[Chaunce1234]

quote ajm222:

Pain in general is just such an interesting topic. It seems that in some cases it’s not even that damage is occurring to cause pain but instead some sort of sensitization process begins where the nerves are simply over excited after surgery and never quite settle down. I wonder if this is how injections and conservative pain management most often leads to resolution – almost like training the brain to ignore the area and any false signaling and to relax, which eventually leads to improvement.

Anyway, I’m just rambling at this point.

I don’t think you are rambling at all, this is an important topic.

Pain is so incredibly complex, chronic pain perhaps even more so, and there is obvious need for extensive research to manage and treat it effectively.

You are right though, and what you describe is one of several theories about chronic pain. That is, that chronic pain may be more of a secondary mechanism or interpretation by the nervous system rather than from a new or ongoing tissue injury, whether due to the original injury or due to repeat pain signals being sent to/from the brain which eventually overly excites that particular neural pathway. Two quite different but similar mechanisms occur with eating extremely spicy food which often sensitizes to temperature and other spices, and sexual arousal which sensitizes to stimulation but in a pleasurable manner. The difference in those situations however is eventually the stimulation ends, and so does that sensitivity. With chronic pain, that stimulation and sensitivity continues, for an uncertain reason. The pain is still very real, but perhaps it is a different mechanism of pain compared to the typical “injury = pain” route.

​​​And as you allude to, that also may be why sometimes pain diminishes over time, or can be diminished over time with things like nerve blocks, medications, various brain training, and it may even be the functional mechanism for why certain other treatments can be helpful to some people. There is also a variety of working theories that medical marijuana may be effective for chronic pain for a similar reason, whether by distraction or by offerring indirect changes to brain signaling and pain interpretation. You will also find that many experienced pain management doctors will push their patients to engage in mentally challenging and mentally consuming tasks too, since the brain is clearly a major component in the pain experience, and participating in mentally difficult tasks causes changes to the brain itself, that’s essentially what learning is.

Here’s a recent interesting article on brain plasticity, and while it’s not on the direct topic of pain, you can imagine why it’s relevant:

http://news.mit.edu/2018/mit-scientists-discover-fundamental-rule-of-brain-plasticity-0622

[Chaunce1234]

I am sorry you are going through this.

I don’t specifically know of any surgeons in Canada outside of Shouldice, Shouldice is very well regarded but it sounds like your case was an emergency situation and thus why they deferred it.

I would certainly seek out a true expert in hernia repair and hernia surgery complications. You may need to travel. If you’re near Toronto, the following may be helpful options for you in the USA:

– Dr Igor Belyansky in Annapolis Maryland

– Dr Bruce Ramshaw in Tennessee

– Dr Jonathan Yunis in Florida

– Dr Brian Jacobs in NYC, New York

– Dr Shirin Towfigh in Los Angeles, California

You could always reach out to these surgeons and ask for recommendations in Canada as well.

Have you tried any nerve block injections? Any other treatments? How effective has medical cannabis been for you?

[Chaunce1234]

I’m sorry you’re going through this.

Is the pain the same or different from before the surgery? Have you had any nerve block / steroid injections, and if so what was the effect? Does advil make a dent in the pain?

It would be a good idea to find out more information about the original surgery, and the follow-up surgery. What type of mesh was used, were any nerves cut, etc.

If pain is mostly in your leg, perhaps you have some ongoing lateral femoral nerve irritation or compression, though a skilled doctor would be much better at having an idea of what is going on.

Pain specialists can certainly be very helpful for managing pain, so that would be a worthwhile avenue to pursue regardless of what else you choose. Preferably you will want to find a pain specialist with specific experience dealing with the particular type of pain you are having.

You might as well reach out to the original surgeon first and see what they say, and what (if any) experience they have with this kind of issue, and how it was (or wasn’t) resolved. Depending on your location you may have a hernia expert nearby you could consult with too, otherwise you may have to travel.

Good luck and keep us updated on your case.

[Chaunce1234]

You might try consulting with Dr Michael Reinhorn in Boston MA, (617) 466-3373

According to his website he is able to perform all manners of hernia repair: mesh, no-mesh, shouldice, laparoscopic, open, etc, which would likely qualify him as an actual hernia expert. I also just noticed he publishes some of his own case data directly on his own website, where he says he has repaired 2,952 hernias as of 2017.

https://bostonhernia.com/about-us/quality-outcome-cost-data/

Personally I would be very interested in knowing what his chronic pain rate and recurrence rates are as well, but those are questions to ask of any surgeon before a hernia procedure.

There are other hernia experts on the midwest / east coast as well;

– Dr Samer Sbayi in Long Island, NY

– Dr Michael Reinhorn, Newton MA

– Dr William Meyers in Philadelphia, PA

– Dr David Grischkan in Cleveland, Ohio

– Dr Paul Szotek in Indianapolis, IN

– Dr Bruce Ramshaw in Knoxville, TN

– Dr Jonathan Yunis in Sarasota, FL

– Dr Robert Tomas in Fort Meyers, FL

– Dr Igor Belyansky in Annapolis MD

– Dr Brian Jacobs in NYC

I’m not a doctor and have no affiliation with any of these surgeons, so be sure to do your own research.

Good luck and keep us updated on your case.

[Chaunce1234]

quote Bure96:

I did have an ultrasound done back in September of last year (4 months after the surgery) and they did not detect a recurrence, but I was lying down and I don’t recall them asking me to cough or anything, so it’s possible they wouldn’t have caught anything. (The US was ordered by my urologists and was primarily to check out my other side, in which I’ve had periodic burning and aching sensations.)

I’m not a doctor, but I would say you might want to request another ultrasound of the impacted groin site. Specifically you’d want a dynamic ultrasound with valsava maneuver, which is basically you bearing down as if you were going to defecate. The idea behind that type of ultrasound is the following; it’s dynamic meaning a video is recorded of any possible movement/herniation of tissues, and the valsava maneuver can help appreciate a protrusion that may not otherwise show up by increasing intra-abdominal pressure. Sometimes these are done standing up as well so that you have gravity pulling things down further as well.

Anyway, ultrasound is fairly cheap with or without insurance, so it’d be unlikely to be too difficult to get insurance to approve it. If you have a primary care physician they should be able to order one for you as well.

In terms of doctors with specific Shouldice repair, the options may be limited in the USA. You will want to aim to find doctors that have experience with no-mesh traditional tissue repair, which was the standard for many decades until mesh was adopted as the one-product-fits-all approach, often that means older surgeons as the no-mesh repair is not commonly taught in most medical schools anymore, meaning unless a younger doctor has specific interest in learning the traditional tissue repair techniques they will not know them otherwise.

And as [USER=”2042″]Jnomesh[/USER] mentioned, Dr William Brown in Fremont CA is another good resource.

Good luck and keep us updated on your case.

[Chaunce1234]

A standard ultrasound of the groin with valsava should be able to determine if a hernia is direct, indirect, or femoral. But it may be operator/radiologist dependent. This is fairly well studied too: https://www.ncbi.nlm.nih.gov/pubmed/12831490

You may just want to request an ultrasound with valsava of the groin, that should give you a good idea. Sometimes the reports don’t specify what type of hernia but instead they will say something like “protrusion medial to vessels” or “lateral to the vessels”, which a surgeon (or google) can help decipher for you.

This should be helpful in that regard:

“indirect inguinal hernia
– more common
– herniates lateral to the inferior epigastric artery 2
– anterior to the spermatic cord in males 8
– follows the round ligament in females 8

direct inguinal hernia
– less common
– a weakness in the fascial floor of the inguinal canal 10
– herniates medial to the inferior epigastric artery 2
– often through a defect in the Hesselbach triangle

Femoral hernias protrude inferior to the course of the inferior epigastric vessels and medial to the common femoral vein. They often have a narrow funnel-shaped neck and may compress the femoral vein, causing engorgement of distal collateral veins.”

from: https://radiopaedia.org/articles/inguinal-hernia and https://radiopaedia.org/articles/femoral-hernia

CT and MRI will certainly be radiologist dependent, as Dr Towfigh has shown repeatedly that many scans are misread or misinterpreted. It’s also possible the hernia could slide back into the abdominal cavity where it belongs and then not show up on any sort of imaging, simply because you’re laying down.

Given that a CT has radiation and an ultrasound does not, it might be good to start with ultrasound first. It’s also a lot cheaper.

Anyway, keep us updated on what you decide.

[Chaunce1234]

I recall reading that “inguinal disruption” can sometimes be described as a ‘thinning’ that is observable in the groin on ultrasound, you may want to read a bit about Dr Ulrike Muschaweck (leading German hernia surgeon) or perhaps even inquire directly with their clinic.

Where exactly is the bulge? Is it in the region that a standard groin hernia would appear?

You might also try sending any CT/MRI images to a hernia specialist to review them directly, as many doctors just look at a radiologist report and do not look at the images themselves. Furthermore, many radiologists reviewing a CT/MRI may not note a hernia or even see one. Dr Shirin Towfigh is well known for reviewing images herself, for example.

For finding a true hernia specialist you may need to travel out of state. I know it sounds bizarre that even in major cities many do not have a true hernia specialist, but our medical system has determined that hernias are part of the “general” surgery category and so there is very little specialization if a doctor does not directly seek out that specialization themselves out of a direct interest in hernias. Personally I think that is an industry reform that should happen sooner than later, every hospital/facility should have designated hernia surgeons to master the craft through repetition and thousands of procedures, rather than assign them randomly across hundreds of surgeons who may only do a few repairs a year… but now this is getting off topic 🙂

[Chaunce1234]

What is the context of this? And where is it? From a laparoscopic procedure or?

It reads like a post-surgical CT report, but without more details (original procedure(s), complaint / issue, general health, age/sex/weight, etc) it may be hard to get much insight aside from anyone reading it quite literally.

[Chaunce1234]

Removing a tack seems like a reasonable course of action if the staple/tack looks as if it was impinging on a nerve. But yes I would assume that would require diagnostics, whether an MRI or otherwise, depending on what the staple / tack type is to see if it can show up on imaging. Metal tacks and staples should show up on most imaging type I believe, I am not sure about dissolvable tacks. You’d want to confirm that with a doctor of course.

Have you had any treatment for your discomfort thus far? Any nerve block injections or extended anti-inflammatory courses?

Where are you located? If you are regionally near a hernia repair expert, it may be helpful to consult with one.

[USER=”2029″]Good intentions[/USER] makes a good point about the contrast between certainty and puzzled, it reminds me that medicine is sometimes called an ‘art’ rather than a science because there is sometimes imprecision, intuition, and guesswork involved.

Good luck and keep us updated on your case.

[Chaunce1234]

quote Lucky46:

I know 3 people who have had tissue repair by Dr. Tomas. All 3 are doing great no issues. And I know 2 people who have had mesh removal with no issues. Dr. Tomas doesn’t automatically cut any nerves. No neurectomy unless absolutely necessary. He has videos on YouTube.

He removed 90% of mesh on both. I have talked to Dr. Tomas multiple times on the phone. He will be who I have remove my mesh when the time comes. Also, he is very reasonable as far as costs go as well.

That is interesting anecdotal data and good to hear that patients have had a good outcome. Did they have mesh removed due to pain or some other issue? What was their outcome, better, worse, same?

Does anyone know what experience Dr Tomas has with chronic pain? And what his personal chronic pain outcomes are from his own Desarda procedures?

I know his website shows a low recurrence rate so far, it will be interesting to see how/if that changes over time since Desarda is considered a relatively new procedure. Hopefully he will submit and publish his outcomes, whatever they are, using a large sample of his own patients.

I would certainly agree in terms of costs being reasonable, $4000 or so for an ‘all-in’ procedure is much less than many deductibles and co-insurance nowadays, so kudos to him for being responsive to the never-ending insurance debacle. I wish more clinics would offer upfront and package pricing in a similar way.

[Chaunce1234]

Was there some aggravating event? What happened? What was the original surgery type and how long ago was it? What is the pain like now? Did you have pain before the original surgery? Age/sex/weight?

I have read stories on these forums and elsewhere about people who over-exerted with exercise or lifting or athletics or similar and then encountered pain at the site of a prior surgery, perhaps it is from scar tissue being pulled or torn, or irritating nerve, or something else.

Any treatment so far? Have you had a nerve block or anything similar? Any longterm NSAID course (if appropriate to your general health) or anything similar? What did the doctors you have seen thus far suggest?

Good luck and keep us updated on your case.

[Chaunce1234]

What is the pain like? Is it dull and diffused? Vague? Pressure? Burning? Sharp? Electric? Constant or only with activity? Isolated to the area of incision or is it broadly dispersed throughout the groin? Out of curiosity, are you a male or female? How old are you?

Have you seen a doctor yet about the lump? It’s possible it’s scar tissue, it’s also possible it’s recurrence. A fairly easy way to find out if you have a recurrence is to get an ultrasound done with valsava, they’re usually pretty accurate for diagnostics.

Shouldice definitely works on recurrence so I wouldn’t worry about that in terms of returning to them, it’s fairly unlikely you’d even have the same surgeon since they are apparently randomly assigned.

In the LA area, the following hernia specialists could be a good start:

– Dr Shirin Towfigh (who runs these forums) is in LA

– Dr David Chen at UCLA

In Philadelphia, Dr William Meyers or Dr Alexander Poor could be good resources, they typically work with pro athletes.

As for insurance, you’d have to reach out directly to clinics and ask the front desk staff.

Good luck and keep us updated on your case.

[Chaunce1234]

quote drkang:

You have requested for detailed explanation of my Kang repair. But I hope you understand it is almost impossible to accurately and completely explain the surgical process through words. But I will film the process in the near future and inform you once it is posted on our website. A few aspects about my repair is that sedative local anesthesia is used, skin incision is less than 1.5 inches, and that it is a very simple surgery that takes from 15 to 20 minutes only. The outline of the process is to deal with the hernia sac then closing the muscle defect (hernia hole) by suturing.

Dr Kang, would you mind recording a video of repairing all potential hernia types with your technique? Indirect, direct, femoral, even umbilical if applicable? I imagine these would be valuable to add to YouTube for both understanding the repairs and hopefully to help the technique spread in popularity. Something to consider, thanks.

[Chaunce1234]

Sorry you’re going through this.

Have you been to a major pain clinic (university or otherwise) and spoken with someone who has a lot of experience managing chronic pain patients? If not then that might be a good step. Ultimately it’d be ideal to find someone who has worked successfully with similar issues to your own.

What does the quoted 85% “success rate” really mean? And what does the other 15% look like? What are the sample sizes they are working with?

Neurectomy may help but it is ultimately unpredictable, it is not a guaranteed way to remove pain. The most obvious example is people who lose a limb and then experience phantom limb pain despite the fact there are no nerves or limb to feel the pain. A groin neurectomy also can have other unintended side effects that you can read about on these forums and elsewhere.

Dr David Chen at UCLA has substantial experience with neurectomy and may be a good resource for tracking down knowledge and study data. You might try looking around on NIH as well for outcome studies.

​​​​​​​It might be wise to try various less invasive approaches first. Repeat nerve blocks, ketamine transfusion therapy, longterm vitamin C and alpha-lipoic acid, etc etc

[Chaunce1234]

I’m sorry you’re going through this. Based on your history and descriptions, I would strongly recommend reaching out to an expert in athletic pubalgia and groin/pelvic sports injuries.

Vincera Institute in Philadelphia is considered one of the best groin/pelvic/abdominal/core injury clinics in the USA if not the world and they handle many pro and amateur athlete cases.

– Dr William Meyers at the Vincera Institute in Philadelphia PA

– Dr Alexander Poor at Vincera Institute in Philadelphia PA

Other well known resources are:

– Dr William Brown in Fremont CA

– Dr Ulrike Muschaweck in Munich Germany / London UK

There’s a thread in the main forum about sports hernias with additional resources, surgeon names, etc.

Good luck and keep us updated on your case!

[Chaunce1234]

How are you doing now, a few days later?

In the USA, the vast majority of surgeons are general surgeons, and that’s where the majority of hernias are fixed. In the USA there are surprisingly few doctors who are dedicated 100% to hernias and hernia issues, that’s just the way it has turned out for whatever reason. That also doesn’t mean that general surgeons can’t be hernia experts, or vice versa, it really depends on their own interest in the topic and the procedure I’d think. So again I would not worry too much, you likely had a fairly routine experience.

[Chaunce1234]

quote drkang:

Hi Chaunce1234,

I as well feel that I should officially present my surgical method some day. I have performed non-mesh inguinal hernia repair for the past 5 years but it was around the end of last year that I ultimately finalized my method. I wish to present the results of my finalized non-mesh inguinal hernia repair. So I plan to follow up for one year and publish my thesis along with surgery results and everything about my surgical method around the second half of next year. It is a rather sensitive issue at hand than what ordinary people think concerning teaching and learning surgical methods without ever having acquainted each other or without there being some sort of cause. Of course, I am willing to explain in detail to doctors who are interested in my method but I humble myself to approach first to offer to explain. They also don’t have objective data on the results of my method yet so I doubt that they will be interested. Furthermore, Dr. Towfigh has already great achievements in her own field as a laparoscopic hernia surgeon and is still actively playing an important role. So it would be terribly presumptuous of me to try to teach her something. I believe it is best shot to publish my thesis and then naturally share my surgical method to those that are interest.

[USER=”2019″]drkang[/USER] Thanks again for the response, and I understand what you are saying. From a patients perspective, I can hope you present your method and results as I think you have a lot of value to add to the international surgical community and to future patients.

[Chaunce1234]

I’m sorry but this is too vague to offer much thought or opinion, you may want to elaborate more if you are looking for some ideas or a dialog.

What was the surgery? What is the discomfort? Have you had a follow-up with your surgeon? Your surgeon is probably the best place to turn to first, as post-op appointments or contacts can be illuminating during recovery, and they at least know more details about your procedure.

[Chaunce1234]

quote 65 and counting:

A couple of times I felt and saw a rippling movement in my abdomen. Has anyone experienced this?

Could you be describing peristalsis? Which is basically the GI system moving things through the GI tract? Just a thought, I am not a doctor.

An inguinal / femoral hernia can usually be seen or diagnosed with an ultrasound of the impacted groin region with a valsava bearing down, if you are concerned about a “hidden hernia” that may be a good way to diagnose it. I wonder if someone is going to fix your hiatal hernia anyway, perhaps they could take a look further down with a camera and see if you have a groin hernia as well? I am not sure if it would work that way, but just another thought.

Take care and keep us updated on your case.

[Chaunce1234]

quote drkang:

Hi Chaunce1234,

After receiving your inquiry, I reviewed my record of surgeries that I performed since 2015. During this period, I performed a total of 4,700 inguinal hernia repairs and there were 15 cases(0.32%) where indirect and direct hernia were both present (pantaloon hernia). It is very rare to come across it. In cases of pantaloon hernia, it can simply be treated by operating on both indirect and direct hernia simultaneously.
It is true that there are a few times when the pre-surgery ultrasonographic diagnosis and the actual hernia type found during surgery are different. However, a well-experienced radiologist almost always gets it right.
When treating femoral hernia, I localize the hernia sac below the inguinal ligament (in the thigh) and tie it off. Then I push the sac stump through the femoral canal into the preperitoneal space and close the opening(ligamentous orifice) with a continuous locking suture using 3-0 Prolene. It has the identical concept with indirect inguinal hernia repair. I have performed 25 cases like this since 3 years ago and currently, f/u averages on 19 months with just 1 recurred patient.

[USER=”2019″]drkang[/USER] Thank you again for the detailed responses to inquiries!