Watchful
Forum Replies Created
-
Much appreciated, Chuck, but I don’t deserve it. I had a bad outcome even with all that research, so not sure about the quality of my insight.
By the way, Conze wasn’t sold on Desarda when I talked to him. He could do it, but he had doubts about how well it worked. His concern was that Desarda requires a good external oblique aponeurosis (EOA), and it’s not uncommon for people with a weak posterior wall (and hence a direct hernia) to have a weak EOA as well.
Lorenz was more positive about Desarda, but his preference was Shouldice primarily because of the more extensive track record. One other thing you may be interested in knowing about Lorenz… He actually had a Shouldice procedure himself a couple of years back when he was 60. This was actually one of the factors that convinced me to go with a Shouldice procedure. Of course, he had a good outcome, and me not so much…
-
I have one of those sushi rolls in my groin. I got the scar tissue with nerve roll. I can feel it and it’s painful. I think the surgeon put too much Wasabi on mine!
-
ajm222 – Sounds like you’re improving, so going in the right direction. Not sure why you have bulging. Is it visible from the outside, or do you just feel it when palpating the area?
These open surgeries are traumatic. Healing can indeed take a very long time, particularly if you get some stubborn scar tissue or nerve damage. I’m also hoping for continued improvement. I think in my case some aspects are still likely to improve, but not sure if everything will improve and to what degree. My understanding is that improvement can continue even up to one year and possibly beyond.
-
Thanks, MarkT. If it’s based on people coming back complaining about pain after 3 months, then it’s hard to know what to conclude exactly. Proactive follow up is really needed. Still, it’s an impressive result.
It’s interesting that he cuts the ilioinguinal nerve. I wonder what symptoms patients have from that (numbness in certain areas?)
Chronic pain studies seem to be all over the place, which is very confusing. It really feels like it’s ultimately really the choice of surgeon that makes the most difference, and not the particular procedure or its details. I once asked a urologist what procedure he would recommend for hernia surgery. He basically said pick the surgeon, not the procedure. He said go with a surgeon who has done a very large number of whatever particular procedure he prefers with good results, and don’t worry about the choice of procedure because that doesn’t make much difference. I was a bit skeptical of this advice at the time since I had this whole tissue repair vs mesh dilemma stuck in my head, but I now think that he was right.
-
There could be different causes for the pain in different cases. Nerves don’t always heal, or they may heal poorly (neuroma, etc.) Scar tissue can be persistent and cause pain. The pain centralization you mentioned may play a part as well in some cases, but that’s essentially a type nervous system damage – a domino effect caused by surgical trauma.
Once damage is done, one thing can lead to another in complex ways which vary from case to case. That’s the reason it’s critical to minimize the number of surgeries (zero is best!), and make them the least extensive and least traumatic as possible. Unfortunately, many surgeons aren’t careful enough.
-
Just 12 out of 874 with inguinodynia is an amazingly good result. Again, I wonder how he defines it, and how he followed up. Did he actively follow up with 874 patients, and find out that only 12 had related pain of any degree at 3 months or later? That would be superb and very different from results of other studies.
-
Not mentioned in this letter (not what this surgeon does), but doing laparoscopic instead of open surgery also seems to be helpful in reducing the incidence of chronic pain. Not by a large amount, though.
-
Thanks for the summary, MarkT.
Does he define inguinodynia? Many of these studies don’t clarify if it’s any pain, or pain over a certain level of severity, and what that level is.
Does he describe the follow up method? I know it’s a closed system, but some patients may not come back even if they have pain simply because they don’t think it’s bad enough, or they don’t think they can be helped.
Did he mention what percentage was tissue repair?
-
Not very clear to me – unhappy with the technique, repair not as good, but excellent outcomes?
A 5% risk just for pain caused by nerve damage in open surgery is pretty shocking. You still need to add to that pain for other reasons related to the surgery. None of the surgeons with whom I consulted shared such high numbers. Most dismissed chronic pain as extremely rare (even with open surgery), which I knew wasn’t consistent with studies. The baffling thing to me is that some of the surgeons I talked to have a very large number of on-line reviews without anyone complaining of pain, so I can’t say I understand the picture well. Maybe some surgeons are truly wizards at not causing pain.
By the way, we’ve had patients on this forum who had bad outcomes with guest surgeons: Brown, Koch, Muschaweck just off the top of my head. I know of additional bad outcomes with guest surgeons.
-
Hernia is a high-volume, low compensation field, and this explains the situation that you’re describing at least partially.
I did talk to a couple of hernia surgeons in Germany (Conze and Lorenz) who I felt had a better mindset. I think Conze has some experience with sports hernias, and he does some revisional hernia surgeries. He seems to be very aware of the need to be careful with the tissues and nerves, and avoid excessive harm.
I understand the need to deal with someone who is nice and compassionate, and my experience has been that these qualities are indeed rare among US surgeons these days. However, competence, experience, and meticulous attention to detail are more important. There are a few surgeons in the US with those qualities, including those who did mesh removal on some people on this forum.
There are success stories, but that doesn’t mean that your case will be successful with the same surgeon, or that the surgeon won’t make a mistake in your case for whatever random reason.
Even Dr. Brown had mostly good reviews, but then it looks like he botched your surgery. How could you have known? I didn’t feel comfortable with him when I met with him shortly before his retirement, but he might have been better when you had your consultation. It’s very frustrating because the whole thing is such a crapshoot. That’s the reason I always advise people to avoid surgery unless truly necessary.
-
If I remember correctly, you already talked to most of the relevant surgeons. I think one or two others were mentioned here on a previous thread. Not sure if you talked to them. There are very few groin specialists out there, unfortunately.
-
Doctor’s notes in the US typically bear little resemblance to what was actually said during the consultation. It’s some bizarre CYA thing, often with boilerplate language, although I don’t know how it helps the doctor legally because there is no real input or acknowledgement from the patient.
I don’t know how seriously you should take the details in the op report either. Some of it could be copy-and-paste. Part of my op report at Shouldice was most likely copy-and-paste because it contradicted what the surgeon told me was done during the surgery, and it seemed to be taken from a generic description of the procedure. One important thing that happened had no mention at all in the op report.
-
Yeah, I’m not particularly disappointed that prolene sutures were used instead of steel. I think it’s a really minor aspect in the scheme of things. It’s very rare that this is the thing that causes issues. It’s typically other things about the procedure that get you.
By the way, the problems related to prolene mesh aren’t so much the amount of prolene used in mesh vs sutures. It’s the surface area, the tissues that the material comes into contact with, and other aspects which are specific to mesh (fixation, movement, folding, etc.)
-
Right, and this distorts the picture. The full extent of the issue of post-surgery pain isn’t known because of this and other reasons. It’s pretty clear that the pain problem is worse than what it seems because of limited follow-up and the reluctance of many patients to describe the problem fully.
-
GI,
I did look into it a bit way back, but I don’t remember the exact numbers. I do remember that the conclusion was that the amount of prolene you get in your body with Shouldice is lower than with mesh.
I would have preferred stainless steel sutures because prolene is slightly more likely to cause some inflammation or granulomas. I was very surprised when they used prolene on me at the Shouldice Hospital. I didn’t even bother asking about that before the surgery because I was so sure they would use steel.
Chuck,
There are many hundreds of thousands (800K?) of hernia surgeries with mesh in the US every year. If the rate of issues with mesh was high, there would be a lot more outcry and noise about this procedure. For example, if a quarter of people ended up with meaningful issues either short term or long term, it would add up to millions so far, and I don’t see that.
Describing lap or robotic inguinal hernia surgery with mesh as “minimally invasive” is indeed misleading. When I learned what is done in these procedures to insert the mesh, the size of the mesh, etc. I realized that this is anything but “minimally invasive”.
I explained before why I didn’t go with Dr. Kang. The extensive track record of Shouldice was important to me, and I was concerned about the risk of recurrence with the Kang technique.
My hernia was indirect, so the Kang technique was very tempting in theory since it’s so much less extensive than Shouldice for indirect hernias. However, I had a very large and long-standing hernia, and didn’t feel like taking the chance without a lot more track record.
If I had a direct hernia, I would be less tempted actually because I think the difference in that case isn’t as huge between what he does and Shouldice, so I think there may be less of a case for not just doing the full Shouldice. Not sure, though – maybe I’m missing some important aspect there.
-
Luck does play a big part in surgeries and in other medical treatments. It’s the nature of the beast, unfortunately, and doctors rarely give patients an accurate and complete picture. It’s more of a crapshoot than anyone likes to admit.
You really should stop fighting with yourself on this, Chuck. You made a very reasonable choice. It happened not to turn out well, but that doesn’t mean you were negligent in your research or thinking. Most of these mesh procedures (both open and lap) turn out just fine. A minority of cases end up with various degrees of trouble, but that’s the situation with tissue repair as well. There isn’t a hernia repair technique that always works well, and all surgeons have some bad cases.
Dr. Obney who was one of the top Shouldice surgeons was once asked if he was bored after doing tens of thousands of hernia surgeries. He answered not at all because all cases are different in some ways, so every surgery is interesting.
-
The body can indeed keep healing over very long periods of time. I had a minor fracture in my elbow that took a decade to heal fully, and stop causing any pain, but that’s a bone. Soft tissue can take a long time to heal as well, and nerves are certainly notorious for that.
It really is a big hit when these surgeries go badly, and having to do additional surgeries at the same location feels like digging a deeper hole to some extent, but sometimes it’s necessary and helpful overall. Too bad these hernia surgeries are such a crapshoot with some going very well, and some leading to a domino effect of more trouble and reoperations.
I’m just going to give it time. Definitely not going under the knife again unless things take a radical turn for the worse, and it’s something that additional surgery could truly fix. I’m just glad I’m not in an occupation that requires physical labor, and that I didn’t have any athletic hobbies. Still, pain and discomfort have a bad effect regardless of your occupation and hobbies.
-
ajm222 – About 5 months ago. I’ll post an update at 6 months. There has been an improvement in some aspects, some others are the same or worse. It’s not debilitating or anything close to that, but I do suffer from pain, discomfort, and some other symptoms. At this point, I can say that it was a mistake to do the surgery this way. I really had to fix the hernia, but I should have done it differently.
If I had to do it all over again, I would go with mesh. Lap mesh would be my preference, but not sure that would have been possible because my hernia was very large (with intestine protruding in it, a scrotal element, etc.), so I’m not 100% sure it would have been possible to reduce it without open surgery. I got mixed opinions about that, although most said it would be ok. One surgeon said there was a 20% chance he would have to convert to open. With hindsight, if lap mesh wasn’t possible, I would still pick mesh (Lichtenstein) over Shouldice in my case.
This doesn’t mean that Shouldice isn’t the better option in some other cases. It just wasn’t the right choice in my case. Unfortunately, it was hard to tell in advance. Based on what I know now, I would say that if you have a very large hernia, go with mesh. I think the Germans are correct in having some guidelines on what cases qualify for Shouldice. For example, indirect hernias not exceeding a defect size of 3cm (mine was double that size.)
Another piece of advice is that watchful waiting is good, but only up to a point. If you see that the hernia isn’t stable anymore, and it is growing significantly, have it fixed, and don’t wait until the repair is more difficult than needed, or you’re forced to rush to fix it.
-
One problem is that there are very few high-volume tissue repair surgeons in the developed world. Your choices are very limited, so it’s hard to create an “all else being equal” scenario. If you have a large hernia (like I had), your choices are even more limited because some of the tissue repair surgeons (like the Germans) will go with mesh on large hernias. Very few places are hard-core enough to do tissue repair on large hernias. These include the Shouldice Hospital, Dr. Tomas, Dr. Kang, and maybe a couple others.
Another problem is that tissue repair isn’t as “one size fits all” as mesh. The picture really changes depending on your particular anatomy, size of the hernia, and tissue quality. For example, I used to think that the Shouldice procedure is pretty generic in its applicability. I knew that it doesn’t work with bad tissue quality, but other than that, I thought it’s fine. Well, not really… I learned this the hard way only after going to the Shouldice Hospital. They will do the surgery on cases with a groin anatomy and hernia size which are problematic for this procedure, but these become long and difficult surgeries, which is something you really want to avoid. My case was like that, and I had discussions with my surgeon afterwards where he described these challenges (primarily related to tissue depth and hernia size) that I hadn’t been aware of because they aren’t really described in the papers about the procedure. You need to talk to a surgeon who does it to learn about how the level of difficulty of the procedure can vary. Lichtenstein, for example, can be a lot easier in such cases. So, for someone like me, it wasn’t really “all else being equal” even though I had a high-volume specialist with significant experience. It was the difference between a difficult surgery and a pretty straightforward surgery.
This led to a difficult recovery, and I’m still dealing with some persistent issues (pretty frequent pain and discomfort). In other words, tissue repair has its problems as well, not just mesh, and in some cases the risk is actually higher with tissue repair (or at least with Shouldice) because the repair is particularly difficult in those cases.
One last thing on this is that most tissue repairs (including Shouldice) aren’t really reversible. The anatomy is changed, and you can’t go back to the original if you have problems. With mesh, you can have the mesh removed. This can be a difficult and complex surgery, but it’s at least possible to get pretty close to a “normal” groin since the anatomy isn’t modified.
I’m certainly not as big a fan of tissue repair as I used to be. I would still go for it on an ordinary inguinal hernia which isn’t particularly large, and if the tissue anatomy and quality are good. The problem is that you can’t necessarily tell much of this in advance. This makes surgeon choice even more challenging because what you really want is someone who is excellent at both tissue repair and mesh, and let them decide what’s best in your case, possibly only during surgery.
-
Makes sense. Would you say that there’s a certain number of years of experience when the rate of bad outcomes goes down significantly? You learn from experience how best to handle different anatomies, and how to avoid trouble. Would it be 3 years? 5 years? 10? 20? More?