Watchful
Forum Replies Created
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I’m not a surgeon, but here’s my opinion.
I don’t know why some of your doctors recommend a neurectomy. Nerve involvement would be symptomatic well before 5 years.
It sounds like you simply have a recurrence. If your symptoms are minimal, you could just wait with that as one of your doctors recommended. If it bothers you too much, then you have to decide how to fix it. If it was me, I would go with laparoscopic mesh in this case. This is also what I was told at the Shouldice Hospital when I asked what to do if I get a recurrence after my Shouldice procedure.
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Right, what’s the role of the Shouldice part in this case? I guess there could be some types of tissue damage where just mesh isn’t sufficient.
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There’s also the other combo option of open preperitoneal mesh combined with a version of Shouldice. This is what is done at the Shouldice Hospital in rare cases of bad tissue quality (based on what I was told there).
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An inguinal hernia is one potential cause, but there could be others, such as a varicocele or a hydrocele.
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David M,
I’m not an expert on this. It seems that this depends on the tissue. Skin evolved to heal relatively well, but various internal tissue layers (such as fascia and muscles) may be different.
Internal scar tissue commonly appears in these open surgeries, and it’s one of the reasons for the difficulty with reoperations. I believe the injury to the internal tissues causes inflammation which results in scar tissue. This scarring can even spread further from the immediate vicinity of the injury as the inflammation sometimes spreads. The more extensive (or repeated) the injury, the more inflammation and scar tissue.
The scar tissue can encapsulate or impinge on various nerves and vessels, and it can cause nociceptive pain as well. In addition, you can get inflammation and scar tissue in the areas of stitching as you mentioned.
Reducing this type of injury is one of the advantages of laparoscopic or robotic surgery.
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Isn’t there an even larger area of interface between the mesh and the spermatic cord in the preperitoneal space? That’s what I’ve been told by surgeons. Not sure about differences in the nerve anatomy between the two areas in terms of what could adhere to the mesh.
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GaleW,
Sorry to hear the results aren’t good so far. As GI said, one month is still quite early.
It’s interesting that pain persists even with triple neurectomies, but that’s not rare based on what I’ve been told. It’s not an area that’s all that well understood.
I had a Shouldice procedure on one side 9 months ago. I never felt “pulling”, but I did feel pressure and pain, and still do. Luckily, my symptoms aren’t debilitating and they aren’t constant, but they are certainly bothersome.
Did Dr. Conze mention if this possibility of a lymphatic drainage issue can be diagnosed somehow (imaging), and if anything can be done about it? Does it mean that scar tissue is impinging on lymphatic vessels or some such thing?
I’m speculating that scar tissue is causing a lot of my issues, and my surgeon seems to agree. I can feel that hardened tissue which is painful when palpating the area. I’m not sure if anything can be done about it. Another surgery may add more trouble (including more scar tissue), or exchange one problem for another.
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Based on my biases…
If you’re a good fit for tissue repair, I would just go with that. It’s not always easy to tell before surgery, though.
Between open mesh and lap mesh, I’m not sure what to say. I’m also biased against lap (for similar reasons to yours), but I realize that this may not be evidence-based.
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Always depressing to look at these studies, unfortunately. One out of ten with discomfort (even if mostly mild) after 5 years is pretty lousy. Considering the huge number of hernia surgeries, this translates to a heck of a lot of people out there living with long-term chronic discomfort from these surgeries.
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I’ve always found things to be a bit questionable and biased with him. Some examples… He was very liberal with cutting nerves without paying attention to the risk of neuromas and other issues. He claimed 1% chronic pain at the Shouldice Hospital even though this wasn’t really studied, and even they quote higher numbers now (which aren’t based on a study either). He switched from steel to prolene sutures because he found prolene to be easier to handle, but without study of what’s best for the patient. In particular, I found his statements about chronic pain with the Shouldice procedure to be misleading and lack a solid basis.
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I was surprised too in my case. Like you said, recovery varies from person to person, and it can take a long time. This surgery is a bit brutal to be honest. If you look at the video posted by BioHernia on YouTube of this procedure, you’d be surprised that patients don’t come out of it in a lot worse shape…
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Hi Sam,
You should expect further improvement even well beyond the 3-month mark, so don’t be overly alarmed by the current symptoms unless you’re experiencing something severe. This procedure takes a long time to heal in my experience. I don’t think I would have been able to handle an elliptical at 3 months, but I probably could now at 8 months.
What pills are you taking for this?
I did follow up in person one time, and later on by video call. I don’t know what they would say in your particular case, but my guess is that they will suggest anti-inflammatory drugs and pregabalin or something similar (if you have nerve symptoms). Also, hot compresses and massages to increase the blood flow to the area and expedite the healing.
I hope things get better for you as they did for me, only faster.
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It shouldn’t really take a miracle not to have pain at all after 8 months. I hope it resolves completely for you with time. I’m in the same boat, and had my surgery about the same time as you.
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Having some pain (even if minor) 8 months after the surgery isn’t exactly what one would hope for… Certainly not a bad result, but not great either.
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Dr. Conze is wise. The attitude of my surgeon regarding pain after surgery was the opposite. He told me that it was rare to have significant pain after hernia surgery, and having this indicated an increased likelihood of getting chronic pain. Fortunately, I did improve eventually, but it took 8 months to go from what I considered an unacceptable level of symptoms to acceptable.
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Thanks – I certainly hope so. It’s progressing in the right direction.
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David M,
It varies. I don’t have a constant level of pain or discomfort. I experience levels 1-4, but not 5-7. Most of the time I’m at 1-2, sometimes 3, and fairly rarely 4. This is now. Earlier on, it was worse. I was at 4 more often, and even reached 5 and 6 on occasion.
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Mesh infection is rare as far as I know. The vast majority of problems with mesh are not from the mesh getting infected.
I think it’s very reasonable to look at any pain in the region regardless of severity or impact. No one wants to live with chronic pain even if minor, so that’s still a bad outcome, just not as bad as more serious pain. I don’t agree with ignoring pain that’s less severe than level 4 (pain present, cannot be ignored, and interferes with concentration on everyday activities) as some studies do.
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Based on the research I did a while back…
Stainless steel causes the least amount of reaction (unless you’re allergic to its elements such as nickel). Hardly anyone uses it in hernia surgery, though, because it’s a pain to handle.
I believe polypropylene is the most commonly used suture material in hernia, and it causes little reaction typically. I read that polybutester and nylon cause even less tissue reaction. Note that tissue reaction isn’t the only important property of suture material, and I guess polypropylene has the best combination of properties since it’s the one most widely used.
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They don’t know enough about their own results since they don’t follow up, and they certainly can’t compare to the results of other surgeons and procedures.