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Ventral hernia with rectus diastasis
Dr. Towfigh,
I just listened again to your HerniaTalk with Dr. John Fischer and have a question about plication of the anterior abdominal wall muscles to close a ventral hernia and associated rectus diastasis without mesh. I’m wondering if you can specify the maximal size of the defect that a surgeon might reasonably try to repair with this approach.
I’m certain that your answer will depend to some extent on the patient’s specifics. In case you would be willing to consider my situation, I’ll provide some background and I understand that you may be limited in what you can say. I am tremendously grateful for the gift of knowledge that you continue to put into the world through the HerniaTalk platform. Thank you so much for your time, efforts, experience, etc. And thank you in advance for any information you can offer at this critical time for me.
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Incisional trocar hernia open tissue repair 2019 by Dr. Petersen after 2016 robotic cholecystectomy. This hernia extended several inches laterally. There was incarcerated omentum. No mesh was used. No drains were placed and I developed a huge seroma which wasn’t infected and wasn’t drained or treated.
An incidental finding on abdominal CT scan in 2021 was the hernia for which I am currently seeking repair. I did ask Dr. Petersen about repairing this ‘new’ hernia and he told me that he thought the ‘new’ hernia was a failure of his 2019 hernia repair. Dr. Petersen ordered a March 2022 CT scan.
Excerpt from the March 2022 CT scan report. “Relatively large umbilical/periumbilical hernia again identified. Associated diastases of the rectus muscles seen. The orifice of the hernia measures roughly 7.6 cm transverse dimension and 6.0 cm craniocaudal dimension, with hernia sac extending approximately 10.8 cm transverse dimension, 10.0cm craniocaudal dimension, and anteriorly approximately 3.0 cm. A very tiny amount of small bowel does minimally extend into the proximal portion of the hernia.”
Note, the diastasis is approximately the same diameter as the hernia transverse dimension.
Female, 63 y.o.
Non-smoker
No diabetes, very good health
BMI approx. 30 (I’m large framed and muscular) after losing 40+lbs since April 2022 using acupuncture, dietary changes and exercise.
No Rx medications (I do take supplements and herbal formulas)Allergies and autoimmune issues:
ANA negative
Allergic to metal eyeglass frames (titanium is fine), lactose intolerant & gluten sensitive (Dx by doctor), tendency to be itchy when wearing synthetic fabrics.
Rosacea (controlled by acupuncture and topical herbal creams)
Hx non-Hashimoto’s hypothyroidism (after course of TCM herbal formula, I’m normal thyroid with no medication)Symptoms: Occasional low back pain, mild nausea and abdominal pain with bowel activity. Some increase in symptoms with the weight loss, but I am able to work and exercise and live my life and plan to continue weight loss (especially if a tissue repair is possible).
Other surgeons who have viewed my CT report (and in some cases the disc as well) have commented:
Petersen: Tissue repair is possible
Spencer-Netto: Requires mesh due to size of defect
Kang: 50-50 chance can be done as tissue repair, otherwise mesh
Sbayi: Probably robotic tissue repair (but didn’t have access to the images)
Yunis: Robotic mesh has the best chance of being the longest-term repair with a defect this size, if attempt tissue repair there’s a 40% chance of re-ruptureAt this moment I have scheduled a mesh repair in one month from a surgeon who is in-network on my plan who only does robotic mesh repairs. This surgeon has been described to me by one of the above surgeons (who’s not in-network for me) as an extraordinary surgeon highly respected by other hernia surgeons for his abilities to do robotic mesh repairs. As soon as the date was confirmed, I just became so frozen with fear that I’ll get an ASIA response to the mesh. I wish I knew for certain whether or not the defect is too large for a tissue repair.
I will note that all of the surgeons I mention above have been so helpful, generous with their time (in person, virtually, by phone or email) and passionate about the approaches they provide or suggest. I appreciate their help and expert opinion. I don’t want to have a recurrence. I’m just scared I’ll have a bad reaction to the mesh at some point.
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This discussion was modified 1 year, 10 months ago by
drtowfigh.
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This discussion was modified 1 year, 10 months ago by
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5 Replies
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I’ve had limited success in finding recent articles on repairing/managing swiss cheese hernias or hernias in people with connective tissue disorders when searching on Google Scholar. Are there any comprehensive reports?
I plan to do an update on my situation soon, just seeing if anyone out there has any info handy.
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Kudos on the impressive article, Dr. Towfigh!
j. of abdom. wall surg., 30 January 2023
https://doi.org/10.3389/jaws.2023.10983
Patients With Systemic Reaction to Their Hernia Mesh: An Introduction to Mesh Implant Illness
http://www.frontiersin.orgNegin Fadaee1, http://www.frontiersin.orgDesmond Huynh2, http://www.frontiersin.orgZayan Khanmohammed3, http://www.frontiersin.orgLaura Mazer4, http://www.frontiersin.orgIsabel Capati5 and http://www.frontiersin.orgShirin Towfigh5* -
Thank you.
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In general, incisional hernias are best repaired with mesh. Studies show 50-60% recurrence when repaired without mesh.
Incisional hernia in the midline of up to 2cm can be considered reparable without mesh if combined with a fascial plication.
A multiply recurrent incisional herniaeasuring 7cm requires some amount of fascial components separation and mesh.
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Drs. Towfigh and Spencer Netto (tissue repair expert) conclude that mesh is needed for a reliable repair.
LD50 fears developing an ASIA response to the mesh.
Have any immunologists or allergists developed tests that would address her fear that she might have a negative immune response the implanted polypropylene mesh?
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