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Hi Bob P,

Have you had an evaluation of your umbilicus? I wonder if you have a hernia recurrence.

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Yes, I would go back to the surgeon. He/she has more insight into what he/she did and so there are no surprises. They can make the best decision based on that knowledge about you.

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So sorry to hear about this. Dr. Paul Szotek is an excellent resource for you in Indiana. It seems you need an abdominal wall reconstruction.

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If you Dr. Meyers’ tissue repair resulted in pain, without an obvious hernia, sometimes there are microtears or tears resulting in an unstable repair. Supporting the repair with mesh may be helpful. Choice of mesh will be important.

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Primary first-time hernias may be successfully repaired without mesh. I offer a robotic option for this as well.

Once the tissue has been affected with prior operations, then the results from non-mesh repair are dismal. More than half will fail, and then you are left with a more complex hernia to re-repair.

There are new hybrid mesh that may be a good compromise in a patient such as yourself. For example, TelaBio has a new product, Ovitex, which has minimal amount of polypropylene in it. The rest is a high quality biologic tissue with low inflammatory potential.

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Mesh removal remains a rare operation. The grand majority of patients do well with mesh, do not need it removed, and have a better long term outcome with using mesh than non-mesh options. I am hopeful that newer products will reduce the need for mesh removal in even this small subset of patients.

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This sounds highly concerning for an inguinal hernia. What is pelvic tension myalgia, anyway? Please see a hernia specialist or a general surgeon to get evaluated. You need not suffer so.

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Dr. Novitsky has published about preoperative optimization. L-arginine supplementation has been shown to improve outcomes from abdominal surgery. Nutrition in general is important, focusing on a high protein diet, as proteins are the building blocks of healing. Vitamin C and Zinc supplementation are associated with improved healing. Not much research has definitively shown any other OTC supplement to help with healing.

For sure, removal of mesh off the external iliac vessels can be risky. I have removed all the mesh in all of my patients, with 4 exceptions. However, I see patients with mesh-related pain, not just meshoma-related pain, so 100% removal is more important in that subset of patients.

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To clarify: my data is solely focused on mesh removal after inguinal hernia repair. Outcomes and safety from removal of mesh after abdominal/ventral hernia repair are much much better. There are typically no major vessels or nerves in the region of the abdominal wall or ventral hernias, and these are at risk with inguinal hernias. Abdominal and ventral hernia mesh may involve intestine, and so careful technique remains paramount regardless of the type of mesh removal.

Note, that this data is specific to me. I perform this procedure of mesh removal on a regular basis, so these numbers may be different by other surgeons, especially if they are not specialists. Yes, mesh removal has its dangers. I strongly recommend against mesh removal from an inguinal hernia unless performed by a surgeon with experience.

Clots, such as deep vein thrombosis, may result from a long operation (e.g., 4 or more hours) or immobility. We usually do not blame the operation itself if the clot and associated death occurs years after the operation.

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The majority of abdominal wall hernia repairs result in some amount of seroma fluid. We do not address this unless there is tightness and pain associated with it. They resolve on their own.

Seroma fluid typically occurs because the space where the hernia used to bulge from is now empty. The body doesn’t like empty spaces, and so it fills the space with fluid, until the space scars in.

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Andrew,
It sounds like you had an open inguinal hernia repair with mesh. The recovery is different from person to person, and it can be technique-dependent.

It is not uncommon to hear symptoms such as yours in the early stages of a repair. Stabbing pain, searing pain, to the point that it catches you off guard, may be part of the normal healing. We just don’t know who will be feeling these symptoms. I think these symptoms are due to the tightness of the repair and the inflammation reaction from the mesh. So, I recommend anti-inflammatory regimens: e.g., ice works really well. Also, Aleve (naproxen), taken daily. As for the tightness of the repair, perhaps increasing activity such as walking and stretching of the groin, slowly, can help rehabilitate the region.

In rare cases, there may be a nerve injury at the time of the repair, and this can cause excruciating neuropathic pain. This is rare and the pain is felt within hours to about 3 days after surgery.

Nerve entrapment is a different scenario. If it is entrapped by a suture at the time of the repair, then that is basically the same presentation as a nerve injury. Nerve entrapment by scar tissue or mesh does not occur until much later. Usually 6weeks to 6 months after surgery. And, no, as far as we know, there is no scientifically proven way to reduce the risk of nerve entrapment by scar or mesh.

Unless there is a clear finding of nerve injury or a failure of the repair, we surgeons usually do not re-operate or perform any intervention until 6weeks to 3 months after surgery. Depending on the severity of the symptoms (e.g., if they are mild), some may even allow 1 year or so to pass, as most of these symptoms have shown to resolve on their own as your body remodels the scar tissue in the area and the mesh- and surgery-related inflammation reduces.

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In general, if performed by a skilled surgeon, especially one who performs mesh removal on a regular basis: Yes, mesh removal is safe.

Of course, it can happen, but it would be expectedly rare to have a death, loss of limb, or other devastating complication from mesh removal.

I presented my own data on mesh removal after inguinal hernias. 84% had improvement in their pain, of which 22% had a cure (pain of 0/10 or 1/10). However, it is not necessarily a cure-all. 16% had no improvement or worse pain after surgery. They required more procedures, including nerve blocks, cord denervation, etc.

Mesh removal for infection is much safer and easier to perform.

Mesh removal from the abdominal wall is much safer and easier to perform than from the groin

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What you describe (barbed wire under the skin and into the inner thigh) is suggestive of nerve pain, specifically the ilioinguinal nerve. This may be temporary and just due to inflammation in the area, which will resolve. Anti-inflammatories, such as Aleve, may help with this until your are fully recovered. If it is severe, then neuropathic pain can be temporized with a local injection of anesthetic with or without steroids. A surgeon or pain medicine physician can help with that.

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Hidden hernias in women usually have pain in the same area, with radiation to the hip, back, vagina, or down the leg. Infrequently, we see an isolated burning pain and that is all. With extra sensitivity in the area.

MRI pelvis should be the most sensitive study to identify this. It is best when performed with beardown views AND correctly interpreted by your radiologist and/or surgeon.

Psoas impingement is activity related. And the area is usually not tender to touch. A good orthopedic surgeon should be able to help figure that one out. Other hip problems can also exist, such as labral tear.

You need a detailed review of the entire scope of issues and then your pain can be treated successfully. I would be happy to see you in person or you can choose to send me your information to review and help figure it out. I offer online consultations for those who cannot fly in to see me.

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In my opinion: a return of symptoms after a hernia repair done years ago is a hernia recurrence until proven otherwise. A good general hernia surgeon who may also be able to perform laparoscopic surgery, would be the best start.

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True and astute observation: if you have more fat under the area of the mesh placement, then removing it is somewhat easier over sensitive areas, such as nerves and vessels.

That said, we don’t typically place mesh with the primary intention of removing it. :p

Very very thin people have virtually no fat in these spaces. They have been shown to have more postoperative chronic pain, possibly due to the lack of fat to buffer some of the inflammation and stiffness from the foreign body. I usually tailor options for patients, including taking their BMI into account, when recommending options for them surgically.

Most people naturally have fat in these places, even if they are considered thin by U.S. standards. That amount of fat is adequate. Also, you cannot gain fat in the retroperitoneum. You either have it or your don’t and gaining weight will not preferentially increase the size of the fat cells in the region. If anything, gaining weight may jeopardize the outcome after mesh removal, by increasing surgical site infection risk and hernia recurrence risk.

Short answer: no, we do not recommend gaining fat prior to mesh removal.

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Thanks for sharing the video on Parietex. In my opinion, it is a very very misleading video and I disagree with much of its content.

Specifically:
A) Parietex ProGrip is not impossible to remove. It is no different to remove than any other mesh. I have yet to find a mesh that is “impossible” to remove. And I perform more mesh removal than almost every other surgeon in hernia.
B) We have not seen the Progrip to be “the most defective and dangerous” hernia mesh on the market. In fact, those of us who are in the know, have remarked that we see a disproportionately lower number of patients with mesh-related chronic pain due to ProGrip as compared to other mesh.

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The recovery from open non-mesh/tissue repair is on average longer than that with “tension-free” mesh repair, although complications from mesh have been encompassing most of the complaints posted on the internet. One of the reasons why mesh repair gained favor in the 70s over tissue repair was exactly for this reason.

Now, you should not be in so much pain many months after your operation. The reasons for pain may be many. From a tissue repair, the most common reason for pain is that it is now a relatively tight area as compared to prior to the operation. So, imagine wearing a tight pair of jeans. That can be uncomfortable. You mentioned your hernia was larger than average. After your hernia repair, since there is no mesh there, your natural tissue will often stretch out in the area to accommodate for the tension in the region. It may take at least a year to notice appreciable stretching.

The risk with a tight repair is that it will not stretch out enough for you to remain pain free, and if you fall, you are at risk of tearing the repair. That implies another repair, with mesh, and then you submit yourself to possibly recurrent issues in the area. This is why I feel that the decision for a non-mesh/tissue repair must be tailored to the needs and lifestyle and risk factors of the patient.

In short, if you just have pain in the area, and your doctors have deemed there is no neuropathic (nerve-related) component to it and you have not torn the repair, then most likely it is because of a relative tightness in the area. In my practice, I would not limit your activities. If you tear it, such as with a fall or other reason, it was inevitable and not necessarily related to any one specific movement. Remaining fit and being in good physical shape and fit can help protect from a tear. Also, slow stretching such as Pilates or some Yoga, can help.

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Ziggy,

Thanks for the heads-up on the pictures. We fixed the problem.

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Every surgeon has their own spiel regarding risks and benefits of hernia repair. Discussion about chronic pain varies based on each surgeon’s expected outcomes and experience. Trust that your surgeon did what she felt was in your best interest. Surgeons and other doctors in general want the best for their patients, including good outcomes, which is a reflection on them. So I do not want to encourage a pessimistic analysis on intentions of your surgeon. As an example, if you had nausea and vomiting after surgery, that is typically either from the anesthesia or is unrelated to your operation.

I agree that you need an evaluation of your repair. Imaging will be an important part of it. Dr Petersen is a very good option for patients like you who have had open hernia repair with mesh.

but mesh removal and revisional surgery is serious. For example, In women, there is risk of nerve injury or need for nerve being cut which my affect sensation to the labia and possibly therefore affect sexual gratification. Thus I would still encourage you get more than one consultation to understand your diagnosis, treatment options, and all risks and benefits associated with each option.