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Questions to Ask General Surgeon

I suggest you search this forum for discussions about women’s hernias. There is a lot more written than I can repeat on this thread.

You are correct that women’s hernias are often overlooked. This is because the presentation and findings of inguinal hernias are often different among women vs men.

Symptoms range from groin pain to pain radiating around the back, into the vagina, down the upper thigh or inner thigh. It is worse during periods. Nausea and bloating may be notable. It’s worse at the end of the day, best with lying flat.

If you have point tenderness at the internal ring when you are being examined, that is the most sensitive finding predictive of hernias among women. We reported in our study that 87% of women with chronic pelvic pain and this finding on exam ended up having an inguinal hernia, and surgery will cure their pain.

A dynamic ultrasound or MRI pelvis will help confirm this diagnosis prior to surgery.

In my experience, a skilled surgeon who will listen to your story as oppose to rely on typical exam findings seen among men, will suit you fine.

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Learning about various techniques: Dasarda Technique versus Mesh surgery?

Tissue (non-mesh) repair is usually an option for inguinal hernias. There are multiple options for tissue, the most common and highly validated being the Shouldice repair and the Bassini repair.

Technique and the expertise of your surgeon in performing a tissue repair is of utmost importance, as these are most likely to affect outcome.

That said, in general, long term outcomes are best with mesh repair, when looking at hernia recurrence rates. They are typically (much) lower with the mesh repair. Anyone who claims a less than 1% hernia recurrence rate with non-mesh repair should be queried as to their data, whether it is published in a peer reviewed manner, length of followup, how recurrence was determined, etc. It is very difficult to get recurrence rates that low with tissue repair, as it relies on the integrity of the Patient’s tissues, and anyone who has a hernia, by definition, has some tissue impairment. For example, studies show lower amount of mature collagen in Patient’s with hernias. This, sewing abnormal tissue to itself is more likely to fail than if new tissue/mesh is brought in to support the repair.

Chronic pain may be more in some patients with mesh implantation. And that is certainly a trend we are seeing in this age of mesh use as the gold standard for hernia repair of the groin. However, non-mesh hernia repair is also at risk for chronic pain. In fact, there are studies which show no difference in incidence of chronic pain between the mesh and non-mesh eras.

With regard to the Desarda technique, I am certainly familiar with it. My concern is that it is similar to a technique performed in the 1950s/60s which was eventually abandoned due to its high recurrence rates. I remain skeptical about it until there is more validation of this technique.

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Small Umbilical Hernia Repair Advice

Looks great. Your swelling will reduce with time.

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Swollen Groin after Mesh Removal

Laparotomy for a laparoscopically placed mesh removal seems a bit extreme, but laparoscopic removal of laparoscopically placed mesh is performed by very few of us in the nation so sometimes you have no choice but to do what your surgeon is most experienced with.

Did you have your hernia repaired after the mesh was removed? If so, in what manner?

Seroma or hematoma fluid collections can be easily ruled out with ultrasound.

Did you communicate these findings with your surgeon? We have our out of town patients send us pictures or do followups by email, phone, even FaceTime as needed.

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Groin Pain – 4+ years of pain and frustration

Sounds like you initially had groin pain due to recurrence from the first operation.

The Gore BioA plug is absorbable. As far as I know, it’s intended to be used with the patch. I don’t use it.

Then after the laparoscopic hernia repair with mesh, you have pain. The question is why? Is this another recurrence? A balling up of the mesh (meshoma?) pain related to a nerve injury or spermatic cord injury?

To help answer that, we need the following:

– what is the type and quality of pain? Does it radiate to the testicle, around the back, down the leg?
– exactly where is the pain?
– what sets off the pain? Is it constant or related to certain activities?
– imaging will help show recurrence of meshoma. I would order an MRI with valsalva in my practice

These are all part of a thorough work up to get to the answer so that your pain treatment can be efficient and effective.

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CT scan without contrast

Make sure the CT scan is done ” with valsalva.”
It means you bear down. That may show a small hernia better.

A CT scan should be able to show most Spigelian Hernias.

Good luck!

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How hernia surgeon could miss hernia?

Yes, it is possible to miss a hernia during laparoscopy, unless the peritoneum was take down and the fascia level itself was visualized.

Not sure where or what the picture is showing as there is no obvious Spigelian or incisional hernia seen. Perhaps point to the area?

Spigelian hernias are very difficult to see or palpate unless they are large.

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Fat in Inguinal Canal vs Hernia vs Cord Lipoma?

If you have groin symptoms that are carefully evaluated and found to be consistent with a groin hernia AND you have tenderness in the are on exam with or without a bulge AND you have fat in the inguinsl canal, then that is a symptomatic inguinal hernia in my book.

I disagree that fat in the inguinal canal is normal and expected. I believe that is always a hernia. If you’re not symptomatic from it then that is an asymptomatic hernia and there is nothing to do about it. That’s all.

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Pain in LLQ started about 2 months ago

Thanks for posting!
Definitely sounds like this could be a groin hernia, especially based on location description and types of symptoms.

Read the earlier post on Chronic Lower Left Quadrant Pain http://herniatalk.com/hernia-discussion/1078-chronic-lower-left-quadrant-pain.html

Have your general physician order s dynamic hernia ultrasound of both groins. That’s the first start.

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Hernia Surgeon

Dr Goldstein would be a great choice for you!

In some, the urachusbis patent (open) and is basically a communication from your bladder up to your belly button as a small tube down the middle. A CT scan with contrast or ultrasound can tell you if you have a patent urachus. It’s not common and your symptoms are likely due to your hernia.

In TEP, the fascial entry is actually to the side, so it’s a non-issue with the urachus. I agree with Dr Earle that I would not change the port placements based on this supposed problem. If a patent urachus is noted, it can be addressed and should be stapled off very low at the bladder level and sent to pathology for examination.

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Training in Radiology

CT scans: most surgeons can read one but usually not as accurately as a radiologist.
MRI: very difficult to read. Most surgeons cannot read them well.
Ultrasound: is very technician-dependent and a good hernia ultrasound is hard to come by. There are a lot of maneuvers which need to be made. And that can confound the ultrasound interpretation. Similar to MRI, most surgeons cannot confidently read ultrasounds for hernias.

Radiologists are not good at reading or checking for hernias regardless of the type of imaging. You really have to push them into looking specifically for a hernia. In my opinion hernias are low on their priority list when reading films. And most doctors rely on the radiologist’s report and do not re-evaluate the image themself.

This is a huge shortcoming of imaging for Hernias.

I read my own CT and MRI for exact this reason, but ultrasound is still difficult.

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Inguinal hernia?

Read recent post on “Chronic Lower Left Quadrant Pain”
http://herniatalk.com/hernia-discussion/1078-chronic-lower-left-quadrant-pain.html

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Chronic Lower Left Quadrant Pain

Hernias in women can be painful with minimal bulging or other exam findings. The pain is usually just above the groin crease. It can radiate around to the back, down the front of the leg, into the labia or vagina, and sometimes up toward the belly button. The pain is typically activity-related, such as with bending, straining, prolonged standing, coughing/laughing, prolonged sitting. It may be worse during your menses.

A truly negative MRI is usually a good bet you don’t have a hernia. The MRI must be of your pelvis and with addition bear-down (valsalva) views.

If it’s debilitating, I agree with Dr Earle that it may be worth it to have a surgical exploration or get a second consult from a hernia specialist especially one interested in hernias among women. Where do you live? We can help you find one.

If not life-altering, then carry on with your life, including exercise, and time will demonstrate if this is a hernia.

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Fascia Tightening ??

I have run this case by a couple of vascular surgeons. They have not seen it to this extent with even lower extremity fasciotomies, where you would expect even more problems. Their concern is perhaps there is an outflow obstruction that is causing the painful pooling of blood.

Have you been evaluated for venous flow obstruction? Perhaps a deep venous thrombosis of the upper extremity or a thoracic outlet obstruction in the shoulder or neck region cruising reduced flow of venous blood back to your heart on that side?

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Auto immune disease and mesh rejection

BIOLOGICS mesh are derived from Cadaveric tissue from humans or animals. It is decellularized so there is no immunologic rejection. The basis is mostly collagen and other fibers. Depending on the manufacturing, they can be very inert with little to no inflammation associated with it, unlike synthetic mesh b

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pain in my right groin going around my back

Hi
Any update?

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recurrence or normal healing from multiple hernias

Hi
Please provide an update

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Femoral Hernia

Ldavis:

Try Dr Goodyear in Lansdale.

Also log on to http://www.americanherniasociety.org and see if any surgeon in your state is located near you

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Auto immune disease and mesh rejection

Sandiego,

My inclination to your question is: YES!

We have no proof that patients with autoimmune disorders have a different reaction to mesh than others. However, in my experience, I have anecdotally noticed that patients with lupus, rheumatoid arthritis, fibromyalgia, chronic fatigue syndrome have had a prolonged and abnormally high inflammatory response (aka pain) to mesh implantation. Removal of the mesh has resolved their flare up.

I systematically do not place mesh in such patients. If they need mesh, I choose a Biologics tissue with low inflammatory potential (but higher risk for recurrence). There are also hybrid meshes coming to the market that have very little synthetic mesh.

I wish to have an opportunity to study this patient population. To date, no blood tests are abnormal among them to help predict this mesh reaction.

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Please Help!

This is great news.
If your pain improves with PT, that’s great.
If you feel that PT actually hurts, then see Dr Ramaswamy again as you may have an occult inguinal hernia.