[Good intentions]

It looks like Dr. Sheen used the “sportsman’s hernia” diagnosis as the premise to do surgery. His observations once he got in and could see and poke around were some combination of direct and indirect hernias. In a TEP procedure a large piece of mesh is used to cover both areas.

In sum, he felt confident that surgery would help, and it did. But there was a recurrence. Recurrences are known for laparoscopic mesh implantation, even with large pieces of mesh. 15 x 12 cm = about 6 x 4 3/4 inches.

The large pieces of mesh that have been encapsulated by your body are part of the new decision. Mesh removal could cause new problems. Overall, an open mesh or open pure tissue repair seem to make the most sense. Leave the 5 year old mesh in place if it has not been bothering. Fix the recurrence by another method. The 5 year old mesh is probably tied up with other critical nerves and vessels. It’s how “incorporation” works.

Don’t fret over what has already happened. You’re in a new situation. Listen carefully to the surgeons, take a list of questions with you and don’t commit to anything unless you really understand what is being proposed. You’ve already had one failure by a top well-known expert in the field using the most publicized repair method. Dr. Sheen is one of the HerniaTalk surgeons, listed at the top of the page. Good luck.

[Good intentions]

That is unfortunate that his “Main findings:” don’t match his “Inspection:”. Some surgeons cut and paste their reports using parts from past reports.

The thing about mesh implantations though, is that it doesn’t really matter. The mesh will cover the same area, for either direct or indirect hernias. Since you had good results from the first mesh implantation a new surgeon will probably just do the same thing over again.

For what it’s worth, Parietex mesh is a brand name for a series of polyester (PET) meshes. I would guess that he used the Parietex lightweight monofilament flat mesh, since he did use fixation with the Tisseel fibrin glue. The monofilament Parietex is the polyester analog of the common polypropylene flat meshes, which are very commonly used for TEP procedures.

https://www.medtronic.com/covidien/en-us/products/hernia-repair/mesh-products.html

[Good intentions]

Here is a search page about treatment of athletic pubalgia, with fairly recent results. Opinions have changed over the years.

https://scholar.google.com/scholar?hl=en&scisbd=1&as_sdt=0%2C48&q=treatment+pubalgia&btnG=

[Good intentions]

I don’t know if this will help you or not but Dr. Sheen seems to run counter to prevailing opinion on treatment of athletic pubalgia. Many surgeons say that they do not use or recommend mesh for its treatment. But there also seems to be some discussion about how to define the problem.

You are in an odd spot, since Dr. Sheen is a firm proponent of mesh. He publishes often about mesh implantations. You might consider getting away from the mesh repair experts and see what an open repair surgeon thinks.

Here is a fairly recent paper by Sheen et al trying to show the efficacy of the TEP mesh procedure compared to open repair.

https://academic.oup.com/bjs/article/106/7/837/6092871

Here is another paper describing an open repair method on young athletes. It has some good diagnostic methods based on where the pain is that might help you understand your condition.

https://kosovajournalofsurgery.net/wp-content/uploads/2023/03/D-Litwin-2-KJS7_merged.pdf

[Good intentions]

Did the pain return suddenly after a specific action? Or more slowly, like days/weeks/months? Have you been very active over the five years or more sedentary?

Sportsman’s hernias (athletic pubalgia) pain usually happens during activity, not so much afterward. While running or sprinting, for example.

If the pain is the same as before it seems reasonable to suspect that the same nerves are being affected. Not sure how a surgeon would address that since mesh has already been implanted. Mesh is known to shrink over time, so one possibility is that the mesh moved far enough that the previous weakness has been exposed. It is also known to fold and bunch up as it shrinks.

I am not an expert or a surgeon or a doctor but a TAPP procedure to view the abdominal wall from behind, followed by adjustment and/or placement of new mesh seems possible. I can imagine a surgeon recommending that as a possibility.

Just some ideas. Good that you got five pain-free years though. Hopefully the next will last longer. Good luck.

[Good intentions]

Here is an interesting description of all of the mechanisms that occur when abdominal pressure is increased and the muscles are activated. There are more than I had realized. I would imagine that the disrupted tissues from any type of repair need to be worked in order for new collagen to form/align correctly and to resist the natural tightening of the scar tissue. It seems like a balance between too much and too little, in order to get the complete and correct healing process.

https://worldsurgeryforum.net/2017/07/surgical-anatomy-of-inguinal-canal.html

[Good intentions]

I have had a recent experience that might give you guys some ideas. I recently had some persistent discomfort around the area of the original hernia and scrap of mesh that remains after mesh removal. This was after several days of long walks and hikes and some somewhat strenuous physical work. It seemed like a nerve problem since there was some referred pain that seemed to originate from the mesh scrap area.

I decided to try doing more and heavier weight lifting and more pushups on the thought that the pain was from a small irritated spot on the nerves in the area and that stressing/straining/stretching the abdominal wall might pull the damaged spot to a new smoother area where it could heal. It seems to have worked.

So, maybe try some things that are counterintuitive.

[Good intentions]

I don’t think that your doctors will take requests for the diagnostic methods that they should use. In other words, they will tell you what they think has happened but will not take the advice of a non-professional. It wouldn’t make sense to let the patient decide the diagnostic methods.

The best that you can do is to learn as much as you can about your hernia and the first repair attempt so that you can assess whether or not what the doctors are suggesting fits with what you know. At least find out what type of mesh was used. Ask them how a new hernia could appear if the mesh was supposed to cover all potential hernia sites.

Unfortunately, when problems occur after what is supposed to be a simple procedure there is a tendency to try to avoid the reality of a failed procedure and suggest that something new has happened. For example, in this case it would not be a surprise if the group that did the first repair calls what happened a “new” hernia, while a different surgeon, a second opinion, calls it a failed repair.

If it was me, I would go to the appointment with the group that did the repair, listen to what they have to say, then decide whether or not to get a second opinion. It won’t be surprising if they try to get you to commit to a second surgery to fix whatever has happened without doing any imaging at all.

Sorry to be so cynical.

[Good intentions]

I would get the notes from the surgery to see what was found and how it was addressed. Tell them you want them for your records. You should be able to get them directly from the front office, either by phone or by filling out a form online.

To summarize what you wrote – you had a mesh implantation in March, felt better, but in May you had problems and had an ultrasound, which identified a hernia. It’s only been 3-4 months since the implantation. A recurrence after the repair of a “small” hernia seems odd.

Take time before making a decision to undergo more surgery. Make sure you have the right people to get it right. Every surgery is very traumatic to the body. Get a second opinion from a different group if you feel like something is not being disclosed.

Also, beware of working with people within the same group. In other words, make sure that you understand what happened and what they plan to do to make it right before you commit to more surgery. Many of these “groups” are actually partnerships, where each member has a vested interest to protect everyone else in the group. You could end up on an assembly line of people promising to try to help. Be careful. Good luck.

[Good intentions]

Chuck, it would probably help your decision-making if you categorized and ranked the types of repair and the surgeons separately. Rank the methods, rank the surgeons, look for overlap.

So far it looks like you’re leaning toward a Lichtenstein repair. Dr. Chen seems to be the most rigorous in his thought process about how to do one. He also is learning about the many other various techniques and does mesh removal. Overall, he seems like the best person to consult with, to start. Since you have time, no urgency, you can schedule an appointment as far out as Dr. Chen’s calendar requires. Since he removes mesh he has probably seen cases of mesh sensitivity. He might know whether or not what you experienced was from the mesh or from some other factor. He probably has seen or heard of cases like yours or can have staff research it for him.

Even so, Dr. Chen is a believer in the mesh Guidelines even though he must know that they are suspect. So that’s a dilemma. He is toeing the party line. But, maybe, he has the mental capacity to realize that mesh can be wrong for some people.

In the end, even the experts are just normal people, susceptible to major marketing campaigns, like you are. Just like your anti-vax stance, most hernia repair surgeons are pro-mesh. They’ve been trained to believe in it and the message is reinforced throughout the educational and post-education fields, and the professional news media that they learn from. Similar to your opinions many have taken the absolute approach – mesh is always good. As you think that vaccines are always bad. Peas from different pods. Realizing that might help you communicate with the various hernia repair surgeons.

Dr. Chen’s web page looks pretty impressive. If I was starting over I might have tried to consult with him first.

https://www.uclahealth.org/providers/david-chen

[Good intentions]

I can’t make a recommendation for you Chuck. It’s not clear that you actually have a problem. Your original problem was prostatitis. You have not confirmed that the prostatitis is gone now. You haven’t reported problems since the mesh was removed, just a fear of recurrence.

At the moment, my main issue seems to be irritation from the remaining piece of mesh. It is what limits the duration of any activities. So, my future planning is focused on that, if it gets worse or if I decide to take another chance on improving my situation. It is tolerable now but I feel limited. Dr. Kang does remove mesh but I don’t know that there aren’t state-side surgeons who could do the same, since mesh removal is now becoming big business. I have even considered contacting Dr. Billing again to see what he thinks since he knows what was left behind.

If you’re considering a Lichtenstein repair then Dr. Chen seems like the best option if you can get in there, or ask him for a referral to a surgeon he trusts. But, if you look around you will find that Dr. Chen seems to be leaning toward laparoscopic mesh repair. The marketing is very powerful. He might recommend another mesh repair or he might recognize that you have a sensitivity to mesh and should not get another mesh repair. You haven’t provided enough follow-up about your mesh removal to even guess at what might be best for you. If mesh caused your prostatitis then I would certainly avoid all mesh repairs.

You need to understand where your original problems came from and avoid doing that again. Good luck.

[Good intentions]

What type of hernia?

[Good intentions]

The 0.5 % is his “complication rate”. Not chronic pain. He doesn’t talk about his own chronic pain rate. He does mention that the overall rate is “realistically” above 5%. Which is certainly a disingenuous statement, especially for a person in his position. He must know that the vast majority of studies show a rate of ~15%. They just can’t help defending what they do. It’s human nature.

He still seems like a good person, but he is also still captured by the industry talking points. He tries to downplay the real numbers and can only get from 15% to 5%. Which is actually good, he uses real numbers, just not the right ones.

He must realize that his statement about the benefits of lap are muddled. Lower than 5%? Or lower than 15%? Disingenuous.

” Chronic pain rates, realistically, are over 5%, affecting patients’ quality of life. Minimally invasive laparoscopic and robotic techniques have matured to provide excellent outcomes with benefits of early recovery and lower rates of chronic pain.”

Why is he talking about “our personal risk”?

” In inguinal hernia repair, our goal as surgeons is to lower our personal risk for complication to less than 0.5%, but that number can and will never be zero. Whatever can happen in surgery, will happen.”

…

“. While I am still below my aspirational 0.5% complication rate for inguinal hernia repairs”

[Good intentions]

Thanks for the reply Pinto. The description of immediate pain after the first surgery was a distraction, it was not clear to me that you had apparently healed and been okay for two full years after the initial pain of the first repair. My new understanding is that the pain resolved and you were fine for two years. Then you had another hernia.

I have noticed that some surgeons will refer to a new hernia after a previous hernia as a “recurrence”. But, literally, recurrence means the same thing happened again. Was your second hernia the same, original, sliding hernia reappearing? Or a new type of hernia. This is an important distinction.

“Recurrence” implies a failure of the original repair. The appearance of a a different type of hernia could be a side effect of the original repair, from abnormal distribution of tension, or just a naturally occuring follow-through of weakening tissue.

[Good intentions]

Sorry Pinto but I can’t understand what you’re saying in your account in the other thread. The writing style is strange, from first person to third person and there are details missing. It seems to say that you had intense pain immediately after the first surgery and lived with it for two years. My memory was that you had the pain but it was addressed soon afterward. Maybe it did take two years, I was uninvolved with the forum for a while as I was dealing with my own issues.

If you could just write a simple description, from the realization that you had a hernia all the way through the diagnosis and imaging and first and second repairs it would help people understand. You seem to be saying that prior imaging showed a sliding hernia and that Dr. Kang would have known this. Is this the case? It implies that Dr. Kang’s initial thought about how to repair a sliding hernia were not good enough or that he missed the sliding hernia. Did he say which it was?

Here is your account of “a” surgery. Doesn’t identify it as from Dr. Kang but I assume it was. Not clear.

“Overall, I had a painless surgery and quite pleased with my hospital experience. However there were two difficult post-op aspects in the first four days: immense pain getting out of bed and immense pain walking. After one-day hospital stay, I was discharged but only after requesting crutches. Bumps during my taxi ride back to my hotel were pure agony.”

Then you describe a second surgery two years later. By the writing, you had an attempted repair at the Gibbeum Hospital, had immediate pain and lived with it for two years, then went back to Gibbeum Hospital and had another repair. You’re implying that your “recurrence” happened immediately, probably from just getting out of bed. That’s what the words say.

“Given that Pinto followed the surgeons guide for a safe post-op, he believes if he was able to stay in the hospital in a motorized bed for at least three days, recurrence might not have occurred. It might have even proved the surgery was done flawlessly. He subsequently had a successful operation by the same surgeon two years later without any trouble—- without need for crutches or motorized bed.”

[Good intentions]

Good luck Oceanic. Could you describe the experience in broader terms? Where you stayed, the facilities, languages spoken, type of anesthetic used, any notes from the operation?

Also, when you say you could barely walk, what type of pain were you experiencing? Not much is known about Dr. Conze’s work, on the forum.

[Good intentions]

Actually, the point is that the expensive meshes are really no different than cheap mosquito netting. Your statement should really have any “petroleum-based mesh currently on the market” in place of “mosquito netting”. Except that the one you recommended is probably petroleum-based after the absorbable component disappear. It’s the same as mosquito netting.

Synthetic meshes are well-known for stiffening and shrinking very soon after implantation. The “replication” of abdominal wall movement disappears and the mesh becomes something completely different than when it was implanted. All hernia repair surgeons know this.

Most of the marketing that you read for any medical device is designed to make the sale. I hate to use the word “lie”, disingenuous is probably the best word for it.

“50% volume dissolvable and have multidirectional tensile stretch to replicate the way the abdomen moves”

[Good intentions]

I thought that pinto’s case was one of a missed sliding hernia. Not a recurrence. People keep calling it a recurrence like it happened months or years later. It happened within hours or days, as I recall. As I understand things sliding hernias are unusual and often missed. It’s one of the reasons that Shouldice dissects the cremaster muscle. So they don’t miss anything.

https://herniatalk.com/forums/topic/pintos-2nd-surgery-with-dr-kang/

Pinto makes a good comment about being a lifer once you have a hernia. Besides the fear of future hernias, it really opens a person’s eye to how messed up the medical field is and how machine-like it is in treating patients. It’s actually very industrial and getting more so, with robotics and ambulatory surgery centers. The surgeon can walk in and perform the surgery without actually seeing the body of the patient on the table. It can all be done by video screen and control panel.

On various posters on the forum – there is a lot of “recency” effect happening here. Taking something they read on another web site, or heard from some guy down the street, within the last few months as indicative of the probability of success in the future. And very poor understanding of numbers overall, or willful misstatement. All of the decisions we make in life have a possibility/probability of being wrong or going wrong. If a surgeon has done 1,000 hernia repairs and had 20 pain or recurrence cases, that would be worse than a surgeon with 5,000 repairs and 20 pain or recurrence cases. A rational person would choose the 20/5000 surgeon over the 20/1000 surgeon. People are comparing only the 20 cases that they heard or read about, within the last few months, as indicative of the probability of a successful repair, without considering the successful repairs from the same surgeon. Numbers don’t work that way.

In the end it’s an educated gamble. Watchful went about his research in the right way. But he ended up as one of the 20. That doesn’t mean his decision-making process was wrong. It means he had poor information to work with or he just ended up as one of the unlucky ones. Not much different than getting killed by a drunk driver, or bitten by a shark, or struck by lightning. Don’t drive after midnight, don’t swim in shark-infested waters, don’t go outside in a thunderstorm. It can still happen though. Nothing is certain.

Pinto’s 2nd Surgery with Dr. Kang

[Good intentions]

An older article about mosquito netting. What’s really interesting is that they don’t raise the larger more obvious question of why cheap mosquito netting shouldn’t be used everywhere. There seems to be no reason to pay the extra money for the products of the big medical device makers.

https://onlinelibrary.wiley.com/doi/abs/10.1111/ans.17174

REVIEW ARTICLE
Inguinal hernia repair: a global perspective
James O’Brien MBBS, BMedSci, Sankar Sinha MS, MEd, FRACS, FACS, Richard Turner MBBS, BMedSc, PhD, FRACS
First published: 22 September 2021 https://doi.org/10.1111/ans.17174

“… Conclusion
We postulate that the most cost-beneficial method of hernia repair for implementation in LMICs is using open-mesh procedures with sterilised mosquito net under local anaesthetic. Further cost–benefit research is required in this area. “

[Good intentions]

Here is what I had originally tried to post. I pulled out the two links above so it should work this time.

Here is an article that demonstrates how chaotic the mesh business really is. All of the big manufacturers have promotional material describing the advantages of their products. But, at the end of the day, it’s really simple fish net or mosquito netting material. Might even be made at the same factories.

Pretty crazy. It’s just a letter to the Editor of the BJS. Links below. The time frame is 15 months.

Link in post above –

Fully extraperitoneal laparoscopic inguinal hernia repair using conventional mesh versus tailor-made mosquito mesh: a randomized controlled trial from Cameroon
B. Essola, J. Himpens, A. Limgba, J. Landenne, D. D. Tamchom, E. Ngaroua, P. Lingier, E. T. Mboudou, J. Souopgui, M. P. Hermans … Show more
British Journal of Surgery, Volume 108, Issue 9, September 2021, Pages e294–e295, https://doi.org/10.1093/bjs/znab188

“… In this prospective study, the authors found no difference between the groups in short-term complications and medium-term outcomes. The perioperative financial benefit of mosquito mesh is clear, as are the economic value and clinical non-inferiority, with low-cost mosquito mesh 1/1000 the price of commercial meshes …”

Here’s the about page for BJS.

https://academic.oup.com/BJS/pages/about