Soliciting advice, and maybe input from Dr. Towfigh

Hernia Discussion Forums Hernia Discussion Soliciting advice, and maybe input from Dr. Towfigh

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    • #33412
      ajm222
      Participant

      So many of you know I had progrip mesh placed on one side robotically in 2018 for an indirect hernia (and a lipoma removed at the same time), and then had that mesh removed by Dr. Belyansky in 2021 after three years of constant discomfort and pain.

      Since the removal I have been quite active and generally doing well, but there has been lingering pain and discomfort that increases and fades in intensity for no real discernable reason. At times that pain and discomfort rivals what I dealt with before the mesh was removed. There have been improvements in terms of the frequency of discomfort along with the tightness I had with the mesh, though.

      While no new hernia has been detected, I have been dealing with a modest bulge that sticks out on the removal side that seems to have gotten larger in the last few months. I was examined again by Dr. Belyansky and even had a CT scan because I was certain the hernia returned because it looked and felt just like that area did before my first mesh surgery. His diagnosis was that this was not a true hernia but there was perhaps some retroperitoneal fat pushing on that spot along with another lipoma, and maybe the removal weakened the area enough to allow for this bulge. The CT didn’t show an obvious hernia either.

      I asked if surgery could correct this bulge and whatever is causing it and he said that he could do another surgery but it wouldn’t be a full Shouldice type repair where the whole inguinal canal is opened up as that didn’t seem necessary. He would instead remove the lipoma and just use some stitches to tighten the area basically (and use absorbable stitches if I wished). But he said if it were him he would just leave it alone if it wasn’t bothering me because it’s such a minor thing. He also said that it might not get any larger, unless I gained weight. I pointed out that one of the reasons I came back to see him was because it was in fact bothering my quite a bit in terms of discomfort and pain.

      I am wondering if perhaps fixing this area might improve the discomfort and occasional pain, and make the area feel stronger. When I go on longer runs (3-4 miles), the bulge gets bigger, and it is more sore. Every surgery has risks, but I’ve always thought that some day I might need another surgery to strengthen this area. I know another patient that felt better after getting an open repair after removal, even though he technically hadn’t reherniated. This would also be an open repair on mostly virgin tissue given that my other surgeries were lap. That said, the spermatic cord is once again involved given the lipoma, and I guess there is always risk of testicular pain or complications (though his assistant advised this was low risk for chronic pain).

      Complicating this is that for the last few weeks the usual pain and discomfort subsided considerably, and almost vanished for the first time in years. It has come back a little this week but not in a major way. I am almost convinced at this point that any pain I have had is possibly even mostly psychological – I’ve wondered if scheduling a surgery was enough to put my mind at ease last month. Anyway, I don’t want to jump right back into the fire, but I also suspect one day sooner or later I will want this fixed in some fashion.

      So I am just unsure what to do and looking for some feedback. More importantly I STILL don’t quite understand how there would be a bulge here if there was no ‘true hernia’ present. The whole anatomy of this area is just so confusing. I am also trying to asses the true risk. Given that it sounds like a fairly minor surgery compared to a full open hernia repair, and given that it will be done by an excellent surgeon, in virgin space, and giving him an opportunity of directly observing whatever is going on, it would seem the risk would be fairly low for permanent damage or complications. On top of that, they said that it would be further insurance against future direct and indirect hernias on that side. And I’m still young-ish at 46 and this could pay dividends when I am much older given some of the damage likely caused by removal and lack of any reinforcement besides scar tissue from that surgery. It also may alleviate some of the soreness I experience as I am thinking this pressure from whatever is causing this bulge could be what’s responsible for some of the discomfort.

      Any thoughts?

    • #33413
      Good intentions
      Participant

      Is it possible that the pain and swelling is the result of external forces causing internal irritation? Like the elastic band pressure of whatever you are wearing? I had found that certain clothes caused irritation because the waist height caused pressure at the bump left by the original direct hernia area. In my case though, there is still a piece of mesh at that spot. This lasted for years and has only resolved recently.

      In other words is there a correlation between clothes and discomfort. I remember that you run a lot of miles on a regular basis. A small force might have large consequences. It might explain the seeming randomness of the problem.

      I am just past five years since mesh removal and the last six months have been pretty dramatic in terms of improvement. I am doing much more and feeling fewer delayed after-effects. It might be both heartening and disheartening to suggest that you wait. If you do find a correlation with clothing or certain activities it might be worthwhile to avoid those for months at a time then retry later. See what happens.

    • #33414
      Chuck
      Participant

      Good intentions…thanks for posting. Can you comment on the strength you feel you have after removal? Can you lift weights, ride a bike> hike? curious if you have been tiptoeing around like a porcelain doll to avoid doing any more damage…and what you feel your longterm prognosis is…

    • #33415
      ajm222
      Participant

      Thanks, GI. It’s definitely internal. No issues or discomfort on the surface. It gives me kind of a squishy feeling inside, and I can actually kind of feel the fat or whatever that’s in that pocket moving around a little when I move. Unfortunately, while I imagine I will continue to improve in a number of other ways over time, in the same way I’ve improved over the last two years, I think that this particular issue, since it’s very similar to a true hernia, won’t get better, assuming it’s indeed a result of a laxity or whatever in the abdominal wall. Again, Dr. B did say there’s a chance that unlike a full hernia it won’t actually continue to grow and get worse. But I suspect over many years it’ll probably continue to get a little larger and more problematic, just based on what I’ve seen the last few months. Maybe there’s a point though where it’ll reach some sort of stability (if it hasn’t already).

    • #33427
      Good intentions
      Participant

      Chuck, I have written quite a bit on the forum about the recovery from mesh removal. I don’t have any strength issues. Over the years the only thing holding me back had been the knowledge that I would be sore for a few days after extended activities. Instead of hiking five miles I would only hike two, for example. Plus there was some concern about recurrence but my view is that I will just live the life I want and if I get a recurrence I’ll deal with it.

      In addition, because of the stiff bulging belly left behind, certain clothes were uncomfortable. And certain motions, like working with my arms extended overhead, caused soreness in the lower abdomen. It has taken quite a while to loosen up.

      Otherwise, especially when I was getting a home ready to sell and needed to do lots of lifting and moving for long periods of time, I was fully functional. I just spent more time being sore.

      I also did quite a bit of physical work with the mesh implanted, over the course of a year, and I could feel that damage was happening, internal wear and tear, that eventually led to other specific physical manifestations that I’ve also written about. The more active I was the worse it got. Removing the mesh was the only possible solution for me so I have no second thoughts about it. If I have future problems, I will take appropriate actions.

    • #33597
      Amelia Aria
      Participant

      It sounds like you have been experiencing pain and discomfort since the removal of the mesh for your indirect hernia. Your surgeon has examined you and conducted a CT scan and determined that there is no new hernia present, but rather a bulge that may be caused by retroperitoneal fat and a lipoma. Your surgeon has offered to perform a surgery to remove the lipoma and tighten the area, but has also stated that if it were him, he would leave it alone if it wasn’t bothering you. It’s important to consider the risks and benefits of any surgery, and to discuss them with your surgeon. Additionally, it may be helpful to get a second opinion from another surgeon to gain a better understanding of your options and the potential risks and benefits of the surgery. Check out for more information absorbable sutures

    • #33657
      drtowfigh
      Keymaster

      @ajm222

      I don’t know the specifics of your situation since you’re not my patient, but based on what you’ve shared, it sounds pretty convincing to me that you have a hernia recurrence. A) you have a bulge, B) you have symptoms, C) CT scan shows a hernia via the cord lipoma/retroperitoneal fat, D) you had no hernia repair once the mesh was removed.

      – If you have mesh removal after a hernia repair with mesh, you will have a hernia recurrence. Scar tissue alone is not strong enough to keep the hernia from recurring (except in some cases related to mesh removal due to infection).
      – CT scan is inadequate to fully evaluate the pelvis for recurrence. A) the imaging must include valsalva (beardown views) and B) MRI is much more sensitive to detect occult or smaller hernias.
      – sounds like the CT scan actually does show abnormalities. Sounds like it shows retroperitoneal fat and/or spermatic cord lipoma. That is a hernia.
      – assuming you have a hernia recurrence, you need a bonafide hernia repair. There are a lot of options. Shouldice is one of them that would not involve any type of mesh. I would not do a Marcy, which seems to be where Dr B is alluding to. That does not work for male inguinal hernias, let alone a recurrent one.

    • #33658
      drtowfigh
      Keymaster

      @ajm222

      I don’t know the specifics of your situation since you’re not my patient, but based on what you’ve shared, it sounds pretty convincing to me that you have a hernia recurrence. A) you have a bulge, B) you have symptoms, C) CT scan shows a hernia via the cord lipoma/retroperitoneal fat, D) you had no hernia repair once the mesh was removed.

      – If you have mesh removal after a hernia repair with mesh, you will have a hernia recurrence. Scar tissue alone is not strong enough to keep the hernia from recurring (except in some cases related to mesh removal due to infection).
      – CT scan is inadequate to fully evaluate the pelvis for recurrence. A) the imaging must include valsalva (beardown views) and B) MRI is much more sensitive to detect occult or smaller hernias.
      – sounds like the CT scan actually does show abnormalities. Sounds like it shows retroperitoneal fat and/or spermatic cord lipoma. That is a hernia.
      – assuming you have a hernia recurrence, you need a bonafide hernia repair. There are a lot of options. Shouldice is one of them that would not involve any type of mesh. I would not do a Marcy, which seems to be where Dr B is alluding to. That does not work for male inguinal hernias, let alone a recurrent one.

    • #33664
      ajm222
      Participant

      Thanks so much, Dr. Towfigh.

      The actual CT says the following:

      “There is no pelvic adenopathy. There is no soft tissue mass. There is no free air, or free fluid.

      Reported postoperative changes status post prior right inguinal hernia repair. There is no residual or recurrent hernia. There is no adenopathy. Inguinal region is unremarkable. There is no lipoma. Vasectomy clips are seen.”

      Would a surgeon be able to tell upon direct inspection during surgery if the area requires more work once he got into that space? I could always clarify if he’s planning on doing a Marcy but willing to convert to a Shouldice if the situation changes after he begins operating.

    • #33665
      ajm222
      Participant

      I also think Dr. Kang has said,
      “Furthermore, I cannot understand why the healthy floor of a Hesselbach triangle has to be opened and sutured again during surgery for indirect hernia, where the deep inguinal ring is enlarged. I am sure that the results of Kang repair have proven that this process is not necessary at all.” Suggesting perhaps in his mind something more akin to a Marcy could in fact be sufficient in the case of an indirect hernia. But maybe I’m misunderstanding his words. Just wondering if this could be a fair point of contention amongst surgeons.

    • #33669
      Watchful
      Participant

      That’s exactly what he’s saying. Assuming his numbers are correct, then his Marcy variant works well even in adult males (Koreans, at least). There are others who claim that Marcy works well. There was a study in Japan that showed this. Dr. Brown claimed to have success with it, although he was all over the place in terms of techniques he was using, and his criteria were never clear.

      One problem with studying this is that there is no “standard” way to do the internal ring stitching part of Marcy. Dr. Kang claims to have a particularly effective way of doing this that he refined over the years. I don’t know if that’s the key to his success, or it’s just a minor aspect that improves it a bit.

      The bigger problem is that tissue repair is out of favor, and almost no one practices it. We are not likely to get better information about this topic, unfortunately.

    • #33670
      Good intentions
      Participant

      Dr. Towfigh makes a very firm statement that “If you have mesh removal after a hernia repair with mesh, you will have a hernia recurrence. Scar tissue alone is not strong enough to keep the hernia from recurring (except in some cases related to mesh removal due to infection).”

      But, as far as I’ve seen, there is no evidence supporting that statement. Just like there is no registry for mesh repairs, there is no registry or followup for mesh removal. If the statement is true then there should be as many “repair after removal” stories as there are removal stories. There might be anecdotes among friendly surgeons, but there are no studies focused on the probability of hernia recurrence after mesh removal.

      Sorry Dr. Towfigh. If you have evidence please present it. It should even be presented professionally, at a SAGES or AHS conference. If what you say is true then every surgeon who removes mesh should be firmly stating to their patients that they “will have a recurrence”, so that they can plan for the future repair. Dr. Belyansky has not done this in ajm22’s case.

      Besides that, what would the repair be? More mesh? If that is the only possibility then the patient has to relive the possible horror of chronic mesh pain. If the recommended repair after mesh removal is a pure tissue repair then that begs the question of why not pure tissue in the first place.

      Whenever a person takes a deep dive in to what’s going on in the hernia repair field the question of “why are we using so much mesh?” keeps forming. Mesh removal is mainstream now and the lawsuits keep growing. It must feel like you’re living in an insane world.

    • #33672
      Andy Elliott
      Participant

      @drtowfigh

      I had lap mesh placed, then had an indirect hernia recurrence. I then had a shouldice repair done which has held up. I have had issues ever since the original mesh placement with digestion, brain fog, non restorative sleep etc. If I remove the mesh laparoscopically would I risk damaging the shouldice repair. I realize one is a posterior vs the shouldice anterior approach, but I know by looking at my operative records my mesh is against my posterior wall. The shouldice repair strengthens the posterior wall. So if they had to peel mesh off of the posterior wall laparoscopic even if it’s on the other side would that damage the shouldice?

    • #33673
      drtowfigh
      Keymaster

      @ajm222
      – I don’t trust imaging reports. I look at the imaging myself and based on our own published study, 3 out of 4 times the imaging report is incorrect. So, I do not rely on a radiology report to determine my plan of care. Also, CT scan is not sensitive enough for small hernias which may be symptomatic. Also, the technique of the imaging is important. Valsalva (bear down) helps demonstrate hernias that may not be evident when lying supine. So, there are many reasons to believe that your CT scan results do not accurately reflect your clinical situation.
      – The reason why the entire floor (including the direct space) is opened for tissue repairs even if there is only an indirect inguinal hernia is because in doing so, you are taking tension off the repair of the indirect inguinal hernia by spreading the tension over a wider space. Marcy repair does not do that, hence the poor results for most male hernias. We must not forget history. These questions have been battled out for decades before many of us were born.


      @good-intentions

      – my strong statement is based on my own experience as well as that of others. I can no longer study it, as I rarely remove mesh without fixing the hernia (except in cases of mesh infection). Every time I have done so, the hernia has recurred, and I have told the patient to expect that, and they have come back for the recurrent hernia repair. The options for recurrent hernia repair at time of mesh removal are plenty and are dependent on the needs of the patient. They include: a) lap/robotic repair with synthetic mesh, b) lap/robotic repair with hybrid mesh, c) robotic iliopubic tract repair (r-IPT) without mesh, d) open tissue-based repair, usually a Shouldice.


      @hernia2012

      – laparoscopic removal of mesh should not disrupt a Shouldice repair.

    • #33674
      Watchful
      Participant

      @drtowfigh

      The part that isn’t clear is the basis for the claim that Marcy has poor results for adult male hernias. I found only one study, and it showed good results. Doctors who practiced it (Kang, Brown) claimed good results. I think that’s the reason this keeps coming up. Where was the battle that you mentioned documented? There’s also the question of the stitching technique. Maybe recurrence is lower with the way some surgeons (such as Kang) stitch it when compared to some other way.


      @hernia2012
      (Andy Elliott) – The symptoms you mentioned after your lap mesh surgery could even be effects of the anesthesia rather than the mesh. These chemicals cause bad reactions in the brain and other parts of the nervous system with a lot of variation from person to person. Unless you have a good reason to believe it’s the mesh itself, be careful. If what you are really sensitive to is the anesthesia, going through yet another surgery will only make things worse. There really isn’t a good understanding of the effects of anesthesia, and the theory is that the chemicals used cause an inflammatory response in the nervous system which can lead to anything from brain fog and sleep issues to delirium and cognitive dysfunction. How your body reacts depends on many factors – genetics, cognitive reserve, any existing degenerative processes, etc.

      • This reply was modified 3 days, 22 hours ago by Watchful.
    • #33676
      ajm222
      Participant

      Thanks again, Dr. Towfigh. That all makes sense. And I know I have an issue based on the physical symptoms, so I wasn’t really putting any stock in the reading of the CT scan to begin with. And Dr. B did admit that there’s certainly a chance of hernia even if it wasn’t evident on the scan. He just wasn’t able to see it when I saw him in person on two separate occasions (maybe because of the long car ride and all the sitting) or detect it when he examined me while I coughed. The only thing he could detect was the lipoma, which I don’t think is causing the bulge. So it’s just sort of a weird situation where there’s a visible bulge some of the time that I would say is roughly ping ping ball sized, but at other times it’s not very prominent.

      I asked his nurse if he would convert to the Shouldice if he got into the area and noticed it was worse than anticipated, and she said he definitely would. I will be sure to have the conversation with him on the day of surgery and let him know that I would like him to do so if the situation warrants, and I might also ask about the tightness of a Marcy-type repair and if that risks a future failure.

      Dr. B for his part has said he hasn’t yet known anyone with an indirect hernia who had mesh removal done by him that recurred, for whatever that’s worth.

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