surgery, probably with full or partial mesh removal and some other method of hernia repair.

Often though, as I understand things, the peritoneum looks fine from the viscera side during a TAPP exploration, even though problems exist on the anterior side. Before my mesh removal surgeon opened the peritoneum and removed the mesh, mine looked as it should, smooth and distortion free, but my surgeon found a folded area and movement of the mesh plus much edema. So if you get the wrong lap surgeon they might not see anything and just leave everything alone.

Your dilemma, I think, is choosing between mesh removal or another type of hernia repair. Since your pain is the same as it was with the hernia it seems like another repair should give similar results. My mesh pain was completely different from my hernia pain. I knew absolutely that the mesh was the problem and that removal was probably the best solution. Your case is different.

It is not uncommon to have mesh on both sides of the abdominal wall, if, for example, you got an anterior mesh repair by open surgery. The Prolene Hernia System (PHS) is designed that way. But I don’t know much at all about the repair methods used for female anatomy, it might not be appropriate.

Frankly, I would find an expert in female hernias. The ratio of female to male hernias is about 2 to 25. There are probably surgeons out there who have never repaired a woman’s hernia. Even those that have do not have much experience. They can’t, there just aren’t enough cases.

If Dr. Towfigh comes back maybe she can recommend an expert in your area. Since Dr. Sheen is apparently not available.

[Jack2021]

Hi Gale,

Sorry to hear about your situation.

I’m also based in the UK. My suggestion would be to contact Dr Joachim Conze, who runs a clinic in Munich – 0049 89 9209010 / https://www.hernien.de/

He worked in partnership with Dr Ulrike Muschaweck for many years until, from my understanding, buying her out or coming to some agreement of sorts and taking over the clinic.

Dr Muschaweck is renowned for her sportsmen’s groin repair (the Muschaweck repair) which doesn’t involve the use of mesh. She does run a clinic in the UK once a month still I think, so you could see her also, even just for advice. A consultation will cost £400-£500 so not cheap and she’s not registered with many private medical insurance companies either, even if you have cover.

Dr Muschaweck is mid-seventies now so well beyond standard retirement age for a surgeon in Europe and is expensive too. She’s operated on the likes of Alan Shearer and Michael Owen many years ago.

To find out about UK appointments, you can contact her either through Biohernia, or more directly via her PA, Gonzalo Rojo at [email protected] / 0049 89 9545 338 20.

Dr Conze treats many top athletes and sports people too and can offer the same treatments at similar prices, though you’d need to travel to Munich. He’s probably in his fifties, I’d guess and would be my preference of the two if you were to undertake surgery, because he also looks to preserve the nerves and my understanding is that Dr Muschaweck is more likely to cut them, as they’d say in basic layman’s terms, which she does with her inguinal hernia repairs as standard I believe. He would Taylor any surgery and can use mesh if it’s required.

Were you to travel to Germany, they’d provide all the details about where to stay etc, so it should be relatively straightforward, aside from having to travel for it.

They can both do open surgery repairs for a variety of hernias and would both do their own dynamic ultrasounds, rather than relying on a report from a radiologist, as they know exactly what they’re looking for.

Hope that’s helpful and please feedback on the forum regarding how you get on, as it’s always really helpful for other members to know.

All the best,

Jack

[Jack2021]

Just to add, it’s knocking on 2 years since I was in touch with Gonzalo, so he may have moved on I guess.

[GaleW]

Thank you Good intentions and Jack for your responses! I really appreciate it
I will contact Dr Conze and see what happens

[GaleW]

I have contacted Dr Conze and he responded the following:

it seems that reinforcing the posterior wall with a synthetic mesh (15×12 cm) brought peace into the groin… at least for more than years. But if you recall the history of your primary complaints and diagnostic measurements…. there was no real hernia defect detectable in fist place… just like it seems now… no clear hernia defect but a slight protrusion of the mesh-reinforced posterior wall of the inguinal canal.

From what you describe I can only hypothesize that the mesh reinforced posterior wall is now pushing onto the inguinal canal…. something I call a “pseudo”-recurrence! … missing a real direct defect and hernia sac with a bulge.

Did any of you hear about it? know more info?
I’ve tried googling it but didnt get anywhere
Would love to find someone that had a similar problem
Can anyone help me?

[Good intentions]

It’s not clear what you are asking Gale. Dr. Conze is saying that you probably have the same problem that you had in the beginning – pressure on areas in the groin that cause pain. The mesh worked for five years and now it has stopped working. Disappointing that he did not offer a plan of action to solve the problem. Maybe you can ask him about that.

“Pseudo-recurrence” just means something that has the symptoms of a recurrence but is not an actual recurrence. Physically, if this is true, you are in no danger of incarcerated viscera, because everything is where it should be. You are in the category of “physically healthy patient with pain”. Dr. Sheen can say his procedure is and was perfect. But the pain is a new situation. Unfortunately, even though your case is different, the path forward is very similar to that of a typical chronic pain patient. You’ll need to find a doctor that believes that chronic pain is real and has ideas about how to solve it.

https://en.wikipedia.org/wiki/Pseudo-

[GaleW]

Thanks to everyone…just to update…
I have had the modified Shouldice repair done by Dr Conze in Munich on both sides
He also checked the nerves during the surgery and then did a triple neurectomy on both sides.
it has now been exactly a month since surgery but unfortunately I am still very weak, feel pulling on both sides and even a small effort puts me out for a few hours.
I also feel pressure on both sides which Dr Conze suggests could be due to problems in lymphatic drainage (it is my third surgery in the area)
Is it normal? I find it extremely frustrating!
I recovered much faster from the previous surgeries (a caesarian and a laparoscopic mesh repair)
Would appreciate your advice

[Good intentions]

I don’t think that your overall situation is normal so there probably aren’t many people to compare to.

One month after a bilateral hernia repair procedure is really not very long. In your first post you said that you had pain. Now you’re saying that you’re weak and a small effort “puts you out”. Are you saying that things are different now? What does that mean. Is it low energy or pain?

No offense intended but I think that you might be expecting too much too soon. While you were having the pain before surgery you were probably getting weaker overall because you were inactive. Trying to avoid the pain. Maybe you started from a lower base of overall strength.

If you read some of the older Shouldice posts you’ll see that “pulling” is one of the typical feelings after a Shouldice procedure. So that is normal, it’s the nature of the procedure. Apparently it can resolve over time.

Anyway, it doesn’t sound like you are in danger or need another surgery. I’d monitor progress of any kind and keep trying to get stronger. It’s the best that you can do. Good luck.

[Watchful]

GaleW,

Sorry to hear the results aren’t good so far. As GI said, one month is still quite early.

It’s interesting that pain persists even with triple neurectomies, but that’s not rare based on what I’ve been told. It’s not an area that’s all that well understood.

I had a Shouldice procedure on one side 9 months ago. I never felt “pulling”, but I did feel pressure and pain, and still do. Luckily, my symptoms aren’t debilitating and they aren’t constant, but they are certainly bothersome.

Did Dr. Conze mention if this possibility of a lymphatic drainage issue can be diagnosed somehow (imaging), and if anything can be done about it? Does it mean that scar tissue is impinging on lymphatic vessels or some such thing?

I’m speculating that scar tissue is causing a lot of my issues, and my surgeon seems to agree. I can feel that hardened tissue which is painful when palpating the area. I’m not sure if anything can be done about it. Another surgery may add more trouble (including more scar tissue), or exchange one problem for another.

[David M]

Watchful, I wish I understood scar tissue better. How, when and where it’s formed.

From reading the forum, I get the sense that it’s mostly formed as an encapsulation of foreign material, not necessarily from the healing of tissues that were cut. If i cut myself, for instance, generally the healing process of tissue to tissue doesn’t leave that much of a scar. This is not always the case, but generally so. I had thyroid surgery almost 15 years ago and I can’t even tell where my scar is, though it was fairly prominent and swollen after the surgery. (On the other hand, I have a fairly prominent scar on my knee where I cut myself with a coke bottle at a young age, and there are people who do have to watch the over-scarring.)

So, here’s a question I asked a surgeon a couple of weeks age. If you double breast the transversalis fascia, do the two layers grow together. He said something about there always being scarring, but does that sound like the right answer? It seems to me that tissue to tissue of the same kind like that would be less likely to scar than to either do nothing or grow together stronger.

So, my thinking -very possibly incorrect – is that most of the permanent scarring in an operation will come from the foreign matter being encapsulated and open wounds of different types being in proximity to differing types of tissue. in the case of Shouldice, mightn’t most of the scaring be in the area of the stitching?

Do you (or anyone else) have any thoughts on this?

[Watchful]

David M,

I’m not an expert on this. It seems that this depends on the tissue. Skin evolved to heal relatively well, but various internal tissue layers (such as fascia and muscles) may be different.

Internal scar tissue commonly appears in these open surgeries, and it’s one of the reasons for the difficulty with reoperations. I believe the injury to the internal tissues causes inflammation which results in scar tissue. This scarring can even spread further from the immediate vicinity of the injury as the inflammation sometimes spreads. The more extensive (or repeated) the injury, the more inflammation and scar tissue.

The scar tissue can encapsulate or impinge on various nerves and vessels, and it can cause nociceptive pain as well. In addition, you can get inflammation and scar tissue in the areas of stitching as you mentioned.

Reducing this type of injury is one of the advantages of laparoscopic or robotic surgery.

[William Bryant]

Hello Gale, if you are in th uk there’s Prof David Lloyd. He is well respected for sports hernia injury rectification.

[Author]

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