Good intentions
Forum Replies Created
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We’re a week in to September, 2/3 of the way through the year, and still not a peep about the update to the Guidelines. I wonder if the people involved have become aware of their liabilities in promoting this document. The mesh lawsuits that looked like they were about to have a global settlement, so that business could continue as usual, have been delayed and a similar single mesh lawsuit had a huge settlement, in the millions of dollars. It would be awkward to promote the use of a product with 100’s of millions or billions of dollars worth of legal costs associated to it. And there’s no reason to expect the constant stream of new lawsuits to diminish. The products and procedures are essentially the same.
It’s unclear what the real reason is for the delay. Silence after exuberance usually comes from a realization that things aren’t as they seemed.
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I’m still not clear on how that matters. PeterC continued to have pain after the first surgeon(s) worked on him. Dr. Brown tried to help. Why does it matter if he removed a piece of mesh? It should also be pointed out that PeterC said that the mesh had no tissue ingrowth but then said it was pulled out with bloody tissue attached to it.
Sorry, but I don’t see the point that you’re trying to make. You’re just showing other parts of PeterC’s story. They don’t seem connected.
And, why do you show up as two separate screen names? Do you have two accounts on the forum? Doesn’t really matter, it just confuses things.
How is your recovery coming along? You were going to post an update.
The mesh that was removed sounds like a Gore Medical PTFE product. The kind that Dr. Grischkan uses for his “modified Shouldice” procedure.
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No offense intended Guygolo but I don’t know what you mean. Are you saying that in the beginning he had the same problem on both sides but he had a neurectomy and mesh placed on only one side? I don’t understand. Why would that be done?
My point was that Dr. Brown did not ruin a perfect body. Previous work had been done and Dr. Brown was trying to help with a pre-existing problem. This wasn’t a simple hernia repair. The other doctors had apparently given up or had no ideas to move forward with. Damage had been done before Dr. Brown got involved.
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The full story should be told. PeterC’s problems started with a prior operation, that included a neurectomy and a mesh implant. Dr. Brown attempted to help him resolve his problem with high intensity chronic pain at rest after exercise, after these procedures did not work. He tried to help improve his quality of life. PeterC’s story is an example of why many surgeons don’t want to get involved with mesh problems. The attempts to help often don’t work, and the person that attempts to help gets blamed.
PeterC had apparently been dealing with groin pain for a while even before he had any procedures done. So, there was pre-existing pain, a neurectomy, a mesh implant, and the pain continued. Dr. Brown got involved in the middle/end of a long trail of problems. Do the people that came before bear some responsibility? Where are they now? Should they also be avoided?
PeterC’s story is also an example of how chronic pain affects a person’s thinking. It really is mentally debilitating.
https://herniatalk.com/forums/topic/my-experience-with-dr-browns-sports-hernia-surgery-pt-2/
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Before going in to Dr. Brown, I had had only one procedure to remove a part of my illioinguinal nerve, accessed through the external oblique aponeurosis on the right. They left a solid small local
mesh (not perforated) there in the opening of the external oblique aponeurosis that closed/healed over it. The rest of my abdominal muscles (internal oblique, transverse,rectus etc) were not touched whatsoever. They thought
I had pain due to entrapped illioginal nerve and that anything else would heal over time. The first surgery lasted 40 minutes total. Right away I knew that it wasn’t my issue
because the next day my pain was still there and my gait was still a little off on the right side.I went on to dance for 2 years after that surgery – in that condition hoping I would heal naturally. For the most part I had almost no pain during high-intensity exercise but high chronic pain at rest/after to the point where
it became difficult to have quality of life.
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Yunis and Tomas are Florida.
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The suture material matters. Absorbable apparently has more recurrences.
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Do you know the details of the Shouldice repair? 2 layer, 4 layer, modified, etc. Stainless steel, Prolene, or absorbable sutures? Apparently you did not have it done in Canada.
There might be some clues there. If the repair is splitting open somewhere (dehiscence) it might be that permanent sutures could get it back to where it should be if they weren’t used, or something like a Lichtenstein. Of course, that would depend on where the problem is exactly. If the sutures are holding and the tissue is failing again that would probably require a different focus.
But if it is a suture line opening, if the split is pulled back together the pain should resolve, since you only have pain during movement. The neurectomy would be insurance. In your case, since you didn’t have pain before the dehiscence, and you don’t have pain when relaxed, nerves growing back should not cause a problem. It’s the straining of existing nerves that is the problem. Remove the strain and the pain should resolve, seems rational.
These are just ideas. You know more about what causes the pain. It is definitely a difficult decision when there are so many different opinions, from beginning to end.
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p.s. if you’re getting up there in years, consider the fact that your healing response is reducing. Be careful that you’re not making decisions to try to regain your youthful performance. Things can get very bad if you get in to the repeat surgery regime.
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It seems like you must be doing some pretty strenuous activities. Have you been allowing enough time for healing to occur before testing the area again? I had a minor knee injury and tried to return to action after just a week of rest, week-by-week, based on whether the knee felt good or not. I got in to a weekly re-injury cycle because I didn’t understand how long it took to heal completely. A couple of weeks of physical therapy with a professional and the knee has been fine ever since.
“Dehiscence” just means that the the imaging shows some deformation, like the start of a hernia. Which would mean that the nerves are being stretched. Since the premise of the original surgery is that the modified tissues can rebond and heal, it might be wise to give the area plenty of time to heal and strengthen then to work back in to action slowly. The new Shouldice inguinal canal is not like the original inguinal canal.
As far as the potential cures, the lap surgeon who said that lap mesh might not fix the problem seems like the most straightforward and clear explanation. It’s a sign of the times though, that he only does lap mesh so can’t try to cure you by some other means. Lap surgeons do lap, mesh surgeons do mesh. Very siloed and confined in their ability to heal people. They do procedures. Watch out for surgeons with no experience in your specific problem who promise to try their skill on you but have no experience to show that their efforts will work.
Each new surgery has new risks. Neurectomy will introduce numbness and might have other side effects. Any mesh procedure introduces the potential for mesh problems. The percentages are very well-defined, don’t let anyone try to convince you with words like most or majority. Look at the percentages, and consider the level and type of your activity. There’s no reason for vagueness. Dai Greene comes to mind.
As far as traveling and expense, you might contact Biohernia. Dr. Muschaweck apparently travels to different countries to do surgery at various clinics, and has worked on many professional athletes. The Biohernia network might be growing larger, there might be somebody close by that can help you. Good luck.
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The type of repair, and type of mesh, and type of fixation might offer some clues. There is a wide variety, and a wide variety of combinations. “Open with mesh” is very undefined.
Lichtenstein, plug and patch, Prolene hernia system (PHS), Onstep with Onflex mesh, and TREPP are examples. Plus an array of different meshes, and a variety of fixation materials.
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Hello CursedGroin. Do you know what type of repairs were done on the hernias, and the “sports hernia” (athletic pubalgia)? Mesh, non-mesh, method?
And where did you have the repairs done? You are close to Dr. Muschaweck, who is known for working on professional athletes.
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Did your parents keep copies of the medical records? It would be good to know what type of procedure was done. There are many types of mesh repair.
Dr. Krpata at the Cleveland Clinic would be a good place to start. It sounds like you must be in Canada. Which part?
https://my.clevelandclinic.org/podcasts/butts-and-guts/chronic-groin-pain-clinic
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They ranked them at the end of that section.
“…
In general, the risk of POUR is most significant in spinal anesthetics, followed by epidural anesthetics followed by general anesthetics.[1]
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It’s a hot topic. Here’s a recent paper that suggests that there are many causes.
https://www.ncbi.nlm.nih.gov/books/NBK549844/
Postoperative Urinary Retention
AJ Pomajzl; Larry E. Siref.“…
Anesthesia can pharmacologically impact normal micturition. General, spinal, and regional anesthetics can all lead to POUR by suppressing micturition control and reflexes at both the central nervous system level (pontine micturition center) and the level of the peripheral nervous system by blocking neural transmission in the sacral spinal cord.[2][3]
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How are you doing with your recovery? I pasted your thread link below. Did Dr. Pauli do your surgery?
https://herniatalk.com/forums/topic/pain-after-inguinal-sports-hernia-repair/
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There is no mention specifically of Dr. Pauli’s specialty at his practice’s web site. Interesting that someone of Medvedev’s level would see him. There must be word-of-mouth, or a professional network that knows something. Worth adding Dr. Pauli to the list of European surgeons to see. The web site is in Dutch.
https://azmonica.be/artsen/steven-pauli/
https://azmonica.be/zorgaanbod/medische-diensten/algemene-heelkunde/specialismen/
“You can contact us for the repair of abdominal wall defects such as inguinal hernias, umbilical hernias, epigastric hernias, incisional hernias, parastomal fractures, and also more complex abdominal wall defects.”
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Thanks Gullick. I found another paper from the same authors describing the method used, for athletic pubalgia. It shows a suture-based non-mesh repair. It’s an interesting look at the thought processes in 2012. They talk about how mesh was being used at the time but they had some success with the suture-based method.
Dr. Pauli has not published much since then. His practice sites are in a foreign language.
http://www.actaorthopaedica.be/assets/2629/05-Jans_et_al.pdf
Acta Orthop. Belg., 2012, 78, 35-40
Results of surgical treatment of athletes with sportsman’s hernia
Christophe JANS, Nouredin MESSAOuDi, Steven PAuli, Roger P. VAN RiEt, Geert DEClERCq
From Monica Hospital Deurne, Belgium“…
Fig. 1. — Surgical technique : After incision of the external
oblique muscle (O) and retraction of the ductus deferens (D),
the lateral side of the rectus abdominis muscle (R) and conjoint
tendon (C) are sutured to the inguinal ligament (L). Pubic symphysis (S), external inguinal canal (E), femoral nerve (n), artery
(a) and vein (v) are displayed.
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Here is a study that finds no statistically valid difference between several methods and TREPP. But, a person should wonder about the ability to repair any problems that do occur. For example, as seen and described in videos and surgery reports, mesh often sticks to various nerves and arteries, like the inferiors\ epigastric artery, and the material stuck to the mesh must be sacrificed in order to remove the mesh.
The subject of hernia repair should be expanded to include the follow-on effects of problems. Any surgery is damaging but which methods leave the best field to work on if there are problems?
https://link.springer.com/article/10.1007/s10029-020-02291-7
Transrectus sheath pre-peritoneal (TREPP) procedure versus totally extraperitoneal (TEP) procedure and Lichtenstein technique: a propensity-score-matched analysis in Dutch high-volume regional hospitals
Original Article
Open Access
Published: 16 October 2020
volume 25, pages1265–1270 (2021)The paper does contain a surprising weakness, considering especially when it was published. Their definition of pain is very weak and arbitrary. Almost useless.. But the fact that they did the work shows that TREPP is becoming more common.
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Outcome measures
Patients were scheduled for regular follow-ups at the outpatient clinic at two–six weeks postoperatively. More visits were scheduled only in case of adverse events. Every outcome that was mentioned in the electronic patient file was noted in the database. For postoperative pain specifically, patients scored a “yes” if they: visited the outpatient clinic after a regular follow-up because of inguinal pain; received pain treatment or had any further pain evaluation (e.g., ultrasonography, MR-imaging, referral to pain specialist).
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Somewhat like the Desarda pure tissue method, its newness means that not many surgeons use it. Of course, that is a good thing overall, the world doesn’t need surgeons jumping on every new method that pops up. But, with the rationale behind it, as the results come in, it might become more popular.
https://link.springer.com/article/10.1007/s10029-021-02554-x
Review
Published: 10 January 2022
Meta-analysis of the outcomes of Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) for inguinal hernia
S. Hajibandeh, S. Hajibandeh, L. A. Evans, T. J. Havard, N. N. Naguib & A. H. Helmy
Hernia volume 26, pages989–997 (2022)“…
Conclusions
The best available evidence suggests that TREPP may be a promising technique for elective repair of inguinal hernias as indicated by low risks of recurrence, chronic pain, haematoma, and wound infection. The available evidence is limited to studies from a same country conducted by almost the same research group which may affect generalisability of the findings.
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Here’s another that kind of shows where my thoughts were way back then. Things are actually getting better, there’s more of a focus on quality of life now, but a lot of the old ways still exist. A person can walk in to any of hundreds of hernia repair clinics or hospitals today and be back in 2014, where I started.