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I believe neurectomy should be performed judiciously and only if absolutely necessary.

For open inguinal hernias, many believe in the triple neurectomy. I believe in selective neurectomy and that is my practice.

Fortunately for robotic or laparoscopic mesh removal, neurectomy is almost never required. If it is, it’s usually limited only to the genitofemoral Nerve.

My results are 80% are cured or significantly better after mesh removal and/or neurectomy. The other 20% require further treatment or there is a non hernia related cause of their problem.

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Those of use who do tissue repairs and mesh removal are few.

On the West Coast: I do them. I know Dr Brown does them. Dr Nguyen is a new hernia surgery resource for those in the Kaiser Permanente system, which may be why you can’t read much reviews on him. I don’t know how adept he is with tissue repairs.

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Hi
It was in our list but we didn’t get to it. Will try next week.

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Thanks everyone for participating. If you missed tonight’s Live Q&A session, you can watch it on my YouTube channel: https://youtu.be/HwOuUTeX-oQ

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Thanks. Don’t forget to register (link in original post) or watch it on my Facebook live (@Dr.Towfigh) this Sunday!

Keep sending me inguinal hernia and tissue repair questions. As you know, Dr Brown has been a wonderfully active surgeon participant in this discussion forum.

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So glad you all enjoyed it. The full hour with Dr. Jacob can watched on my YouTube Channel: https://youtu.be/jhXCmTeP1vc

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It would be very rare to have a systemic reaction to suture material. They are not enough foreign body to mount such a MJ autoimmune or inflammatory reaction.

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I understand. I will record it and post it on my YouTube channel for others to view later. Let me know what other times work for you for me to consider for future Q&A sessions.

Hi there,
We will have our first LIVE Q&A session this Sunday.
I hope you can all join. Please share.

You are invited to a Zoom meeting.
When: Apr 5, 2020 05:00 PM Pacific Time (8:00 PM Eastern; +7 GMT)

Please register in advance for this meeting:
https://zoom.us/meeting/register/vpclduuqqTstBkgwxTgGzQ2AMfm4YqyBDA

After registering, you will receive a confirmation email containing information about joining the meeting.

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Hi everyone
Let’s plan for this weekend: I will devote an hour Saturday and an hour Sunday. I’ll confirm date/times shortly. It will be on Zoom.

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Hi everyone
Let’s plan for this weekend: I will devote an hour Saturday and an hour Sunday. I’ll confirm date/times shortly. It will be on Zoom.

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Likely no major consequences. Depends on what is actually in the hernia. I recommend robotic approach next time. It’s a better repair for most of them.

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Nice idea.

Any particular times that work best? I may experiment.

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That’s helpful.

I looked Into Zoom. It seems to be better for face to face live discussions with patients. And everyone can watch it too. Thoughts?

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Wow. Likely your surgery is canceled. But odd that no one contacted you. We are not expecting to be able to offer elective surgery until May at the earliest

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Make sure they remove ALL the mesh. Many surgeons leave mesh over dangerous areas (eg, Major vessels). To truly address ASIA syndrome, all the mesh must be removed. If they are too afraid to take off some mesh, then they should have a surgeon do it who feels more comfortable with the anatomy and operation.

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1. In my experience, ASIA syndrome and mesh reactions tend to occur early, ie, weeks to months after surgery, not late (years. That said, this remains a poorly understood problem. Note that the syndrome involves multiple systemic reactions, not just brain fog.
2. Regardless, with regard to robotic mesh removal, the only nerves that can be injured are the genitofemoral and lateral femorocutaneous. Neither affect erection. And in general, sacral nerves contribute to erection, and no sacral nerves are at risk with any hernia repair or revision.

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My take:

OPEN WITH MESH
Pros:
– can be done under local anesthesia with sedation. Ie, no general anesthesia.
– allows for plication of tissue in case of direct hernia.
– allows for reconstruction of giant inguinal hernias with complete pelvic floor blowout
– cosmetically hidden scar in hairline
Cons:
– mesh interacts with spermatic cord and can cause testicular pain and affect sexual function
– mesh can interact with nerves.
– mesh at risk for infection (low risk)
– mesh-based chronic pain, tightness, shrinkage
– larger scar than laparoscopic
– longer recovery than laparoscopic
– higher recurrence than laparoscopic if done by specialist.

OPEN REPAIR WITHOUT MESH
Pros:
Pros:
– can be done under local anesthesia with sedation. Ie, no general anesthesia.
– no mesh-related complications
– cosmetically hidden scar in hairline
Cons:
– highest recurrence rate of all options (Data claiming lower recurrence rate is based on cherry picked low risk patients)
– chronic pain risk due to tightness, tear, nerve injury/entrapment. This is important. Chronic pain is a real problem with tissue repair as well.
– larger scar than laparoscopic
– longer recovery than laparoscopic or open with mesh

LAPAROSCOPIC REPAIR WITH MESH
Pros:
– small scars
– short recovery
– lowest recurrence rates of all options
– lower risk of mesh-related complications than open repair with mesh
– less nerves at risk of injury as compared to open repairs
Cons:
– requires general anesthesia
– visible scars, cosmetically
– mesh-related complications, including adherence to spermatic cord, folding
– direct hernias and giant hernias are mostly patched and not plicated or sewn (robotic approach allows for sewing).

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Watchful waiting has been studied prospectively for up to 10 years. The risk of needing emergency surgery was 0.18% per year. That’s a very low number, and thus watchful waiting is considered safe in men with asymptomatic or minimally symptomatic inguinal hernias.

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– unfortunately, many use the term “hernia specialist” as a marketing ploy and are not true specialists.
– in Crohn’s disease, make sure the mesh is never place inside the abdomen (intraperitoneal). Otherwise, it should be fine. But I agree with @drbrown that I would prefer a non-mesh repair in patients with Crohn’s, if possible, to reduce risk of disease exacerbation by the inflammation from the mesh.

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– tissue repair is also on more tension than before the repair. You are closing a hole between two potentially weak tissues. There are ways to reduce the tension and muscle does stretch.
– mesh shrinks 10-25%. ePTFE mesh shrinks 40% and most surgeons don’t use that die inguinal hernias. Yes, if placed loose to allow for that shrinkage, a mesh repair can be without tension with excellent results.