drtowfigh
Forum Replies Created
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Laparoscopic or Open Approach
– in thin patients and in the average female, I do not recommend mesh repair, unless perhaps it’s lightweight and placed laparoscopically. The risk if mesh-related pain in this subset is higher than average. A tissue repair done in open fashion should be considered
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exhausted-struggling to find diagnosis.
Your symptoms and the area of pain are all consistent with a possible inguinal hernia. For sure, you should seek the diagnosis first from your medical doctor, and then from a general surgeon. If your general surgeon is not convinced or if your doctor says its a strain or it’s all in your head, then move on to another surgeon. Your imaging may or may not show a hernia: much of it is based on interpretation, so I do not recommend you get more studies until a hernia specialists or an expert radiologist confirms you have no hernia on your scans.
Hernia specialists are not common. If there are none near you and you cannot get a radiologist specialist to re-read your scans, then I recommend an MRI with valsalva to demonstrate a small hidden hernia. It is more common among women.
Let us know how it goes. You are going through the same struggles as everyone else on this discussion board.
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Laparoscopic or Open Approach
The American Hernia Society website is a great first start. Ask the offices you call about the doctor’s experience and interest in hernias, especially hidden hernias among women. If they are not aware of it, then perhaps you should move on. If they have done over 500 or so inguinal hernias laparoscopically, that is a good start for you.
As for the ultrasound, there are no cystic lesions that typically occur in the inguinal region. More commonly, these are hernias. A specialist can examine you and help determine the cause of your pain and provide treatment. Your symptoms are very much consistent with a hernia. Another possibility could be a hip problem, such as a labral tear. That gives the pain with external rotation.
Lastly, an open repair is a perfectly sound option, as long as they also look for a femoral hernia and can repair a femoral hernia via open fashion. I would shy away from any mesh, unless it is a lightweight mesh or you are a heavy built person.
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Frustrated – trying to get proper diagnosis
That sounds like a very unfortunate consultation.
As you may have read on other posts and also online, a hidden hernia is a phenomenon that is well described and known for decades. It is most common among women. Surgery is a cure for the pain associated with it.
That said, it seems yours is not truly a hidden hernia because you actually see and feel a bulge, though only after your workout. This is not uncommon among healthy, young patients with strong abdominal core muscles: they have a hernia, which is a hole in the muscle or fascia, but the hole is maintained and supported by strong surrounding muscles. I.e., you do not have a gaping hole with contents flowing out easily. Your abdominal muscles are trying to keep the hole as closed as possible.
An ultrasound, done correctly with multiple maneuverings, should be able to prove your hernia, though, if the surgeon can feel the hernia or see the bulge, I do not recommend imaging.
Perhaps you can try other surgeons at the same facility. I recommend Dr. Michael Alexander, who is a very talented surgeon at the Shouldice Hospital.
That said, the Shouldice technique would be a great choice for you to repair your hernia, and the Shouldice Hospital in Toronto has published the best results from this technique. Other options are to cross the border or go to Montreal, where I also know reputable hernia specialists, such as Dr. Melina Vassiliou.
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Laparoscopic or Open Approach
I’ve mentioned these before in these posts, and I hope this discussion board can be a tool to spread this information to others, including your physicians:
1. If you have a bulge on exam already, then imaging is not necessary. You have a diagnosis. Imaging rarely offers anything more than confuse the sutuation, such a as the radiologist saying it’s negative.
2. If a CT scan is negative for a hernia, and there is clinical evidence for a hernia (suggestive by story and by exam), then either a) the CT scan is misinterpreted (commonly), or b) you must seek a more sensitive test, such as MRI. In JAMA Surgery, my paper will be out soon that discusses the different imaging modalities and their use to determine hernias.
3. Laparoscopic surgery should only be performed by a specialist who has at least 250 (and some say 500-750) laparoscopic inguinal hernias in their experience. Otherwise, the recurrence rate and complications may be too high. So, do not choose laparoscopic surgery just because It sounds better; in some cases and with most surgeons, open repair is safer and with better outcomes.
4. If no hernia is found, do not undergo hernia repair or mesh placement. You cannot become better. And you may be subjecting yourself to risks. (Perhaps you misunderstood your surgeon: if on one side a hernia is noted, mesh is always placed to cover that hernia and those around it on the same side. That is standard.)
5. If you have a hernia and hernia-related pain, then repair will cure you. In women, the hernia may be small and the findings minimal. However, the associated pain may be severe and repair will help you. Most do not yet appreciate this among women.
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Femoral Hernia
😉
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Possible femoral hernia
It was nice seeing you today! It just occurred to me that you are from this post!
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Inguinal Hernia when Pregnant
Not necessarily.
Bed rest helps all inguinal hernias when they are very symptomatic. I.e., laying flat helps relieve inguinal hernia-related pain.
However, it is not recommended that you have bed rest during your pregnancy to prevent hernia-related pain.
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Lumbar Hernia – Mesh Patch
That is a tough one. Lumbar hernias are very rare. It is possible that you had a tight repair, with mesh, plus… mesh shrinks, so it is possible that the tight repair became even tighter with time. Also, mesh does not stretch, so it may feel even tighter.
The technique and operative findings should be reviewed, based on your operative report. I doubt there is any direct relation to your lungs, diaphragm, and breathing. It may just be a bit too tight.
Removal of the mesh is complicated and should only be done by a surgeon with experience in doing so, after determining that that is the problem.
If anyone else has experience with lumbar hernias, please offer your advice on this site.
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Can an Inguinal Hernia repair reoccurred?
Hernias tend to be genetic. Thus, if you have one hernia, you may have or develop more hernias, but not in the same place. That would be considered a recurrence.
All repairs of hernias have a rate at which they may reoccur. No one can claim a 0% recurrence rate. The recurrence rate varies based on technique and surgeon.
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Recommendations
Hi and thanks for your post.
Our paper will be coming out soon, as it is published in JAMA Surgery. So, then you can share it with your general surgeon.
MRI pelvis with valsalva would be the most sensitive study. Ultrasound may also be helpful if done by a skilled radiologist, with a lot of maneuvering, pushing in and out, etc. CT scan is less likely than all of these to provide an answer. But perhaps it will show…!Unfortunately, the concept of hidden hernias is not widely known.
I do not know of any surgeons in Mississippi who are hernia specialists. If you find one, and you are happy with their performance, please share on this discussion board. Nearby, you can try nearby states:
Tennessee: Drs. Ben Poulose, Greg Mancini, Guy Voeller.
Louisiana: Karl LeBlanc, David Treen, Charles BelllowsGood luck, and please let us know how you do.
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Possible femoral hernia
Glad your orthopedist found something that is treatable.
I also agree that it’s best to have a hernia specialist review the MRI, as a hernia is typically under-called by radiologists. In fact, in my practice? Less than ¼ of images are accurately diagnosed for hernia.And, yes, I have seen patients with both problems, but it is rare.
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Mesh removal after hernia repair
At this time, there is no specific test.
I am working on a research project to determine exactly that problem.
That said, a true mesh allergic reaction is very very rare. You would know it. There would be a red patch of skin outline of your mesh. However, many have an intolerance of the mesh, with persistent inflammatory reaction and/or chronic pain. That is much more common. There are no tests for it now but hopefully, if my research pans out, there may be one soon. -
Mesh removal after hernia repair
Omyra mesh is an ePTFE mesh that is macroporous, ie, there are holes in it that are wide, allowing in-growth of tissue. There is little clinical evidence about this mesh and it is not a mesh with broad usage by surgeons, so I cannot scientifically assess it’s risks and benefits.
Proflor is also newly introduced in the US. There is more experience with this mesh outside the US and it has been positive.
My bias is that bulky mesh (such as Proflor) and shrinking mesh (such as ePTFE, similar to Omyra) have drawbacks and I prefer simpler mesh products.
Mesh removal is only indicated if there are mesh-related complications. Headaches and fatigue may be related to mesh reaction (inflammation) or mesh infection. I do not recommend mesh removal due to hernia recurrence. Mesh removal is a complex operation with multiple risks, and it should only be done by specialists. Laparoscopically placed mesh can be removed laparoscopically, by a skilled surgeon with prior experience. There are serious risks associated with this problem.
The Desarda technique is a non-mesh hernia repair technique promoted by Dr Desarda of India. It’s longterm results remain to be seen.
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Possible femoral hernia
Yes! And thanks for your post.
First, my research had shown that CT scan is very unhelpful for small or hidden hernias in the groin. Ultrasound and MRI is better. So the fact that CT scan was negative despite your symptoms means 1) it was not read specifically to look for hernias. 2) the hernia is too small to see on CT. When symptoms are suggestive and CT is negative for hernia, I recommend MRI.
Femoral hernias can present with pain radiating down the from of the upper thigh. Sometimes it can also radiate up and out to hip and lower back. They are often too small to be felt on exam. So, symptoms are important to determine the plan of care. Pain is often activity related, with pain while sitting for a long time, sneezing, standing on your feet.
I recommend MRI pelvis, without contrast. I have developed a hernia protocol which includes Valsalva and dynamic images to accentuate very small hernias. In my experience, women are more likely to have small or hidden hernias and they can be very painful.
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pain in my right groin going around my back
Let us know how it goes with Dr Jacob.
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pain in my right groin going around my back
Dr. Jacobs has read all that you have posted on HerniaTalk.com and his recommendations come based on the information you provided, discussion with me, and his significant experience.
I defer to you and the surgeon you choose to treat you to have a discussion about what is ailing you and how it can be treated. That said, if you wish to have a cure, and surgery is the cure for your ailment, then you must mentally prepare yourself to make that decision. It is a decision you must make alongside your surgeon.
I am truly shocked with the number of repeat imaging studies and other procedures you have had in a very short time. Thus, my hesitation that another study is being ordered, when a prior study has already answered the question. Besides, you should save your resources for actual treatment by a specialist, rather than performing studies which may not be necessary.
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pain in my right groin going around my back
Please explain why you are afraid of laparoscopy and what you believe laparoscopy entails.
Laparoscopy is your best option if he believes you have examination findings suggestive of a structural problem.
As I explained before: I do not recommend more imaging. But to answer your other question: no, no contrast is indicated for the MRI. And yes, MRI pelvis will show your appendix.
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pain in my right groin going around my back
I do not recommend more imaging.
Colonoscopy does not cause hernias. Not do I believe it is causing your groin pain, though I don’t have the privilege to examine you.
I recommend you see Dr Jacob and take him all your studies. He is aware of your post. Let his office know you were referred by me and you have posted on herniatalk.com. -
pain in my right groin going around my back
What insurance do you have?
Most hernia specialists have limited insurance carriers and/or are out of network.
Dr George Ferzli is another gifted surgeon in NY who may be of help.
You can also consider searching for doctors on the americanherniasociety.org. Website.
If you cannot find one, I strongly recommend you invest in a hernia specialist. I am shocked that you have had such a runaround of care and waste of resources to date, wth expensive tests and procedures and exposure to radiation.