Herniahelper
Forum Replies Created
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Personally I think a posterior repair via an open approach is a terrible idea. Logistically it makes sense. All the benefits of a posterior repair without any of the logistical problems that a company intra-abdominal surgery.
But in practice I don’t think that you can deploy a posterior mesh reliably and safely blindly.
There are a lot of sensitive structures back there. Potentially more contributing to bigger problems than nerve entrapment in an anterior approach.
But you still get that nerve entrapment risk from an anterior approach because that’s how you got there in the first place. Admittedly it may be less if you’re not deploying a mesh there.
You develop a space blindly and then lay mesh back there blindly and hope that it lays out properly without interfering with any sensitive structures, all of which are in the neighborhood.
When things go wrong it’s extremely difficult to remediate.
The advantage of a posterior approach for a posterior repair is you can see exactly what you are doing to minimize complications with sensitive structures back there.
Admittedly it has many drawbacks such as violating the peritoneum and adhesion risk.
TEP seems like a very attractive approach for a posterior repair for that reason.
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If we know anything at this point it’s that three-dimensional meshes Do not integrate well simply because they do not retain their designed shape. They contract, pull away from the defect, migrate, entangle sensitive structures as they do so, and are highly perceptible to the end user because they become a big lump of scar tissue concentrated in a particular area which push pressure on everything around it.
It’s a failed concept. I think half the reason why people still use this technique is simply because it’s what they were taught in residency. There’s a lot of people out there that were trained on it.
So it’s the thing that they use and they are trying to improve upon it utilizing the same concept.
But it’s a failed concept at this point.
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Incidental asymptomatic hernia… I wouldn’t dream of touching it.
If it doesn’t bother you or impact your life in any way… that’s a tough thing to “improvove upon.”
With the risk of harm being clearly established now I would argue it’s flirting with malpractice to even touch it.
Well I’m sure a surgeon could make a creative case using your logic that hernia is a progressive disease, at some point in the distant future it could become symptomatic, and this is causing the patient anxiety over when that day might, if ever, occur…
But it’s a stretch.
Anyone who is quick to offer you surgery as quick as you are asking for it you should run from.
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It is not uncommon to experience genitofemoral nerve irritation as a result of the hernia. The nerve that supplies the sensation to the testicle is in the neighborhood of the area where the tear in the abdominal wall occurs. The local injury and inflammatory response can irritate the nerve resulting in vague testicular aching or irritation you can’t quite put your finger on.
In fact for some people they have this for quite some time before they develop a clinically evident hernia. It’s part of the reason they end up being sent to urologists and other specialists and the diagnosis gets missed for quite some time. Eventually the hole gets big enough that fat comes through and then the diagnosis is obvious.
The pain does not necessarily mean that material is going down into your testicle and causing irritation there.
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As I stated in my previous post information is lacking and it’s difficult for any of us to wrap our head around this without it. Please do your best to go back and respond to our questions if you can.
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If anything I feel like it’s the athletes who are very in tune with their body and are putting high degrees of stress on their repair that are never quite happy. Same with laborers. Assuming you have reasonably healthy tissues, and don’t do other things that are likely to put significant strain on your repair like chronic cough or constipation… You’re probably less likely to have difficulty presuming you don’t develop a nerve injury or other technical problem from your surgery.
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And is that discomfort in the same area as your original hernia and is it similar in character?
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Odds are if you’ve been fine, and now you have problems you have a recurrence. It would just be nice to know that for sure or exhaust less invasive options before surgery.
And if the hernia does progress and enlarge as you said was your prior experience… You may develop a bulge or other signs that make the diagnosis more certain. But I sympathize with your desire to get things taken care of and get on with your life as quickly as possible. Has shouldice offered you surgery? Or is that 12 weeks just to get on the schedule to be seen?
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How far out are you from your original procedure? And what was your trajectory of recovery like? Were things totally fine for a while and then this problem developed or was it like this immediately after surgery and never got any better?
It’s the pain you know versus the one you don’t.
There’s no easy answer here. And I absolutely sympathize with the difficulty of this decision. This is part of the reason why forms like this are so important for people to share their experiences. It’s also why Dr. Towfigh’s research, professional and public engagement are so important. People need to hear all this stuff in order to better make decisions on what they should do.
How long have you been living with it? It sounds like if you are relatively comfortable and you can put off certain things and deal with the inconvenience you have the luxury of time. You don’t have to make any quick decisions. And the more time that goes by the greater the experience grows around remediating hernia complications.
That’s saod I do fear that really talented doctors working in this area may leave before you have an opportunity to benefit from their experience.
I think it’s a very challenging area to specialize in. The cases are complicated, the surgeries are exhausting, and the patients are already upset. Many centers are completely overloaded. I don’t blame surgeons after dabbling in it for moving on.
I think you need to talk to different people and see if you can find someone you feel understands your problem and inspires confidence for a good outcome.
You might see one specialist that paints a very negative picture. And that might be because they don’t want you to be disappointed or have unrealistic expectations. It may also be because they know they don’t have the skill to give you a good outcome.
Another surgeon might tell you that it’s a walk in the park. And you have to determine if it’s because they understand your problem, they know how to fix it and their level of skill is there… Or if they’re just hungry for business.
You need to find someone who is thoughtful, who is willing to think about your problem, come up with ideas with you that intuitively makes sense to you. It doesn’t sound like you’ve found anyone yet who’s giving you an option that you want to take that risk for.
I recommend that you fly around the country, as much as a hassle as it is just do it. Meet with the people out in your neck of the woods and if nothing feels right try Dr. T.
Right now you have no clear answer because you don’t have a good option.
And remember everyone’s experience is growing. With every case they learn a little more.
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I think there’s some confusion here. I’m going to assume that you had an inguinal hernia and that you had a piece of fat protruding through the abdominal wall defect known as a cord lipoma. Very commonly encountered in hernia surgery. The presence or absence of it isn’t really relevant to how difficult it will be to remove the hernia system. The hernia system is essentially a bilayer mesh. One portion of it is on the outside, and another portion is on the inside of the abdominal wall and then it is connected by mesh. It’s somewhat of a difficult system to remove because it sandwiches the abdominal wall. You have all the risks of disturbing the anatomy on the front, and then also risks of disturbing the anatomy behind the abdominal wall.
So to summarize the bilayer nature of the hernia system that you have probably has a greater impact on the difficulty of removing the mesh then whether or not a cord lipoma was encountered during your initial surgery. If the only comment on your surgical report was that a cord lipoma was encountered I suspect that your defect is small and that maybe your system is small and that may make it slightly easier if your burden of mesh is smaller.
In all honesty I don’t think it matters. Whether or not nerves are damaged from or during the procedures, and whether or not you can achieve a good hernia repair after it is removed and a defect is created are greater questions.
And some of those depend on what damage has already occurred as well as the skill of the surgeon and also just luck.
Who is the plastic surgeon?
Does he have a lot of experience removing mesh?
Do you know if he’s planning to do a primary tissue repair after the removal?
You mentioned he specializes in nerve repairs, is he planning any type of ‘nerve repair’ for you?
This is all very interesting and please update us on your progress. The community would love to know what kind of success you have with this person.
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With regards to your question about what happens if you have an occult recurrence? That’s part of the reason your surgeon may want to go in and look. If no other explanation can be found and you’re having a lot of symptoms going in and looking, while not benign may offer some answers. If a hernia is found in the region of your pain how a doctor corrects it will likely vary. Some surgeons are of the opinion that more damage is caused by removing mesh and so they just try and add more. Other surgeons think that that’s a terrible idea and may try and remove mesh and completely revise the repair. How much risk of nerve injury there would be is likely very surgeon-dependent. Those are important questions to ask.
If your symptoms are minor I would think long and hard about having invasive procedures done unless your surgeon is extremely confident that they aren’t going to hurt you.
I do see people posting here that they want their mesh out because after they do their daily 8 mile run the area is a little itchy. Or there was a vague tugging sensation intermittently. I think that’s an extremely risky proposition. But I do know of cases where they had it done and they were not any worse. Which really says a lot about the skill of the surgeon. They weren’t any better either but frankly it’s amazing they aren’t any worse.
It’s somewhat counterintuitive but I have noticed people who complain of aches and pains with meshes sometimes report improvement with light activity. I sort of think of it like the pebble in the shoe analogy… If you have a mechanical pressure on an area for too long, moving things around can help relieve that. Or maybe it’s just a distraction and doing things improves people’s mood which makes them less susceptible to pain. For the most part though activity usually worsens pain, particularly with reoccurrence.
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There’s not really enough information here to know whether or not removing your mesh is a good idea. I would just suggest that you seek the opinion of several experts that have practices devoted to remediating hernia problems.
If you do decide to have your mesh removed please come back and post here. We would really love to know who you saw and how it went.
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I’m really sorry that it sounds like you have not had the best outcome yet.
I’m genuinely curious.
What were the symptoms you were having before surgery, what were you told your diagnosis was, how was your diagnosis determined, what were the goals of your surgery, how confident was your surgeon that they correctly identified your problem and could give you a good outcome?
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I suspect that you are being sent for a CT scan because your providers are diagnostically destitute.
You’ve had physical exams, other modalities of diagnostic imaging, and none of them have explained your symptoms… More or less everyone on Earth that complains of pain near the abdomen for long enough is going to get a CT scan.
I think part of your reaction is that another doctor is saying “I can’t believe so and so didn’t get this test, or operated on you before getting this test…”
I don’t know what your circumstances are but I highly doubt that it would have showed anything regarding your groin injury or changed your course at that present time.
The vast majority of people with true hernias don’t get any imaging at all. It’s purely a clinical diagnosis based on exam.
There are rare instances where subtle hernias or groin injuries are found on imaging. There are instances where technical problems with a repair like a meshoma can be visualized and it can help diagnosing the source of a patient’s pain.
Most surgeons are more comfortable reading CT scans more than anything else. That’s where they start. Because the majority of their practice is built around fixing the things that CT scans show best.
But people that do a lot of work with groin injuries and hernias may choose to start with an MRI because in their hands that can provide them with much more information about those problems than a CT scan.
Was your problem a presumed sports hernia?
If you were complaining of musculoskeletal groin pain and had ultrasound and MRI I think it’s unlikely a CT scan is going to add anything unless there’s something about your complaint that makes people suspicious that bone or bowel is involved. So I don’t think it’s wrong at all not to get one.
The secondary question of if all of your initial studies were mostly negative… Should you have continued to get more and more studies until you definitively found a problem? That’s a personal choice. I think it’s always risky offering someone surgery when you’re not really sure what you’re trying to accomplish.
And there’s a lot of people out there that have meshes and want them removed that look completely normal on imaging.
I think surgeons are much more excited about revising or ex-planting a mesh when there’s clearly a recurrence or other technical problem that’s visible on exam or imaging which can be corrected. Groin explorations or sports hernia treatments should have more sobering expectations.
Of course we don’t know how any of this was presented to you or what your specific problem was.
I do know that Dr. Brown has said to patients in no uncertain terms that ‘revising a groin hernia should be viewed as a palliative procedure. Full recovery should not be the expectation.’
Sometimes it can be hard to read between the lines based on all the information that’s being given to you. Patients want to hear ‘I can offer you this procedure that might make you better.’
I don’t know how confident you’re diagnosis was or what the objective of your surgery was.
For patients that are looking for a doctor to help them with their problem it’s really important to ask difficult questions and try and nail down how confident they are and their ability to identify and correct your problem.
Most of them are not chasing money, they legitimately want to help you. Finding the right person for your problem can be really difficult if nobody even knows what your problem is.
So the short answer to your question is no it is not wrong to get surgery without a CT scan. Even if you had a CT scan that showed nothing different than your MRI I’m not sure it would have changed anything regarding your decision making. Getting a CT scan now is also appropriate. And if it shows something does that mean it should have been obtained a long time ago? Hindsight is always 20/20.
Personally if I could pick any imaging modality for groin pain and I had to only pick one it would be MRI. It shows you all of the anatomy. The new ones with huge magnets can go fast enough to catch moving bowel now. And it doesn’t involve any radiation for the patient. How many general surgeons or even radiologists are use to reading abdominal and groin MRIs? Probably not many, because it’s just not a big part of most people’s practice.
It sounds like you’re going to get your CT scan and so you will know whether it was relevant or not soon enough.
At this point I would caution you not to embark on any additional surgeries very carefully. If you have the benefit of seeking the opinions of world experts you absolutely should.
As I’m sure you have noticed there are many different ways to repair hernias and every surgeon has a different idea about what’s best. Some will tell you that if you believe the sports hernia data all inexplicable groin pain in an athlete with normal imaging can be fixed by stuffing a mesh in it. And they may seem very confident about it.
It sounds like you have a very tricky problem. I’m not sure that Dr. Towfigh can offer you a fix. But if you haven’t yet I think that it would be well worth the expense to go visit her. She has the luxury being able to take the time to be very thorough and she seems to enjoy problem solving difficult cases.
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Question is what’s the likely problem? I think the short answer is yes the anterior and posterior components of the mesh can be removed. A bigger question might be does it need to be. When you start proposing bigger dissections and less targeted approaches I think there’s more potential for complications.
As posted above the fact that Dr. Towfigh was able to remove a plug and patch and the individual is now pain free is extraordinarily impressive.
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If it’s only been a few weeks I would give it some serious time to work itself out before rushing into surgery. At least several months. If you had a full work up in the emergency room with negative ultrasound and CT scan the likelihood that there’s an emergency there is low. Any variety of groin strain or sprain is possible and may take months to sort itself out. I know another hernia is anxiety provoking but you don’t need to rush into it.
An MRI does have the advantage of potentially showing other soft tissue injuries as well.
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The hernia’s that heal without surgery are often not true hernia’s that represent an abdominal wall defect.
Why don’t they heal? Well the tissues are held open by tension, and also often fat is stuffed in them. More over the tissues that fail are often thin and almost membranous. Think like a stretching a laytex sheet. It’s strong. But a tiny defect propagates larger rapidly under tension.
Why can’t it be stiched? Try it. With the above example. Put a stitch in the hole in the laytex sheet above. It will probably cut right through the the material as you try and pull it tight. And your body is going to be pulling it tight every time you move.
If you fold the edges of the hole on itself, put in many layers of stitches, even incorporate a few areas of healthy laytex sheets over it so the force is distributed across a large surface area… You can kind of see in your imagination that it would be more likely to hold.
Or if you just slap a piece of flex tape across it which would be somewhat analogous to a mesh, again you’re distributing the force over a large area.
To make matters worse often the tissue that developed the defect because it had structural problems in the first place. Stiching two pieces of virgin tissue paper together is hard enough, now imagine if it’s wet to simulate prior degradation.
In essence many of the suture repairs sort of create their own mesh of sorts. They are not a single stitch but many passes and layers. I think there’s much less foreign body reaction and since you’re overlapping tissue layers I feel like there’s more opportunity for your body to remodel things into something more natural even if the original anatomy is distorted and things begin somewhat tight.
With the mesh repair there’s a much higher burden of foreign material. And if it’s creating a mechanical problem… Your body is likely not going to be able to sort it out beyond just encapsulating the heck out of it. And that may or may not resolve the problem.
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So we need a little more information. We need to know what was your original procedure, and what your pain is like. Is it on the surface of your skin, if so where? Did you pain change after your revision?
I’m going to guess that you had a Liechtenstein open inguinal hernia repair with mesh? And that when that match was removed there were two nerves in the field that were taken at the time the mesh was explanted. Did you notice any changes as a result of that?
Regarding the comment about lymphedema… This is generally not a subtle problem. If your leg is swelling up like a marshmallow, or you have clear fluid pouring out of your incision after the surgery for days… You have a lymphatic problem. If you had dramatic problems I would suspect you would have mentioned them. You mentioned the feeling of swelling, you used the term swelling, the word association with the physical therapist is probably to mention lymphatic problem. But from your description it does not sound like it.
What does come to mind however is occult recurrence. I mention this because you don’t like sitting and you say that your symptoms get worse as the day progresses. Generally if you feel good in the morning when you wake up and after standing all day or being active you’re unhappy… It’s something to consider.
Also regarding the sitting problem if your original procedure involved
a plug, folding everything over on that when you sit down is generally bothersome. Again we don’t know what your original repair is so it’s difficult to know if that could apply to you.When you say you don’t understand how the two nerves adherent to the mesh could be removed and your pain is unchanged… The answer to that maybe that the nerves were not the cause of your pain. I know the post above goes into nerve pain in great detail and how neurectomy can improve or worse than that. But there’s nothing based on your description that leads me to believe that it is nerve pain to begin with.
For the major nerves in the groin most of them have an obvious sensory component. And patients with nerve pain are often very vocal about abnormal sensations and unrelenting pain that really doesn’t change with much of anything.
Your daily eb and flow or ok in the morning, worse with sitting, worse as the day goes on, feeling pressure at the end of the day…
Makes me suspicious your symptoms maybe mechanical. There may be a technical problem with the repair.
Lots of assumptions here. I’m just trying to give you a framework, your mileage may vary.
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Since it has come up several times in this thread I think it’s worth mentioning swimming.
One of the most frustrating things for people undergoing watchful waiting, or those with a hernia complication is discomfort with exercise. For active people sports that that involve cutting, or rapid changes in direction, are often the worst. Running is often out.
It’s often the way I gauge how bad somebody symptoms are. If someone tells me they have a little irritation after they run 10 miles… I’m much less concerned then someone who for example can’t make any sudden movements at all without seriously hurting themselves.
So how do you stay active and do cardio comfortably?
As several people above have already discovered swimming tends to be the most well tolerated form of cardio.
Assuming you already know how to swim eefficiently, people with hernia problems often can maintain a high degree of fitness swimming.
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Regarding your situation I think I only have two concepts to guide you.
If it doesn’t bother you too much, then don’t worry about it. Especially if it seems relatively stable.
The second question is what’s the trajectory? Is it stable? Or is it becoming more painful, is it getting bigger, is it starting to limit your life more?
If it bothers you, especially if you feel like it’s progressing… Then it may be time to think about having something done.
You can’t live your life not lifting anything. Is that because it hurts and is getting bigger or is that because you’re just worried that it will?
If you do decide to have it repaired in general if it’s small enough I think finding someone that has very good results with a open primary tissue repair is probably your best bet. I think it’s what I would choose.
If it’s big and you need to have mesh I would go with a robotic or laparoscopic approach with someone who’s very experienced. And in general if you’re having absolutely no trouble whatsoever with the other side I would probably tell the surgeon beforehand if you find a hernia on the other side, don’t touch it.