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The “physics” of mesh lap vs open
I don’t have an engineering or science background, so the use of the term “physics” is not to be taken literally, and I also know very little about the nature of the tissues involved in mesh placement, so what follows is mostly just lay speculation. But I’ve been trying to imagine why despite laparoscopic placement of mesh possibly being stronger, that that same strength might make it more awkward in another regard.
Good intentions just made a comment about how it almost felt like he a plastic bowl in his abdomen. Previously, he had referred to it as almost feeling like armor. And the third thing I remember him saying is that the discomfort made it hard for him to sit sometimes for long periods of time.
AjM had also made comments about his discomfort that might have been along the same lines, though I don’t remember particular descriptions. I do remember him saying that he really couldn’t be sure how much of it was mental and how much was physical. I’d put a guess on physical, because of his seeming interest to get past the feeling. At any rate, for some reason it reminded me of Good intentions descriptions.
So, I’m thinking about Good Intentions plastic bowl and the shape of the abdomen vs the way the mesh gets shaped in the inguinal canal. The internal side of the abdomen is shaped somewhat like a bowl, whereas the inguinal canal, it would seem, is more likely to hinge like a book cover as we walk, move, sit down.
I’ve been given the bicycle tire patch analogy by a primary care physician as to why lap would be stronger. I’ve also heard the same analogy elsewhere that a patch on the inside of a tire is better than on the outside. In Dr Kang’s presentation, he covered the same idea with a patch on the inside of the dam being stronger than a patch on the outside. Obviously true in both cases that the air pushing out and the water pushing out should help secure the patches against the walls just as the abdomen pushing out should more easily hold the mesh against the muscle wall. So, it definitely seems true that it would be better able to hold contents contained and be more durable.
But maybe that creates a problem in the healing process as the tissues are formed around the mesh. It seems like healing process around the mesh would resolve with more flexibility with open mesh, where all of the fibers are more loosely flexible and hinge-like than those that become attached internally to specific spots on the tissues.
Maybe this is too beside the point, but as I sit here in my chair, my abdomen is far more locked, even without a mesh, than the part of body where the inguinal canal is. And that more generally locked nature might make it more susceptible to tighter healing.
Just some thoughts, very possibly having no bearing on the actual way the body heals.
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7 Replies
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Interesting post…as far as I know the role of fascia has only recently started being fully understood, which also means most of the surgeons might still not understand it. In some martial arts it has a pivotal role in transmitting force from one part of the body to another, and they actively train to remove “knots” that are seen as an impediment in the transmission. I think any surgery modifying the fascia layer is likely to have an impact one way or another. Personally I think when watchful waiting it is equally important to train the core muscles as well as the fascia, or at least I try to…
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“Camper’s fascia serves as a protector and an insulator to the deep, vital organs of the abdomen. The function of the fatty layer is to absorb impact and dissipate forces across a large surface area to reduce the amount of impact that is transmitted internally. The adipose tissue also acts as insulation to help maintain a constant temperature within the abdomen. Its thickness varies depending on one’s body habitus.
As a part of the fascial layers of the abdomen, Camper’s fascia serves a vital role by separating the skin from the muscles.[4] In the skin, there are nerve endings that contribute to touch, proprioception, and pain. Muscular nerve endings are responsible for muscle contraction and tone. If there is a break in the fascial plane, new nerve connections can form and cause undesirable outcomes.[5]”
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“The fascia of Camper is a thick superficial layer of the anterior abdominal wall.[1][2]
It is areolar in texture, and contains in its meshes a varying quantity of adipose tissue. It is found superficial to the fascia of Scarpa.”
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wikipedia description of Scarpa’s fascia function:
“Scarpa’s belief that the fascia stops hernias from forming is not thought to be true today. Some anatomists suggest the membranous superficial fascia is the scaffold which attaches the skin to the deeper structures so that the skin does not sag with gravity but still stretches as the body flexes or changes shape with exercise”
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Yeah, but I don’t know if those layers are purposed for holding back the hernia. When you watch the videos, Scarpa’s fascia and Camper’s fascia seem more amorphous to me and look more like flexible fat than a holding tissue barrier. Obviously the external oblique is something of a retaining barrier, but are the other tissues in between it and the transversalis fascia meant for retention or padding. To be honest, though, the transversalis fascia itself looks almost like saran wrap, but it must initially be tougher than that.
I would love it if Dr Towfigh could give us more of a primer on the functional nature of these tissues.
In one of her videos, her guest said something about patients not understanding that the hernia coming through was not that large. While my hernia portrays as the size of a tennis ball, the core hernia might be smaller ….maybe closer to a golf ball(?), with the layers of fascia and skin covering it making it seem bigger. Still, I wonder if these interposed tissues have any actual retaining function. Maybe they are there for padding protection of the cord, etc.
You initiated some good questions for thought.
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Not sure how good this tire patch analogy is because even in the case of anterior mesh, there are still more layers on top of the mesh. It’s not like your mesh is outside, or just under your skin.
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I mistakenly referred above to scarpa’s and camper’s fascia as being between the external oblique and the transversalis fascia instead of between it and the skin.
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