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Hi William,
I’ll post another update in a month or so. There has been some improvement overall. It takes time with these things to discover what heals quickly, what takes longer but still heals, and what (if anything) you’re stuck with for the long run.
This surgery is pretty traumatic on a number of fronts, and the rate of healing is different for different aspects of it. I hope my groin feels completely “normal” at some point in the future, but I’m not there yet.
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I’m sure it’s different for different people, but the only thing that worked for me was simply waiting until there was no choice but to do the surgery. While I was able to live with the hernia, I stayed away from surgery.
Once it started bothering me significantly on a daily basis, I was able to pull the trigger on surgery (Shouldice). It was so bad that I sometimes had to find a place to lie down by the street or on the grass in some park when going for a walk. It would bulge way too much, cause pain when that happened, and was debilitating too frequently. One time I had to ask my wife to go get the car to pick me up while I was lying down on the street. I remember another time when people were asking my wife if I was ok when I was lying down on the grass in a park.
All the surgical methods for inguinal hernia scared the heck out of me. I was actually less scared of open surgery than lap or robotic for a number of reasons, including the ability to avoid general anesthesia. Recovery from Shouldice isn’t a walk in the park, but it isn’t actually too bad unless something goes wrong (like nerve damage).
The incision does take a few months to heal fully, but it’s not a big bother typically. The skin heals very quickly. The layers underneath take a much longer time. You get this hard “healing ridge” under the incision which takes months to soften fully.
There are sporadic aches and pains that you may deal with for months as well. Again, unless something went wrong during surgery, none of this should be too bad.
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How do you know your spermatic cord is “just under the skin”?
Regardless of whether it was needed or not in your case, dissecting and reconstructing the inguinal floor shouldn’t cause the symptoms you have.
What he did with your external oblique is not clear.
Something seriously destructive must have been done to cause the extensive problems you’re describing, but it’s not clear what it was, and it sounds like it wasn’t clear to the surgeons with whom you consulted either. It doesn’t sound like they even have a theory, right? Someone mentioned a nerve, but what could that be? There are no motor nerves there in the anterior groin other than for the cremaster/dartos.
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I think that was in the context of laparoscopic neurectomy.
The nerves encountered in the anterior surgeries like Peter had are supposedly all sensory in that area even though they are mixed sensory/motor further up. The only exception is the genital nerve branch which provides motor innervation to the cremaster.
One thing I always wondered about is whether damage to these distal nerves can lead to more proximal damage in the area where there’s motor function as well, but I never read about such a mechanism. Damage in the other direction does happen – proximal damage leads to distal damage through the process of Wallerian degeneration.
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It’s not clear if and how what he did was different from Desarda. With Desarda, you have the remaining two edges of the EOA which can be pulled together and closed over the repair. The spermatic cord is under that closure of the EOA.
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Standard tissue repair procedures (like Shouldice or Marcy) are a known entity and don’t change the anatomy in ways that would cause the issues you mentioned. The trouble they cause (in the bad cases) is almost always either recurrence or chronic pain.
A repair for recurrence is still possible, sometimes with another tissue repair, or more often with lap mesh. Serious chronic pain can often be treated with a neurectomy, but not always. This can be challenging with mesh as well, even with removal. I think mesh is a worse situation to deal with when it goes bad. Again, when compared to a standard tissue repair. Having said that, mesh is clearly a reasonable choice, and for certain anatomies it can be a better choice because tissue repair would be difficult or problematic.
If a surgeon rearranges your anatomy in some insane way, it’s a different situation. It sounds like this is what happened to you. However, this is not a standard hernia repair.
“Sports hernia” seems to be a term used for different types of overuse injuries which aren’t even truly a hernia. It’s really dangerous territory because surgeons get creative. It’s not a standard problem with standard well-studied surgical solutions as I understand it, but I haven’t researched it much.
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Apropos Dr. Bendavid – he was very liberal with cutting nerves. Famous for his “no nerve, no pain” approach. Dr. Amid didn’t agree with him on that. Another example of how there is simply no agreement among experts in the field, so what hope do we patients have to make informed choices.
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Just to clarify – it sounds like he did screw up on you, and that was wrong. This is one of the risks, though, with having surgery done. When considering doing surgery, the thought about what happens if the surgeon screws up should be on one’s mind. It happens even with good surgeons.
Humans do unpredictable things sometimes. It’s not right, but that’s what you have to deal with. It’s one of the many risks that should be weighed against the potential benefits when making a decision about surgery. It’s not even just the surgeon – the anesthesiologist can do something wrong or even the assisting nurses – the weakest link can get you. Once you put your life in people’s hands, you are taking a risk of suffering grave consequences from them making mistakes for whatever unpredictable reasons.
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I don’t see how you could prevent something like this from happening to you by research. You went to someone who had good reviews and success stories. He was a very experienced surgeon, and clearly competent overall. You could dig up a couple of bad cases, but that’s the case with all surgeons, even the very best – they all have some bad cases. Clearly, he wasn’t messing up on a large scale. He had a private practice, and would have been out of business from lawsuits (even in California) if he had been harming people left and right.
The main lesson I learn is to take surgery very seriously. The most effective way to avoid this kind of trouble is simply to avoid surgery. Sometimes you have no choice but to have surgery, and I don’t know if that was the case with you or not, but the bar for pulling the trigger on surgery should be set very high.
There are two aspects to this: really needing it, and having a high level of confidence that surgery can actually cure the problem. Then you pick one of the best surgeons you can for the procedure, but things can still go haywire, so avoidance of the whole thing altogether (if possible) is truly the best protection.
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Thanks – I hope you’re right and I’ll manage to recover fully. It feels like I still have some tissue that needs to recover from the surgery. There’s pain in a number of places which feels like injured tissue. Also, an irritated or damaged nerve. None of it is severe enough to be debilitating, and it’s not constant, although when I press in certain areas, there’s pain that’s always there. Regardless, it’s certainly bad-enough to be quite annoying on some occasions every day. The overall picture is better, but not each and every symptom. Some areas still have as much pain as after the surgery, and some are better. The nerve issues actually got worse until recently, and then improved a bit. Since I now reached the 3 month mark, I guess I’m officially in the “chronic pain” category, although it’s not severe in my case thankfully.
By the way, they aren’t particular at all about patient selection. At Shouldice, they have a BMI limit, and they refuse patients with some comorbidities. That’s about it. Kang and Tomas have an even lower bar. As I mentioned before, I think the top German surgeons handle this better using careful ultrasound imaging in advance to make an initial assessment of the best approach, and then also taking into account what they encounter during surgery. It doesn’t make much sense to subject the patient to an overly traumatic surgery which can be avoided with the use of mesh. Having said that, who knows what would have happened if I had used mesh. I would have most likely had an easier surgery, but maybe I would have suffered from mesh-related issues.
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Probably true for tissue repair. I don’t recall Dr. Kang saying this, but Dr. Towfigh said in one of her videos that if you want tissue repair, fix the hernia early.
There are cases where tissue repair is problematic, yet places like the Shouldice Hospital, Dr. Kang, and Dr. Tomas will still do tissue repair even in those cases. I personally don’t think that’s wise. For example, my case would have been fairly straightforward with Lichtenstein, but was a difficult long surgery with Shouldice.
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ajm22,
Sounds like it went well – glad to hear that.
What kind of tissue repair did you end up having? What type of hernia did the surgeon find?
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The scar for these open inguinal surgeries isn’t really noticeable unless you shave the area. It’s pretty far on the side.
I wasn’t wearing a hernia truss. Not sure how well these work for large indirect hernias. Maybe they work – I didn’t research it much or try any.
Wearing a truss can actually help with swelling and pain after the surgery. A nurse told me that it’s best to wear “tighty whities” and a truss on top of that. They give you a special truss for that at the Shouldice Hospital. It does help in my experience. Boxers let gravity pull everything down which may increase pain.
Surprisingly, I didn’t have much anxiety during the days leading to surgery or even during the night before. Not sure how to explain it. I was mentally very ready for surgery, and I figured (correctly or not) that I was going to be in good hands for this particular surgery.
Paradoxically, I think going far away for the surgery, and staying the night before in the hospital actually reduced anxiety and improved sleep the night before. There’s so much going on that you don’t have time to dwell on the surgery and freak out too much. I think I wouldn’t have been able to sleep if I had been home, but I did manage to sleep 5-6 hours before surgery at the hospital. They wake you up before 6am. I was lucky to be alone in my room that night.
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It tells me how little is actually known and how little agreement there is among experts. I find it to be a very frustrating aspect of medicine.
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Mine was about 3 months ago, and the hair already grew back, and I think it’s not far from its maximum length. It grew back everywhere, including the scar area. You can see the scar, but it doesn’t stand out much. I expect it to become even less visible with time. The scar is the least of your worries with this surgery…
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Yes, but it’s not nearly as well studied as the classic techniques.
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What did he do with the remainder of the external oblique aponeurosis when closing up at the end of the surgery?
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Sure. Here’s a link. You need to log in, but it’s free. It’s a very interesting discussion – worth reading.
“Dr. Bendavid: I have done thousands of repairs when I have divided the nerve. I have always maintained that if there’s no nerve, there is no pain. And I’ve been somewhat cavalier also in dividing nerves for that matter. It seems that the sensory loss is minimal, and certainly considering that we have cut the nerves on nearly 7000 cases a year, we have not seen the kind of situation that Dr Amid is talking about. However, there seems to be a clear picture that Starling refers to as inguinodynia in Surgical Clinics of North America, where the contact of a severed nerve end with Marlex results in a pain syndrome.[51]
I’ve seen many patients with pain, but very few actually go on to the chronic type, which we should define as pain beyond a year; only 1% of these patients go on to have chronic pain. I don’t understand the problem, and I don’t think we have the answer. Perhaps, somehow, a twig or branches of the nerves are included in a suture line. I don’t know. It’s a very difficult problem to which I don’t have an answer. But certainly in the past, generally speaking, no nerve, no pain.”
“Dr. Bendavid: Well, I certainly have, over the years, severed many an ilioinguinal and an iliohypogastric, and don’t forget that when you do herniorrhaphies for recurrences from an anterior approach, you may not even see them, so that they are very often severed, and certainly if they are in the way, I have never hesitated to remove them, to resect them, and simply leave the stump behind without any ligation and have literally never seen any problems associated with this. And as I’ve said, the sensory loss is so minimal it seldom is larger than a 2 cm to 3 cm circle at the very medial portion of the inguinal area.”
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With nerves, one challenging part is what he talks about starting around 2:40 (anatomic variation with multiple branches), and another starts at 3:44 (hidden nerves).
I actually had both of these in my case. Atypical branches in the way (most likely of the ilioinguinal nerve), and an unseen iliohypogastric nerve.
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I don’t know any tissue repair surgeons who “regularly” cut nerves other than the genital nerve branch which is sometimes cut as part of the Shouldice procedure. I know one Lichtenstein surgeon who regularly cuts the ilioinguinal nerve.
Even focusing just on tissue repair, there is a potential problem where a nerve is located in a place which interferes with the repair. I’m not a surgeon, but my understanding is that sometimes it’s hard to avoid cutting it in such cases. Also, sometimes a nerve or some branch of it is not identified by the surgeon, and it gets caught in stitches or ends up where scar tissue would form. If the surgeon now notices it, what should they do? Again, I’m not a surgeon, but I think they typically cut in such cases where they notice that a nerve may be compromised during surgery.
My point is that it’s a tricky situation. My understanding is that cutting is considered better than injuring a nerve, or leaving an injured nerve without cutting it.
On the other hand, cutting can cause trouble as well – neuroma formation, deafferentation pain, etc. Not sure when that does or does not happen. For example, it doesn’t seem to happen when the genital nerve branch is cut in the Shouldice procedure. Also, those Lichtenstein surgeons who cut the ilioinguinal nerve prophylactically would be in trouble if issues were common with that.
For people with chronic neuropathic pain, neurectomy does seem to help in most cases (70%?), so nerve cutting is sometimes the right thing to do. Of course, if you do another surgery to go back in for that, other damage can happen making things worse overall. So, when a surgeon encounters an iffy situation with a nerve during surgery, it’s a real dilemma.
This looks like one of those areas where not enough is known, and there’s a lot of variations between patients in terms of their nerve anatomy and how they react to nerve injury, nerve cutting, etc. Also, there doesn’t seem to be agreement among surgeons even on how to cut a nerve (when needed) in terms of the best way to do it to avoid problems with that nerve later on.