[Chaunce1234]

quote Tino_7:

I have a Grade 2 indirect inguinal hernia.

I saw a surgeon who does mesh but also has done tissue repair (Bassini and McVay). Another surgeon in his practice recently spent two weeks at the Shouldice Hospital learning that technique.

The surgeon I saw is around 69 years old – so he’s done hernia repairs prior to the wide use of mesh repairs. He’s personable and has very good reviews, and practices at one of the top hospitals in the Midwest.

He thinks I should just wait and watch it, and go on with my life. I kind of want to do something about it before it gets worse.

It says a lot, I think, when a surgeon looks at your hernia and takes a very conservative posture. Many will rush you into surgery. So, I have a lot of confidence in him for that, and as I said, he’s quite likable.

Do you know if certain tissue repairs produce a more favorable outcome for indirect inguinal than others? I’ve heard very little of Bassini but much about Shouldice.

Thanks. I’m still gathering information in trying to make a decision. I know from this forum that there are many good doctors out there, some of whom contribute to the forum. It’s still not an easy decision, and especially when one has to travel distances.

[USER=”2966″]Tino_7[/USER] can you share the name(s) of the surgeons you saw in the midwest who will perform non-mesh hernia repair? I’m attempting to maintain a list of doctors who perform these procedures. Thank you.

[Chaunce1234]

[USER=”3024″]andrew1982[/USER] do you mind sharing what surgeon performed a non-mesh repair for you?

You can message me privately if you’d rather not share it publicly here. I am trying to maintain a list of non-mesh hernia surgeons, so any additional doctors to add to the list would be welcome

You last posted about a week ago, have you noticed any change in your symptoms since?

There is some evidence that 500mg Vitamin C daily can gradually improve nerve pain over time. Don’t expect immediate results.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3389328/

If you are located in a region that allows medical marijuana, some patients report positive experiences with reduced nerve pain over time with that as well.

Best of luck, keep us updated on your case and how you’re doing.

[Chaunce1234]

[USER=”2511″]lbpd16[/USER] and [USER=”2580″]DrBrown[/USER] thank you for sharing this information.

Similarly, I have read that Shouldice in Toronto charges US patients somewhere around $6500-$8000 for a standard hernia repair including three days hospital and meals, but anyone interested should inquire with Shouldice directly to get an accurate quote.

Also worth mentioning is that apparently you can sometimes submit paperwork to an insurance company for reimbursement after paying out of pocket for a procedure, so that could be a consideration for some people who are must travel out of insurance networks for needed care.

[Chaunce1234]

My opinion is that the spread of knowledge is good, so the more information sharing that can occur the better. It might be less than ideal but even a very low-budget solution like recording the conference presentations with an iPhone and putting those videos onto YouTube would be better than nothing. I know the larger an organization with the more members and players involved, the more difficult this kind of thing can be, but I think it’s worth the effort anyway.

I do want to thank [USER=”935″]drtowfigh[/USER] for the work that you do. From the outside looking in, it appears that [USER=”935″]drtowfigh[/USER] is one of very few speakers at the Americas Hernia Society meetings to regularly raise awareness about potential issues with mesh, with a strong focus on the patient, while also promoting tissue repairs as valid for many patients. Why those views are not widely adopted by everyone is a mystery given the evidence. So thank you again Dr Towfigh, please keep up the good work.

[USER=”2029″]Good intentions[/USER] I think you are hinting at a valid concern, it would be obviously problematic if industry was improperly influencing conferences, talks, decisions, studies, education, or medical care in any way that distracts from the benefit of the patient. Ultimately the patient and patient quality of life must always come first.

[Chaunce1234]

How do you feel? And what did the surgeon recommend in terms of activity and return to running?

I imagine that if sufficient healing time has passed, and you feel good, and you got a stamp of approval from the surgeon, then the doctor advice and your friends recommendation of “listen to your body” is probably reasonable.

If you’re a few weeks out with no pain, and the doctor gave you an approval for increased activity, try it out and see what happens. If it hurts, back off a bit, rest, and give more time to heal. If you have some limited soreness after activity, ice and NSAID might be helpful.

Keep in mind that you are still healing, and that scar tissue will continue to remodel for quite some time too.

Best of luck and keep us updated on your case and progress.

[Chaunce1234]

[USER=”2790″]kls007[/USER] you can attempt to trigger the cremaster reflex yourself by basically brushing your inner thigh with a pen, the diagram on this page may be helpful

https://en.wikipedia.org/wiki/Cremasteric_reflex

If you are concerned about a hernia but there is no physical bulge or cough impulse for anyone to identify, then you might consider requesting an ultrasound of the groin while bearing down, it is fairly cheap and insurance shouldn’t complain too much.

Best of luck and keep us updated on your case.

[Chaunce1234]

quote DrBrown:

Dear Jnomesh.
I would like to thank Dog for allowing us to share his photographs.

Hernia Sac: this is the sac or balloon that is filled when the intestines pop out through the indirect hernia.
Hernia Sac Opened: In this photo, hernia sac has been cut open and at the very bottom is the hernia. As you can see, even though the hernia sac is large, the actual hernia is small. This is one reason the recurrence rate for indirect hernias is so low.
Floor Weakness and Anatomy: Dog had had his hernia for a long time. It had stretched the muscles medial to the indirect hernia. In the photo, notice that the inguinal floor is mostly fat. There is no bulge but there is also no strength. To reconstruct this weakness I will suture the transversalis to the inguinal ligament.
Reinforce Floor: The sutures have been placed between the transversalis and the inguinal ligament.
Repaired Floor: The area of weakness (fatty area) seen in the photo “Floor Weakness and Anatomy” has now been reinforced.

I hope that clarifies some of your questions.
Regards.
Bill Brown MD

This is really fascinating even to a laymen like myself, so thank you for sharing these surgical photos [USER=”2580″]DrBrown[/USER] and [USER=”2608″]dog[/USER]

Is this essentially a modified Shouldice or Bassini repair?

If the weakness had torn all the way through the inguinal floor to become a direct hernia, would this still be a suitable repair?

Does this approach also apply to a femoral hernia?

[Chaunce1234]

Without practicing the non-mesh repair, those who do not know how to perform a non-mesh repair will not know how to perform a non-mesh repair. Sort of a self-fulfilling situation which maintains the status quo, or worse as the skilled non-mesh surgeons continue to retire in the USA. Admittedly, it is complicated and requires a very strong understanding of complex anatomy which differs per patient, but as Shouldice has shown repeatedly, practice makes perfect.

As to why patients are seeking non-mesh repairs… I think that is fairly obvious. Not everyone wants a permanent implant in their body, particularly an implant that is associated with known significant risk and is also incredibly difficult to remove if there is a problem with it. How and why patients come to that conclusion varies greatly, but the idea that patients are being misled by legal ads is fantasy and denial.

Interestingly, I stumbled into a slide from the recent AHS 2019 conference that appeared to be from a talk focused on protecting from lawsuits by disclosing all the possible mesh risks in fine print of consent paperwork before surgery. So liability is the main concern for some. Think of that what you want, but regardless many patients will read that fine print and then ask for a non-mesh repair as a result.

So for hernia surgeons, I strongly think they should be able to confidently perform both a non-mesh repair and a mesh repair. Then the surgeon and the patient can make a decision together based on their specific case, preference, risk profile, concerns, comfort, etc. One size does not fit all.

[Chaunce1234]

quote BobbyO:

DrBrown, I had open Inguinal Hernia surgery in 2016. Pain started 2017, Second surgery 2018 for the pain but didn’t help. The pain level and area varies from day to day. Walking and exercise irritates it. It can be in the groin and inner thigh one day, the knee the next day, outer thigh the next day, sometime down to my ankle. When it is bad I cannot put weight on the leg and it feels like a sprain in my groin. Trying a Cortisone shot in the L2 and L3 nerve on Wednesday.

How was your experience with the cortisone shot and did it help with your groin pain and leg pain?

Have you had a nerve block or cortisone injection targeting the groin nerves and did that have any impact?

Please keep us updated on your case and progress, thanks.

[Chaunce1234]

quote lbpd16:

I’m in Texas and am in the “watchful waiting” period. But when the time does come I am definitely going no mesh. I’m considering Dr. Brown or Dr. Tomas in Fla.

You would think that there would be someone in Texas. With UT, Houston, San Antonio and Dallas you would imagine there would be at least 1 very good no mesh doctor. It seems that is not the case.

In Texas, you might try contacting Dr. John Etlinger in San Antonio, who apparently does a non-mesh repair on select hernia patients.

I am also very interested in the idea of maintaining a list of hernia surgeons who are able, willing, and competent at non-mesh hernia repairs. It’s increasingly difficult to find these surgeons and typically patients must travel far, often out of state, out of insurance networks, or even out of country (like a recent US Senator) to get a non-mesh repair.

[Chaunce1234]

quote drtowfigh:

Tensor fascia lata grafts are how native tissue grafts used to be used prior to invention of cadaver Biologics. It is still used but rarely. It’s a highly morbid operation with many complications, pain, risk for nerve injury, cosmetic deformity, long recovery, and disability.

Interesting and good to know, thank you for adding a clinical perspective on this.

Perhaps growing suitable replacement tissue using a patients own stem cells would be the dream solution? I hope someone is working on this.

[Chaunce1234]

Mesh or not, it should not be considered acceptable or ‘the new norm’ for chronic pain to impact 10%-30% of patients for a routine surgery. I genuinely do not understand why chronic pain prevention is not given the highest priority in inguinal hernia repair.

[Chaunce1234]

Thanks for the continued updates [USER=”2608″]dog[/USER] please let us know how you continue to do.

If you speak to other persons and patients about hernias perhaps recommend them to come onto this forum and share their experiences as well.

[Chaunce1234]

Is there a mesh like this that is 100% absorbable and still effective for groin hernia?

Perhaps an absorbable mesh that is made of different absorbable materials that absorb at different rates, maybe with a slower absorbing lattice to reinforce the repair strongly initially while native tissue growth occurs to hold the repair long term?

Is there substantial ongoing research on this kind of thing?

[Chaunce1234]

[USER=”2608″]dog[/USER] I am genuinely impressed that you’re healing so quickly, from surgery to vacation in a week is really quite expedient. I have to wonder if you’re just a particularly healthy patient and a fast healer, or if that’s a normal experience for some hernia repairs. Thanks for sharing your hernia story, it will surely help other future patients in making their own decisions.

By the way, your Letterman appearance was very amusing and you have a great sense of humor, thanks for sharing that.

[Chaunce1234]

I think many posts are held for spam review, out of necessity. Sometimes posts get flagged as spam erroneously or held for moderation, it is more aggressive sometimes than others.

Anyway, be persistent and as long as it’s not spam it will likely come through. Sometimes you can include a moderators like Dr Towfigh in the reply to expedite the moderation process.

[Chaunce1234]

This information was retrieved from a Twitter posting by the doctor:

https://twitter.com/NovitskyYuri/status/1099360858579394561

More information on Dr Novitsky in NYC here:

http://columbiasurgery.org/yuri-novitsky-md

Holiday-shortened week, but still good 3 days of surgeries:
2 open TARs
5 lap inguinals
1 Shouldice
1 roboTAPP ventral
1 roboIPOM ventral
1 Robo B/L groin mesh removal/repair
11 satisfied customers!

Gotta love the spectrun of great options we have in Hernia field these days.

— Yuri Novitsky (@NovitskyYuri) February 23, 2019

[Chaunce1234]

quote retriever:

I’ve been reading here off and on for several months and have learned a TON from this forum – what a great resource! I’m trying to find the right surgeon to do a non-mesh repair on my inguinal hernia (heard way too many bad mesh experiences from friends, and I have more than enough medical issues to deal with already).

From my reading in this forum and others, Dr. Brown in Fremont is very appealing, but also far away (I’m near the northeast corner of Iowa), so I’ve been trying to look at closer possibilities before making a decision.

I’m wondering if anyone has any knowledge of or experience with Dr. Ashwin Maharaj (Ansa Health Care – https://www.ansahealthcare.com/hernia-repair/) – spent time at Shouldice (1300 repairs), now has his own practice in Toronto offering Shouldice repair on an outpatient basis) or Dr. Paul Szotek (Indianapolis Hernia Center – https://www.indianahernia.com/) – his webpage says he does non-mesh repairs (as well as laparoscopic repairs, robotic repairs, etc.). I believe I heard/read that he chooses the best repair based on each patient (like Dr. Brown), but likes to use a partially absorbable mesh if the patient is ok with it but is OK with doing non-mesh repair? No detailed information available on Dr. Szotek’s webpage.

Does anyone have any knowledge or recommendations about either of these surgeons? Or any other surgeons you might suggest or recommend?

Dr Paul Szotek in Indiana occasionally interacts with this forum, so you might be able to ask a question to him directly here [USER=”1197″]pszotek[/USER], or by sending an email on his own website.

Dr David Grischkan in Ohio is also in your general neck of the woods and has significant experience with non-mesh hernia repairs.

Shouldice hospital is located in Toronto CA and is basically the world expert on Shouldice repairs, if Dr Maharaj in Toronto was also trained there he is likely very skilled in that repair method.

There are certainly other options scattered around the USA too.

You’ll likely have to travel outside of Iowa, as non-mesh inguinal hernia repair practice is unfortunately becoming an increasingly rare skill. You might try calling around and asking older local surgeons if they are familiar with the non-mesh procedure and have confidence in performing it as well, but getting specific procedure questions passed front desk staff can be challenging or impossible sometimes.

Good luck and keep us updated on your case and decision making.

[Chaunce1234]

quote Jnomesh:

Chaunce123,
agree. With mesh removal seemingly being done more often focus needs to be on products and ways to deal with the unfortunate event should the mesh need to be explanted.
BTW the surgeon I was speaking of who made the statement of removing TEP implanated meh was dr. Belyanski. The takeaway wasn’t that TEP placed mesh can’t be removed but that in his opinion or statement it is much more challenging to do so..

Interesting thanks for info, I was always under the impression that both TAP and TEP were basically the same, aside from initial approach, and so I assumed removal would be the same for either case too.

[Chaunce1234]

There seems to be a significant number of different products with different outcomes, which surely confuses the tracking of outcomes and in determining what works best, when, why, for who, and, most importantly, what offers the best quality of life to the particular patient.

The Swedish Hernia Register is an interesting source of information on hernia repairs and complications, and some fascinating studies are done using their data. Once such conclusion using a significantly larger sample size (13,000+ repairs) suggest that lightweight mesh is associated with less pain and less stiffness, but with slightly higher recurrence rate risk. Unfortunately the most important data that really matters to the patients – quality of life, chronic pain risk, pain severity, etc – is still not emphasized much at all, which is disappointingly typical.

https://www.researchgate.net/publication/327210930_Lower_recurrence_rate_with_heavyweight_mesh_compared_to_lightweight_mesh_in_laparoscopic_totally_extra-peritoneal_TEP_repair_of_groin_hernia_a_nationwide_population-based_register_study

Also, unrelated, but I stumbled into an older British study of 4000 patients that compared mesh and non-mesh repair, which found recurrence risk is 1.4% for mesh and 4.4% non-mesh – both sound quite low. But unfortunately there is no focus on chronic pain or quality of life of the patient in this study either, and there is no mention on the type of mesh used, nor the type of non-mesh repair used.

https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1365-2168.2000.01539.x