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What technique after failed tissue repair?
Hi forum!
I had a Shouldice repair 5 years ago for an incipient inguinal hernia (right side). Apart from discomfort and a feeling of tightness in my right obliques all had been more or less fine up until this January, when following strenous physical activity something happened in the previous surgery’s scar that is causing me intermittent pain, although there is still no visible or palpable recurrence (small dehiscence of 10×17 mm is only detectable via dynamic ultrasound). I consulted 5 different surgeons, who gave me 5 different opinions. No surgery (“I onyl operate palpable/visible hernias), triple neurectomy (on its own), laparoscopy, open Lichtenstein with neurectomy etc. I literally have no idea what way to go. Those surgeons’ reasoning who said a neurectomy might be necesary was that the Shouldice creates a pretty significant area of scaring (a “scar sandwich” was one surgeon’s wording) which easily entraps nerves and my symptoms indicate nerve involvement. The one who’d do a lichtenstein with the neurectomy said by opening the previous surgery’s site he could free and excise the nerves and insert an inlay mesh (lichtenstein). Dr Towfigh recommended laparoscopy and that I seek a 2nd opinion, which I already have far exceeded. I cannot travel to Germany, USA, Korea,Japan or the South Pole to have a world class hernia surgeon take care of me because of I don’t have the money, so please don’t even start recommending such options.
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20 Replies
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I am definitely not someone who knows, but your description sounds like it could be the genitofemoral nerve.
“I got discomfort, pain, shooting sensation and even some burning in my adductors, testicles, groin onbviously and even higher up (like halfway up towards my belly button).”
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Totally serious when I say that you have excellent English skills being from Hungary.
Don’t fume. It won’t help! I don’t know what the effectiveness is, but don’t they have some means of identifying which nerves are being traumatized?
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The suture material matters. Absorbable apparently has more recurrences.
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Yeah the report says it was a 4 layer Shouldice. And indeed, it was not done in Canada.
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Do you know the details of the Shouldice repair? 2 layer, 4 layer, modified, etc. Stainless steel, Prolene, or absorbable sutures? Apparently you did not have it done in Canada.
There might be some clues there. If the repair is splitting open somewhere (dehiscence) it might be that permanent sutures could get it back to where it should be if they weren’t used, or something like a Lichtenstein. Of course, that would depend on where the problem is exactly. If the sutures are holding and the tissue is failing again that would probably require a different focus.
But if it is a suture line opening, if the split is pulled back together the pain should resolve, since you only have pain during movement. The neurectomy would be insurance. In your case, since you didn’t have pain before the dehiscence, and you don’t have pain when relaxed, nerves growing back should not cause a problem. It’s the straining of existing nerves that is the problem. Remove the strain and the pain should resolve, seems rational.
These are just ideas. You know more about what causes the pain. It is definitely a difficult decision when there are so many different opinions, from beginning to end.
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p.s. if you’re getting up there in years, consider the fact that your healing response is reducing. Be careful that you’re not making decisions to try to regain your youthful performance. Things can get very bad if you get in to the repeat surgery regime.
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It seems like you must be doing some pretty strenuous activities. Have you been allowing enough time for healing to occur before testing the area again? I had a minor knee injury and tried to return to action after just a week of rest, week-by-week, based on whether the knee felt good or not. I got in to a weekly re-injury cycle because I didn’t understand how long it took to heal completely. A couple of weeks of physical therapy with a professional and the knee has been fine ever since.
“Dehiscence” just means that the the imaging shows some deformation, like the start of a hernia. Which would mean that the nerves are being stretched. Since the premise of the original surgery is that the modified tissues can rebond and heal, it might be wise to give the area plenty of time to heal and strengthen then to work back in to action slowly. The new Shouldice inguinal canal is not like the original inguinal canal.
As far as the potential cures, the lap surgeon who said that lap mesh might not fix the problem seems like the most straightforward and clear explanation. It’s a sign of the times though, that he only does lap mesh so can’t try to cure you by some other means. Lap surgeons do lap, mesh surgeons do mesh. Very siloed and confined in their ability to heal people. They do procedures. Watch out for surgeons with no experience in your specific problem who promise to try their skill on you but have no experience to show that their efforts will work.
Each new surgery has new risks. Neurectomy will introduce numbness and might have other side effects. Any mesh procedure introduces the potential for mesh problems. The percentages are very well-defined, don’t let anyone try to convince you with words like most or majority. Look at the percentages, and consider the level and type of your activity. There’s no reason for vagueness. Dai Greene comes to mind.
As far as traveling and expense, you might contact Biohernia. Dr. Muschaweck apparently travels to different countries to do surgery at various clinics, and has worked on many professional athletes. The Biohernia network might be growing larger, there might be somebody close by that can help you. Good luck.
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I’m also someone with no knowledge of medical, who is here because I have a problem. My problem is different from yours in that I have a very visible hernia, but no pain and have had my hernia for 15 years.
I think what the doctors are saying makes some sense, in that if you don’t have a hernia and you do the lap, it may not solve your problem. So I would be cautious about whether anything should be done. Has it gotten any better or worse since you first noticed the problem in January?
I would like to ask how much the pain is actually interfering with your life? Could you go for a fast walk for exercise without it flaring up? Does it interfere with your means of making a living? Does it prevent you from concentrating when relaxed?
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This reply was modified 1 year, 3 months ago by David M.
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This reply was modified 1 year, 3 months ago by
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Is there anything in particular about your symptoms that makes this surgeon suspect that there’s more going on than just a recurrence?
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I’m not a surgeon, but here’s my opinion.
I don’t know why some of your doctors recommend a neurectomy. Nerve involvement would be symptomatic well before 5 years.
It sounds like you simply have a recurrence. If your symptoms are minimal, you could just wait with that as one of your doctors recommended. If it bothers you too much, then you have to decide how to fix it. If it was me, I would go with laparoscopic mesh in this case. This is also what I was told at the Shouldice Hospital when I asked what to do if I get a recurrence after my Shouldice procedure.
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I had Lichtenstein on the 13th of October, with transversalis fascia plication. The recovery has been fine so far, although a lot slower than if it was a first time repair. The surgeon had to carve out a lot of scar tissue plus cut some nerves out (I don’t really know which but the base of my male member on the right side is kinda numb), and for this reason they had to put in a drain to let the juices ooze out, to prevent a seroma I guess. I still had major swelling for more than a month and my groin still is looking slightly puffy on the right, but it’s slowly improving. I have not gone back to full training, I’m taking it extremely slow and cautiously, so for only been walking and ding some very gentle PT. Going to see a PT guy next week to start formal PT’ing with him. Not planning to do any sport for another 2 months, and even then it’s only going to be swimming, hiking, leisurely cycling and paddle boarding (the latter in the summer of course). That’s it for now.
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I was alright after the repair. My right oblique felt tight after it but I had no pain. I gradually eased back into training and did all sorts of sportive activity, with no problem. I have to add I never had a typical hernia bulge, but a weird asymetrical look to my groin before my surgery that never went away.
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Yeah, I am speculating it is the genitofemoral plus the ilioinguinal, judging by the affected area. This weekend I was somewhat more active – had to fix the window shutters – and I have like a 3-4/10 pain down there but interestingly it’s localized to the inguinal region and maybe goes a little to the testies, no adductor pain this time.
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Thank you for the compliment. I was studying English Applied Linguistics in university but unfortunately life intervened and I had to prematurely quit. Also spent some time in England specifically to learn English, but it was a long ago.
So yeah, apparently with ultrasound guided nerve block injections they could identify the nerve or nerves that are causing the pain. Unfortunately single neurectomies are a lot less effective – according to the literature – then triple.
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It doesn’t even say the type of suture used in the report…I am fuming.
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I am 40 and I made peace with not being 25 anymore. “Unfortunately” I still look 25 but my body is saying no to the type of training I had abused it with for 15 years now. It’s all cool, I am fine with leisurely swimming and hiking for sport, but chronic pain I cannot accept.
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I had not done anything strenous for months now. Today I thought I would do some very light exercise and the pain is back altough not at full swing fortunately. This lap surgeon who I mentioned is the one who said in my particular case a Lichtenstein with neurectomy might be more suitable. I guess every lap surgeon also has to be able to do a solid Licht since that is the default they convert to in case there is anything going South during surgery. What you wrote about the numbness caused by neurectomy would be a godsend compared to pain. Unfortunately there is no guarantee the surgeon could find all 3 nerves in the scared mess and even if he did, nerves can regenerate. That is why I am kind of wary of Lichtenstein,the inlay placement of the mesh means it is right there where the nerves would be trying to grow back. I appreciate your Biohernia recommendation, I have contacted Muschaweck’s office months ago. The surgery would be 8K euros which is half of my savings. I can’t afford that…I’m in Eastern Europe, it’s a lot of money (for me) here.
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Walking is one of the few things that does not really make my symptoms worse, quite the opposite. If I am careful enough not to aggravate my groin I can be largely painfree with some amount of discomfort only, that doesn not interfere with my current job or relaxing.
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Well when I had a flare up of my symptoms, I got discomfort, pain, shooting sensation and even some burning in my adductors, testicles, groin onbviously and even higher up (like halfway up towards my belly button). I guess this leads some surgerons to think there might be nerve involvement. What I described was my worst flare up in May, since then I haven’t had such serious relapse but this is due to me not really doing anything strenous. Traning I was previosuly able to do is almost completely off limits now. If I just walk and do my daily businness (only lift and carry my groceries) I almost feel normal.
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Hi!
Thanks for the reply. The surgeon said it is possible, that this January (and subsequently a couple of more times this year) while performing strenous physical activity I managed to rupture the scar tissue and possibly some part of the stitches of the Shouldice repair, which are now putting some mechanical stress on some of the nerves when the abdominal muscles are either contracting or being twisted. This last surgeron who recommended Lichtenstein with neurectomy said if he did a laparoscopy (which is his main specialty by the way) I might end up with no resoltuion to my pain because the nerves are still going to be entangled in scar and physical activity will take me back to square one…
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