drtowfigh
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Dear rcl0223,
Very good questions about nerve damage and chronic pain with mesh vs with tissue non-mesh repair. It is a myth that non-mesh repair has lower chronic pain or nerve damage risk. The best study on this was also the first to study such an issue. It clearly shows a significant chronic pain risk with non-mesh tissue repair. See attached. Note that this study was done during an era where most of the surgeons were skilled in non-mesh tissue repair. Everyone was focused on reducing hernia recurrence back then (hence the advent of mesh repairs) and that was the main outcome that was measured. Pain was assumed to be part of the profile of hernia surgery. But once hernia recurrence was a lesser issue (due to use of mesh), then the importance of and interest in chronic pain increased.
Today, the outcome numbers quoted for non-mesh tissue repairs are all over the place. The reason may be that the recurrence and pain/nerve injury rate is very much a factor of the surgeon’s technique and experience. Each surgeon and institute has their own data. For example, recurrence rate may be between 0.5% and 15%. Chronic pain may be between 1% and 20%. The outcomes from tissue repair are no longer as predictable as the more standardized mesh technique.
Attachments:
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Dear A2ZTXMOM,
Sorry your son has pain. It is very important to determine the exact cause of the pain before delving into invasive procedures. Mesh removal is always possible, and best performed in the hands of expert surgeons who do so for a living. However, it should not be taken lightly. It is not common to have a true mesh reaction. It happens, but it is not common. More commonly, there can be a meshoma (folding of the mesh) or a hernia recurrence. Also, nerve injury or spermatic cord injury is possible. Each of these has a different optimum treatment.
Depending on the timing and type of pain, your surgeon can guide you through the best treatment plan. I am happy to see your son. You can also search through this site for surgeons near you who can handle this.
Are you from Texas? I don’t know of any of my colleagues who can offer you the type of evaluation you need in Texas. Tennessee may be the closest for you
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Fair enough.
Bard did not carry a lightweight mesh until the past decade or so. It’s called Softmesh.
Ethicon is the only major brand that has ultra lightweight mesh. Its density is about half that of Softmesh. It’s very very lightweight and many of us feel it would be too lightweight for some inguinal hernias, such as a recurrent hernia or a direct hernia.
The mesh and its exact type and lot number should be logged somewhere in each patient’s medical records. Usually it’s in the nursing record of the operation.
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Can you clarify? The Bard Softmesh is the lightest weight mesh that Bard carries.
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Glad the distention is improving. If part of it was due to the spineal stenosis, then perhaps your muscles are recovering from that.
I cannot answer any questions about cancer. That is a whole different forum.
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As long as your pain is gone, there is no need for surgery.
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The recommendations for exercise are based on low impact exercises that focus on core strengthening and that also do not increase abdominal pressure. There is a bit of research done on this. Most exercises are considered safe and/or encouraged. These can include safely performed weight lifting, situps, Yoga, Pilates, cycling. Jumping and squats are considered to increase the abdominal pressure, so I recommend no Cross-Fit type exercises.
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Femoral hernias should be repaired, as the risk of strangulation or at least incarceration and need for surgery, are quite high in comparison to other groin hernias.
Did the ultrasound confirm a femoral hernia? They are uncommon and often not diagnosed early.
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Sounds great, mamadunlop. It’s due time you get your definitive repair. I strongly urge my patients with elevated BMIs to reduce their weight. It will be the best decision before seeking hernia repair.
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Please exercise! It is good for hernias… at the least, it keeps the muscles around the hernia strong and may even reduce symptoms.
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Dr. Ramshaw is always an excellent choice. Also, Dr. Igor Belyansky (MD), David Chen (CA), and of course, I am happy to review your situation and see how I can help you.
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There are many studies comparing different mesh products and techniques. There is no best mesh. There is no ideal mesh. Whereas one patient may do very well with one type of mesh, another would not. For example, perhaps an obese patient will do better with a heavier weight mesh, a thin patient may do better with a lighter weight mesh or no mesh, a patient with a wide-based hernia may do better with a sandwich type designed mesh. A direct hernia may be best treated with a heavier weight mesh, but what if you are thin and have a direct hernia or a wide-based hernia? The permutations are plenty. There is no formula to plug in to tell you which patient will have the best outcome with which technique. Each surgeon has a different outcome with each technique and each patient has a different outcome with the same technique. That is where the art comes from.
Many mesh companies profit nicely from selling implants, especially since mesh repair is considered gold standard in the US. Surgeons don’t have contracts with mesh companies. In fact, in many situations, the type of mesh carried is an economic decision.
Medicine, as you may have figured out by now, is not a profits-first business. Patient needs supersede profit margins. Unlike most businesses, patients’ lives come first. So, e.g., if the patient requires a certain treatment, implant, procedure, etc., and they can’t pay for it, or their insurance doesn’t cover it, or the insurance pays too little to make the procedure profitable, that is often not a reason to prevent the patient from having a life-saving, life-altering, or to withhold health care. It is part of the reason why the US healthcare is bankrupt: improvements in technology and availability of new technology precludes the doctors to take advantage of the new technology and provide the best care to their patient, even though it is often at higher cost. Same with pharmaceuticals. The real winners are the industries that provide this technology. For sure, it is not the doctor. They intend to provide the best care for their patient.
Perhaps this is too much information.
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All good points, Good Intentions.
The problem is partly that patients and surgeons look at the same problem differently and perhaps there is some loss in translation.
When I mention the importance of listening by the surgeon, you validate my point because it frustrates you when your surgeon barely hears your words. Also, listening and learning from the patient allows the surgeon to tailor the operative plan to each patient’s needs.
Recurrence is not the only outcome by which we measure hernia repair success. That was proven to us in the mesh era, when recurrence became a much lower problem (as compared to non-mesh tissue repairs), and chronic pain raised as a more important outcome of measurements. Almost all modern studies, including outcomes databases such as the AHSQC, include short term and long term quality of life parameters as a measure of outcome, and therefore success, of hernia repairs. That said, hernia recurrence can significantly affect quality of life, so it should not be discounted as one of many outcomes factors. Europeans are much more advanced in tracking population data than in the US.
There are a few surgeons, Dr. Ramshaw being one of them, where research is being performed with the goal of helping predict the best plan of care/surgical technique/mesh implant, etc., for each patient characteristic. It is quite a complex system of analysis. To date, there is no science that can predict the best surgeon/technique/implant for each individual patient. Each surgeon can only apply his/her best knowledge and experience to help determine that on an individual basis.
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Thanks for your post.
– if the mesh is not mentioned on CT scan, that does not necessarily imply it cannot be seen. Most mesh are visible on CT scan. This is the reason why I read the images myself, as radiologists may not be familiar with normal and abnormal findings related to mesh hernia repairs.
– the Ethicon mesh for laparoscopic inguinal hernia repair has not been recalled.
– recurrent inguinal hernias are best repaired with mesh, otherwise the recurrence is very high and after recurrence. That said, if the hernia was repaired when your husband was a child (not a teenager), then it is plausible to seek a non-mesh repair, as many of us do not consider that type of recurrence similar to a recurrence of an adulthood repair. That said, the recurrence may still be higher than a non-mesh repair and you and your surgeon should have an understanding of the risks and benefits of each repair before embarking on surgery.
– strongly urge against any further hernia repair until all risk factors for failure are addressed. In your husband’s situation, the coughing due to postnasal drip must be cured. -
There is no standard. Every institution and surgeon has their own protocol as to whether they require that patients urinate after hernia surgery before they are cleared for discharge home.
The risk of not requiring this is that the patient in fact may not be able to urinate after surgery. It is a well known risk after hernia surgery of all kinds. If you cannot urinate then you will need to be seen in the emergency room to decompress the bladder/rest the bladder with a urinary catheter.
Burning with urination is a common initial symptom with the first or second urination if a urinary catheter was placed and then removed.
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Good Intentions,
Just to clarify: surgeons do not implant mesh for material gains. There is no gain in implanting mesh. Surgeons don’t get paid extra to place mesh in patients. Institutions/facilities lose money each time a mesh is implanted in a patient, as there is no extra payment for that procedure.
There are a lot of quality of life studies performed on patients with and without mesh implantation. It is a fallacy to believe that non-mesh patients in general, as a population, have significantly improved quality of life. That has never been proven.
However, population studies and trials are different than individual experience. For sure there are individual patients that have complications after hernia repair with mesh. Of that population, some of the complications may be directly related to the mesh itself. We are struggling to determine the mesh-related risk on an individual basis before it is implanted in a patient. There are a few studies looking into it.
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Good Intetions:
The American Hernia Society has a Quality Collaborative (AHSQC) that many of us submit our patient lists to in order to provide some quality comparisons with national outcomes and those of our peers. Please encourage your surgeons to register and submit their patient outcomes into this prospective database.
The reality is surgery is as much an art as it is a science. Surgical technique is one determinant of outcome. Patient characteristics are very different and also affect outcome. No one technique is the best for all patients.
Also, it may seem true that surgeons with longer number of years may be better at what they do, but that is not always the case. One can do the same procedure one was taught in residency, and perhaps newer and better techniques have been developed since then. What is most important is that your surgeon has an interest in doing what they are doing, listens to the patient, and is involved in self-education.
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I’m happy to help. Contact my office and speak with Sheila (sheila@beverlyhillsherniacenter.com, 310-358-5020) and she can make it happen.
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I am sorry to hear about this.
There are a lot of reasons for abdominal distention. If it is related to eating (e.g., wake up in the morning flat, then look pregnant after any oral intake), then a gastroenterologist needs to be involved. If the distention is only on the left or right side, i.e., asymmetrical, then that may be due to nerve damage at the spine level. If there is a history of pregnancies and weight gain, then diastasis recti is a possible contributor.
Some of these are correctable problems. A CT scan can help with the diagnosis.
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Saro,
A scrotal inguinal hernia may not necessarily have any higher risk of strangulation than a non-scrotal hernia. In fact, some may argue the risk is lower, as the hole is actually wider.
