[Watchful]

GI – It must be month/year, not month/day.

Yeah, I really wish Chuck stopped popping up with new identities here. I don’t know if this person is Chuck too.

[Watchful]

Devastating. I don’t have any ideas to offer sadly. Did they ever tell you what went wrong with the first surgery, and what they were trying to fix in the right and left open revision surgeries? Did you go to very experienced surgeons? Sounds like a huge amount of incompetence.

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Not sure how good this tire patch analogy is because even in the case of anterior mesh, there are still more layers on top of the mesh. It’s not like your mesh is outside, or just under your skin.

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I don’t follow. You asked for good mesh stories, so I described the ones I know personally, both lap TEP and Lichtenstein.

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My brother-in-law is quite active. Really no issues. He jogs a lot, he climbed some tall mountain in Nepal with my sister. He had the Lichtenstein procedure many years ago.

One of the lap TEP patients is the son of a colleague. He’s in his early 20s, and had the procedure about a year ago. Active young guy. I chatted with him a few times at the office, no issues or complaints.

The other lap TEP patient is a neighbor in his 60s. Not a particularly active person, but he does ride his bicycle around the neighborhood. Talked to him many times. No issues. Not sure when he had his surgery exactly, but it was a few years ago.

I think both tissue repairs and mesh repairs are a huge problem when they go bad and cause chronic pain and/or discomfort. I don’t agree with you that mesh is necessarily worse in this regard. With mesh, removal is at least a possibility (not saying it’s an easy surgery with no repercussions). Many tissue repairs (e.g. Shouldice, Desarda) change your anatomy in an irreversible manner.

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I have asked the 3 who didn’t have any issues enough questions to believe that they feel normal. One of them is my brother-in-law, and my sister never heard him complain either. As a result of this questioning, I found out about the rare minor pain in one of the Lichtenstein cases.

I know it’s hard for people like us who had bad results to believe that people can have zero issues with the same procedure that gave us so much grief, but that’s how it is.

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I know 5 people who had mesh repair of inguinal hernias. 2 lap TEP, and 3 Lichtenstein. The lap TEP guys and one of the Lichtenstein are doing fine – no issues. The second Lichtenstein is doing fine, but has minor rare pain. The third Lichtenstein is actually a general surgeon himself. He had pain and needed a neurectomy. He’s doing fine now. I don’t think any of them would be interested in posting here, though.

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That’s good to know – thanks. I hope you improve while these drugs keep the symptoms under control.

My feeling is that the body can heal certain things, but not others, so a lot depends on the exact damage you have. I guess that’s actually obvious. For example, a nerve that got a bit injured, stretched, or moved may heal with time (possibly a long time). However, if the nerve is caught in scar tissue, a stitch, or mesh, it’s a different situation. Not sure how that can be resolved other than through some invasive means.

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I’m not a triple neurectomy expert, but from what I learned about it there aren’t significant issues when it’s done distally from where the nerves become sensory-only. You do get numbness, but that’s preferred to pain. You don’t get atrophy when cutting sensory nerves with no motor function. The question in my mind is whether there’s a way to make sure a painful neuroma doesn’t form on the cut nerves.

I totally understand not wanting another surgery. I suggested it since you said you’re doing terribly, can’t work, etc. If you’re doing reasonably well with medication, then it’s a different calculation. It sounds like you’re getting the right combination of nerve pain medication. There’s also pregabalin which is somewhat similar to gabapentin.

Have you noticed any significant side effects with these drugs?

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@herniacomps

There are many nerve branches in that anterior area. It’s easy to harm them directly or indirectly while performing surgery there, particularly when it’s a reoperation where it’s even harder to see them because of scar tissue. Also, there’s all the other tissue damage that can cause nociceptive pain.

I’m not an expert on triple neurectomy, so I don’t know how invasive or risky it is. The studies I’ve seen show that in the large majority of cases there’s significant pain relief. Those nerves in the anterior area are all sensory other than the genital nerve branch which innervates the cremaster. If my condition was severe, I would definitely explore that option further. I wouldn’t be quick to pull the trigger, but I would definitely look into it.

What medication are you taking? Pregabalin (Lyrica)?

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@herniacomps

Could a neurectomy help in your case?

We have a lot of common symptoms, although mine seem less severe. In my case it was caused by tissue repair (Shouldice); no mesh or plug.

I decided to give it at least a year until exploring what can be done. I’m leery of undergoing additional surgery because of the risk of making things worse. A neurectomy of some kind may make sense, but not sure. Other than that, I don’t know what can be done. For example, if scar tissue is causing some of this, can they remove it without creating even more scar tissue?

I’m also hoping for improvement with time. So far, my experience has been that the intensity of the symptoms varies from time to time, and perhaps the non-pain neuropathic symptoms improved, but the pain actually worsened a bit with time, and became more frequent. The tissues keep “remolding” for months and maybe longer, and it feels like the symptoms also change somewhat with that process. I don’t know when that process ends, and I don’t know what to expect in the long run. I would say that my symptoms are moderate – not severe, but not mild either. I’ve been able to function, but the pain and discomfort definitely take their toll on me.

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@herniacomps

That’s awful – sorry to hear that. What happened after the removal, and how are you doing now?

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Lichtenstein is the most common. It’s open anterior mesh placement. There are open posterior (preperitoneal) mesh techniques (Kugel, TIPP, TREPP), but they are much less commonly practiced, and more difficult. As to what’s better, who knows… You can look up some studies comparing them.

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Some Lichtenstein surgeons routinely cut the ilioinguinal nerve, or some branch of it – not sure what exactly. I don’t know about Dr. Jacob.

Note that even surgeons who don’t cut routinely will cut sometimes if they feel it’s needed. This happens in tissue repairs as well if there’s some nerve that gets in the way. The nerve anatomy in that area varies quite a lot from person to person.

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Best of luck, Sensei. What a nightmare. It’s good that you persisted and got to the bottom of it in spite of so much wrong information that was thrown at you on the way.

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Very interesting. Thanks, KC. Indeed, my hernia was a life-long indirect hernia since birth. I didn’t know that this could be displacement of the inner ring (which is not worn out in this case), and that it can be repositioned in surgery. Instead, an unusually difficult and long Shouldice procedure was performed which caused a bunch of issues.

Your level of understanding of the groin anatomy and how to repair it with minimal surgery tailored for the particular problem is extremely rare, unfortunately. I don’t know what it is about the groin anatomy that makes it so hard for surgeons to master. Mesh made things a lot worse because surgeons just learn enough to place the mesh, so they now know even less.

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Thanks, Dr. KC for providing further details. Most of us on this forum are patients, not surgeons, so it’s hard for us to understand much of it, but we get some idea.

It’s excellent (and I guess surprising) that your technique works without a problem on large hernias. Again, understanding that is beyond my ability with my limited knowledge of the groin anatomy.

I had an indirect hernia with a large defect of 6cm. This is large-enough for inserting four fingers, and larger even than some meshes used in open repairs. Are you saying that you can repair such an indirect hernia without a problem with your method? It was a difficult and long operation even with the Shouldice technique.

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KC, Dr. Lorenz in Germany may be interested in studying this further, so you may want to contact him. When I talked to him, he was interested in researching the Kang technique for indirect hernia which sounds similar to yours. He seemed to know the details of that technique.

I’m guessing that the tricky aspect of this technique is performing this more elaborate stitching inside the inner ring so close to the spermatic cord without injuring it.

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Let’s hear from KC, but I think I understand what he’s doing. Instead of closing the defect on one plane with a simple stitch, he uses some kind of a transverse stitch which makes the closure multi-plane – it has depth which makes it more solid.

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KC,

Thanks for giving us some idea of the difference in the technique. Sounds like stitching vertically instead of horizontally. Is that correct? Why would this improve the outcomes?