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Tissue repair experiences – pain and recovery
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I remember Dr. Brown mentioning that silk sutures do degrade or dissolve over time. I found an interesting research paper about suture materials from 1970, linked below. It also talks about polypropylene and has an interesting aside about the quality of the polypropylene material changing, affecting the way the suture responded in the body.
Very interesting also to see a time when doctors did real research. A two+ year study, with microscopy and analysis. Real critical thinking instead of the common “meta-study” that is done today, where old databases of dubious quality are collected and parsed through using search terms that the researcher thinks will define the area of study, or support the researcher’s premise.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1396901/
Here’s a direct link to the pdf file.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1396901/pdf/annsurg00414-0086.pdf
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Dr. Ponsky is a very interesting surgeon. His specialty is hernia repair in children, but in the video that William posted you can see that they are exploring non-mesh repair in adults. He mentions it at about 11:48, a study in Norway. His father is a well-known mesh repair surgeon at the Cleveland Clinic, so the contrast is intriguing. He must know quite a bit about mesh repairs.
The video is from four years ago. I can’t find a publication about the results of the study in Norway that included adults. I had some correspondence with him and he seems to have lost his passion for promoting non-mesh repairs. It was a short email exchange and I hope that I am wrong but I got the impression of another surgeon beaten down by the mesh industry. He also has a video with Dr. Towfigh where he talks about mesh repair as something that he leaves to the “experts”. Overall, disappointing, but there’s always hope.
https://scholar.google.com/citations?hl=en&user=biO4e40AAAAJ&view_op=list_works&sortby=pubdate
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https://herniatalk.com/forums/topic/laparoscopic-non-mesh-hernia-repair-todd-ponsky/
Heres Good intentions thread about Todd Ponsky.
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Todd Ponsky talks about it in this video
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I thought there was an American (?) Surgeon who presented to a conference that he was using / trialling a tissue repair usually used in children for adults. It was high litigation I think… Would that be Marcy? Watchful?
I think I’v linked to it and I think Good Intentions has.
I do get a bit mixed up so could be wrong but it may jog someones memory.
The recurrence thing though would tie up with what you heard about 2 out of 4 being there for recurrence?
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G,
The Marcy thing goes beyond mesh vs tissue repair. Even within the small group of surgeons who perform tissue repair, Marcy-like repairs are not used in adult male hernias (Kang is an exception.) If you ask them, most will say the risk of recurrence is too high, and others will say further study is needed before using it that way.
Some Lichtenstein mesh surgeons (like Dr. Chen) do a Marcy in addition to the mesh. The Marcy isn’t considered sufficient by itself.
I’ve always been very curious about this because if Marcy-like repair works well for adult male indirect hernias, why on earth isn’t such a minimal procedure done instead of mesh, Shouldice, Desarda, etc.? It’s the question I find the most perplexing in inguinal hernia repair.
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Thanks, G. Analysis paralysis is definitely one of my biggest struggles. Took me about 6 months to decide to go with a mesh repair, then 2 1/2 years to decide to remove the mesh. And now several months of agony trying to decide if I should have another surgery. Then again, I guess some folks take years before they do anything at all. Which is understandable given how confusing all of this is and the risks involved with any groin surgery.
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Watchful it’s interesting that you point out Dr. Kang is the last one doing Marcy like pure tissue repairs. He will retire as all doctors do. When? Who knows. Then according to your observation no one will be doing them. It seems the unwitting consumer has brought this unfortunate demise upon themselves. This lack of choice. It reminds me of a Native American proverb. When asked which wolf would overcome the other wolf, the elder responded the one you feed will prevail. It will get stronger and win. By choosing, or letting our doctors choose mesh for us we have in essence “fed” one wolf while “starving” the pure tissue no mesh wolf. One is big and string and the other is withering away. It’s interesting how that works.
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Watchful my hernia was rather large and getting larger every day. I would attribute that from continuing to workout and run along with waiting. I needed to wait years to get on Medicare and off my employer provided healthcare. With Medicare I could pick my own doctor, a no mesh doctor like Dr. Brown.
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G,
I think ajm222 is right about the sutures because Dr. Brown indeed told me that he was going to use silk sutures for my procedure when I asked him about that.
Marcy is a very minimal procedure, and it’s great that it has worked so well for you so far. Was your hernia very small? The only surgeon left that I know of who does a Marcy-like procedure on adult male hernias is Dr. Kang.
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ajm222 I remember Dr. Brown saying the sutures would dissolve. That was about three years ago. I’m almost seventy years old now. People at the gym think I’m in my fifties. I lift weights and exercise six days a week while working a full time job. On Sunday I walk for about an hour. It’s good to take it easy one day a week. Dr. Brown gave me my life back. I wasn’t going to get a mesh repair and Dr. Brown was strictly a no mesh surgeon. If I could give any advice I would say what worked for me was to ask a power greater than myself for what I wanted. Then I just did the footwork. Over thinking it (“paralysis by analysis”) has turned into trouble for me in the past. As you hear many posters here lament about how they had figured this mesh, or that surgeon, or this or that was the answer only to end up in regret attests to that. All the best to you ajm222
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Watchful I had a Marcy or Marcy type repair, no Desarda. Since I had an indirect inguinal hernia a Marcy repair made the most sense. If I had a direct inguinal hernia a Desarda would be more appropriate. All the best with your recovery Watchful.
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I’m guessing it was Desarda which can be done with absorbable sutures.
Dr. Brown was a fan of the Desarda technique, although he didn’t like to call it that. He used to mix and match it sometimes with other procedures which was strange. For example, in my case he wanted to do something that sounded like a combination of Marcy and Desarda. It was hard to get specifics about what he was going to do exactly, which scared me away.
I think he had the right idea of tailoring repairs to patients, but for him that didn’t mean simply picking the best repair among the proven ones. He would sometimes perform a combo from a couple of procedures or more, essentially creating his own hybrid procedure, which was hard to assess.
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Thank you for that! And that’s incredible. I’m quite sure I won’t have that pain free experience with Dr. B, but hopefully it won’t be too bad. Quick question – I’d always thought Dr. Brown used silk sutures. How did he come to use absorbable in your case? Thanks again.
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I had pure tissue repair with Dr. Brown before he retired. Part of the protocol with Dr. Brown was taking a recommendation of vitamins and herbs before and after the surgery. If memory serves me right Dr. Brown credited Dr. Towfigh with her expertise and knowledge regarding including these herbs and vitamins. Dr. Brown did an excellent job of repairing my inguinal hernia and I never once had to take any pain medication. I was almost completely pain free from the beginning and released to drive my car back home shortly after. I can’t see why, with limited exceptions, anyone would opt for anything other than a pure tissue repair. And on a side note I personally do not consider Shouldice a “pure tissue” repair, a no mesh repair yes. Since Shouldice uses permanent stainless steel sutures I don’t consider it pure tissue. Dr. Brown used dissolvable sutures. Since I don’t come on here very often I wanted to take this opportunity to thank Good Intentions for his positive work of researching and support for this forum. His efforts and dedication to enlightening others is truly a shining light in the darkness.
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thanks, GI! yeah, I remember reading his journal actually, and someone else who went to Brown. plus I guess all the Kang folks here. they all seemed to be quite mobile after a week. i think it’s those first 2-4 days that are a little dicey. unless someone has a complication, in which case a variety of problems could drag on for quite a while. hoping to avoid any weird nerve damage or large hematoma.
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If you put ( site:herniatalk.com dog brown ) in a Google search box you’ll get a link to Dog’s Dr. Brown open surgery comments and others who saw Dr. Brown.
Nine days seems like far enough along to where you could sit and be comfortable.
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Thanks! Dr. Belyansky is the surgeon. He did my removal.
I’ve heard initial pain is higher (and of a different nature) than with robotic surgery, as you might expect. But I know a number of people that kind of preferred the discomfort of the open repair (tissue or otherwise) compared to lap/robotic. I personally hated the robotic surgeries because they made me feel terrible and like my whole torso was swollen for several days. I just felt incredibly uncomfortable.
I’ve also heard some folks say that after a few days post tissue repair, while they still had pain, it had improved a lot and they were up and about and in some cases even doing light lifting and walking several miles. I guess as with everything your mileage may vary.
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Who is doing your repair? Best of luck!
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Not sure ajm but like your attitude. I’d be petrified. I am. Probably why I’m putting off surgery
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I have a cold pack I’m using but haven’t been using it enough. Started later today using it more. They said 20 off, 20 on as needed. But I haven’t been using it but once every hour or two. Need to do it more.
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@ajm222 just curious, are you using any ice or ice pack which is supposed to alleviate swelling? maybe it also depends on how much time you are using ice each time and how often you are using it?
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It truly varies from patient to patient. I didn’t have much visible swelling after the surgery. Only a bit around the incision area. I could feel internal swelling, though. It was nothing like the size of my hernia, but my hernia was very large.
My roommate had more visible swelling, even though his recovery was much better than mine. He basically had almost zero pain or discomfort.
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That’s really interesting, thanks. I’ve had very little discomfort but lots of swelling. I sent pic to nurse and she’s sharing with surgeon to see if he thinks it’s fine.
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It tells me how little is actually known and how little agreement there is among experts. I find it to be a very frustrating aspect of medicine.
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Mine was about 3 months ago, and the hair already grew back, and I think it’s not far from its maximum length. It grew back everywhere, including the scar area. You can see the scar, but it doesn’t stand out much. I expect it to become even less visible with time. The scar is the least of your worries with this surgery…
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Thanks again! Very helpful.
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It has been quite a while, so I can’t recall it too vividly…anything flexing the core generated a bit of pain (getting out of bed, rolling over in bed, sudden movements), but it was momentary. You deal with that by propping yourself up on your elbows and relying much more on your arms to manoeuvre, to get up and sit/lay down, etc. You quickly realize how much you use your core for so many movements and I remember my triceps getting a good workout!
About the ‘worst’ thing that can happen is sneezing, which gives you a nice jolt of pain for a few moments, but it passes…and virtually nothing you can do will damage the repair.
It might have felt a little tight, but I wonder how much of that was the pins they used to help seal the incision (they essentially folded up the skin and pinned it), which made for a strong closure with a narrow scar. It felt good when those came out. I’m also not sure if they still use that method.
I did not need any assistance to get up or to do anything. If I recall, I took Tylenol at the recommended intervals and I never felt that I needed anything more than that. It was as much pre-emptive as ‘necessary’, I think.
Classifying pain even on a 1-10 is hard. I’ve never experienced ‘horrible’ pain in my life that I would think falls in the 8+ range…so maybe a 5-6? The first few days were a little challenging, but pain was momentary and never terrible. The pain also guided what I could do because I would get a pang of momentary pain if anything was too much/too quick.
It really can vary between people though. On one end of the scale, one guy was gently riding a stationary bike the day after his surgery (that was certainly more than I was willing to attempt). On the opposite end, an older guy had difficulty even walking and had a meal the next day in his room while everyone else had little problem walking to the dining hall.
They strongly encourage (almost force) you to move after surgery…from turning over in bed periodically to walking at least up and down the hall several times per day (if not outside, weather permitting), to partaking in their ‘exercise program’. I think that really helps with avoiding stiffness that contributes to pain.
You can find some more info by googling ‘shouldice exercise’…from hospital recommendations to patient experiences…and even some videos of people’s experiences and the exercises they were doing post-op.
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Sure. Here’s a link. You need to log in, but it’s free. It’s a very interesting discussion – worth reading.
“Dr. Bendavid: I have done thousands of repairs when I have divided the nerve. I have always maintained that if there’s no nerve, there is no pain. And I’ve been somewhat cavalier also in dividing nerves for that matter. It seems that the sensory loss is minimal, and certainly considering that we have cut the nerves on nearly 7000 cases a year, we have not seen the kind of situation that Dr Amid is talking about. However, there seems to be a clear picture that Starling refers to as inguinodynia in Surgical Clinics of North America, where the contact of a severed nerve end with Marlex results in a pain syndrome.[51]
I’ve seen many patients with pain, but very few actually go on to the chronic type, which we should define as pain beyond a year; only 1% of these patients go on to have chronic pain. I don’t understand the problem, and I don’t think we have the answer. Perhaps, somehow, a twig or branches of the nerves are included in a suture line. I don’t know. It’s a very difficult problem to which I don’t have an answer. But certainly in the past, generally speaking, no nerve, no pain.”
“Dr. Bendavid: Well, I certainly have, over the years, severed many an ilioinguinal and an iliohypogastric, and don’t forget that when you do herniorrhaphies for recurrences from an anterior approach, you may not even see them, so that they are very often severed, and certainly if they are in the way, I have never hesitated to remove them, to resect them, and simply leave the stump behind without any ligation and have literally never seen any problems associated with this. And as I’ve said, the sensory loss is so minimal it seldom is larger than a 2 cm to 3 cm circle at the very medial portion of the inguinal area.”
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With nerves, one challenging part is what he talks about starting around 2:40 (anatomic variation with multiple branches), and another starts at 3:44 (hidden nerves).
I actually had both of these in my case. Atypical branches in the way (most likely of the ilioinguinal nerve), and an unseen iliohypogastric nerve.
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I don’t know any tissue repair surgeons who “regularly” cut nerves other than the genital nerve branch which is sometimes cut as part of the Shouldice procedure. I know one Lichtenstein surgeon who regularly cuts the ilioinguinal nerve.
Even focusing just on tissue repair, there is a potential problem where a nerve is located in a place which interferes with the repair. I’m not a surgeon, but my understanding is that sometimes it’s hard to avoid cutting it in such cases. Also, sometimes a nerve or some branch of it is not identified by the surgeon, and it gets caught in stitches or ends up where scar tissue would form. If the surgeon now notices it, what should they do? Again, I’m not a surgeon, but I think they typically cut in such cases where they notice that a nerve may be compromised during surgery.
My point is that it’s a tricky situation. My understanding is that cutting is considered better than injuring a nerve, or leaving an injured nerve without cutting it.
On the other hand, cutting can cause trouble as well – neuroma formation, deafferentation pain, etc. Not sure when that does or does not happen. For example, it doesn’t seem to happen when the genital nerve branch is cut in the Shouldice procedure. Also, those Lichtenstein surgeons who cut the ilioinguinal nerve prophylactically would be in trouble if issues were common with that.
For people with chronic neuropathic pain, neurectomy does seem to help in most cases (70%?), so nerve cutting is sometimes the right thing to do. Of course, if you do another surgery to go back in for that, other damage can happen making things worse overall. So, when a surgeon encounters an iffy situation with a nerve during surgery, it’s a real dilemma.
This looks like one of those areas where not enough is known, and there’s a lot of variations between patients in terms of their nerve anatomy and how they react to nerve injury, nerve cutting, etc. Also, there doesn’t seem to be agreement among surgeons even on how to cut a nerve (when needed) in terms of the best way to do it to avoid problems with that nerve later on.
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Thank you. I believe it’s because he had a negative experience with a patient who was in pain due to a couple of previous surgeries, and he cut a nerve thinking it would help but it just made things much worse. Ever since I started consulting with him, going back to probably 2019, he has very much been against messing with the nerves if at all possible, and has always taken a very conservative approach with me. He’s been very careful to point out that he will do his best but there is always the possibility of an unfavorable outcome. Regardless of what happens, I’ve appreciated his honesty and realism.
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I wish you the best @ajm222 . I’m surprised to see that Dr. Belyanski is taking such a minimalist approach if I recall correctly a few years ago I had read of some people on here having him as their surgeon and he was regularly cutting nerves and didn’t seem like the minimalist type. Either way its great you feel comfortable with your surgeon I hope it all works out for you
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I think they can handle so many surgeries because they let their assistants do most of the work and only supervise when needed….is it bad? Maybe… I had a hernia right above the navel that was operated 20 or so years ago: the chief surgeon was supposed to operate on me but in the end the assistant did it. She felt the hernia was very small and opted not to use a mesh ( at that time I did not even know what it is and was not told this could be used in my surgery). I have had discomfort for a month, started back on swimming after about 6 weeks, have never had any problem ever since. A mesh surgeon wanted to convince me in recent time that this would eventually fail and require mesh….I ignored his opinion
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@Watchful what you said is so very true, there is always a luck element! you went to Shouldice, right? do you know which surgeon operated on you?
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@ Andy2023 I was able to move around slowly fine. A numbing agent was used during the surgery that supposedly lasted for about 24 hours. Normally its not used but there was concern about pain because I could not take any pain medication. At 24 hours I never noticed it had worn off. There was concern that I would be in a world of hurt at 24 hours but it never happened. I think the near constant icing helped. I was able to get up and down fine. Ive had previous abdominal surgeries (hemicolectomy) they told me to do really quick breathing when you need to get up as it prevents your core from engaging that helps.
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@ miner you didn’t take any pain medication?? that’s so brave. Was yours inguinal hernia or? Did you have someone help you with walking, getting up and sitting down etc in the first few days?
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