[Herniahelper]

Well the short answer to your first question regarding me noticing a lot of people with repairs have some degree of chronic discomfort…

I have to save from my experience that really only applies to mesh repairs BUT… I suspect that is because it is what everybody has. It is very very rare that I encounter somebody that had a hernia repair without mesh unless they were a child. It is more or less what everyone has gotten in the United States for the last 30 years. Most general surgeons do not feel comfortable with a non-mesh repair. Most of them dabbled in it at some point and they just had to high recurrence rates.

I have one friend who is a very well respected trauma surgeon basically tell me that he doesn’t want to do hernia repairs anymore. He hates when they come in the door. Because he has all these patients with chronic pain and he has no idea what to do about it. He just says it’s a really difficult problem…

Here he is at the end of his career and he is bothered by this.

That said I do see people with mesh repairs who are basically fine.

I think for most laborers that I see with repairs, it bothers them but they push through it. If they were not a laborer it might not.

I would also say that I think there is category of person which I have never really seen discussed here which is the “Very Sensitive Person.”

These are people who are very sensitive to stimulation and in tune with their bodies.

They have to sleep with blackout curtains, ear plugs, they can’t wear jewelry or watches because of the constant sensation drives them crazy. And while they are very sensitive, doesn’t mean that they they are babies with pain. These are normal high functioning people…

But I suspect if you put a mesh in them, they’re going to know. They might not have severe chronic pain, it might not limit their life, but when you ask them about it, they know something’s there, and it irritates them and they know that something is wrong in that area. And because there is a mesh there it will never have the opportunity to remodel well.

It’s sort of their curse. Everything that goes wrong with their body, they are unlucky enough to be constantly reminded about it.

So while it is not a true allergy, I think that some of these people might be poor candidates to have an appliance that is designed to cause irritation in an anatomically complex and highly sensitive/ mobile area.

That probably is also a factor in why younger people tend to have more difficulties with chronic pain than the older people. They’re nerves are just not working as well, everything else hurts, they just don’t notice it as much.

[Herniahelper]

Well I will say regarding your chronic pain figures that whenever I hear academics discussing chronic pain I’m very suspect of the numbers.

Look at the meta-analysis they are going over papers that are tabulating rates of chronic pain. But I think that they are vastly underreported in those studies.

I think that the vast majority of patients go back to their surgeons and tell them that they are unhappy and they are dismissed. They are evaluated clinically for a recurrence, if none is found they declare the surgery a success and try and get rid of them.

So often I see surgeons blaming a labral tear, or some other problem on their discomfort when it clearly is not.

And many patients just internalize that their doctor is basically saying that they can’t do anything more for them and so they don’t come back. As far as the surgeons concerned he thinks it’s another cure.

I see a lot of patients with inguinal hernia repairs and I ask every single one of them how is it.

I would say only about 40% say it’s fine. The vast majority says that it bothers them from time to time and they don’t like it but they live with it. And then there’s a much smaller number that are seriously debilitated. But a lot of people just adjust their lives.

I remember I asked one patient the other day how his repair was and he replied:

“They tell you it’ll be good as new. They lie.”

I would say probably more than half of patients that have this done have some type of difficulty with it. However they can live with it.

Regarding the above statement that this person is doing a lot of things with his life therefore he shouldn’t get surgery… He may be doing all of those things with a lot of difficulty. He’s trying to live and he’s trying to make use of the time that he has and so he’s suffering through the pain. And he’s checked off a lot of things on his list and now he’s willing to risk being better.

I have never understood the people here who say that they’re getting their mesh explanted for very minor non-specific symptoms.

I think that there are people that are really miserable, and even though they are doing things like swimming, they have drastically changed their life and they live with a lot of pain. They don’t sleep well, they don’t eat well, everything is a struggle for them. They can’t even carry their groceries out to their car.

And if their exam is abnormal, and they’re imaging as abnormal… Like there’s clearly a problem and there’s something to fix.

I think it’s reasonable to take that risk.

But if your symptoms are vague, and you’re imaging is normal… It is very easy I think for that person to be worse than they were. Especially if their symptoms were not even related to their hernia repair which is entirely possible in those situations.

[Herniahelper]

I think your information is out of date.

5+ years ago most surgeons used the argument that hernia’s NEEDED to be fixed ASAP to justify a procedure. Strangulation risk or “hernia’s are a progressive disease it will only get bigger if you wait” were the most common ways the surgical community would dispel any lingering doubt regarding the necessity of a surgery. Both for themselves and patients.

There has been a paradigm shift in recent years regarding the advent of chronic pain following hernia repairs. It is an established risk now.

Such that if you have a patient with an asymptomatic hernia, why risk touching them…

Then risks and benefits must be weighed. For the vast majority people with small asymptomatic hernia’s the literature has proven the strangulation risk is prob lower than the other risks of the surgery, such as chronic pain.

However someone might still want it for cosmetic reasons, then benefits may be worth the risk.

It’s an individual decision.

It is true hernia’s are often a progressive disease. Small defects grow. How fast, how big, is very patient dependent. However for many patients the paradigm shift is that watchful waiting is a genuine part of the discussion now.

Where as before the mentality was schedule EVERYTHING for surgery.

Your comment about sports “hernia’s” confuses things a bit in the sense that they are not true abdominal wall defects. They often represent a groin tear/ injury. In many cases the anatomy is still in close enough proximity to heal with conservative measures. It’s not a hole fat stuffed into it.

Soorts hernia unfortunately is often a label given to people with no other explanation for groin pain. Like most things we can’t definitively diagnose, the body sorts them out with time.

But there are definitely people with clear musculoskeletal groin injuries and there is data to suggest that groin reinforcement with meshes or hernia like repairs can “fix” them.

Again people need to be careful how they use the catch all phrases.

If you have small bump on your belly button that’s been there for the last 10 years that you could care less about… And a surgeon is pressuring you to get in the OR schedule ASAP because you could incarcerate at any moment… Run.

[Herniahelper]

The mesh may be filling in with scar tissue and incorporating. It may shrink or pull on structures or nerves. Or sometimes it doesn’t incorporate well, particularly if it’s a small mesh, and applies a lot of forces and begins tearing tissue or working itself free.

In the vast majority of cases the minor aches and pains eventually work themselves out but it may take up to a year.

[Herniahelper]

How does groin pain and dysfunction lead to needing knee replacements in 3 years if you’re starting with healthy cartilage and barely walking it all anymore?

There is a lot of psychosocial stuff going on in this post…

Dr. Brown was one of the only people dealing with sports hernia type things in his day. There is newer technology and people that have more resources at their disposal now. Before you lose hope I suggest you see one of them. Are many people here with the great deal of experience remediating these cases.

[Herniahelper]

Everyone has their biasis. He runs the “Lichtenstein…” Clinic. It was a huge part of his up bringing as a surgeon so I’m not surprised he touts it as a strong option in his hands. However what I find most interesting here is the admission that because he was operating on a VIP, he selected the TEP repair. Presumably because I’m his mind, out of all the repair options in his armormentarium, he believed it to be the “best” in terms of chronic pain rate and other complications.

… And then he got screwed by an unforseen complication of prior surgery. “#LOL”

The blind dissection with TEP intuitively seems like a drawback where adhesions lay in wait. Good old TAP has the drawback bowel injury or adhesions but you can see what’s going.

The second thing I find interesting here is that due to the bowel injury he likely needed to select a tissue repair, and he chose an open shouldice.

Dr. Towfigh has published a novel robotic primary tissue repair technique. I’m certain Dr. Chen is aware of this technique as they collaborate togeather.

I’m just curious if this would have been an option in such a case since they were already in there and if so does anyone know if Dr. Chen ever performs this repair as well?

While this case had the modifying factor of bowl injury, I’m curious if for those undergoing mesh removal who don’t want more mesh, is an open shouldice a ‘better’ option or does this robotic tissue repair seem similar in the right population?

[Herniahelper]

Personally I would skip Dr. Harris. While he is a thoughtful and very experienced surgeon I sense he feels there are others more specialized in hernia repairs and revisions than himself and that people would be better served seeking the advice of those experts.

Dr. Chen runs a very very busy clinic. The waiting room is packed tight with patients in very rough shape. I did not feel as though he had the time to think specifically about my case. I got general big picture statement doing a very brief interaction. I got the impression he would just sort of figure it out in the OR.

The person whose name I think you really should consider that is conspicuously absent from this list is Dr. Towfigh. I traveled around the country, I saw many of the big names. Out of all of them she was the only one who examined me carefully, listened to me, reviewed my imaging and spoke to me about my problem in a way that demonstrated any understanding of it.

I don’t know what her outcomes are like, or how they compare to the others on the list. If I could turn back the hands of time she would be my choice for primary or remediation.

Personally I would not get hung up on prestige. It doesn’t correlate with good outcomes.

Shouldice has an excellent reputation for good outcome under certain circumstances. If they think that you are a good candidate for their repair, go for it.

I think in experienced hands laparoscopically people are having great outcomes too.

I know many incredibly active people that have had both open and laparoscopic mesh repairs and have absolutely no problems.

To a degree it’s a roll of the dice. Try to find someone who has operated on someone you know, that is similar to you, and has had the outcome you want. Some surgeons have no complaints from their 60-year-old patients but all of their young ones are getting them redone elsewhere.

[Herniahelper]

We would love to hear your story and how things go. Please update us with your progress.

[Herniahelper]

When it comes to subtleties on imaging, things are a bit like reading tea leaves. Even among radiologists they will all have different impressions. Depending on their experience one doctor may be able to convince another. And even if there’s a consensus that doesn’t mean that’s what you’re going to find interoperatively.

I think the imaging only really helps if there is something grossly abnormal.

As much as people with minor symptoms who are on the fence about revisional surgery would like to rely on imaging as the tiebreaker… In cases like this I don’t think you are going to get a reliable answer. If you feel that you want more information you could request to have an MRI with bare down views.

However I think what is going to guide your decision the most is how disabling are your symptoms, have you exhausted all the other options, and have you given it enough time to be sure it won’t work itself out.

The possibility of creating a new problem is real. You have to be relatively certain that you wouldn’t want to continue living the way that you are.

That may sound harsh but the forums are brimbing with people who have chronic pain after hernia repair and we know that there are many surgeons revising them. But I don’t see many success stories being discussed. Giving the number of people complaining, you would think they would be eager to share the successes of their cure. Outcomes are very mixed.

I think we would all really like to hear from people who had a good outcome. I really wish more people would post their experiences.

[Herniahelper]

@nacly

The hoops are:

1) See a doctor. Tell them you want to see a specialist about your chronic groin pain, but need an MRI. The reason for your visit is to obtain a prescription for this and for the referral to the specialist you researched(if required by your insurance).

2) Call outpatient imaging centers and find out how much a the MRI costs cash. $400-700.

3) Call your insurance company and ask how much the MRI will cost if you use insurance. Probably more. But it will count towards your deductible if you are anticipating surgery.

4) Make appointment with specialist you picked that takes your insurance.

And/ Or

Pay the flat rate to see Dr. Towfigh online, or in person if you’re serious.

Get as many opinions as you can.

Reguarding the pain being far from your surgical site and moving all around making sense… It makes anything but. Further explanation will be needed. You need to know what your chasing and what the goal is.

[Herniahelper]

It’s not an uncommon story. People have a difficult recovery the first year. Things settle down and they have a period of significantly reduced symptoms or they return to activity. But for lack of a better term it’s just not a good repair and they end up in a cycle of reinjuring themselves with minimal things and then convalescing and repeating.

I have heard about some improvement with exercise intermittently and always wondered about that. A question maybe a small cord lipoma or piece of fat getting trapped causing pain that then gets shifted with activity. I don’t have a good explanation.

But overall I would put people with the above in this category of “just a bad repair.”

They don’t have nerve pain, or major psychosomatic factors. The surgeon tells them it’s a success because he cannot detect recurrence but they can put their fingers right on the spot where the hernia was and say ‘this is where it hurts, your repair sucks.’

As basic as that sounds I think it’s often true.

I think what patients should take away from the ever common “there’s no reoccurance” statement is not that there’s nothing wrong. It’s basically their way of saying that they can’t help you.

People then get post holed into the chronic pain category. They are somewhat functional, but pain with activity severely limits their life and intuitively they know that something is wrong. They can’t walk their dog, pick up their child, or lift their groceries without fear.

But the prospect of exploratory surgery with nothing to fix is terrifying and many of the stories available on ‘mesh removal’ does indeed make it sound like a palliative last resort. The possibility of being worse not worth the risk.

Something that I know I would like to see discussed on Hernia Talk is the patient who has prolonged episodes of debilitating pain with activity after hernia repair that resolves with convalescence. What is the surgical experience with these patients? Do they do better and should they have a lower threshold for considering revision.

Do outcomes very when imaging appears normal versus when imaging is abnormal (folded mash, meshoma, bulky plugs, migrated plugs, heavy scaring, etc).

[Herniahelper]

@nacly

I think most surgeons will check for a hernia on physical exam and if none is detectable, and none is detectable on imaging, they just chalk it up to chronic pain. The surgery from their point of view is a success, “there is no recurrence” they will proclaim triumphantly and then walk out of the room.

However this story is a very common story.

And if most surgeons do not find something to operate on they will tell you that it’s a groin strain, a labral tear, a urologic problem even…

And if you get pelvic MRIs on just about anybody over 40 who has lead an active life a tiny labral tear is most likely going to be there even though it’s asymptomatic and unrelated.

And a percentage of these, if you leave them alone, will improve on their own. Intuitively I think that things are not stable, but when a little bit of tearing occurs, it causes pain, more scar tissue forms, and maybe things can stabilize. Or perhaps everything just calms down over time.

The fact that you were pain-free for a year following your surgery speaks against the idea of chronic pain related to the mesh.

And I think that that is the very important key piece of information.

If you give it a year, and it never settles down and you can’t live with it I think it’s reasonable to consider having it revised and treating it as if it’s a recurrence. However very few people feel confident about giving someone good odds. Two experts that I have spoken with regarding the above topic consider these procedures to be “palliative” in nature. And they try to emphasize that patients should not have hope of returning to a normal life, but just having less misery than they do now. So they really should think long and hard about whether or not it’s worth it. The subtext here being outcomes are not universally great in their hands.

A lot of people I think present with nerve damage that has already occurred, or vague minor symptoms like “brain fog” or just generalized anxiety over a foreign body being in them. In those situations better outcomes are probably much less clear-cut.

However for the cohort of people that were pain-free for a time after their surgery, and now have pain where they’re hernia was, that is of the same character as their original hernia…

I think it would be really interesting to know how often a recurrence is actually found interoperatively and if outcomes are better for them following a second repair as compared to the rest of the chronic pain group?

And this doesn’t have to be a study. I would love to hear from surgeons and patients that have seen this, and know what their personal experience has been like with it.

Many people are in this boat, but are afraid to do anything about it, however they may be more likely to have a good outcome because there is actually something that can be fixed.

[Herniahelper]

@mitchtom6

It would be great to hear if anyone, patient or surgeon, had such a case operated on and what the result was?

[Herniahelper]

Question for the surgeons:

When a patient complains of symptoms such as new onset pain with lifting, but has no exam/ imaging findings to suggest reoccurance, how often is an occult reoccurance found intraoperatively?

[Herniahelper]

Dr. Ramshaw does not seem to be alone here. Many of the most common names in complex hernia revision/ mesh explantation seem to be moving on to other things.

I imagine its exceeding challenging. The surgeries are tedious, patients already injured/ upset and have unrealistic expectations. Volumes are low along with reimbursement.

Many doctors are on the brink of burnout the day they graduate residency as it is.

Clearly there are bigger systematic problems in play.

However as we see names like Ramshaw and Belyansky step back from this field, will there be anyone to take their place?

Will the current providers with these skills continue to practice? Will new providers emerge? Or will patients see fewier and fewier options in spite of the efforts of the brave pioneers here?

[Herniahelper]

[You speak specifically in the case of mesh? Such a “weak spot” is a precursor to hernia or is already formed one?]

Speaking of previously poorly placed mesh. If things get pulled on or torn, there’s still a foreign body reaction and perhaps if babied And I’ve scar tissue may form to stabilize things. It’s just a thought as a mechanism for why people could have problems similar to hernia recurrence that eventually resolve with conservative management. However these are generally not strong and will likely cause problems in the future.

If there is a weakness that is small theoretically it could heal but without a scaffold to promote that, hernia’s generally are considered to be a progressive disease. Once the hole is there it will just get bigger. There are anecdotal reports of people healing their questionsble hernias with physical therapy but without actually looking inside or imaging I don’t really know how you would prove that’s what happened. They could have simply had some other musculoskeletal problem that worked itself out with time.

[Herniahelper]

I mean you will need to see somebody in order to get a plan together but in general overall you can probably give it a year and see if it works itself out. Sometimes if you have a weak spot it will scar down. Or if it doesn’t get better or you can’t live with it you’re probably going to be faced with having someone go in again.

If you are able to live 50 lb and it’s only sore for a few days I’m not sure it would be worth the risk. Because it doesn’t that debilitating by your description.

[Herniahelper]

If you were pain free and now have pain similar to your prior hernia… Illicited by lifting and better when laying flat…

That’s a great story for occult reoccurance. Sometimes I feel there’s enough coverage to prevent clinical reoccurance, but things are weak. Maybe there isn’t enough strength and when strained tissue tears or is pulled on.

Does the pain linger for weeks after such that you feel fragile reguarding core strain?

Or is it painful, but then immediately better.

50 lbs is pretty good.

[Herniahelper]

I think the real question is whether many of the next generation of general surgeons should (or even could) be trained how to do a good primary tissue repair as part of their armamentarium?

Even if someone is an excellent candidate for it, it’s just not an option right now it seems.

So many generations have been brought up on mesh based repairs that you probably don’t even have the experience among the faculty to teach this if you wanted?

[Herniahelper]

See:

“The Millikan modified mesh-plug hernioplasty.”

He published a case series in 2003 and again in 2008. Instead of deploying the plug in the traditional manner, the outer leaflets of the plug are deployed through the hernia defect and pulled back like a pre peritoneal patch in the pre peritoneal space. The idea being you get the benefits of a pre peritoneal patch without all that mesh back there to create complications.

I think there are several concerns that are unique to this approach, which potentially we’re not considered by operators who continue to build upon it.

The first is that the plug is shaped like a pleated shuttlecock. It’s outer leaflets have pleats and waves and we’re not designed to lay flat in the pre peritoneal space. As a result it may not adhere flat to the wall well due to the memory effect of the material.

The second issue is that the size of the overlap is actually very small in comparison to a real pre peritoneal patch. This results in less strength. More so as surgeons select even smaller plugs as in your case for this method. The size of the overlap of the outer leaflet is likely very small.

However if everything is done as the original author published, it shouldn’t be an issue because of all of the other components of the repair adding additional strength… However there are some nuances here.

The small size and pleaded nature of those outer leaflets make it less likely that it’s going to flatly adhere well to the abdominal wall in the pre peritoneal space. Even if the interleaflets are anchored well with non-absorbable sutures those outer wavey petals can ball up, even invert like an umbrella turned inside out in the pre peritoneal space. The result is a mass of scar tissue interfering with everything nearby.

Another big consideration is the fact that the outer leaflets are designed to have a memory effect to hold a cone shape. When the outer leaflets are pulled back in the pre peritoneal space, they are being brought under tension. The entire configuration is now spring loaded and attempting to push itself deeper. If absorbable sutures are used, or if the anchor point fails earily in recovery the whole thing is going to want to ‘walk’ deeper.

Think of a barbed foxtail seed working deeper into your sock as you walk.

I suspect as scar tissue incorporates into the 3D nature of the plug deployed like this, these forces increase if not well adheared to the abdominal wall.

It is very possible you could have mass effect on the structures you mentioned related to the above. If you do it should be relatively apparent on CT or MRI imaging.

You haven’t told us anything about your symptoms but start locally and get imaging.

Then seek the opinion if experts. And opinions can varry widely. Some world experts on this topic have the approach that you can’t tell where pain is coming from with mesh and that all of it needs to be removed. They will explore your groin from both sides in an attempt to exclude all causes of pain in one very invasive surgery. Another expert listening to your symptoms and looking at your imaging may decide that you have a problem related to a meshoma compressing those structures you mentioned and may offer you a more targeted approach.

Having traveled the country and spoken with most of the big names that come up in these discussions, I would offer a +1 for Dr. Towfigh. She is exptional and her skill set may be particularly wellsuited to the problem you describe.