drtowfigh
Forum Replies Created
-
Please Help!
Kleiter,
Do not give up! As you can see, there are others with similar symptoms. Not all hernias present with bulges. That is a fact.
Your symptoms are classic for an inguinal hernia and that must be top of the list for the cause of your pain.
What is this labial cyst? Perhaps this is your hernia?
If you cannot find a surgeon near you who will treat you, you must travel. If you wish, refer your surgeons to herniatalk.com. Also, I am happy to field their call if they wish to discuss your situation.
The Mayo clinic should be nearby as is the University of Minnesota. Consider visiting them as well. -
Importance of lipoma of the cord
Both cord lipoma and inguinal hernia may cause groin symptoms. Usually they occur together. Repair typically involves addressing both of them at the same time.
-
Concerns with laparoscopic repair
Any “posterior” repair may have a risk of disrupting the peritoneum and this a risk of the mesh coming in contact with the intestine. So a laparoscopic repair (TEP or TAPP) or an open repair with a posterior component (PHS, Plug, Kugel) can all have this risk. This is rare and even if it happens it is even more rare for it to cause an intestinal obstruction. The peritoneum may tear due to technique or a lot of scar tissue. Also, some people have really thin peritoneum and are at higher risk for the peritoneum to tear. It is unpredictable. In my mind this concern is certainly not a reason to choose lap vs open repair. There are much more important differences in risks and benefits that should be considered when choosing what is best for you.
Regarding the femoral nerve: injury to that would be a reportable case. I have seen it but it should never happen. It actually is more likely to happen with open repair due to too lateral of a stitching or too tight of a stitching. Once again: almost never an issue. The femoral nerve is a deep structure and lateral, so it is very difficult to injury it laparoscopically.
-
concern of Hernia Repair an Lookin for 2nd opinion
Please give us an update on how you’re doing. It’s not uncommon to feel sore and bloated after a hernia repair but you should get better with time.
And what area was your hernia? -
Importance of lipoma of the cord
uAhah! You have been doing your research.
This article is just another example of complications that can occur when you have not yet met the steep learning curve for laparoscopic surgery. Lipomas of the spermatic cord can very effectively be removed at the time of laparoscopy unless they are very deep into the scrotum, but it must be part of the checklist of things to do while performing the dissection.
Ultrasound does not reliably differentiate cord lipoma from fat-containing hernia.
-
Experience bias in laparoscopy vs. open studies
Overall, it is expected that laparoscopic inguinal hernia repair with mesh will have a lower postoperative chronic pain risk than open inguinal hernia repair mesh. This is because there are less potential nerves to irritate or injure in the retroperitoneum during laparoscopic surgery and no cutting or sewing of muscle in the groin region.
That said, as with any operation, mishandling of the structures, especially the spermatic cord, aggressive or non-delicate dissection in the area, and inappropriate mesh and/or tack placement can lead to chronic pain even with laparoscopic surgery. Technique and surgeon experience is super important as the learning curve is steep with this procedure.
Most studies about laparoscopic surgery outcomes are biased in favor of laparoscopy, as they tend to be published by experts in the field. The VA trial (L Neumayer et al) is one of few that actually evaluates laparoscopy vs open hernia repair among all surgeons, including mostly non-experts, and the results are in favor of open surgery (with lap best only for bilateral or recurrent hernia or if performed by experts).
If you read articles published by top open inguinal hernia experts, such as P Amid, their results are similar to that of laparoscopy in many facets, including chronic pain or inguinodynia.
Lastly,surgeons may be experienced in open and not lap, or in lap and not open, or perhaps in both open and lap. It would be incorrect to presume that most open surgeons are inexperienced. I would venture to guess however, since only 15% of all inguinal hernias in the USare done lap, that most open surgeons are not experienced in lap.
-
laparoscopic repair and prostate surgery
Excellent question. This topic has been debated since the introduction of laparoscopic inguinal hernia repair with mesh.
Most modern day studies, where prostatectomy operations are performed robotic-assisted, have shown no significant problems after laparoscopic inguinal hernia repair with mesh. That is, patients were able to undergo uneventful robotic-assisted radical prostatectomy after having had laparoscopic inguinal hernia repair.
The caveat is: the laparoscopic mesh must be appropriately placed:
a) the bladder must be out of the way during the hernia repair, otherwise the mesh is more likely to involve the bladder. I routinely place a Foley urinary catheter during the operation to assure this. Many surgeons do not do this but have the patients urinate prior to the operation.
b) the mesh must not be placed any lower than the pubic bone (pubis). Any lower, it will involve too much of the vessels and the lymph nodes and may not only complicate future need for lymph node dissection but also may cause groin symptoms after hernia surgery.Other things to know about hernia repair and prostate surgery:
– Open prostate surgery is very difficult to perform after laparoscopic inguinal hernia repair with mesh. It is not impossible, but there are reports of some surgeons having to abort the prostate surgery due to the amount of scar tissue and the mesh obliterating the space where they need to access the bladder. That said, these are older studies where the techniques used for laparoscopic hernia surgery were not as refined as they are today. Also, urologists are more aware of how laparoscopic inguinal hernia repairs are performed by their general surgery colleagues and therefore they able to work around the area to be able to complete the prostatectomy. My own father had an open prostatectomy after laparoscopic bilateral inguinal hernia repair with mesh and it was not an issue.
– Open inguinal hernia surgery may involve mesh placed in the same space (retroperitoneum, or space of Retzius) as laparoscopic hernia repair. The mesh may be the Plug, the Prolene Hernia System, or the Kugel patch. These open repairs may also affect prostate surgeons and there are reports of mesh plugs migrating into areas where the urologists needed to perform the lymph node dissection. Of course, this is not a common problem, but just be aware that open inguinal hernia repair may also involve retroperitoneal or posterior mesh placement, similar to laparoscopic repair. -
Chronic pain and recurring Hernias
At least diagnostic. Can be therapeutic. Depends on the reason and cause for the nerve injury.
-
Should I be thinking about surgery?
It’s very very rare to have a hernia by the ribs. If you have one, it’s called a Spigian hernia. As with most hernias, they should be repaired if they are causing pain. Otherwise, those can be watched and no activity restrictions are necessary.
-
Chronic pain and recurring Hernias
I reached out to Dr Martindale on your behalf.
Please give us an update on your consultation and how you do. -
Why there is no foolproof method?
This would be a great one for Dr Ramshaw to answer. His lifelong research interest is this problem.
He will tell you that it’s because hernias and our individual bodies are complex systems. A mesh repair in one patient will act differently in another patient even if performed exactly the same. Until we can approach it with this in mind and determine the best modality depending on the specifics of each patient (cancer treatment is finally moving in that direction), then the problems you present will remain.
-
Desperate
1. Can you palmate the area of your pain? If so, is it tender to touch? If so, then follow below:
I am not clear as to where exactly your pain is in the left lower quadrant. Nevertheless, I would pursue the hernia question. Try dynamic Ultrasound of the groin and left lower quadrant first. If negative, follow up with MRI pelvis with Valsalva (see other posts for details). If still negative, make sure the films are being read correctly by seeing a hernia specialist.
If the pain is not from a hernia, then it should be from T11-L2 depending on where it is exactly where your pain is.
Read earlier posts and see if you relate to the symptoms listed for occult hernias. If do, then don’t give up til you find someone who can cure you.
-
MRI with valsava for imaging & diagnosing hernia?
Here are details for best imaging for small or occult/hidden inguinal hernias:
– non-contrast MRI pelvis. Nothing to drink. No injections.
– 3Tesla machine is preferred. Some centers get good results with 1.5T but the tech must be very diligent there is minimal motion artifact, etc.
– no open MRI. Won’t give you enough clarity of picture
– Valsalva (bear down) is key to finding the very small ones.
– they should mark the area of your pain
– in my center, they also do dynamic video images. Doesn’t add much more to the Valsalva still images, frankly.
– in my center, they also do close ups of the hip, which helps rule out a hip problem as the cause of groin pain.RJ: your symptoms can absolutely be due to a femoral hernia. Usually these present as groin pain that radiates down the top of the thigh. Not sure why an MRI is necessary when ultrasound already shows the femoral hernia. With laparoscopic repair (now gold standard for femorals), any other inguinal would be found and repaired anyway. Lastly, all femoral hernias should be repaired. They have a high rate of strangulation, unlike other inguinal hernias.
-
future of inguinal repair and PT
Fantastic discussion by all.
We really truly need a defined physical therapy regimen for pre- and post-hernia repair patients. I’m so glad do many of you have brought up this topic. At the Shouldice clinic in Toronto, where everyone has a 48 hour stay after their inguinal hernia repair, they are asked to ride stationary bikes those two days. There are bikes all over their campus. They also have pool tables, encouraging bending and other movements.
I strongly believe that all abdominal and inguinal operations, not just hernia repairs, should be followed by a strengthening regimen–just like orthopedic surgery. We just don’t have any hard evidence to support any specific regimen. It’s not been in the culture of general surgeons.
I would love to work with any therapist, patient, and surgeon who is interested in helping devise a regimen, and then test its efficacy.
WasInTN: very informative posts. Please name your surgeon here so that others may seek him for similar excellent care.
-
Scar Tissue Healing
Scar tissue takes about a year to maximally reform itself to a more normal structure. Some advocate massaging it. There are topics creams over the counter which usually work within the first few months of a wound. Dermatologists have machines that can help reformulate scars after the one year mark has passed. If there is no pain, no drainage, then usually this is of little concern.
-
Mesh removal after hernia repair
Great question.
In pathology, if the mesh is removed, the pathologist can view signs of acute vs chronic inflammation under a microscope.
In MRI, inflammation can be seen if it is quite a lot.
We do not have any sensitive laboratory values to show inflammation from mesh. Blood tests such as ESR may or may not be elevated.If the inflammation is causing pain, anti-inflammatory medications or steroids, in more extreme cases, may be helpful. For chronic pain due to inflammatory status from the mesh, there is little to help. Some may require mesh removal as a cure, and that is also for extreme cases.
-
Pain after mesh repair
Please share this site with your physicians and surgeons.
-
Pain after mesh repair
Troy,
I suggest you see another surgeon. For a second opinion. I do not personally know of anyone in Utah. Go to the American Hernia Society website to find someone. If not, you may have to travel.Pain 9 or more months after a hernia repair is often due to a new recurrence. It is often worse with increased activity or end of the day, better when lying flat. Nerve pain rarely starts so late unless it is related to impingement from a recurrence. I recommend MRI pelvis to assess the groin after a prior hernia repair. Ultrasound is often inaccurate as the mesh distorts the visible field. Also, the MRI is best performed with Valsalva (bear down) and dynamic images. Not all radiologic centers do this.
I hope this is helpful! -
Pain after mesh repair
Stacey,
Thanks for the update.
Re MRI for occult hernias:
– I don’t believe the situation is as sour for non-inguinal hernias. The reason is because the groin area is poorly evaluable with CT but the abdominal wall is pretty well seen. That said, all hernias are underreported in imaging. It’s not high on radiologists’ radar.
– Hernias from laparoscopic operations are very rare. I’ve also published on this. See the Bariatric Times article “to close or not to close port site hernias.”
– Upright MRIs are excellent alternatives to MRI with Valsalva. But open MRIs are not sensitive enough to show occult hernias.
– You can take your CD to any radiology group and ask for a second opinion or re-evaluation. You may have to pay cash for it. -
Inguinal hernia: 33 year old female patient- mesh?
I agree with Dr Goldstein. There have been no reports that I am aware with problems with pregnancy, delivery, or Csection after laparoscopic inguinal hernia repair. I would mention to the obstetrician that there is mesh there. And theoretically there can be problems (mesh infection). I review this with my female patients and still recommend it. Also, if thin female, I recommend lightweight mesh.